"When I got pregnant, it was hard to walk to the field to defecate as the path was not safe. My mother-in-law used to accompany me because I needed help sitting down and getting up."--Maheshwari (25), Raichur, India. India has the highest number of people, 732 million, with no access to proper toilets and women and girls are among the worst affected.

India, the world’s second-largest country by population, has the highest number of people (732 million) without access to proper toilets, according to a new report.

The report by WaterAid, titled Out Of Order:The State of the World’s Toilets 2017, further stated that 355 million women and girls lack access to a proper toilet. If they were to stand in a line, the queue could circle the Earth more than four times.

Source: WaterAid
Note: Data as of 2015

India’s low ranking on the sanitation index is despite the changes brought by the government’s Swachh Bharat (Clean India) Mission. Launched in October 2014, it increased the country’s sanitation coverage from 39% to 65% by November 2017, according to government data. In this period, 52 million household toilets were built in rural India.

The cleanliness campaign has reduced the proportion of people defecating in the open by 40%, meaning more than 100 million people now use toilets, according to the WaterAid report.

India also ranks sixth among the top ten nations working to reduce open defecation and improving access to basic sanitation. The percentage of population without access to at least basic sanitation fell from 78.3% in 2000 to 56% in 2015, according to the report.

Diarrhoeal diseases kill 60,700 Indian children each year

Each year, 60,700 children under five years die from diarrhoeal diseases, the WaterAid report said.

Diarrhoea remains the second leading cause of death in Indian children under five years, killing an estimated 321 children every day in 2015, as IndiaSpend reported on July 29, 2017, based on a World Health Organization factsheet.

Hookworms, which can spread through open defecation, cause diarrhoea, anaemia and weight loss in women, according to the report. These problems are linked to low birth weight and slow child growth--38% of children in India under five are stunted, according to the National Family Health Survey, 2015-16, (NFHS-4) data.

Indian states with poor access to sanitation report high incidence of diarrhoeal diseases. Uttar Pradesh, Bihar, Madhya Pradesh, Assam and Chhattisgarh had the highest rate of mortality among children under five years of age, higher stunting (low height-for-age) rates and higher prevalence of diarrhoea due to poor sanitation, as IndiaSpend reported on April 26, 2017, based on NFHS-4.

States With Higher Access To Improved Sanitation
Had Lower Prevalence Of Anaemia, Diarrhoea

Access To Improved Sanitation: Top 5 States
State Households with improved sanitation Prevalence of diarrhoea* Non-pregnant women who are anaemic** Pregnant women who are anaemic**
Kerala 98.10% 3.40% 34.60% 22.60%
Sikkim 88.20% 1.50% 35.20% 23.60%
Mizoram 83.50% 7.60% 24.60% 26.60%
Punjab 81.50% 6.60% 54% 42%
Haryana 79.20% 7.70% 63.15 55%
India 48.40% 9.20% 53.10% 50.30%
Access To Improved Sanitation: Bottom 5 States
State Households with improved sanitation Prevalence of diarrhoea* Non-pregnant women who are anaemic** Pregnant women who are anaemic**
Jharkhand 24.40% 6.90% 65.30% 62.60%
Bihar 25.20% 10.40% 60.40% 58.30%
Odisha 29.40% 9.80% 51.20% 47.60%
Chhattisgarh 32.70% 9.10% 47.30% 41.50%
Madhya Pradesh 33.70% 9.50% 52.40% 54.60%
India 48.40% 9.20% 53.10% 50.30%

Source: National Family Health Survey 2015-16
*reported in two weeks preceding the survey **Among women aged 15-49 years

The tables above show the top five and bottom five states based on the percentage of households with improved sanitation, according to NFHS-4. States with higher percentage of improved sanitation have lower levels of anaemia among women (both pregnant and non-pregnant). These states also reported fewer cases of diarrhoea than the national average.

For example, Kerala, which had the highest percentage of households with improved sanitation (98.1%)--the national average was 48.4%--also had the lowest prevalence of diarrhoea (3.4%) and the lowest percentage of women with anaemia (22.6%).

Bihar, with only 25% households using improved sanitation, had the highest prevalence of diarrhoea (10.2%) and the highest percentage of anaemic pregnant women (58.3%).

For women, high risk of illiteracy, harassment

Apart from poor health, lack of toilets means that more than 1.1 billion women and girls globally get limited education and face harassment. In rural India, high dropout rates and non-enrolment among girls can be attributed to absence of toilet facilities, as IndiaSpend reported on July 19, 2017.

In rural India, 23% of girls have listed menstruation as the chief reason for dropping out of school. As many as 28% of them said they do not go to school during their period because they lack clean and affordable protection, as IndiaSpend reported on June 19, 2017.

Sanitation policies should cover the needs of those who are vulnerable, said Raman VR, head of policy at WaterAid India.

“Adolescent girls and women want facilities in which they can manage their periods safely and hygienically,” he said, “Pregnant women need easily accessible and usable toilets, and the elderly or people with disability require toilets with design features that help overcome the physical constraints they typically face.”

Correction: An earlier version of this story said 732 million Indians (including 355 million women and girls) lack access to a toilet. The correct datum is that they lack access to basic sanitation--meaning a proper toilet. We regret the error.

(Salve is an analyst at IndiaSpend.)

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