Health and environmental sanitation in India: Issues for prioritizing control strategies.

Environmental sanitation is a major public health issue in India. Recent interventional studies on environmental sanitation in India highlighted the importance of prioritizing control strategies. Research related to the appropriate cost-effective intervention strategies and their implementation in Indian context is a big challenge. This paper discusses various intervention strategies related to environmental sanitation in India and emphasizes to prioritize it according to the need of country.

INTRODUCTION

Environmental sanitation envisages promotion of health of the community by providing clean environment and breaking the cycle of disease. It depends on various factors that include hygiene status of the people, types of resources available, innovative and appropriate technologies according to the requirement of the community, socioeconomic development of the country, cultural factors related to environmental sanitation, political commitment, capacity building of the concerned sectors, social factors including behavioral pattern of the community, legislative measures adopted, and others. India is still lagging far behind many countries in the field of environmental sanitation.[1] The unsanitary conditions are appalling in India and need a great sanitary awakening similar to what took place in London in the mid-19th century.[2] Improvement in sanitation requires newer strategies and targeted interventions with follow-up evaluation.[3] The need of the hour is to identify the existing system of environmental sanitation with respect to its structure and functioning and to prioritize the control strategies according to the need of the country. These priorities are particularly important because of issue of water constraints, environment-related health problems, rapid population growth, inequitable distribution of water resources, issues related to administrative problems, urbanization and industrialization, migration of population, and rapid economic growth.

PRESENT SCENARIO

As per estimates, inadequate sanitation cost India almost $54 billion or 6.4% of the country's GDP in 2006. Over 70% of this economic impact or about $38.5 billion was health-related, with diarrhea followed by acute lower respiratory infections accounting for 12% of the health-related impacts.[4] Evidence suggests that all water and sanitation improvements are cost-beneficial in all developing world subregions.[5]

Sectoral demands for water are growing rapidly in India owing mainly to urbanization and it is estimated that by 2025, more than 50% of the country's population will live in cities and towns. Population increase, rising incomes, and industrial growth are also responsible for this dramatic shift. National Urban Sanitation Policy 2008 was the recent development in order to rapidly promote sanitation in urban areas of the country. India's Ministry of Urban Development commissioned the survey as part of its National Urban Sanitation Policy in November 2008.[6] In rural areas, local government institutions in charge of operating and maintaining the infrastructure are seen as weak and lack the financial resources to carry out their functions. In addition, no major city in India is known to have a continuous water supply and an estimated 72% of Indians still lack access to improved sanitation facilities.

INTERVENTION STRATEGIES

A number of innovative approaches to improve water supply and sanitation have been tested in India, in particular in the early 2000s. These include demand-driven approaches in rural water supply since 1999, community-led total sanitation, public–private partnerships to improve the continuity of urban water supply in Karnataka, and the use of microcredit to women in order to improve access to water.[7]

Total sanitation campaign gives strong emphasis on Information, Education, and Communication (IEC), capacity building and hygiene education for effective behavior change with involvement of panchayati raj institutions (PRIs), community-based organizations and nongovernmental organizations (NGOs), etc. The key intervention areas are individual household latrines (IHHL), school sanitation and hygiene education (SSHE), community sanitary complex, Anganwadi toilets supported by Rural Sanitary Marts (RSMs), and production centers (PCs). The main goal of the government of India (GOI) is to eradicate the practice of open defecation by 2010. To give fillip to this endeavor, GOI has launched Nirmal Gram Puraskar to recognize the efforts in terms of cash awards for fully covered PRIs and those individuals and institutions who have contributed significantly in ensuring full sanitation coverage in their area of operation. The project is being implemented in rural areas taking district as a unit of implementation.[8]

A recent study highlighted that policy shift to include better household water quality management to complement the continuing expansion of coverage and upgrading of services would appear to be a cost-effective health intervention in many developing countries.[9] Most of the interventions (including multiple interventions, hygiene, and water quality) were found to significantly reduce the levels of diarrheal illness, with the greatest impact being seen for hygiene and household treatment interventions.[10] Interventions to improve water quality at the household level are more effective than those at the source.[11] Unfortunately, in developing countries, public health concerns are usually raised on the institutional setting, such as municipal services, hospitals, and environmental sanitation. There is a reluctance to acknowledge the home as a setting of equal importance along with the public institutions in the chain of disease transmission in the community. Managers of home hygiene and community hygiene must act in unison to optimize return from efforts to promote public health.[12] A survey through in-depth interviews with more than 800 households in the city of Hyderabad in India concluded that, even if provided with market (not concessional) rates of financing, a substantial proportion of poor households would invest in water and sewer network connections.[13]

