Research shows that social factors, in addition to medical care, significantly influence health outcomes. These social determinants include clean air, healthcare, food, education, decent working conditions, adequate housing, clean water, and standard of living. Access to safe drinking water is a key factor in improving health outcomes and reducing health disparities. The importance of access to safe water has been recognised as an international agenda and priority, with the United Nations' Sustainable Development Goals (SDGs) highlighting its importance.

India's National Health Policy 2017 included "safe drinking water and sanitation to all" as one of the cross-sectoral goals related to health. However, India has yet to reach the SDG targets, with 50% of its population reporting a lack of access to safe drinking water, which is essential for human development and building a healthy nation.

Lack of access to safe water sources is the leading cause of infectious diseases like diarrhoea, cholera, dysentery, hepatitis A, typhoid, and polio, and is also one of the primary causes of illness and death among children under 5 in low- and middle-income countries. Increased access to safe drinking water would not only improve health outcomes but also contribute to developing resilient communities and enhancing the country's economic growth.

A desk review of India's drinking water schemes, programs, and policies was conducted, under a recent study by Vikas Sheel et al examining documents from central government websites. Primary studies were reviewed to understand the disease burden from contaminated water, providing a comprehensive picture of water, health, and development links, and offering actionable recommendations for the government.

Current scenario of drinking water and disease burden

The World Health Organization (WHO) defines safe drinking water as having at least 20 liters of water per person per day from an improved source within 1 km of the user's dwelling. As per NFHS-5 (2019-21), 95.9% of households had access to improved sources of water, with 48.5% using primarily piped water. The percentage of households having improved sources of water has increased from 89.9% in 2015-16 to 95.9% in 2019-20.

Water diseases are illnesses resulting from the direct consumption of contaminated drinking water or indirect contact with contaminated water through the skin. These diseases are classified into four main classes: water-borne diseases, water-washed diseases, water-based diseases, and insect vector diseases. Unsafe water-handling practices (WASH) practices account for 1.4 million deaths globally, with the leading cause being diarrhoea, followed by acute respiratory infections and undernutrition. Children under the age of five bear the brunt of the global burden of diarrhoeal disease, contributing approximately 69% of the total WASH-related disease burden.

Lack of clean water for washing can result in water-washed diseases like scabies and conjunctivitis. Water-based diseases are caused by host organisms that develop into human parasites, including schistosomiasis and dracunculiasis. Insufficient water intake or limited access to water can lead to dehydration, negatively impacting physical and cognitive abilities. High levels of arsenic in groundwater are a significant concern affecting over 226 million individuals in over 100 countries.

Evolution of schemes and initiatives to improve the availability, access and quality of water

India's government has implemented various initiatives to ensure safe drinking water for its citizens, starting with the National Water Supply Programme in 1954. Over the past seven decades, these schemes have evolved to improve access to clean drinking water. The Accelerated Rural Water Supply Programme (ARWSP) was launched in 1972 to address areas with low water availability and waterborne diseases. The National Drinking Water Mission (NDWM), also known as the Technology Mission, was launched in 1986 to provide scientific input and cost-effective technological solutions to address water scarcity. 

The National Water Policy was drafted in 2012 to institutionalise mechanisms and develop a legal framework for resolving water management issues in India. The National Health Policy 2017 aimed to provide access to safe drinking water and sanitation to all as one of the cross-sectoral goals related to health. The Jal Jeevan Mission (JJM) was launched in 2019 to provide Functional Household Tap Connection (FHTC) to every rural household by 2024.

The JJM not only focuses on providing tap water connections but also gives equal importance to the quantity and quality of water supplied through these connections. The Water Quality Monitoring and Surveillance System (WQMIS) has been instrumental in ensuring the quality of water by testing water samples at the village/gram panchayat level through field testing kits and laboratories established at block and district levels. An integrated management information system has been developed by the Department of Drinking Water and Sanitation (DDWS) for monitoring the physical and financial progress made under JJM.

The output-outcome framework under JJM outlines the broad vision of the mission, including increasing access to water, reducing acute diarrheal diseases, and achieving a 5% reduction of waterborne diseases compared to the incidence reported in the National Health Profile 2019.

Evolution of schemes for drinking water in India

Discussion

Infectious diseases, such as diarrhoea, schistosomiasis, trachoma, and intestinal helminths, cause approximately 60% of deaths worldwide. Between 1.5 and 2 million children die annually due to water-related diseases, while millions suffer from illness, pain, and discomfort. Inadequate and unsafe water sources and sanitation significantly impact the health and well-being of children. Access to safe drinking water remains challenging in rural areas, with over 60% of households lacking access to piped water. The GoI flagship scheme, Jal Jeevan Mission, has significantly improved access to clean and safe drinking water across rural households in India.

A study by Kremer et al. estimates that successful implementation of the Jal Jeevan Mission and the provision of water free from microbial contamination could potentially avert 1.36 lakh deaths among children under the age of 5 annually. A WHO study estimated that the mission could potentially avert 4 lakh diarrheal deaths and prevent 14 million Disability Adjusted Life Years (DALYs), resulting in cost savings of $101 billion.

Evidence from past literature shows that access to clean drinking water and sanitation leads to a reduction in diarrhoeal diseases. A meta-analysis of 46 studies from developing countries showed that clean drinking water and sanitation have an additive effect on the reduction of diarrhoea-related morbidity by 33%. Improved sanitation coverage can avert up to 3 lakh diarrhoeal and PEM deaths.

Lack of access to clean water also impacts women's health and quality of life, as they are primarily responsible for fetching water from distant sources in both urban and rural areas. Improved household water availability will reduce the disproportionate burden of fetching water on women and children, helping to develop resilient communities by reducing absenteeism from school and work, providing a safe environment, and cutting healthcare costs.

Conclusion

The Indian government is committed to making safe drinking water accessible, affordable, and easily accessible, leveraging existing platforms for decentralized governance. This is reflected in financial allocations under the JJM to states and additional resources through FC-XV grants for water and sanitation through rural local bodies. India has made significant progress in ensuring access to safe drinking water, especially in rural areas, but challenges still remain. Investments in water infrastructure development, such as water treatment plants, pipelines, and distribution networks, are needed. Innovation and technology in water management can improve efficiency.

The "Health in All" approach requires convergence between health and non-health sectors working on water, sanitation, and health to optimize results and avoid duplication. Community-based fora within existing platforms of the National Health Mission and Jal Jeevan Mission may be connected to have an integrated approach towards access to safe drinking water. The GoI has launched new interventions, such as establishing Block Public Health Units (BPHUs) and Integrated Public Health Laboratories (IPHL) under the Pradhan Mantri Ayushman Bharat Infrastructure Mission (PM-ABHIM), to ensure improved surveillance and early detection of outbreaks.

Encouraging and involving local communities in water management and conducting awareness campaigns and education programs can promote water conservation and sustainable use practices, ensuring the long-term sustainability of water resources and creating a water-conscious society.

The full paper can be accessed here

Sheel V, Kotwal A, Dumka N, Sharma V, Kumar R, Tyagi V. Water as a social determinant of health: bringing policies into action. Journal of Global Health Reports. 2024;8:e2024003. doi:10.29392/001c.92160