Payal Seth and Palakh Jain

NFHS-5 Data Can Help India Become a Truly Open Defecation Free Country

The data shows that it is essential to measure the success of sanitation interventions on adoption, rather than access as representative of the true state of the scenario.

India released the fifth round of the National Family Health Survey (NFHS-5) (2019-21) data on November 24, 2021. Given the independent, high quality, and national as well as sub-national representation of the sanitation data collected in this survey, one can assess the impact of the Swachh Bharat Mission (SBM) on India’s sanitation status and the validity of India’s open defecation free (ODF) status. To answer these, we refer to one indicator reported in the state factsheets: population living in households that use an improved sanitation facility.

In figure 1, we see that at the all-India level, there is remarkable progress in the use of improved sanitation facilities from 49% in NFHS-4 (2015-16) to 70% in NFHS-5 (2019-2021). Since the period between the two surveys coincides with the duration of the SBM (2014-2019), this improvement can be largely attributed to SBM. At the end of the SBM, based on the number of toilets built by the government, India was declared an ODF nation. This implied that all the households had access to toilets.

Figure 1: Percentage of population living in households that use improved sanitation in India.

However, NFHS-5 informs us that while many states are on the path of achieving the ODF status, India cannot yet be claimed as an ODF country. States and UTs like Ladakh, Bihar, Jharkhand and Odisha still have only 42-60% of the population living in households that use improved sanitation facilities. Similarly, besides Kerala and Lakshadweep, every state needs significant improvement in the use of toilets to reach ODF status. For the future, it is essential to measure the success of sanitation interventions on adoption, rather than access, because it represents the true state of sanitation across a country.

The figure also informs us that there is heterogenous progress and prevalence of rural and urban sanitation. Rural sanitation improved from 37% to 65%, while urban improved from 70% to 82% from NFHS-4 to NFHS-5. Rural India needs to bridge the gap of 35%, while urban India 18% to achieve ODF status. This differentiated progress calls for a differentiated approach to success.

Future national sanitation schemes need to address the challenge of stubborn social norms in rural India which lead to the preference for open defecation even in the presence of toilets. Hence, allocation of funds to programs like behaviour change communication (BCC), that can inform the communities about the harms of open defecation and benefits of toilets, will be necessary to upend the practice.

Also Read: Here’s Why India Is Struggling to Be Truly Open Defecation Free

The issues for urban sanitation are different. Here, the challenge is not the BCC aspect but managing the solid and liquid waste (SLW) generated from the higher use of toilets. India is the world’s third-largest generator of solid waste in the world and its management is riddled with sub-optimal collection and disposal as well as limited state funding. Unlike the rural areas, where a twin-pit (no sewage connection required) toilet is built under SBM, new toilets in urban areas need a connection to existing sewage systems. Better management of this system, along with the upgradation of the sewage system after every few decades will encourage more people to install and adopt toilets.

However, it is also important to interpret these statistics with caution. For example, respondents are asked to report the place where the household members usually defecate. The response of one member of the household is extrapolated to generate the sanitation practice of the household or the population living in the household. Given that the research has shown heterogeneity in the use of toilets – adults use it more than children, women more than men – the survey might systematically undermine the presence of open defecation in the nation. We call for a more comprehensive assessment of sanitation practices in the future.

India has a long way to go before achieving universal sanitation. NFHS-5 can play a vital role in reaching that target. NFHS-5 is government sourced, and representative at the district, state and national levels. This can help the authorities identify target locations for intervention. For instance, at the state-level much improvement is needed in Ladakh, Bihar, Jharkhand, Odisha and Manipur. At the district level, 411 out of 707 districts have more than 70% of the population living in households that are using an improved source of sanitation. Focusing rigorous application of sanitation programs in the remaining districts will be beneficial.

Similarly, rural areas will require a differentiated approach from urban areas. Recognition of these diverse challenges and the use of NFHS-5 data to precisely identify the places that need sanitation intervention will help India achieve the goal of becoming an ODF nation.

Payal Seth is an economics researcher at Tata-Cornell Institute, Cornell University and a PhD Scholar at Bennett University and Palakh Jain is an associate professor at Bennett University.

What NFHS-5 Tells Us About the Status of Child Nutrition in India

India isn’t making as much progress as it should have towards ‘ending all forms of malnutrition by 2030 for children under 5’.

The Union health ministry released the second phase of India’s fifth National Family Health Survey (NFHS-5), conducted in 2019-2021, on November 24. The data for the previous round, NFHS-4, was released in 2015.

NFHS-5 is the most comprehensive survey to date on the health and nutrition indicators of India’s men, women and children.

Since India has the most malnourished children in the world, it’s worth analysing what NFHS-5 has to say about India’s progress towards achieving UN Sustainable Development Goal (SDG) 2.2: “ending all forms of malnutrition by 2030 for children under 5”.

