Access to sanitation reduces the incidence of diarrhoea–caused by bacterial, viral and parasitic infections, mostly spread by faeces-contaminated water–studies show. Diarrhoea is the leading cause of malnutrition, and is the second leading cause of death in children under five years, as IndiaSpend reported in July 2017.
 
As of January 2018–with a year and a half left to the Swachh Bharat Mission’s target of eradicating open defecation–60 million (76%) rural households and 4.2 million urban households have a toilet, and 11 states, 1,846 cities and 314,824 villages have declared themselves open-defecation-free (ODF), according to data available on the Swachh Bharat Mission (Clean India Mission) website.
 
“The challenge, however, will be in ensuring that ODF villages and cities are firstly, truly ODF, but more crucially that they remain so,” as Avani Kapur, fellow at Accountability Initiative, pointed out in this January 2018 article for Mint.
 
The Centre’s expenditure on information and education–which experts say is the key to solving India’s sanitation problem–continue to remain low.
 
It is in this backdrop that Finance Minister Arun Jaitley is set to present his government’s last full budget ahead of the general elections in 2019.
 
Access to sanitation improves child health, leads to more productive adults
 
Sanitation is crucial for India’s plans to reduce infant mortality. The National Health Policy, released in March 2017, aims to reduce the country’s infant mortality–deaths of children under the age of one–from 41 deaths per 1,000 live births in 2015-16 to 28 in 2019.
 
“If you live next to neighbours who defecate in the open, there are germs on the ground, lot of the people don’t wear shoes, they get their fingers on it [germs], their moms get their fingers on it and then there are flies on it and they get on the food and the entire environment is where is lot of faeces and there is lot of opportunity to get on germs,” Dean Spears, co-founder of the Research Institute for Compassionate Economics, told IndiaSpend in this August 2017 interview.
 
This cascading effect of health hazards is corroborated by data: Diarrhoea, as we said, remains the second leading cause of death in children under five years, killing an estimated 321 children every day in 2015, as we reported in July 2017.
 
Access to sanitation reduces cases of diarrhoea, one of the major causes of malnutrition among children, according to this World Bank study.
 
As many as 50.2% boys and 44.6% of girls with no access to toilets are stunted, compared to 26% boys and 24% girls who live in homes with toilets, according to this September 2017 study released by the National Institute of Nutrition.

Source: National Institute of Nutrition
 
Unsafe water, poor hygiene practices and inadequate sanitation are not only the causes of the continued high incidence of diarrhoeal diseases but a significant contributing factor in under-five mortality caused by pneumonia, neonatal disorders and undernutrition, according to this 2016 report by the United Nations Children’s Fund.
 
Besides, there is also an economic cost to the problem.
 
“If children are healthy when they are babies then they grow up stronger and taller, they are able to concentrate at school and learn more and they have higher achievement,” Spears told us in the above mentioned interview. “We find that adults are paid more and are more productive if they are born in a better disease environment. Their families get to consume more and they pay more taxes and government gets more revenue.”
 
“If you can cause a household to stop defecating in the open, just one household, there would be money in the future but it will be an equivalent of increasing the revenue of India by Rs 20,000 per household. That’s just looking at government’s revenue, but then the family gets to eat more, there is more productivity and they will be healthier and they will be more likely to survive,” Spears added.
 

What Doesn’t Kill You Makes You Poorer: Adult Wages And Early-Life Mortality In India

Source: R.I.C.E
 
Inadequate sanitation–management of human excreta, solid waste, and drainage–costs India Rs 2.4 trillion ($53.8 billion) every year in losses due health, damage to drinking water and tourism costs, according to a January 2011 World Bank study.
 
Allocation to rural sanitation up 33%, but sub-par spending on education hinders toilet use
 
In 2017-18, the Centre allocated Rs 13,948 crore for SBM-G–administered by the ministry of drinking water and sanitation. This was a 33% increase over 2016-17 when Rs 10,500 crore was allocated to the programme.
 
However, expenditure on information, education and communication (IEC)–vital for changing personal attitudes and perspectives–has been below par.
 
The programme guidelines recommend that 8% of SBM-G and 12% of SBM-U expenditure be earmarked for IEC. In no year has this target been met.
 
