New data released by the National Sample Survey Office (NSSO) have once again underlined the abysmal state of sanitation in the country, particularly in rural India where two-thirds of the country lives.

Only 32% of rural households have their own toilets, according to the recently released results of a large-scale survey conducted by NSSO in 2012. An additional 9% have access to toilets although the access figure could be an overestimate. The results of the last census had also highlighted India’s gaping sanitation deficit. Census results showed that less than half of Indian households had a toilet at home; there were more households with a mobile phone than with a toilet.

The woefully inadequate progress in sanitation makes India an outlier even among developing countries. Of the estimated billion people who defecate in the open, more than half reside in India. Poor sanitation impairs the health of Indians, leading to high rates of malnutrition and productivity losses. India’s sanitation deficit leads to losses worth roughly 6% of India’s gross domestic product (GDP), according to World Bank estimates, by raising the disease burden in the country. Children are affected more than adults. The rampant spread of diseases inhibits children’s ability to absorb nutrients, stunting their growth.

It is well known that child malnutrition rates in India (and much of South Asia) exceed those of even sub-Saharan Africa. High levels of gender inequality in South Asia and poor health of women, which lead to a very high proportion of low birth weight babies, partly explains this phenomenon. Another key driver is India’s sanitation deficit.

As health economist Dean Spears argued (‘Coming up short in India’, 4 July 2013) in these pages a few months ago, a large part of India’s malnutrition burden is owing to the unhygienic environment in which children grow up. Poor sanitation and high population density act as a double whammy on Indian children, half of whom grow up stunted.

It is not a coincidence that states with the poorest levels of sanitation and highest levels of population density such as Bihar, Jharkhand and Madhya Pradesh also have the highest levels of child malnutrition in the country.

The unhygienic environment in which children have to grow up owes to India’s historic neglect of public health services. While the Indian state has been making interventions to ensure access to curative medical services, it has done precious little to provide preventive public health services to citizens even though such services are more cost-effective than medical services.

The absence of an effective public health network in a densely populated country like ours has resulted in an extraordinarily high disease burden. Water-borne diarrhoeal diseases alone result in annual deaths of about 200,000 children below four years of age in the country, according to a recent study published in the Lancet medical journal. While the poor pay the biggest price of an ineffective public health system in terms of increased health expenditure, reduced earnings and death, even the rich are not spared. Children of wealthy families suffer high levels of morbidity and although deaths are rare, stunting is common.

In a 2005 Economic and Political Weekly article, World Bank economist Monica Das Gupta traced the neglect of public health in India to the decisions of policymakers in post-independent India, who focused on disease-specific interventions rather than on an overarching public health network focused on prevention. India is one of the few Asian economies that did not invest in an integrated public health system involving food safety, water management, waste disposal, vector control, sanitation systems, health education and other health regulations. Partly as a result of that legacy, and partly because public health investments may be difficult to sell to an electorate that may value private goods (such as food grains) over public goods, India’s public health systems are in a shambles.

The long-running debate on high child malnutrition in the country over the past few years, which culminated in the food security Bill, represents another lost opportunity to put the issue of public health on the forefront. As this newspaper has argued earlier, providing additional food in a disease prone environment is unlikely to dent malnutrition rates much.

The only silver lining on the horizon is the growing political consensus on the importance of toilets. If political personalities as disparate as Jairam Ramesh and Narendra Modi have come to acknowledge the urgent need for providing toilets, that must be seen as a welcome development. Hopefully, the political consensus will add heft to a campaign for providing effective public health services. NSSO results show that centrally sponsored schemes such as the total sanitation campaign have only led to large leakages, without achieving much success in improving rural sanitation levels.

Will public health services improve with growing political consensus? Tell us at views@livemint.com

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