Dr. Devendra Kothari
Population and Development Analyst
Forum for Population Action
Fixing dreadful sanitation in India requires not just building lavatories but also changing habits.
Clean and adequate drinking water, sanitation, and hygiene, also referred as WASH, are all essential ingredients to ensure human development. The data from the World Health Organization and UNICEF, among others, indicate that it is the poorest, the young and the women\girls and infants who suffer most from poor WASH.  An investment to improve WASH services, therefore, means good health including lower morbidity as well as mortality and higher levels of school achievement hence greater productivity. As such, policies, institutions and infrastructure to improve WASH services are getting priority in the national development agenda.
India should build 'toilets before temples’, Narendra Modi said in a pre-election speech to mark the birthday of Mahatma Gandhi in 2013. To accelerate the efforts to achieve universal sanitation coverage and to put focus on hygiene, the Prime Minister Modi launched the Swachh Bharat Abhiyan (Clean India Movement) on October 2, 2014. In addition to clean the streets and roads, its main objective is to reduce or eliminate open defecation through construction of individual, cluster and community toilets by 2019, as a fitting tribute to the 150th Birth Anniversary of Mahatma Gandhi. The mission also makes an initiative of establishing a mechanism of monitoring latrine use.
No doubt, WASH inputs are foundations for human development. Yet for a large section of humanity in India these foundations are not in place. Despite massive outlays for drinking water and sanitation in last couple of decades, millions of Indians lack access to these basic services. Every day, millions of women and young girls collect water for their families — a ritual that reinforces gender inequalities in employment and education. Only 47 per cent of households have a source of water within the premises while 53 per cent of households travel more than a kilometre in rural areas and more than 100 meters in urban areas to fetch their supplies, as per the findings of Census 2011. In addition, poor water supply has obvious health costs for both urban and rural households, since only one in three households are supplied ‘treated’ water in the country.  This problem is further compounded by lack of access to sanitation. About half of total households in India still defecate in open. This situation is particularly piquant for women and girls. It is estimated that around 290 million women in India in 2011, the worst sufferers of open defecation, continue with the age-old practice even after 25 years of economic reforms. (As per the most recent Swachhta Status Report of the National Sample Survey Office (NSSO), in 2015, more than half of the rural population of the country still defects in open – a major public health and sanitation problem.) Further, only 51% of the households have drainage connectivity with two third have the closed drainage. It means around 49 per cent of total households in India are not connected with drainage system at all inviting lots of health related problems.  This is a very sorry state of affairs for a country which is the fourth largest economy in the world. Again there are wide regional variations. All the 10 major States of the country differ widely in the flush toilet facilities. More than half of households in Gujarat have flush latrines, while only 20 per cent households in Bihar are lucky to have that facility.
The combination of poverty, poor health and lack of WASH services means that children from un-served homes, miss school more frequently than those whose families do benefit from improved drinking water and sanitation services. The resulting lack of education and social development further marginalizes the children and reduce their future chances of self-development.  Hence, any improvement in access to toilet facilities, water, electricity and LPG is likely to result in a considerable reduction in domestic drudgery especially for girls/women, freeing up their time for other activities including schooling and perusing professional life.
In addition, an investment in WASH facilities is urgently needed to minimizing the impact antimicrobial resistance. India is seized of the challenges of antimicrobial resistance (AMR), noted by the Ministry of Health and Family Welfare, Government of India.  It is because unclean water, lack of sanitation and poor hygiene are responsible for the transmission of diarrhea, cholera, typhoid, dengue, Chikungunya and several parasitic infections; and thousands of people die every year due to such diseases. To manage, these diseases antibiotics are being used on a large scale.
AMR occurs when the effectiveness of antimicrobial drugs – including antibiotics – is diminished due to mutations in infectious bacteria. This happens when antibiotics are ill-regulated and overused, or when they are used inappropriately or for non-human health. Bacterial mutations and the superbugs they create make treating basic infections such as skin sores or diarrhoea next to impossible. They also make surgery risky. If present trends persist, by mid-century AMR will kill more people than cancer, noted by Dr Poonam Khetrapal Singh, Regional Director of WHO South-East Asia Region. 
