Policies to Strengthen the Sanitation System

This report discusses policies to strengthen the sanitation system in developing countries, with a focus on India. It explores the factors shaping health policy and system development, implications for health, and potential policy options. The report provides a detailed description and critical analysis of the National Urban Sanitation Policy and the National Water Supply and Sanitation Program. It also highlights the drawbacks of these policies and the challenges faced in their implementation.

Running head: POLICIES TO STRENGTHEN THE SANITATION SYSTEM
Policies to Strengthen the Sanitation System
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Poster (refer to the poster)
1. Factors shaping the health policy and system development
The development of policies is crucial to meet growing healthcare needs within the
developing countries. The policies play a critical role in removing health inequalities which
are rampant within the current healthcare sector of the developing countries. The policies are
pivotal to reducing the chances of errors within the current healthcare system. Additionally,
the policies ensure that fast and quick delivery of healthcare services is provided. Some of the
factors which are effective in supporting effective policy engagement are: a supportive
environment, dependence on governance and financing, strong links to policy makers.
In this respect, the supportive environment refers to adequate amount of resources
and relevant infrastructural support which are necessary for the effective implementation of
policies within healthcare sector (1). The amount of funds received from government and
federal government agencies plays a crucial role in policy development. Here, it has been
seen that strong links to policy makers can also help in the implementation and incorporation
of policies within the health scenario (2). The evidence based and informed decision making
can play an effective role in policy implementation, as it helps in keeping up to date with
changing needs of the target population (5).
2. Implications for particular aspect of health
The particular aspect of health which has been taken into consideration over here is
poor sanitation within developing countries. The focus country which had been taken into
consideration over here is India. The present condition of sanitation has resulted in an
alarming situation as much of it has been associated with poor physical and mental health of

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people. In this respect, poor sanitation and open defecation have resulted in much of spread
of diseases. It has been seen that out of the 1.2 billion people living in the country 802 lack
any form of sanitation services (4). Some of the most common health related issues are
typhoid and diarrhoea which mainly spreads through inadequate hygiene. The disease burden
has led to malnutrition within people, particularly targeting the growing up children (3).
The implementation of the healthcare policies can reduce the services gaps within
healthcare. It can alongside ensure that equal access to healthcare services are provided to
each and every individual. It has been seen that close personal contacts with policy makers
can help in reducing the implementation gaps (7).
3. Potential policy options addressing health system issue
The current issue of poor sanitation within the developing countries could be
addressed through a number of policies. Some of the notable policies addressing the issue of
poor sanitation are National Urban Sanitation Policy (NUSP), National Water Policy (NWP),
National Rural Health Mission (NRHM), Central Rural Sanitation Programme (CRSP),
National Water Supply and Sanitation Programme (NWSP). These have been implemented to
reduce the health inequalities and disease burden arising due to poor sanitation as a whole.
National Urban Sanitation Policy (NUSP)
 Established a broad enabling environment for urban sanitation
 Different components of the National Urban Sanitation Policy include awareness
generation, institutional roles, knowledge development, capacity building, financing
and national monitoring and evaluation
 Policy aims to remove the practices of manual scavenging

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 Drawbacks- absence of funding system, lack of effective communication between
different channels and networks the policies, higher rate of population growth, lack of
social mobilisation
National Water Supply and Sanitation Programme
 Major focus on building and use of toilets, safe disposal of child faeces, washing of
hands with soap after defecation, safe storage and handling of drinking water Goal of achieving health for all
 Drawbacks include limited water resources, ground water depletion, water pollution,
inadequate price incentives and inter-sectoral imbalances
 Agencies have substantial resources when speaking in terms of information and data,
trained personnel and research capability
 Non-government sector has potential to have phenomenal outreach to communities
and deliver government programmes Strengthening of community management is possible

