Can sanitation reduce stunting?  (The Hindu)

How Indians got the vote  (The Indian Express)

National Health Protection Scheme (Live Mint)


Can sanitation reduce stunting?

(The Hindu)

Synoptic line: It throws light on the issue of how difficult it is to change toilet habits.

(GS paper III)



  • In India, around 38 per cent of children younger than five years of age are stunted, a manifestation of chronic undernutrition.  Stunting and other forms of under-nutrition are thought to be responsible for nearly half of all child deaths globally.



  • Stunting is associated with an underdeveloped brain, with long-lasting harmful consequences, including diminished mental ability and learning capacity, poor school performance in childhood, reduced earnings and increased risks of nutrition-related chronic diseases, such as diabetes, hypertension, and obesity in future.




  • While India’s economy has been growing at impressive rate, the country still has the highest number of stunted children in the world, representing one-third of the global total of stunted children under the age of five.



Assessment of trial



  • Studying the impact of sanitation on stunting is considered to be tricky, and the much-awaited result of two ambitious new trials also shows the same.




  • The trials, which implemented water, sanitation and hygiene (WASH) interventions in Bangladeshi and Kenyan villages for two years, were an effort to prevent stunting seen in children less than two years in developing countries. Specifically, the WASH interventions included replacing poor-quality toilets with improved ones, chlorinating drinking water, and promoting hand washing all in an attempt to protect toddlers from the faecal pathogens that are believed to interfere with their growth.




  • But when the trials ended, disappointingly, the researchers found these children were not taller than those who did not receive these interventions. The findings are a setback to the hypothesis that improving sanitation can thwart childhood stunting. But how big a setback they are is disputed.



Open defecation problem


  • Bangladesh and Kenya see childhood stunting, different from countries such as India on a critical count. India is the only country today in which over 50% of the rural population still defecates in the open. Bangladesh, while close to India in population density, brought down open defecation rates from 42% in 2003 to just 1% in 2016.


  • Only around 3-9% of the participants in the trial in Bangladesh, and less than 5% in the trial in Kenya, defecated in the open at the start of the experiment. Most people already had toilets, albeit poor-quality ones, which the trial improved. It is likely that the children sampled were exposed to lower levels of faecal pathogens in the first place, which is why the trials didn’t impact stunting.


  • The new trials raise doubts about the link between sanitation and stunting in India too. An epidemiologist at the Stanford Woods Institute in the Bangladesh study, says that the villages in his study saw high rates of both contamination and stunting. Yet the WASH improvements made no difference, which means that other factors could be driving stunting. “This heightens concerns that similar mechanisms underlie the association between open defecation and stunting in India”.


  • Stunting is a complex problem, even though prenatal health, breastfeeding and diet, among dozens of factors, have been implicated in stunting, trials to encourage breastfeeding or supplement the mother’s and child’s diets have come up short.


  • Since 2010, some six groups, including three in India, have experimented with sanitation approaches to tackle stunting. Nearly all failed because they were unable to convince enough people to use toilets in the first place. Another predicament is that for WASH interventions to be truly effective, more than one generation of families may need to adopt them. Most trials do not last longer than two years, given how expensive and logistically challenging they are.


  • India’s Swachh Bharat Abhiyan (SBA) is an example of how difficult it is to change people’s sanitation habits. Even though the SBA aims to eliminate open defecation by 2019, data from the 2015-16 National Family Health Survey show the campaign hasn’t changed much since it began. “Almost halfway through the SBA, open defecation remained quite common in rural India and its distribution across districts looked pretty similar to 2011”.


  • Programmes like the SBA that focus on constructing toilets can’t do much in the face of deep-rooted cultural beliefs about open defecation because they presume that people do not build toilets for financial reasons. If behavioural change campaigns are not initiated to tackle the problem, Indians will continue to defecate in the open even if they get toilets for free.


Way ahead



  • India has the highest number of stunted children worldwide. Not just toilet numbers but poor toilet use and hygiene behaviour too need urgent redressal at the policy level to reduce stunting. The Bangladesh study is significant because it did succeed in changing participant behaviour. It provides critical information for countries that have already eliminated open defecation.



Question- If behavioural change campaigns are not initiated to tackle the problem, Indians will continue to defecate in the open even if they get toilets for free. Critically analyse.


How Indians got the vote

(The Indian Express)

Synoptic line: It throws light on the issue that how Indians got the voting rights.

(GS paper II)



  • India’s electoral democracy has tended to see, as an inheritance of the British Raj or a product of an elite decision-making and institutional design. As the people had little or no role in making democracy or the Constitution. 


  • The origin of Indian democracy, in particular the establishment of its edifice through the implementation of universal adult franchise, was an ingeniously Indian enterprise. It was no legacy of colonial rule, and was largely driven by the Indians, often by people of modest means. 





  • To turn all adults into voters was a staggering democratic state-building operation of inclusion and scale, which surpassed any previous experience in democratic world history and this work, was undertaken by Indian bureaucrats between August 1947, when the country became independent, and January 1950, when it adopted the Constitution.