The role of the WHO Guidelines for Drinking Water Quality emphasizes an integrated approach to water quality assessment and management from source to consumer. It emphasizes on quality protection and prevention of contamination and advises to be proactive and participatory, and address the needs of those in developing countries who have no access to piped community water supplies. The guidelines emphasize the maintenance of microbial quality to prevent waterborne infectious disease as an essential goal. In addition, they address protection from chemical toxicants and other contaminants of public health concern.[14]

When sanitation conditions are poor, water quality improvements may have minimal impact regardless of amount of water contamination. If each transmission pathway alone is sufficient to maintain diarrheal disease, single-pathway interventions will have minimal benefit, and ultimately an intervention will be successful only if all sufficient pathways are eliminated. However, when one pathway is critical to maintaining the disease, public health efforts should focus on this critical pathway.[6] The positive impact of improved water quality is greatest for families living under good sanitary conditions, with the effect statistically significant when sanitation is measured at the community level but not significant when sanitation is measured at the household level. Improving drinking water quality would have no effect in neighborhoods with very poor environmental sanitation; however, in areas with better community sanitation, reducing the concentration of fecal coliforms by two orders of magnitude would lead to a 40% reduction in diarrhea. Providing private excreta disposal would be expected to reduce diarrhea by 42%, while eliminating excreta around the house would lead to a 30% reduction in diarrhea. The findings suggest that improvements in both water supply and sanitation are necessary if infant health in developing countries is to be improved. They also imply that it is not epidemiologic but behavioral, institutional, and economic factors that should correctly determine the priority of interventions.[7] Another study highlighted that water quality interventions to the point-of-use water treatment were found to be more effective than previously thought, and multiple interventions (consisting of combined water, sanitation, and hygiene measures) were not more effective than interventions with a single focus.[15] Studies have shown that hand washing can reduce diarrhea episodes by about 30%. This significant reduction is comparable to the effect of providing clean water in low-income areas.[16]

Lack of safe water supply, poor environmental sanitation, improper disposal of human excreta, and poor personal hygiene help to perpetuate and spread diarrheal diseases in India. Since diarrheal diseases are caused by 20–25 pathogens, vaccination, though an attractive disease prevention strategy, is not feasible. However, as the majority of childhood diarrheas are caused by Vibrio cholerae, Shigellae dysenteriae type 1, rotavirus, and enterotoxigenic Escherichia coli which have a high morbidity and mortality, vaccines against these organisms are essential for the control of epidemics. A strong political will with appropriate budgetary allocation is essential for the control of childhood diarrheal diseases in India.[17]

COMMUNITY-BASED MANAGEMENT APPROACH

National water policies are shifting to community-based management approach because local authorities are in daily contact with users, of whom about 50% are women. Historically, national policy shifted from attention to distribution of investments in the water sector to reorganization of water agencies and to building up the capacity of private or voluntary agencies. The local context allows for more efficient and effective responses to local conditions. Local institutions and groups are better equipped to solicit local participation. Local water resource planning is very important in strengthening the economic and individual capacity of poor people in underdeveloped areas. Experience in Mahesana, Banaskantha, and Sabarkantha in Gujarat state supports this lesson learned. One of the obstacles in Gujarat to water resource development is identified as increased demand for public water services and inadequate provision of services due to remoteness of the area and financial limitations of central agencies. Infrastructure is also poorly maintained.[18]

Providing private excreta disposal would be expected to reduce diarrhea by 42%, while eliminating excreta around the house would lead to a 30% reduction in diarrhea. The findings suggest that improvements in both water supply and sanitation are necessary if infant health in developing countries is to be improved. They also imply that it is not epidemiologic but behavioral, institutional, and economic factors that should correctly determine the priority of interventions.[19]

Morbidity and mortality due to waterborne diseases have not declined commensurate with increase in availability of potable water supply. More importantly, young children bear a huge part of the burden of disease resulting from the lack of hygiene. India still loses between 0.4 and 0.5 million children under 5 years due to diarrhea. While infant mortality and under 5 mortality rates have declined over the years for the country as a whole, in many states, these have stagnated in recent years. One of the reasons is the failure to make significant headway in improving personal and home hygiene, especially in the care of young children and the conditions surrounding birth.