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Report
Sanitation: the major health issue
India is the second most populated country with an ever-raising human population of
1.34 billion as of 2018 (5). Almost about 69% people of India reside in the rural areas (2).
Development of the country depends greatly on the development of the basic needs of its
people. Not only the rural development but also the development of the urban areas is
indispensable part of growth of the country. Human resource development works with the
aim of improving the health, education, nutrition and sanitation conditions which are essential
parts of the basic requirements of the population. Out of all these, the major challenges are
faced in the sector of sanitation. Sanitation is considered as the proper management of the
wastes and through appropriate disposal of garbage and wastewater, maintenance of a proper
hygienic condition can be achieved. Lack of adequate sanitation is a major health issue in
India. More than half of the population do not have access to a proper sanitation and are
forced to defecate openly which leads to several diseases that can affect the health of the
people greatly and result in many harmful infections and diseases. Unavailability of safe and
usable water, proper sanitation and lack of hygiene maintenance results in infectious
diarrhoea and many other infectious and parasitic diseases. According to World Health
Organization (WHO), 90% child mortality in developing nations such as India is due to
infectious diseases combined with malnutrition (20). The practice of open defecation is a
majorly pressing issue for the spread of contaminating diseases. Multiple policies have been
undertaken to improve the poor condition of sanitation in India. The following discussion is
about the policies that are implemented to strengthen the sanitation system of the country.

5POLICIES TO STRENGTHEN THE SANITATION SYSTEM
Policies to Strengthen the Sanitation System
Various sanitation programmes are implemented in India to address the key issues
regarding the proper maintenance of the health and hygiene of people. Issues such as lack of
awareness, unwillingness of community participation, limited technology options,
underserved areas and poor demand responsiveness were aimed to change with a nation-wide
approach. Multiple policies are developed with a goal to increase awareness and change the
behaviour and mind-set of people (1). By implementing such strategic plans the country can
be freed from open defecation, safe disposal of excreta, proper operational and support
strategy. The followings are few of the earliest and most popular programmes that have been
implemented to improve the sanitation status of the country:
 Central Rural Sanitation Programme (CRSP)
 Total Sanitation Campaign (TSC)
 Nirmal Bharat Abhiyan (NBA)
 Swachh Bharat Abhiyan
Apart from the above programmes, several other policies have also been undertaken by
the Indian government to enhance the sanitation status. Among all those policies, the two
best ones are the National Urban Sanitation Policy and the National Water Supply and
Sanitation Program.
National Urban Sanitation Policy:
The National Urban Sanitation Policy has been developed by the Ministry of Urban
Development, Government of India to make the urban areas of the nation completely
sanitized, liveable and healthy, that ensure the proper growth and development and thereby a
good living environment for all citizens. It is a well-established fact that individual hygiene is
largely dependent on proper sanitation facilities, which establishes a direct relationship

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between sanitation, water and health. The Indian government considers sanitation as a state-
subject that requires on ground interventions. It was reported that more than 7% of the urban
households do not possess a proper sanitation system and many more do not have access to
the drainage networks and thereby cannot utilize the latrines put into their households with
the help of the government (18). Safe disposal of the human excreta in the urban areas is not
done in 37% of cases whereas these are the sectors that are responsible for contributing more
than 60% of the country’s GDP (12). Even though there are some common elements present
in the urban areas, multiple factors are considered that are recognized as solely the constraints
or opportunities of the urban areas regarding the atmosphere, economy, social parameters and
several other variables. This denotes that every city is required to have its own sanitation plan
with different strategies that need to be implemented. These strategies should conform to the
National policy at all times.
National Water Supply and Sanitation Program:
The National Water Supply and Sanitation Program was introduced by the Indian
government with the aim to provide assistance to the States for establishing special
investigations for identifying problems in villages. According to the Indian constitution, it is
the State’s responsibility to handle the sanitation in the rural areas through Panchayat Raj
/institutions (PRI) and in the urban areas through the municipalities (14). Considering the
magnitude of problem and to expand coverage of problems that the villages face every day,
Government of India introduced this programme for implementing uninterrupted supplies of
drinking water to the rural areas of the country. It has been reported that approximately 80-
90% sewage that is untreated, usually gets discharged into the major water sources of the
countries including numerous rivers, streams and canals (13). Along with this, out of the 2.5
billion population that practice open defecation, 665 million lives in India and this leads to
spread of harmful microbes that results in diseases such as dysentery, cholera, typhoid and