NFHS-5 is nationally and sub-nationally – at the state and district levels – representative, so its findings on children’s nutritional status can help policymakers identify critical areas where better policy can provide course correction.

Mortality rates

Infant and child mortality rates have improved since the previous round. The steepest fall has been recorded in the mortality rate of children under 5 – from 49.7 to 41.9 deaths per 1,000 live births.

Vaccination rates

Similarly, vaccination rates have improved since NFHS-4. The fraction of fully vaccinated children between the ages of 12 and 23 months has gone up from 62% to 76%, along with the rates of partial vaccination.

Interestingly, the fraction of children receiving most of their vaccines in public health facilities has also gone up, from 91% in NFHS-4 to 95% in NFHS-5, reflecting the improved coverage of the facilities.

Childhood diseases

‘Childhood diseases’ presents a more mixed picture. While the prevalence of diarrhoea in the two weeks preceding the survey dipped slightly in NFHS-5, the fraction of children receiving ORS and zinc for diarrhoea has gone up substantially.

Children’s access to healthcare services – when suffering from diarrhoea and symptoms of acute respiratory infection (ARI) – has remained almost the same since the previous survey. The latter is an important finding: despite COVID-19, the percentage of children suffering from ARI has not gone up.

Child-feeding practices

Children’s feeding practices have largely improved – except for the percentage of children younger than 3 years who were breastfed within an hour of birth, which remains unchanged from NFHS-4. The largest improvement is in the percentage of children who were exclusively breastfed when under six months – from 55% in NFHS-4 to 64% in NFHS-5.

Nutritional Status

The NFHS-5 data shows that the percentage of children who are stunted (low height-for-age), wasted (low weight-for-height) and underweight (low weight-for-age) has gone down. There is a slight increase in the percentage of severely wasted and overweight children.

The more alarming thing is the 8 percentage points’ rise in the fraction of children suffering from anaemia – from 59% in NFHS-4 to 67% in NFHS-5.

Also read: Does India Know Anaemia Is Running Amok in the Country?

Taken together, while there has been some progress, India isn’t making as much progress as it should have towards SDG 2.2 – since the percentage of stunted, wasted, underweight and anaemic children in India is 36%, 19%, 32% and 67%, respectively.

The advantage of NFHS-5 data is its quality, comprehensiveness, granularity and representativeness up to the district level. The data is collected by Government of India officials, following international protocols to ensure reliability, and as such encompasses the largest set of health and nutrition indicators for the Indian sub-population.

At this point, the government could identify districts that require urgent intervention. For starters, it could bin districts into three groups – green, yellow and green – for each indicator, and prioritise intervention for the ‘red’ districts first.

The government should also consider linking village, district, state and national level metrics to track improvements in children’s health. This will help India mount a unified and more efficient approach to eradicate child malnutrition by 2030.

Payal Seth is an economics researcher at the Tata-Cornell Institute, Cornell University, and a PhD scholar at Bennett University. Palakh Jain is an associate professor at Bennett University.

What Impacts Child Malnutrition in India and Why We Need to Be Aware of These Factors

India loses 4% of its GDP annually due to malnourishment and hence, the objective of economic development cannot be met without addressing the issue of child malnutrition.

India has achieved remarkable levels of economic growth, and yet, despite all the progress, it continues to host the highest number of malnourished children in the world.

Child malnutrition is classified as ‘undernutrition’ (inadequate consumption of calories) and ‘overnutrition’ (excess consumption of calories). Of these, undernutrition leads to low height-for-age or stunting. It is known as the most sinister form of child malnutrition because unlike the loss of weight, height cannot be readily gained back. Hence, it is an indicator of chronic childhood malnutrition, which can lead to irreversible mental and physical damage that is even transmitted to the next generation.

To understand the gravity of this problem, we note one-third of stunted children, globally, are Indian. The implication is that India loses 4% of its GDP (gross domestic product) annually, and hence the objective of economic development cannot be met without addressing the issue of child malnutrition.

The research suggests that tackling child malnutrition requires a multi-faceted approach, for example, improving the quantity and the quality of dietary intake, levels of sanitation, maternal health and education, access to social safety net programmes etc. Based on these important findings, the government had established programmes like Integrated Child Development Services (ICDS) that provides comprehensive health and nutrition services to children under six and pregnant and lactating mothers, mid-day meals to school-going children, Swachh Bharat Mission that is aimed to eliminate open defecation, among others programmes.

And yet, despite these measures, the NFHS-5 data revealed that child malnutrition in India is worsening (see figure 1). Thirteen out of the 22 states have witnessed a reversal in stunting outcomes. Experts have commented that this is due to a decline in budgetary allocation towards children’s health and nutrition schemes (here), while others suggest that it could be due to the slowdown in economic growth (here).

