Child stunting illustrates how richer households can suffer from the effects of poor sanitation. Child stunting is very high in India: 48 percent of boys and of girls were stunted in 2005-06.<sup>4</sup> Yet the most striking feature of the Indian data is the high levels of stunting among the _<u>wealthiest</u>_ quintile of households, compared to lower-income countries in regions such as Latin America or Sri Lanka, which have better public health systems (Figure 1). There is almost no child stunting in the top wealth quintile in these countries, while in India 25% are stunted.<sup>5</sup> Studies <mark>indicate a strong relationship between increases in height and decreases in disease burden.</mark><sup>6</sup> Children in the top wealth quintile are unlikely to be stunted because of shortage of food or medical care.<sup>7</sup> However, they are exposed to contaminated environments outside their homes if not at home. Access to medical care ensures low mortality among these privileged children, but repeated infections expose them to stunting – which is associated with lower cognitive ability, earnings, and longevity.<sup>8</sup> This happens even if a child does not appear ill: ‘Subclinical infections, resulting from exposure to contaminated environments and poor hygiene, are associated with stunting, owing to nutrient malabsorption and reduced ability of the gut to function as a barrier against disease-causing organisms’ (WHO 2014:2).

Recognition of the need to focus on the weakest links in the chain in order to protect the elites was a key motivation for municipal governments in the West to invest in improving sanitary conditions in their crowded and dirty slums.<sup>9</sup> ‘The knowledge that the diseases of the workers who sewed clothes in their filthy tenement homes or who processed food could be spread to decent, clean, and respectable citizens served as a powerful incentive to the reform of public health.’ (Duffy 1971:809).

The Government of India’s ‘Swacch Bharat’ sanitation campaign offers hope that sanitation and public health may get more of the importance they deserve in public policy.

- (b) **_Governance arrangements that impair the accountability of service providers_** , including:

- Devolution of service delivery that transfers funds and responsibilities to elected local bodies, without strong arrangements for holding them accountable for effective financial management or service delivery.

Public health services are especially vulnerable to such devolution, for at least two reasons. First, their success is defined by a _<u>lack</u>_ of (adverse) events. It is far easier for elected representatives to reap credit with their constituents by opening a hospital. Second, decision-making for public health services is highly technical in nature, and needs to shift in response to ever-shifting disease conditions. This is difficult to achieve if key decisions must be approved by non-technical people.

- Fragmentation of services with inadequate coordination arrangements. Public health outcomes depend on the provision of multiple services − in particular water supply, solid waste, drainage, and sewerage.  Poor drainage or uncollected garbage can seriously hamper efforts at mosquito control efforts.  Many other sectors are also involved here, such as those responsible for leveling roads and drains.

Poor coordination of these services is detrimental to protecting population health. This also demoralizes public health staff and citizens seeking to improve health conditions.

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