Unveiling the Stark Reality of Health and Sanitation in India

India is home to nearly 1.4 billion people, and yet for decades, millions of them have had to begin each day without access to one of the most basic human necessities – a toilet. Poor sanitation is not simply a matter of inconvenience; it is a public health crisis with consequences that range from preventable deaths in children to violence against women. Understanding where India stands today – and how it got here – requires looking honestly at the scale of the problem, the communities it harms most, and the long road to meaningful change.

The scale of the sanitation deficit
Why open defecation persists – beyond poverty
The health consequences: who pays the heaviest price
Children: stunting, diarrhea, and preventable death
Women: safety, dignity, and menstrual health
A brief history of India’s sanitation programmes
The Swachh Bharat Mission: ambition and achievement
Where the gaps remain
Sanitation as a development imperative

The scale of the sanitation deficit

The numbers tell a sobering story. According to data from five rounds of India’s National Family Health Survey, the proportion of the population without access to any household toilet stood at over 70% in 1993. By 2021, that figure had dropped to roughly 18% – significant progress, but still representing hundreds of millions of people. A 2023 analysis using India’s Household Consumer Expenditure Survey found that as of 2023, approximately 12.5% of India’s households have no toilet at all, amounting to over 162 million people. Crucially, more than 70% of those without a toilet live in just six states, pointing to deep geographic and socioeconomic inequalities within the country.

The WHO-UNICEF Joint Monitoring Programme (JMP) tracked that in 2015, roughly 41% of India’s rural population was still defecating in the open. By 2022, that had declined to around 17% – but that still means tens of millions of people in rural India lack even basic sanitation access. The government declared all districts “Open Defecation Free” (ODF) by financial year 2024, but independent reports continue to find a gap between official declarations and ground reality.

Why open defecation persists – beyond poverty

It is tempting to explain open defecation purely as a product of poverty. But the evidence suggests something more complex. Research published in Economic Development and Cultural Change found that India has far higher open defecation rates than many countries that are poorer, have lower literacy rates, and have less access to water. In 51 countries poorer than India by asset-wealth measures, only four had comparable levels of open defecation.

A study drawing on national survey data found that open defecation in rural India is strongly linked to beliefs, values, and social norms around purity, pollution, caste, and untouchability – factors that cause many households to reject even affordable pit latrines. This is a crucial distinction: the problem is not only about the availability of toilets, but also about behavioral and cultural barriers to using them. In Bangladesh, for instance, 94% of rural households that do not defecate in the open use pit latrines; in India, the figure is far lower, suggesting a deep-rooted aversion to certain types of sanitation infrastructure.

A 2025 randomized trial published in PLOS ONE confirmed this, finding that combining financial subsidies for toilet construction with community-level information campaigns produced significantly better outcomes than subsidies alone – indicating that information barriers are as important as economic ones. In their baseline survey, more than 95% of respondents in target communities were practicing open defecation despite subsidized toilet access being available.

The health consequences: who pays the heaviest price

Children: stunting, diarrhea, and preventable death

The most devastating health consequences of poor sanitation fall on children. Research modeled across Indian states found that more than 300,000 children under five die from diarrheal diseases every year in India, with economic losses from diarrhea alone amounting to an estimated $13 billion – around 1.5% of GDP annually. The WHO identifies contaminated water and poor sanitation as key drivers of cholera, diarrhea, dysentery, hepatitis A, typhoid, and polio transmission.

Beyond direct mortality, inadequate sanitation stunts children’s physical growth. Research has shown that growing up in environments with pervasive fecal contamination results in repeated gut infections that drain children of vital nutrients, even when food is available. India has recorded some of the highest rates of child stunting in the world, and researchers argue this is driven more by sanitation conditions than by food scarcity – a conclusion backed by the fact that Indian children are on average shorter than children in sub-Saharan Africa, despite higher average incomes in India.

A 2025 study on water, sanitation, and disease burden in eastern India estimated that waterborne diseases generate an economic burden of $600 million per year in India alone, with improper handwashing contributing to approximately 100,000 diarrheal deaths annually among children under five.

Women: safety, dignity, and menstrual health

For women, the absence of private sanitation facilities carries risks that go far beyond disease. In areas without household toilets, women and girls are forced to venture into fields or isolated areas to defecate, typically before dawn or after dark to preserve modesty – a practice that exposes them to physical danger, harassment, and assault. Open defecation for women in India has long been linked to reduced personal safety in rural settings.

Menstrual health is equally affected. Without private facilities in schools, girls who reach puberty are at a higher risk of dropping out. The United Nations Department of Economic and Social Affairs notes that India’s national sanitation drive specifically ensured that schools had toilets for both boys and girls and that girls were provided with the privacy and materials needed for safe menstrual hygiene management – a recognition that sanitation access is directly tied to girls’ education and well-being.