Also read: An Overlooked Strategy to Remedy Malnutrition

Given the rising burden of child malnutrition and budgetary concerns, there is substantial merit in understanding the relative importance of the factors impacting child malnutrition. This can help the policymakers redirect their focus on interventions that will yield the maximum benefits to child health.

Figure 1: Percentage of stunted children below age 5 in NFHS-5 (2019-20) and NFHS-4 (2015-16)

We use data from the NFHS-4 survey for almost 90,000 children below five. Further, we use NHFS-4 variables to construct ten groups that are used to explain the child malnutrition under UNICEF’s framework: age of the child (in months; from 0-5 years), gender, occurrence of infections, medicinal intake, birth characteristics (size and weight at birth), their food intake (breastfeeding and dietary diversity), child environment (open defecation level at the village, access to benefits from welfare schemes, improved drinking water, household size), mother’s characteristics (height, BMI, education, and age at marriage), her environment (access to benefits from ICDS centres during pregnancy, health insurance) and socio-economic controls (wealth, place of residence, etc.).

Our outcome variable is height-for-age z-scores (HAZ scores), i.e. the height gap of a child from the median child with the same age and gender. HAZ score below (above) zero means that the child is worse off (better off) than the median child (here).

To estimate the relative contribution of these ten towards the HAZ scores for our analysis, we use an econometric technique called the Shapley-Owen decomposition, which is useful to calculate the marginal contribution of variables, especially when all the variables are interlinked.

Also read: How Caste Discrimination Impacts Child Development and Stunting in India

After running the decomposition on ten groups, we find that the child’s HAZ scores, child’s age is the most important followed by mother characteristics (and within this group, mother’s height), and socio-economic controls. Our results are in line with the well-established finding in the literature that stunting happens in the first 24 months, and hence it holds the maximum contribution.

In a similar vein, it is unsurprising that the next most important variable is the mother’s height as genetics always had an important role in determining heights. This leads us to recommend that additional efforts should be expended to provide adequate nutrition to children from conception till two years (i.e. the first 1,000 days of life). Next, prioritising the nutritional needs of girls among these children will help India break the pattern of inter-generational transfer of stunting, as mothers who faced stunting in childhood are shown to have under-developed uteruses, which leads to the reproduction of stunted children.

Figure 2: Relative contribution of the determinants of child malnutrition towards children’s height-for-age z-scores

While ICDS’s POSHAN Abhiyaan mentions the importance of adequate nutritional intake during the first 1,000 days of the child’s life, the programme, much like other welfare schemes for children and women, have been receiving budgetary cuts for the past few years. This issue has been raised by noted economists, and our findings also provide rigorous evidence to support the call for enhancing the budgetary allocation for programmes like ICDS which are responsible for providing requisite antenatal healthcare to the mothers and optimal quantity and quality of diets to the children.

Similarly, our analysis also echoes the recommendation of economists who have attributed the rise in child malnutrition to the slowdown in economic growth in recent years. Socio-economic controls are the third most important determinant of HAZ scores. It represents the ability of the household to access diets that are optimal in calories and nutrition, healthcare and general living conditions, all of which, jointly determines children’s health. Therefore, while the supplementary nutrition programmes should be strengthened, their impact on the child health outcomes will be most effective when India is also witnessing a faster economic growth.

Payal Seth is a consultant at Tata-Cornell Institute, Cornell University and a research scholar at Bennett University. Palakh Jain is an Associate Professor at Bennett University.

In Addressing Sanitation Woes, India Needs Separate Approaches for Rural, Urban Areas

In order to end open defecation by 2030, and thereby achieve the UN’s Sustainable Development Goal of 100% access to adequate and equitable sanitation, India needs to consider separately its urban and rural realities.

India has made remarkable progress on several economic fronts since independence in 1947. While the data suggests that there has been a significant rise in literacy, per capita income and life expectancy, India still hosts the highest number of malnourished children in the world. Recent research has established that water and sanitation issues are the most crucial determinants of child health.

While the national sanitation campaigns have been launched since the 1980s with the goal of increasing sanitation coverage, the United Nations’ Sustainable Development Goal (SDG) 6.2 of achieving 100% access to adequate and equitable sanitation, and ending open defecation by 2030, remains elusive. This trend is exhibited in the recently released government’s NFHS-5 data.

No surveyed state has achieved 100% use of adequate sanitation (see figure 1). Ladakh and Bihar have to achieve more than 50 percentage points use to reach the SDG 6.2 goal, whereas other states have to increase adequate sanitation use by 10-35 percentage points. Mizoram, Kerala and Lakshadweep are the only three states close to achieving the target of 100% by 2030.