  • The numerous interactions between people and administrators about the preparation of the first draft electoral rolls on the basis of adult franchise were significant for the institutionalisation of India’s democracy. Because people from the margins found meaning and a place for themselves in the new polity based on universal adult franchise, they also understood the potential new power of making group identity claims.


  • The successful implementation of universal franchise by the time the Constitution came into force enabled the insertion of social identities into the design of political representation and laid the seeds of the dynamic caste and identity politics, which have both deepened and challenged electoral politics in India.


  • The principle of universal franchise was adopted at the beginning of the constitutional debates in April 1947. It was a significant departure from elections under colonial rule, which were based on a very limited franchise and a divided electorate. There was a large gap to bridge in turning this constitutional aspiration into reality at Independence, in the midst of the Partition.


  • Once the actual registration of voters began, distinct forms of disenfranchisement, breaches in the instructions and difficulties surfaced on the ground. In Assam, for example, no regard was given to refugees and immigrants as prospective citizens-voters and there was instruction not to register “the floating and ‘non-resident’ population”.


  • In the face of exclusionary practices in the preparation of rolls, a wide range of burgeoning citizens’ organisations began struggling for their voting rights. Citizens’ organisations also began to demand linking voter’s registration with the acquisition of citizenship. To do so they made their claims on the basis of the Draft Constitution’s citizenship and other provisions, using the Constitution’s language and aspirations, while it was still in the making. 





  • The inventive ways in which Indians made their democracy did not necessarily mean that India would become better than other democracies, nor immune from the problems that have beset democracies elsewhere. Indeed, India’s democracy fell short of its constitutional promises, for example, to promote social and economic equality.




  • During the challenging times, when the values and institutions of democracy are under threat, learning about and gaining a new appreciation of how India became democratic might inspire fresh energy for the challenges of the present.



Question The country’s first election was an ingeniously indigenous an inventive exercise, with unique challenges. The way bureaucracy rose to the task holds lessons for today. Examine.


National Health Protection Scheme

(Live Mint)

Synoptic line: It throws light on the critical analysis of National Health Protection Scheme.

(GS paper III)




  • The Union finance minister announced the government’s vision of Ayushman Bharat, or the National Health Protection Scheme (NHPS). Though it came as a welcome departure from previous years, health has emerged as the central topic of post-budget analysis and critique.



National Health Protection Scheme



  • In the recent budget it was announced that the government will launch flagship National Health Protection scheme intended to cover 10 crore poor and vulnerable families and 50 crore beneficiaries. Under the scheme, 10 crore families will be provided Rs 5 lakh cover per family annually for treatment. The programme is being touted as the world’s largest health protection scheme.



Critical analysis


  • The Media newsrooms have been brimming with policymakers, academics, industry executives and politicians explaining the details and mechanics of the NHPS. Valuable viewpoints, evidence and analysis have surfaced in plenty, laced with a mix of admiration and scepticism, and as a result, the NHPS has been labelled many things- visionary, populist, pro-private insurance market, suboptimal solution for universal health, scaled-up version of old schemes, pre-election gimmick, and more.


  • According to the National Council of Applied Economic Research, the annual incomes of the households which are below Rs1.5 lakh are “Deprived Households”.  Their homes, whether urban or rural, are in locations defined by wretched living conditions. Some 135 million households fall in the deprived category, constituting 56% of the total households in India. And yet, there has appeared not a single report highlighting their opinion. 


  • On an average, the medical expenses of such deprived households with low income capacity hover between 5-6% of total expenses. The pursuit of health may trap them in medium- or long-term therapy regimens, pulling this single-digit proportion into a catastrophic range of 10% or above. Hence, the majority of them do not report sickness, until rendered inactive to work and earn, either by injury or the flare-up of a chronic condition. 


Will the NHPS announcement let such families shed these inhibitions and change their health-seeking behaviour? 


  • As seen in the last two decades, many states had an epidemiological transition, with non-communicable diseases such as heart problems, stroke and depression imposing a greater economic and human burden on society than infectious diseases and nutritional deficiencies.  Eighty per cent of the time, the out-of-pocket expenditure of patients within this strata is, therefore, on outpatient clinics that don’t come under the ambit of NHPS. 



  • Therefore, for deprived households, the NHPS holds limited value. It cannot deliver on the grand claim of complete health for them. It will not reduce the ever-increasing monthly medical bills that go towards managing the chronic diseases they are most susceptible to.




  • The NHPS will not bring an iota of change in the health-seeking behaviour of the deprived sections. That can happen only if the expenditure on health, which has hovered around 1% of gross domestic product (GDP), doubles in the near future to improve access and quality of healthcare to the last mile.


  • Though the insurance of Rs5 lakh per annum would be a comforting thought if one needs hospitalization and surgical intervention (provided in-patient admissions claims processing and reimbursement-related processes do not themselves become added stress factors). Such events may be few and far between.


Question The National Health Protection Scheme (NHPS), must expand its scope to share expenditure on outpatient services for long-duration chronic diseases to achieve Ayushman Bharat. Critically analyse.