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diarrhoea (20). Only 27% of the wastes are treated before being disposed of into the water
lines (11). The National Water Supply and Sanitation Program aims to provide uninterrupted
supply of safe water and proper drainage facilities to all the rural and urban areas of India.
Detailed description and critical analysis of the two policies
The policies which have been discussed over here are the National Urban Sanitation
policy and National water supply and sanitation programme. The implementation of these
policies has brought about considerable improvement within the sanitation and health of the
people living in the poor and downtrodden areas (6). However, as there are a number of
factors such as the involvement of the stakeholders at each level of the implementation of the
policies are required to be addressed for further progress.
National Urban Sanitation Policy
This policy is implemented with a vision to develop a healthy and clean India. With
the help of such policies, the sanitation cover has increased from 27% to 67% by the year
2011 (3). The National Urban Sanitation Policy (NUSP) in India instructs the states to come
up with their own detailed sanitation strategies. The setting of the policy was remarkable
since it was formulated for urban sanitation in spite of the fact that there is no matching
policy for urban water supply. NUSP is one of the few initiatives that have established a
broad enabling environment for urban sanitation. The goal of the policy is to create
awareness and change behaviour so that people adopt healthy and sustainable sanitation
practices. It aimed to develop functional toilets in every school and household (8). The
different components of the National Urban Sanitation Policy include awareness generation,
institutional roles, knowledge development, capacity building, financing and national
monitoring and evaluation. A country-wide information, education and communication (IEC)

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strategy would be designed and implemented for increasing the level of awareness on
environmental significance of sanitation, as decided by the government (16).
The National Urban Sanitation policy aims to remove the practices of manual
scavenging as well as treat waste water, which could be redirected towards agricultural usage.
It was found that 40% of the cities were in the red category, 50% were put in the black
category and only a handful was put in the blue category (15). Here, the red, black and blue
represented need of immediate action, need to considerable improvement and recovering
stage respectably. The Indian government has further declared prizes for the meeting with the
sanitation goals such as the Nirmal Shahar Puraskar which would be awarded to the best
sanitation performers. One of the biggest drivers of the process is effective communication
channels and gateways which are very important for multidimensional channel to function
together. The policy is mainly implemented at the rural and district level.
The drawbacks of the National Urban Sanitation policy are multiple. The striking
fault in the policy is that the major share of the policy had been taken up by the water supply
department on the initial level. However, the department failed to fulfil the set objectives of
the policy. Further, the higher rate of population growth acted as a hindrance in the way of
success of the policy (9). Lack of social mobilisation also acted as a challenge. Other
shortcomings of the policy could be attributed to lacuna in legal policies, dominance of the
higher class of the society in relation to policy making, poor accessibility and low economic
potential of slum dwellers. All these factors comprehensively obstructed the much needed
improvement in sanitary condition on the national scale. The biggest drawback of the policy
is the absence of a dedicated funding system. The government of the country had promised to
explore the potential of providing funds for assisting projects as part of City Sanitation Plans
through its schemes like JNNURM, UIDSSMT, 10% Lump Sum for NE States and Satellite

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Township Scheme. Nevertheless little emphasis had been given on improving the efficiency
of existing sanitation infrastructure and service delivery (4).
National Water Supply and Sanitation Program
The National water supply and sanitation programme is identified by four critical
behaviours that aimed towards improvement of rural health and sanitation. These include:
 Building and use of toilets,
 safe disposal of child faeces,
 Washing of hands with soap after defecation,
 Safe storage and handling of drinking water.
It was found that the ones with access to good sanitation also had to face poor health
outcomes. This could be attributed to the lack of safe storage of drinking water. Additionally,
the people living within the rural areas are less aquatinted with the water treatment
procedures, which possess threat towards the overall community health. The social and
financial considerations also play an effective role in the setting of effective infrastructure for
supporting community good health and improvement through setting up toilets, organising
educational campaigns and programs which aims towards the practice of hand hygiene before
and after eating. The National water and sanitation program was developed with the goal of
achieving health for all. It was found that a direct link exists between safe drinking water
and sanitation. Almost 80-90% of the sewage is directly discharged into the river water and
streams which possesses a larger risk for the entire community (7). Under this particular
program a number of specific targets were determined by the Indian government such as
achieving 50% urban sanitation, 25% rural sanitation along with ensuring 100% urban and
rural water supply (10).