Also read: Claiming That Rural India is ‘Open Defecation Free’ Is Blatant Exaggeration

We now ask an important question: what could be done over the next decade to ensure that India achieves SDG 6.2? The first step would be recognising that nearly 65% of India’s population lives in rural areas, and this implies combatting different sanitation challenges for rural and urban India.

We explore these distinct challenges and the root cause behind the existence of such differences. A deeper recognition and understanding of the rural and urban sanitation challenges will help the Indian policymakers restructure future national sanitation policies distinctly for each area. This can help India achieve the SDG 6.2 target.

Figure 1: Percentage of population living in households that use improved sanitation in India.

Differentiated progress in rural and urban sanitation

Before we delve into specific rural and urban challenges, it is important to understand the sanitation differences (if any) between the two.

NFHS-5 reported significant differences in the proportion of households using adequate sanitation between the rural and the urban areas in states across India. Ladakh had the highest gap within the two regions as the proportion of households in the rural areas had almost 40% lower use of toilets than the households in the urban areas. The highest disparity in Ladakh was followed by Gujarat, Bihar, Andhra Pradesh, Karnataka and so on (see figure 2).

Rural sanitation has lagged behind urban sanitation in almost all states for decades. The only exceptions are north-eastern states like Meghalaya, Sikkim, Manipur and Nagaland, which exhibit an opposite trend as rural households have higher use of sanitation facilities than their urban counterparts.

Figure 2: Percentage of population living in rural and urban households that use improved sanitation in India.

Differences in rural and urban sanitation issues

At the launch of the Swachh Bharath Mission (SBM) in 2014, the most important challenge in rural areas was to overcome the problem of open defecation by increasing households’ access to toilets. Eventually, it was found that these toilets were unused because there was a preference for open defecation (OD), i.e., people preferred to practice OD despite the access to toilets. This preference was driven by the low quality of toilets, social norms and the general belief that OD is healthier than toilets.

Hence, to enhance the adoption of these toilets, SBM rural also allocated funds for information, education and communication (IEC) activities which would induce behavioural change among the rural population. It is important to note that the toilets built under SBM rural were pit latrines, i.e., the household did not need to be connected with a sewage system.

The issues become complex as we discuss urban areas as the most prominent sanitation challenge in urban areas is managing solid and liquid waste (SLW). India is the third-largest generator of solid waste in the world (next to the US and China). Of this, only 70% is collected, and 80% of this collected waste is simply dumped in the landfills. The untreated waste seeps into land, water or is burned – leading to air, water and land pollution. The task of managing the collection and transportation of solid waste falls under the state municipalities. This strains the already limited state funding, deterring the acquisition of new landfills and investment in innovative technology for better SLW management.

Similarly, the management of liquid waste (think fecal sludge) is under the combined authority of the state’s public health departments and municipalities. Unlike the rural areas, it is not possible to build in-house pits for every urban household due to the scarce land and rising population. Hence, the construction of new toilets under SBM has to be followed by building or connecting these toilets to an existing underground sewage system. To avoid the excessive burden, an upgradation of such systems is recommended every few decades.

Why do these differences exist?

The divergence in the sanitation challenges arises due to multiple reasons. Historically, urban areas always have had higher access to sanitation facilities than rural areas. This led to a higher number of people using these facilities in the urban than the rural areas. Hence using toilets in urban areas eventually evolved as a social norm. However, given the historically limited access to toilets in rural areas, open defecation became the prevailing norm.

Also read: Declaring India ‘Open Defecation Free’ Doesn’t Mean Sanitation Goals Have Been Met

What has triggered this traditional establishment of social norms in the two areas? The important complementarities between water and sanitation suggest that it is easier to access piped water in urban areas. Flushing requires nearly 0.5 to 1 bucket of water. While this process becomes easier when the toilets are connected to the piped water (as is the case in urban areas), OD is easier to practice in rural areas. OD requires a mug of water and saves the rural households the toiling task of filling and carrying buckets of water from a central place in the village to their homes.

To summarise, while the rural areas face the challenge of pervasive OD, the urban areas have to cope with the rising solid and liquid waste. Both areas require different sanitation solutions as well: behaviour change communication to make the community aware of the ills of OD for the former, while better management of generated solid waste and fecal sludge in the urban areas.

Besides behaviour change, exploring innovative cost-effective waterless sanitation technologies will also prove beneficial for the rural areas as it will save them from the hassle of worrying about the water aspect of sanitation.

Although India has a long way to go before universal sanitation is achieved in both the rural and urban areas, recognition of the disparate challenges faced by both regions will play an instrumental role in making India an open defecation-free country.

Payal Seth is a consultant at Tata-Cornell Institute, Cornell University and a Ph.D. Scholar at Bennett University. Palakh Jain is an Assistant Professor at Bennett University.