A brief history of India’s sanitation programmes

India’s efforts to address the sanitation crisis are not new. According to a comprehensive account of India’s sanitation history, a formal sanitation programme was first launched in 1954 as part of the First Five Year Plan. The Central Rural Sanitation Programme followed in 1986, but it was construction-led with no behavioural change component, and sanitation coverage increased by only around 9%. The Total Sanitation Campaign (TSC), launched in 1999, and the Nirmal Bharat Abhiyan (NBA) of 2012 attempted to shift toward demand-generation but fell short due to limited political will, inadequate funding allocation, and an absence of sustained behaviour change strategy.

Rural toilet coverage in India grew incrementally – from about 1% in 1981 to roughly 33% by 2011 – but the pace was far too slow. As documented in a peer-reviewed analysis of India’s sanitation campaigns, earlier programmes like the Central Rural Sanitation Programme failed because the reality on the ground did not match the requirements for success, with funds misused and no mechanism for ensuring ongoing behaviour change after initial toilet construction.

The Swachh Bharat Mission: ambition and achievement

The most significant policy shift came in 2014, when Prime Minister Narendra Modi launched the Swachh Bharat Mission (SBM) – Clean India Mission – on October 2, Gandhi’s birth anniversary. It was described from the outset as the world’s largest sanitation programme. The UN’s account of the programme notes that SBM helped 100 million rural households and 500 million residents gain access to toilets across 630,000 villages. The mission trained over 600,000 community volunteers – called swachhgrahis – who mobilized communities at the grassroots level.

The results have been significant in measurable health outcomes. Analysis published by the Wilson Center found that areas with more than 30% of toilets constructed under SBM saw 5.3 fewer infant deaths and 6.7 fewer under-five deaths per 1,000 compared to baseline. The WHO estimates that SBM prevented 300,000 deaths and avoided 14 million Disability-Adjusted Life Years (DALYs) between 2014 and 2019. Households in ODF villages also saw annual savings of around INR 50,000 from avoided medical costs and time saved – with benefits exceeding costs by a factor of seven for even the poorest households.

UNICEF India has highlighted that in an open defecation-free environment, there are measurably fewer episodes of diarrhea – still a leading cause of death in children under five globally – and that a cleaner environment is directly associated with lower malnutrition rates among children.

Where the gaps remain

Despite the progress, significant challenges persist. A 2024 investigation by Down to Earth raised concern that open defecation has not, in fact, stopped – with WHO-UNICEF data indicating that at least one-sixth of India’s rural population still defecates in the open, and a quarter lacks even basic sanitation access. There is a documented gap between official ODF declarations – which measure toilet access – and actual toilet use, which depends on behaviour change that is harder to verify.

A systematic review in Frontiers in Environmental Science found that in certain states, up to 70% of the population may continue to practice open defecation despite having access to toilets – underscoring that infrastructure alone is insufficient without sustained community engagement and norm change. A 2024 study on open defecation in Delhi found that around 80% of surveyed households in slum settlements were still associated with open defecation, pointing to the fact that even in urban settings, the problem is far from resolved.

Caste, wealth, and geography remain powerful predictors of who lacks toilet access. Research on no-toilet households found that the lowest socioeconomic status households are consistently the least likely to have a toilet – meaning that the burden of poor sanitation is concentrated among India’s most vulnerable populations: Dalits, the rural poor, and residents of states like Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan.

SBM Phase 2, launched in 2021, has attempted to address these gaps by shifting focus from mere construction to the sustainability of ODF status, introducing ODF+ and ODF++ certifications that verify consistent toilet use and safe fecal sludge management, and continuing to target solid and liquid waste management at the community level.

Sanitation as a development imperative

Sanitation is not a peripheral issue. It is directly connected to the WHO’s tracking of Sustainable Development Goal 3.9.2, which measures mortality attributable to unsafe water, sanitation, and hygiene. SDG 6.2 explicitly calls for universal access to safely managed sanitation by 2030, with special attention to women and girls. Whether India can meet that target depends not only on building toilets, but on ensuring that every household – regardless of caste, income, or location – has the access, the knowledge, and the social environment to use them consistently.

The story of sanitation in India is ultimately a story about equality. Where people cannot safely and privately meet their most basic bodily needs, every other development goal – education, nutrition, women’s safety, economic productivity – is compromised. Progress has been real, but the work is far from complete.

What do you think? Given that cultural norms around caste and purity have been shown to influence toilet adoption more than poverty alone, should India’s sanitation policy invest more heavily in community-level behaviour change than in toilet construction? And with official ODF declarations increasingly questioned by independent researchers, how should governments balance the political need to show progress with the public health imperative of measuring real-world sanitation outcomes?

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Table of Contents

The scale of the sanitation deficit 🔗

Why open defecation persists – beyond poverty 🔗

The health consequences: who pays the heaviest price 🔗

Children: stunting, diarrhea, and preventable death 🔗

Women: safety, dignity, and menstrual health 🔗

A brief history of India’s sanitation programmes 🔗

The Swachh Bharat Mission: ambition and achievement 🔗

Where the gaps remain 🔗

Sanitation as a development imperative 🔗