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However, the lack of infrastructure or sufficient measures taken by the government often
affects the rate of implementation of the policies. In this respect, the community care workers
are often reluctant to move to the poor or downtrodden areas due to lack of communication
and proper living facilities. Further concerns related to the pitfalls of the program include
limited water resources. The most crucial bottleneck in an effective policy formulation is the
current institutional set-up involving government agencies. Eight agencies are required to
collect data on different water-related parameters such as ground water quality, quality of
surface water, and drinking water supply. Such an approach, which is highly fragmentary,
leads to ambiguity and duplication of the functions as result of which unitary analysis of the
scarcity of water is not possible. Data or information gap also has been found to plague the
sector since there is no availability of published data. Some other factors include ground
water depletion, water pollution, inadequate price incentives and inter-sectoral imbalances.
Against the drawbacks of the program highlighted in the above section, the potential
strengths of the same are to be pinpointed. The main institutes that are responsible for water
resource management are MoWR (Ministry of Water Resources, Government of India) and
its constituents such as the CWC (Central Water Commission), CGWB (Central Ground
Water Board), and the MoEF (Ministry of Environment and Forests, Government of India)
and its constituents such as the NRCD (National Rivers Control Department) and CPCB
(Central Pollution Control Board). These are known to have substantial resources when
speaking in terms of information and data, trained personnel and research capability. These
resources, when pooled together, can bring about significant changes in the concerned area.
Further, the current approaches of Sector Reforms and TSC and the ARWSP and RCRSP are
a vital step in the right direction as they draw on the inherent strength of community
management. Moving forward, significant strength also lies in the fact that the rural water
supply sector has the strong non-governmental sector. The non-government sector has

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potential to have phenomenal outreach to communities and deliver government programmes.
With the aim accountability of protecting human health, the national water supply and
sanitation program is well placed for supporting the water and sanitation sector through
integration of efforts for reducing the burden of diseases in relation to hygiene, sanitation and
water.
Recommendation for one policy
In this respect, one of the policies which could be taken forward is the National
Water supply and Sanitation Program which focuses upon treatment of waste water and
reducing the events of waste discharge in the water bodies. It has been found that in the rural
areas most of the household activities is centred on water bodies like washing of clothes,
utensils. Additionally, most of the household waste is deposited in the water bodies leading to
events of biological magnification (3). Some of these possess risk to the overall community
health as the polluted water is further used for cooking and managing basic household
activities. Sanitation is considered as the safe and secured management of the human excreta,
the safe disposal, confinement, treatment while eliminating all the practices that are harmful
to the hygiene of the people. The lack of access to clear and safe drinking water have been
further associated with the development of sickness such as cholera, dysentery etc. This
policy aimed to assess the roles of various government groups and organizations including
the Panchayats, clubs, Mahila Mandals, schools and villages, in implementing the sanitary
schemes and programs (19). Consideration of the socio-economic and cultural aspects of the
diverse population of India helped the programme to achieve its aim of adaptation to safe
water drinking and sanitation habits by the people. This program documented and analysed
the information (I), education (E) and communication (C) regarding the safe water drinking,
sanitation and related health issues for effective application of the strategic policies (17). A

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number of guidelines have been further stated in this regard which helps in achieving the
objectives such as changing the attitude and behaviour of people through educational means.
Additionally, encouraging full participation of the women are further crucial in meeting with
the objectives of the rural sanitation, as it helps in safeguarding the privacy concerns of the
women. The strengthening of local institutions and application of appropriate technology can
further improve the waste treatment plans. Sufficient dialogue between various federal
government agencies and community healthcare centres are required to implement proper
infrastructure.