For instance, in 2017-18, only 4% of the allocations to SBM were earmarked for IEC.
 
Consequently, 22.6% Indians who had a toilet at home but did not use one said it was because of “personal preference”, according to the Swachhta Status report 2016.
 
“Lot of families with latrines think that if they use them, it will pollute their home and they will never be able to empty them,” Spears told us in the above mentioned interview. “To avoid all this, it is easier is to defecate in the open. It is going to be a hard problem to solve because it is rooted in these old and strongly held issues of social inequality.”
 
As of January 2018, 11 states and union territories have declared themselves as ODF. However, only six of them have been verified by ministry of drinking water and sanitation.
 
In rural India, 51% of 604,084 villages have been declared ODF. However, only 64% of these had been verified as of January 15, 2018.
 
Since October 2014, 60 million households toilets have been built under SBM-G.
 
Of Rs 13,948 crore ($2.1 billion) allocated to SBM-G in 2017-18, Rs 79 crore ($12.3 million) was for solid- and liquid-waste management. As many as 3.8% rural Indians who chose not to use toilets said broken toilets were the reason they defecated in the open, according to the Swachhta Status report 2016.
 
The urban challenge: 58% cities still report open defecation, only 23% garbage is treated
 
As of December 2017, 1,846 (42%) Indian cities declared themselves ODF, of which 1,337 were verified by the ministry of urban development.
 
As of November 2017, 4.2 million individual household toilets–64% of the 6.6 million targeted–were constructed across Indian cities. Similarly, 92% of the 17,193 targeted community toilets were constructed, data show.
 
Besides eradicating open defecation and constructing household and community toilets, SBM-U also aims to achieve 100% garbage collection and disposal. As of January 10, 2018, 68% of India’s 82,607 wards–urban administrative zones–had achieved this target.
 
Solid waste management, however, remains a challenge. As of November 2017, India generates 145,626 tonnes of solid waste every day; only 23% of this is processed.
 
For SBM-U–administered by the ministry of urban development–the Centre allocated Rs 2,300 crore in 2017-18, the same as 2016-17.
 
Since 2014-15, the Centre earmarked Rs 7,366 crore for improving solid-waste management systems under SBM-U, of which only 29% has been released to states as of January 10, 2018, according to a report by Accountability Initiative.
 
This is the concluding part in our series of eight state-of-the-nation reports ahead of Budget 2018. You can read our report on renewable energy here, on agriculture here, on urban development here, on rural jobs here, on healthcare here, on education here and on defence here.
 
(Salve is an analyst with IndiaSpend.)

Courtesy: India Spend
 

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“When I got pregnant, it was hard to walk to the field to defecate as the path was not safe. My mother-in-law used to accompany me because I needed help sitting down and getting up.”–Maheshwari (25), Raichur, India. India has the highest number of people, 732 million, with no access to toilets and women and girls are among the worst affected.
 
The report by WaterAid, titled Out Of Order:The State of the World’s Toilets 2017, further stated that 355 million women and girls lack access to a toilet. If they were to stand in a line, the queue could circle the Earth more than four times.

 
Source: WaterAid
Note: Data as of 2015
 
India’s low ranking on the sanitation index is despite the changes brought by the government’s Swachh Bharat (Clean India) Mission. Launched in October 2014, it increased the country’s sanitation coverage from 39% to 65% by November 2017, according to government data. In this period, 52 million household toilets were built in rural India.
 
The cleanliness campaign has reduced the proportion of people defecating in the open by 40%, meaning more than 100 million people now use toilets, according to the WaterAid report.
 
India also ranks sixth among the top ten nations working to reduce open defecation and improving access to basic sanitation. The percentage of population without access to at least basic sanitation fell from 78.3% in 2000 to 56% in 2015, according to the report.
 
Diarrhoeal diseases kill 60,700 Indian children each year
 
Each year, 60,700 children under five years die from diarrhoeal diseases, the WaterAid report said.
 
Diarrhoea remains the second leading cause of death in Indian children under five years, killing an estimated 321 children every day in 2015, as IndiaSpend reported on July 29, 2017, based on a World Health Organization factsheet.
 