OTHER DEVELOPMENTS

The agriculture sector accounts for between 90 and 95% of surface and ground water in India, while industry and the domestic sector account for the remaining. At the same time, several important measures are being taken to deal with the above issues. On the water resources management front, the National Water Policy, 2002 recognizes the need for well-developed information systems at the national and state levels, places strong emphasis on nonconventional methods for utilization such as interbasin transfers, artificial recharge, desalination of brackish or sea water, as well as traditional water conservation practices such as rainwater harvesting, etc., to increase utilizable water resources. It also advocates watershed management through extensive soil conservation, catchment area treatment, preservation of forests, and increasing forest cover and the construction of check dams. The policy also recognizes the potential need to reorganize and reorient institutional arrangements for the sector and emphasizes the need to maintain existing infrastructure.

While no comprehensive study on equity issues relating to water supply, sanitation, and health has been conducted for the country as a whole, common equity issues that plague the sector in most developing countries also hold true for India. In addition, comprehensive studies on the economic value of the water and sanitation sector in India also do not exist.

It is important to reiterate the need for Rural Water Supply and Sanitation [RWSS] and Urban Water Supply and Sanitation [UWSS] agencies to operate hand-in-hand with their health and education counterparts to jointly monitor indicators of RWSS, UWSS, health, education, poverty, and equity in order to make significant headway in the respective sectors. Existing health promotion and education programmes should be made more effective and geared toward achieving behavior changes needed to improve hygiene.[20]

URBAN SANITATION

Percent of urban population without proper sanitation in India is 63%. The 11th five year plan envisages 100% coverage of urban water, urban sewerage, and rural sanitation by 2012. Although investment in water supply and sanitation is likely to see a jump of 221% in the 11th plan over the 10th plan, the targets do not take into account both the quality of water being provided, or the sustainability of systems being put in place.[21] Increasing emphasis on use of information technology applications in urban governance and management to ensure quick access to information, planning, and decision support systems are the primary concern areas related to environmental sanitation. Solid waste management is also increasingly seen as an important area in UWSS. Legislation on municipal waste handling and management has been passed in October 2000. Some strategies on solid waste management include preparation of town-wise master plans, training of municipal staff, IEC and awareness generation, involvement of community-based and nongovernmental organizations, setting up and operation of compost plants via NGOs and the private sector, enhancement of the capacities of some state structures such as State Compost Development Corporations with emphasis on commercial operations and private sector involvement. Variations in housing type, density and settlement layout, poverty status, and access to networked services will lead to different solutions for sanitation in different parts of the city or within the same neighborhood.[22]

Challenges

Prevention of contamination of water in distribution systems,

Growing water scarcity and the potential for water reuse and conservation,

Implementing innovative low-cost sanitation system

Providing sustainable water supplies and sanitation for urban and semiurban areas

Reducing disparities within the regions in the country

Sustainability of water and sanitation services.

The public health challenge inherent in meeting the MDG targets is ensuring that improvements result in access to water and sanitation for the critical at-risk populations. Innovative approaches are required to ensure the availability of low-cost, simple, and locally acceptable water and sanitation interventions and integrating these approaches into existing social institutions such as schools, markets, and health facilities.[4]

CONCLUSION

Implementation of low-cost sanitation system with lower subsidies, greater household involvement, range of technology choices, options for sanitary complexes for women, rural drainage systems, IEC and awareness building, involvement of NGOs and local groups, availability of finance, human resource development, and emphasis on school sanitation are the important areas to be considered. Also appropriate forms of private participation and public private partnerships, evolution of a sound sector policy in Indian context, and emphasis on sustainability with political commitment are prerequisites to bring the change.