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References
1. Barnard S, Routray P, Majorin F, Peletz R, Boisson S, Sinha A, Clasen T. Impact of
Indian Total Sanitation Campaign on latrine coverage and use: a cross-sectional study
in Orissa three years following programme implementation. PloS one. 2013 Aug
21;8(8):e71438.
2. Elledge MF, McClatchey M. India, urban sanitation, and the toilet challenge. RTI
Research Brief. 2013 Sep 16.
3. Ellis H, Schoenberger E. On the identification of associations between five world
health organization water, sanitation and hygiene phenotypes and six predictors in low
and middle-income countries. PloS one. 2017 Jan 26;12(1):e0170451.
4. Gupta A, Coffey D, Spears D. Purity, pollution, and untouchability: challenges
affecting the adoption, use, and sustainability of sanitation programmes in rural India.
Sustainable Sanitation for All: Experiences, challenges, and innovations. 2016:283.
5. Hammer J, Spears D. Village sanitation and child health: effects and external validity
in a randomized field experiment in rural India. Journal of Health Economics. 2016
Jul 1;48:135-48.
6. Harris G. Poor sanitation in India may afflict well-fed children with malnutrition.
New York Times. 2014 Jul 13;13.
7. Hawkins P, Blackett I, Heymans C. Poor-inclusive urban sanitation: An overview.
8. Heijnen M, Cumming O, Peletz R, Chan GK, Brown J, Baker K, Clasen T. Shared
sanitation versus individual household latrines: a systematic review of health
outcomes. PLoS One. 2014 Apr 17;9(4):e93300.
9. Hirve S, Lele P, Sundaram N, Chavan U, Weiss M, Steinmann P, Juvekar S.
Psychosocial stress associated with sanitation practices: experiences of women in a

14POLICIES TO STRENGTHEN THE SANITATION SYSTEM
rural community in India. Journal of Water Sanitation and Hygiene for Development.
2015 Mar 1;5(1):115-26.
10. Hueso A, Bell B. An untold story of policy failure: the Total Sanitation Campaign in
India. Water Policy. 2013 Dec 1;15(6):1001-17.
11. Hutton G. Global costs and benefits of reaching universal coverage of sanitation and
drinking-water supply. Journal of water and health. 2013 Mar 1;11(1):1-2.
12. Nandi S, Gamkhar S. Urban challenges in India: A review of recent policy measures.
Habitat International. 2013 Jul 1;39:55-61.
13. Onda K, Crocker J, Kayser GL, Bartram J. Country clustering applied to the water
and sanitation sector: A new tool with potential applications in research and policy.
International journal of hygiene and environmental health. 2014 Mar 1;217(2-3):379-
85.
14. Praharaj S, Han JH, Hawken S. Urban innovation through policy integration: Critical
perspectives from 100 smart cities mission in India. City, culture and society. 2018
Mar 1;12:35-43.
15. Ramani SV, SadreGhazi S, Gupta S. Catalysing innovation for social impact: The role
of social enterprises in the Indian sanitation sector. Technological Forecasting and
Social Change. 2017 Aug 1;121:216-27.
16. Rao U. Tolerated encroachment: Resettlement policies and the negotiation of the
licit/illicit divide in an Indian metropolis. Cultural Anthropology. 2013 Nov
1;28(4):760-79.
17. Right to sanitation in India [Internet]. Soppecom.org. 2018 [cited 25 August 2018].
Available from: https://www.soppecom.org/pdf/Right-to-sanitation-in-India-Nature-
scope-and-voices-fro-%20the-margins.pdf

15POLICIES TO STRENGTHEN THE SANITATION SYSTEM
18. Wankhade K. Urban sanitation in India: key shifts in the national policy frame.
Environment and Urbanization. 2015 Oct;27(2):555-72.
19. Water supply and sanitation [Internet]. Planningcommission.gov.in. 2002 [cited 25
August 2018]. Available from:
http://planningcommission.gov.in/reports/genrep/wtrsani.pdf
20. WHO/UNICEF Joint Water Supply, Sanitation Monitoring Programme. Progress on
drinking water and sanitation: 2014 Update. World Health Organization; 2014.