Hookworms, which can spread through open defecation, cause diarrhoea, anaemia and weight loss in women, according to the report. These problems are linked to low birth weight and slow child growth–38% of children in India under five are stunted, according to the National Family Health Survey, 2015-16, (NFHS-4) data.
 
Indian states with poor access to sanitation report high incidence of diarrhoeal diseases. Uttar Pradesh, Bihar, Madhya Pradesh, Assam and Chhattisgarh had the highest rate of mortality among children under five years of age, higher stunting (low height-for-age) rates and higher prevalence of diarrhoea due to poor sanitation, as IndiaSpend reported on April 26, 2017, based on NFHS-4.
 

States With Higher Access To Improved Sanitation
Had Lower Prevalence Of Anaemia, Diarrhoea

Source: National Family Health Survey 2015-16
*reported in two weeks preceding the survey **Among women aged 15-49 years
 
The tables above show the top five and bottom five states based on the percentage of households with improved sanitation, according to NFHS-4. States with higher percentage of improved sanitation have lower levels of anaemia among women (both pregnant and non-pregnant). These states also reported fewer cases of diarrhoea than the national average.
 
For example, Kerala, which had the highest percentage of households with improved sanitation (98.1%)–the national average was 48.4%–also had the lowest prevalence of diarrhoea (3.4%) and the lowest percentage of women with anaemia (22.6%).
 
Bihar, with only 25% households using improved sanitation, had the highest prevalence of diarrhoea (10.2%) and the highest percentage of anaemic pregnant women (58.3%).
 
For women, high risk of illiteracy, harassment
 
Apart from poor health, lack of toilets means that more than 1.1 billion women and girls globally get limited education and face harassment. In rural India, high dropout rates and non-enrolment among girls can be attributed to absence of toilet facilities, as IndiaSpend reported on July 19, 2017.
 
In rural India, 23% of girls have listed menstruation as the chief reason for dropping out of school. As many as 28% of them said they do not go to school during their period because they lack clean and affordable protection, as IndiaSpend reported on June 19, 2017.
 
Sanitation policies should cover the needs of those who are vulnerable, said Raman VR, head of policy at WaterAid India.
 
“Adolescent girls and women want facilities in which they can manage their periods safely and hygienically,” he said, “Pregnant women need easily accessible and usable toilets, and the elderly or people with disability require toilets with design features that help overcome the physical constraints they typically face.”
 
(Salve is an analyst at IndiaSpend.)

Courtesy: India Spend
 

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Uttar Pradesh (UP), Bihar, Madhya Pradesh (MP), Assam and Chhattisgarh had India’s highest under-five mortality, higher stunting (low height-for-age) rates and higher prevalence of diarrhoea due to lack of “improved sanitation”–usually a house with its own latrine connected to a sewer or septic tank–according to the National Family Health Survey 2015-16 (NFHS-4).
 
Unsafe water, poor hygiene practices and inadequate sanitation are not only the causes of the continued high incidence of diarrhoeal diseases but a significant contributing factor in under-five mortality caused by pneumonia, neonatal disorders and undernutrition, according to this 2016 report by the United Nations Children’s Fund.
 
Poor sanitation makes unhealthy children prone to water-borne diseases such as diarrhoea, jaundice and cholera, as IndiaSpend reported on January 6, 2016.
 
Improved sanitation, as we said, refers to a household with its own toilet, connected to a piped sewer system or flush to septic tank, flush to pit latrine, ventilated improved pit/biogas latrine, pit latrine with slab, twin pit/composting toilet, which is not shared with any other household.
 

Source: National Family Health Surveys 2005-06 and 2015-16
Under-five mortality rate: deaths of children under the age of five per 1,000 live births
 
India’s under-five mortality rate–deaths of children under the age of five per 1,000 live births–declined from 74 in 2005-06 to 50 in 2015-16. Over the same time period, households with have improved sanitation have gone up from 29.1% to 48.4%.
 
Bihar has the the lowest percentage (25%) of households with improved sanitation, and the state recorded an under-five mortality rate of 58 deaths per 1,000 live births in 2015-16.
 
One of the leading causes of under-five mortality is diarrhoeal diseases, mostly caused due to lack of sanitation, according to this 2015 study by Public Health Foundation of India, a Delhi-based think tank.
 
