Swachh India review: Knowledge to policy

An on-field study in three States gives the government crucial data on nutrition, water and sanitation needs

This far-reaching field study evaluates one of India’s most substantial policy commitments, the National Rural Health Mission (NRHM), to arrive at telling and cautionary conclusions. The NRHM identifies 18 States as having weak public health indicators and health infrastructure; the major determinants here are nutrition, water, and sanitation. The mission, furthermore, requires State-level departments dealing with water and sanitation to promote local community involvement.

The research team, based at the Centre for Economic and Social Studies, Hyderabad, completed the work in 12 months in 2015-16, studying Madhya Pradesh, Odisha and Andhra Pradesh. The authors acknowledge Ministry of Health and Family Welfare funding and support from the Ministry’s National Health Systems Resource Centre.

Comprehensive study

This is high-quality empirical social science; the research is meticulous and the book is easy to use. The tables provide a wealth of information; many also give chi-square test results and the corresponding significance levels. In addition, dozens of fieldwork photographs are reproduced.

The authors start with a wide literature review, including research from Peru and Somalia among other countries, and note issues like the commodification of water. In each of the three chosen States, they cover direct health interventions on drinking water and sanitation, the processes whereby different institutions interact over NRHM goals, and the outcomes for individuals’ health and for community processes.

The first hypothesis is that in open defecation-free (ODF) villages, functioning local bodies and their interactions with Panchayati Raj institutions (PRIs) are better than they are in non-ODF villages. The second is that the availability of protected water and sanitation may significantly impact household morbidity and the incidence of epidemics at the community level.

The sampling could be a textbook example. The multi-stage selection starts with two high-focus NRHM States, Madhya Pradesh and Odisha, and one non-high-focus state, Andhra Pradesh. In each selected State, the same method is applied to districts, blocks or mandals, and villages; in the study, 36 villages and 720 households figure, with one third of the villages being certified Nirmal Grams, where all houses, schools, and anganwadis or mother-and-child centres have access to sanitary toilets and all residents know the importance of personal and community hygiene, and of clean public spaces. The sampling frame also required each household to have a child up to the age of five, and included village size, location, class and caste profile, and the availability and quality of water and sanitation facilities.

As for the findings, Nirmal Gram (NGP) villages are better only on certain indices, from infrastructure through water quality and availability to residents’ awareness of the Village Water and Sanitation Committees and Village Health and Sanitation Committees, and other local interactions. Yet several practices, such as throwing small children’s faeces into the road, are common to both categories of villages.

Class issues

Clear class divisions emerge across all villages, with poorer residents often unaware of the dangers of not washing fruit or vegetables before cooking or eating them; in addition, the poorest have to use sand or ash to clean their hands after defecation, as they have almost no easy access to clean water. All respondents, however, had at least one bath a day, though the care of drinking-water vessels varied by social class, as did water supply and water treatment before consumption.

Some of the figures are shocking. In Madhya Pradesh, only 13 of the 239 respondents were female, of whom only three were literate; in Odisha, the corresponding figures were 30 and 240, with 27 women being literate; in Andhra Pradesh, 25 of 244 respondents were female, of whom 24 were literate.

Moreover, on certain health indices, the NGP villages are not much better than the non-NGP ones, despite evidence of official neglect in the latter. The authors conclude that the relevant similarities imply political factors in the selection of villages for NGP certification; they recommend far greater procedural transparency.

Surprisingly, literacy is not correlated with defecation practices, partly because indoor or outdoor toilets are often poorly built, and drain badly or flood quickly. Irrespective of NGP status, open defecation is practised by 41% of the sample in Madhya Pradesh, 68% in Odisha, and 43% in Andhra Pradesh. India has almost no chance even of significantly reducing the practice by the 2020 elimination target date. Other research also shows that defective sewage systems cause faecal contamination of the groundwater around dwellings.

The systems for policy implementation are, as always, decisive. Although the required committees are better known in NGP villages than in non-NGP ones, minutes are rarely taken or circulated; themselves underfunded, the committees often do little more than spray their villages with bleaching powder.

Two models

The authors’ recommendations arise directly from their findings, and they conclude that developing local institutional capacity is a clear imperative. They cite two outstanding Telangana models, Hajipally and Gangadevipally, and the obvious implication is that if policy does not give citizens knowledge of institutions and procedures, it will fail. Many governments today consider health policy as being solely a matter of illness episodes, but the authors of this study are to be congratulated.

Swachh India; K.S. Babu et al., Academic Foundation, ₹1,095.

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Printable version | Feb 29, 2020 10:48:38 AM |

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