Public Health in Rural India: Exploring Sanitation Outcomes and the Role of Community Health Workers

India found itself on the brink of economic collapse in early 1991. An emergency loan secured from the International Monetary Fund helped stave off national financial ruin. Terms of the loan agreement required India to liberalize its economy, opening it up for the first time since independence in 1947, to foreign investment. While nationalists were dismayed at the time, there is little dispute that those reforms in the early 1990s spurred India’s rapid economic growth, turning it in to one of the world’s largest economies today. As a result, more Indians than ever before are enjoying middle class lives; with increased access to world class educational opportunities and health services./nYet this growth has in many ways widened the gap between India’s rich and poor. On the other side of this lacuna are hundreds of millions of Indians forced to endure inhumane conditions. For example, nearly 520 million Indians defecate in the open every single day, leading to the spread of fecal contamination. Epidemiological studies have drawn inextricable causal links between open defecation and disease. One gram of feces can contain viral pathogens, bacterial pathogens, protozoan cysts, and helminth eggs, thereby leading to diarrheal disease, the second leading cause of deaths in children under the age of five globally. Fecal contamination can also cause tropical diseases such as trachoma and schistosomiasis. This morbidity has been linked to a reduction in early-life growth, an important marker and predictor of human capital./nSimilarly, maternal and child health outcomes remain poor. India still accounted for 15% of maternal deaths (45,000) worldwide in 2015. And while India’s under-5 mortality rate now matches the global average (39 deaths per 1,000 live births), its infant mortality rate, 32 deaths per 1,000 live births, is nearly three times the global average. Additionally, the Global Nutrition Report from 2018 highlights the burden of wasting and stunting in children under the age of five in India. According to the report, nearly a third of the world’s 150 million stunted children live in India, and over half of the world’s 50.5 million wasted children live in India. Furthermore, both stunting and wasting are associated with increased mortality, especially for those children who suffer from both. Finally, the National Family Health Survey conducted by the Ministry of Health and Family Welfare found that in 2015-2016, 53% of all Indian women were anemic. Anemia, combined with poor antenatal care, is particularly problematic as it is associated with a higher likelihood of a poor birth outcomes./nPaper one is an exploratory paper that qualitatively examines why people in rural Bihar, a state in north India, do not own or use toilets. This paper is rooted in the field of social epidemiology, and as such, seeks to elucidate the possible social determinants of latrine ownership and use in rural India. This paper is guided by the research question: what are people’s lived experiences in trying to build and use latrines in rural Bihar? Overall, we found that not owning a toilet cannot be conflated with a preference for open defecation, the government’s mode of subsidy payment for latrine construction matters, and urban bias – either real or perceived – could be a barrier to improved sanitation outcomes. These findings will help generate new hypotheses that should be tested in future research./nPaper two builds on this work by using the the 69th round of the National Sample Survey in India to examine the association between one specific social determinant – the amount of dwelling space owned by households – and the likelihood of latrine ownership. This paper also examines the variation in household latrine ownership that is attributable to village and state context. Findings from this paper suggest that the amount of dwelling space owned by households is significantly associated with their likelihood of latrine ownership. Furthermore, a significant amount of variation in household latrine ownership is attributable to village and state context. Further research is required to elucidate how village and state context is associated with household latrine ownership./nPaper three focuses on Anganwadi Workers (AWWs) in India. AWWs are one group of community health workers in India who are responsible for ensuring improved maternal and child health outcomes throughout India. The Ministry of Women and Child Development in India has issued guidelines on the amount of time AWWs are expected to spend on key activities. Given that time spent on activities is an indicator of AWW performance, this paper examines the association between various AWW characteristics and whether or not they spend the expected amount of time on certain activities. Our findings suggest that AWW characteristics such as caste, years of experience, and having a helper are significantly associated with whether or not AWWs spend the required amount of time on home visits, feeding children, preschool education, and filling out their paper registers.

Advisor: Smith, Kirk R