Bihar is followed by Chhattisgarh, with only 32.7% of households reporting use of improved sanitation facilities.
 
Uttar Pradesh has the highest under-five mortality (78 deaths per 1,000 live births) and only 35% households reported use of improved sanitation facilities.
 
Only 44% rural households in UP reported toilet coverage till October 2016 under the Swachh Bharat Abhiyan (Gramin), a central government programme to make India open defecation-free by October 2, 2019.
 
As many as 77% rural households practice open defecation (as against the national average of 55%), IndiaSpend reported on October 1, 2016.
 

 
Diarrhoeal diseases are the third largest cause of deaths among children under the age of five in India, according to this 2015 study by Indira Gandhi Medical College and Research Institute, Puducherry.
 
UP, with the highest under-five mortality rate of 78, also reported the highest prevalence (15%) of children suffering from diarrhoea prior to the survey.
 

Diarrhoeal diseases are also responsible for stunting in children (low height-for-age), according to this 2015 study by The institute of Fiscal Studies, a UK-based think tank.
 
“Growth failure (stunting), often associated with poor nutrition, is correlated, likely in a causal way, with lower educational and labour market attainments,” the study said.
 
(Salve is an analyst with IndiaSpend.)

Courtesy: India Spend
 

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Stunting, wasting and underweight together determine malnutrition among children. Malnutrition, which has long-term consequences on sensory, cognitive, social and emotional development, has fallen, on average, across India from 42.4% to 29.4% over 19 years, to 37.9 million children under five.
 

Source: National Family Health Survey 4 and World Health Organisation; figures in %
 
In Sangli district, 23.3% of children under five are stunted, the same rate as in South Africa, while 21.3% are stunted in Mumbai’s suburban district, equivalent to Cabo Verde, a North east African nation that recently made it to middle-income ranks, according to 2014 World Health Organization (WHO) data.
 

Source: National Family Health Survey 4 and World Health Organisation; figures in %
 
The tribal district of Gadchiroli (22.2%) and Chandrapur (16.1%) report wasting among children under five equivalent to conflict-ridden countries, such as South Sudan and Sudan.
 
At the other end of the scale are some cities, such as Kolhapur, where 5.9% of children under five are wasted, similar to relatively prosperous Bhutan.
 

 
(Salve is an analyst with IndiaSpend.)

This article was first published on India Spend
 

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The rail ministry said NO to a question in the Lok Sabha on May 4, 2016, when asked whether it is India’s largest employer of manual scavengers–sanitation workers who clear human excreta, a banned practice–disguised as sweepers.
 
The railways said they used floor scrubbers and vacuum cleaners within trains, and high-pressure water jets in most rail depots where Rajdhani, Shatabdi, Duronto, mail/express and passenger trains originate. Other employers of manual scavengers–almost all Dalits, lowest of Hindu castes–include the army and urban municipalities; like the railways, these organisations also hire them on contract so that they do not appear on their rolls. One Gujarat region has now ordered an inquiry after such contract workers were found cleaning sewers without protective equipment.
 
The Indian Railways are the largest employer of manual scavengers, with an unknown number on their rolls, IndiaSpend reported in November 2015. Most “sweepers”–as they are called to mask their identity as scavengers–with the railways are employed through contractors, and they earn around Rs 200 per day, we reported.

 
As many as 12,226 manual scavengers were identified across India–82% of these are in Uttar Pradesh–according to a reply to the Rajya Sabha (Parliament’s upper house) on May 5, 2016, by Minister of State for Social Justice Vijay Sampla. These are clearly under-stated official figures. Gujarat, for instance, admits to having no more than two manual scavengers, according to government data.

Source: Lok Sabha
 
Yet, as we reported in May 2016 in collaboration with Video Volunteers, a global initiative that provides disadvantaged communities with story and data-gathering skills, in one Gujarat town Dalits were at work in the sewers.
 

 
The video shows how Umesh, 23, a young man belonging to the Valmiki caste, cleans sewers in the town of Dhrangadhra without protective gears and cleaning equipment, a non-bailable offence under the Prohibition of Employment of Manual Scavengers and their Rehabilitation Act (2013).
 