In 2010, India was the world’s largest consumer of antibiotics for human health at 12.9 x 109 units (10.7 units per person). The scale-up in antibiotic use in India has been enabled by rapid economic growth and rising incomes, which have not translated into improvements in water, sanitation, and public health. Antibiotics continue to be prescribed or sold for diarrheal diseases and upper respiratory infections for which they have limited value.
How to mange AMR? Many factors contribute to how antimicrobials are used. Therefore, a multidisciplinary approach is needed to develop, implement and evaluate interventions to promote optimal use of antimicrobials and improve infection control programmes. 
So where does water, sanitation and hygiene come in? Clean water and sanitation are low-cost solutions to India’s gravest health threat and human as well as skill development agenda.  India lags on basic public health measures. Immunization rates (as measured by diphtheria-tetanus-pertussis [DPT3]) coverage in India (72%) lag behind those in Brazil (95%), China (99%), and Indonesia (85%). The percentage of the population with access to improved sanitation facilities in India (36%) was far lower than the percentage in Brazil (81.3%), China (65.3%), and Indonesia (58.8%). Under the Swacch Bharat Abhiyan (Clean India Program), the government has committed to providing toilets and improving sewage systems, but these measures will take time to implement.
Government of India must hasten efforts to achieve safe water and sanitation for all. Communities lacking clean water and effective sanitation should be identified in both rural and urban areas, and steps taken to ameliorate their situation. This could mean treating water at its point of use or systematizing the operation and maintenance of local water supply systems. It could also mean investing in water supply systems to serve unreached populations. At the same time, access to safely-managed toilets should be increased by investing in and building them, and by promoting behavioral change aimed at ending open defecation as well as promoting hand-washing practices. 
It is suggested that the rural employment guarantee scheme (NREGA), which is responsibility of Panchayats Raj Institutions, should be used to improve the basic amenities like water, sanitation and hygiene in rural areas. And the fund allocated to the Smart Cities Mission could be used mainly to develop the basic WASH facilities in urban areas.
In short, clean water and sanitation form the backbone of an effective human development agenda, as argued by the Johns Hopkins University Water Institute. However, the challenges of providing these services in a large and heterogeneous country can be vast. Clean drinking water and sanitation are certainly not cheap. The cost of implementing these for all of India will be very large. Of course, not doing it will also have huge financial implications in terms of health and socio-economic development costs. But the big question remains – will the policy makers acquiesce?
 Refer article – WASH: water supply, sanitation and hygiene Human rights that are crucial to health and development at:http://www.unicef.org/wash/files/1_WSSCC_JMP_Fact_Sheets_1_UK_LoRes.pdf.
 Census of India 2011 –Tables on Houses, Household Amenities and Assets, Registrar General & Census Commissioner, India
 Kothari Devendra. (2012). West Bengal: Household amenities with special reference to water, sanitation and hygiene (WASH) and their implications. Kolkata, West Bengal: UNICEF.
 Refer article: , Ashish and Amadi Chioma. (2013). Impact of Water, Sanitation, and Hygiene: Interventions on Improving Health Outcomes among School Children, Journal of Environmental and Public Health Volume 2013.
Refer SEARO, WHO conference: Combating Antimicrobial Resistance in India at http://www.searo.who.int/india/topics/antimicrobial_resistance/Combating_Antimicrobial_Resistance_in_India/en/ . Also refer article: Antimicrobial resistance in India: A review by S. Ganesh et al (J Nat Sci Biol Med.) 2013. Also refer: Refer WHO Policy Perspectives on Medicines No. 10 entitled: Containing antimicrobial resistance.
 Refer article - Staving off the superbugs: High-quality water and sanitation are low-cost solutions to humanity’s gravest health threat by Poonam Khetrapal Singh at: http://blogs.timesofindia.indiatimes.com/toi-edit-page/staving-off-the-superbugs-high-quality-water-and-sanitation-are-low-cost-solutions-to-humanitys-gravest-health-threat/
 Laxminarayan R, and Chaudhury RR. (2016). Antibiotic Resistance in India: Drivers and Opportunities for Action. PLoS Med 13(3). Also refer:
 Refer article: The importance of water, sanitation, and hygiene as keys to national development, John Hopkins Water Magazine, 2015 at: http://water.jhu.edu/index.php/magazine/climate-change-and-health-why-the-link-to-water-is-critical/.
 Hygiene is four times as important as clean drinking water for preventing diarrheal disease according to research published in The Lancet - medical journal.