Dhrangadhra chief executive officer Charu Mori denied the existence of manual scavenging at the time. “These workers are not our responsibility since they are hired by a contractor,” she said. “I am well-aware that such actions are illegal and thus the municipality does not engage any manual scavengers.”
 
After launching an online petition, Video Volunteers compelled the government into action.
 
The District Collector (DC) of Surendranagar, which covers Dhrangadhra, was scheduled to meet with the CEOs of seven municipalities in the district to investigate manual scavenging in the region. The meeting was twice postponed and is currently scheduled for 29 August, 2016.
 
The issue was brought to the notice of the DC by Video Volunteers on August 1, 2016, when it submitted the video, along with a protest petition signed by 20,000 people, demanding action against Dhrangadhra municipality for violating the law.
 
There are 167,487 households that get employment by manual scavenging in rural areas, according to data released by a 2011 government socio-economic survey.
 

Source: Lok Sabha
 
(Salve is an analyst with IndiaSpend.)

This article was first published on IndiaSpend.com
 

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Every day, 15 Indians are traded against their will to be, among other things, sexual slaves or forced labour, but a draft law to prevent India’s growing tide of human trafficking–cases rose 60% over four  years to 2014, the last year for which data are available–is being criticised for six reasons.
 
It is clear that existing laws under four acts are failing. From a decadal perspective, the trafficking of minor girls surged 14 times over the decade ending 2014: Girls and women comprised 76% of human-trafficking cases that year. Human trafficking in India for sexual slavery has grown in concert with economic growth, IndiaSpend reported in April 2016.
 
To address these failures and create a one-stop law to address diverse facets of human trafficking–sexual slavery, begging, forced labour  and organ trafficking–a draft bill called Trafficking of Persons (Prevention, Protection and Rehabilitation) Bill, 2016, will be introduced in the next session of the  Parliament by the Ministry of Women and Child Development, and it comes up short on these counts:
 

1. The draft bill has not clearly defined trafficking, whether it would include those taken for organ harvesting or forced labour.
2. The draft bill does not talk about modes of rehabilitation and who will be responsible.
3. The draft bill does not refer to the cross-border repatriation of victims from Bangladesh, Nepal and other countries.
4. It is not clear how the government intends to set up the Organised Crimes Investigation Agency, as ordered by the Supreme Court, to investigate trafficking.
5. The draft bill talks about a special investigative agency, but its structure, composition, powers and function are unclear.
6. The draft bill talks of an Anti-Trafficking Fund, but it is not clear what the money will be used for. There is no mention of compensation to victims.

The bill is being introduced “to prevent trafficking of persons and to provide protection and rehabilitation to the victims of trafficking and to create a legal, economic, and social environment against trafficking of persons and for matters connected therewith or incidental thereto”.
 
As many as 5,486 cases–or, as we said, 15 cases every day–of human trafficking were reported in 2014, according to this National Crime Records Bureau (NCRB) report.  

Source: National Crime Records Bureau, 2014
 
Human-trafficking cases rose from 3,422 to 5,486 between 2010 and 2014, according to NCRB data, a 60% increase.
 
Only 23% of human-trafficking cases led to convictions over the past five years. As many as 45,375 people were arrested and 10,134 persons were convicted, with punishments ranging from fines to imprisonment, IndiaSpend reported in August 2015.

Source: National Crime Records Bureau, 2014
 
Most of the victims (3,351) were registered under “immoral trafficking”, a reference to sexual slavery, followed by “human trafficking” (2,605), including men and boys, forced to work at brick kilns and construction sites.
 
80% children rescued at risk of being trafficked again, criticism against new bill grows
 
Advocacies, such as Mumbai’s Rescue Foundation and Kolkata’s Sanjog, have formed a collective to express concerns about the bill, the main criticism against it centred on rehabilitation and prosecution.
 
Up to 80% children rescued remain at risk of being trafficked again, according to this 2015 Harvard University study. Most victims suffer from prolonged psychological disorders such as post-traumatic stress disorder (PSTD), depression and dysthymia (prolonged PTSD and depression).
 
More than 87% of victims tested positive for dysthymia after they were released from rehabilitation centres, said this 2010 study, Bring It All Back Home, by Sanjog.
 
“Most centres today have almost more than 100 girls and they provide for counsellors and not clinical psychologists who can help them deal with the trauma,”Roop Sen, co-founder of Sanjog India, told IndiaSpend.
 
The current system uses a “custodial approach”, where the victim’s opinion is not taken into consideration, said Sen. This needs to change to a “restorative approach” involving victims, particularly because 57% of girls rescued are adults, said the Sanjog study.
 
The primary reason for the low levels of conviction is the lack of funds and coordination between 232 anti-human-trafficking units (AHTUs) in different states, IndiaSpend reported in April 2016.
 
For instance, when investigation officers track traffickers across state boundaries, investigation and travel costs are reimbursed over a period of up to four years, a deterrent to many officers, said Sen.
 
The bill envisages a new agency to handle trafficking cases, but its jurisdiction and funding is unclear.
 
(Salve is an analyst with IndiaSpend.)

Courtesy: Indiaspend.com
 

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 * Of a target of 2.5 million household toilets in urban areas by March 2016, 24% (0.6 million) have been constructed.
 
* Of a target of 100,000 community and public toilet seats in urban areas by March 2016, 28% (28,948) have been constructed.
 
*Gujarat constructed 327,880 individual toilets until December 2015, more than any other state.
 
India’s ambitious toilet-construction programme–part of the Swachh Bharat (Clean India) mission to make India open-defecation free by 2019–is slipping, according to government data submitted to the Lok Sabha, the lower house of Parliament.
 
Another part of the Swachh Bharat Mission, to process urban garbage, is also failing its targets, as the second part of this series will detail.
 
Even if the toilet programme, started in September 2015, is brought on track, Indian cities and towns currently process no more than a third of the sewage generated by 377 million people, IndiaSpend reported in January 2016. The rest is randomly dumped in rivers, seas, lakes and wells, polluting three-fourths of India’s water bodies.
 
As many as 85 million people in urban India lack adequate sanitation, more than Germany’s population.
 
About 1.9 million toilets in urban areas are under construction, according to the government, but progress is slow.
 
Four of five states constructing most toilets governed by the BJP
 
Four of the five states that do best in toilet construction are governed by India’s ruling Bharatiya Janata Party (BJP).

Source: Lok Sabha
 
Gujarat constructed the most toilets until December 2015, with 327,880, followed by Madhya Pradesh. Andhra Pradesh, the only non-BJP state in the top five, comes in third.

Source: Lok Sabha
 
Some areas that are constructing toilets slowly, such as Delhi and Uttarakhand, may already have a high percentage of homes with toilets.
 
More Indians (households) use toilets in urban areas (81%) than in rural areas (43%), according to this Lok Sabha reply. Use varies, as some cities have better toilet facilities than others, although there are no reliable data.
 
As far as community toilet construction goes, Delhi tops the list, indicating a government effort to provide sanitation to slums, which is largely where such toilets are built.
 
Source: Lok Sabha

Source: Lok Sabha
 
Sewage systems are as important as toilet construction. India has 522 working sewage treatment plants, 62 of which are in Maharashtra, according to this Central Pollution Control Board report.
 
Only 36.8% wards in urban areas reported a proper liquid-waste disposal system for community and public toilets, according to the Swachhata Status report, released by the National Sample Survey Organization.
 
Delhi (86.8%), Gujarat (64.4%) and Tamil Nadu (62.6%) were among the states reporting a high percentage of wards with proper liquid-waste disposal systems for community and public toilets, the report said.
 
Maharashtra just announced it would clean its rivers by increasing investments in sewage treatment and solid-waste management. The government’s focus, thus far, has been on industrial effluents alone.
 
A Swachh Bharat cess, levied from November 2015, ramped up toilet construction nationwide, as IndiaSpend reported this week. Nearly 16 million toilets were constructed over two years (in rural areas), according to the government; 95 million need to be built over the next three to meet the government’s target of making India open-defecation free by 2019.
 
This is the first of a two-part series. Tomorrow: Swachch Bharat Mission Fails March 2016 Urban-Trash Targets
 
(Salve is an analyst with IndiaSpend.)
 
Courtesy: IndiaSpend

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