Caste and class interactions in inequality in access to sanitation and hygiene services in India Open Access

In November 2015, the United Nations General Assembly (UNGA) adopted access to clean drinking water and sanitation as human rights, which are essential to realize all other rights (United Nations 2015). After more than a decade of declaration on water and sanitation rights, the United Nations Organization (UNO) 2023 special report on progress toward Sustainable Development Goals (SDGs) shows that at the current pace, SDG-6 (clean water and sanitation, hygiene [WASH]) will not be accomplished by 2030 and multifold (at least three times) intensification of current efforts is required to reach the goalposts. As of 2023, 3.5 billion, 2.2 billion, and 2 billion people do not have access to safely managed sanitation, drinking water, and hygiene services, respectively (United Nations 2023). Access to safe WASH services is crucial not only for personal health and well-being but also has strong implications for society due to the negative externalities of a poor WASH environment.

In India, considering the human development implications of WASH facilities, governments have made efforts to improve access to WASH services, such as the Jal Jeevan Mission (JJM) and the Swachh Bharat Mission (SBM). Still, due to a lack of explicit Constitutional rights to water and sanitation, progress remained slow, and there exists a huge socio-economic inequality in WASH access (Mohan & Dulluri 2017). The latest available household survey data show that 23% of households do not have access to improved sanitation facilities. Compared to only 2% in the richest household, 56% of the poorest households lack improved sanitation facilities. Similarly, 19.4% of the households report that at least one member defecated in the open, whereas the figure is 52% for the poorest households and 35 and 26% for Scheduled Castes (SCs) and Scheduled Tribes (STs) (IIPS & ICF 2021).

In the present study, we focus on two main pillars (sanitation and hygiene) of WASH services because the investment in these sectors has huge potential to improve a wide range of health and nutritional outcomes and society's overall well-being (Amebelu et al. 2021; Waddington et al. 2023). The literature has explored WASH from (social) science, humanities, and interdisciplinary perspectives due to its public health, environmental, economic, and social implications (Hyun et al. 2019; Yamauchi et al. 2022). In India, Geruso & Spears (2018) estimated that a 10% points reduction in neighborhood open defecation (OD) would result in an 8% decline in the average infant mortality rate (IMR). In an experimental setting, Hussam et al. (2022) found a significant impact of hand hygiene on child health and nutritional outcomes in India. Alongside supply and demand side constraints, social attitudes toward sanitation contribute to less effective use of and access to WASH services in India (Gupta et al. 2020).

In India, caste is an intrinsic element of social identity. The caste system has its origin in the Vedic Period and has evolved through different times and spaces. The underlying principle of the caste system – the concept of ritual purity and pollution – has remained a permanent hallmark. Even in the present time, caste prejudice exists among educated and skilled youth in India (Deshpande & Spears 2016). Among the four major constituents of caste, STs and SCs are at the bottom rung of the social hierarchy, followed by Other Backward Classes (OBC) and ‘Others’ on the top. The marginalization of these (STs and SCs) socially disadvantaged communities is evident in the labor market, education, health and nutrition, and basic housing amenities (Deshpande 2011; Borooah 2018; Arora & Choudhary 2024). Access to WASH services is also affected by social status (Dickin & Gabrielsson 2023). A recent study in Nepal found that social identity (caste) is one of the key predictors of access to WASH services (Balasubramanya et al. 2022). In India, Roy (2023) explored the spatial and socio-economic aspects of limited water and sanitation facilities. Prakash et al. (2022) studied the sanitation aspect of WASH services and factors associated with Swachh Bharat Abhiyan (SBA) benefits. Roy et al. (2023a) examined the socio-economic correlates of improved sanitation and water services in West Bengal.

A few studies have explored households' access to WASH facilities in India, but their scope remained limited to specific aspects of WASH services or a geographical unit, and the role of class and caste intersectionalities was also not examined. Furthermore, we have only 7 years to accomplish the SDGs (specifically, SDG-6 on WASH), so identifying low-progress areas and societies is crucial to accelerate the progress and prioritize them. Therefore, the present study attempts to examine the status of access to various sanitation and hygiene services in India using a nationally representative survey designed to assess the water, sanitation, and hygiene situation in India. The study also examines the role of social identity and household socio-economic status in access to safe sanitation and hygiene services and factors associated with OD in India using the WHO and UNICEF Joint Monitoring Program (JMP) sanitation and hygiene service quality conceptual framework (WHO & UNICEF 2021). The findings of the study are relevant to policymaking as the study tries to identify the factors and social and economic intersectionality associated with poor access to sanitation and hygiene services.

The study uses cross-sectional household-level data from the 76th round of the National Sample Survey (NSS), which was conducted from July to December 2018 by the National Statistical Office (NSSO) under the Ministry of Statistics and Programme Implementation (MoSPI Govt. of India 2018). This round contains comprehensive information on household water, sanitation and hygiene (WASH), and housing conditions. A two-stage stratified sampling design was used by the NSS in the 76th round. In the first stage, Primary Sampling Units (village in the rural area and Urban Frame Survey [UFS] block in urban area) are selected, and the Ultimate Stage Units (USU), which are households, are selected in the second stage. The survey is nationally representative and collected information from 106,838 (63,736 urban and 43,102 rural) households across 28 states and 8 Union Territories (UTs) of India.

The 76th round of the NSS on water, sanitation, and hygiene collected comprehensive information on the socio-economic status and demographics of selected households. Following the literature on access to sanitation and hygiene services and Indian setting our explanatory variables include sex and level of education of household head, place of residence (rural-urban), household size, religion (Hindu, Muslim, and Others), caste (Scheduled Tribe [ST], Scheduled Caste [SC], Other Backward Class [OBC], and Others), usual monthly per capita consumption expenditure (MPCE) as a measure of economic status (Balasubramanya et al. 2022; Prakash et al. 2022; Ghosh et al. 2023; Roy et al. 2023a). Finally, we define class status by constructing five (poorest to richest) quintiles of MPCE.

Primary outcome variables are binary in nature; therefore, frequency distribution by background characteristics is used for bivariate descriptive statistics. Multivariable logistic regression is applied to identify the predictors associated with access to safe sanitation and hygiene services and no sanitation facility (OD) at the household level. For each outcome, separate regression models are used. To account for the effects of other covariates, the regression models are mutually adjusted for the household head's sex, level of education, and socio-economic status. The estimated odds ratios are reported with a 95% confidence interval. To estimate the predicted probabilities, average marginal effects are reported as marginal effects quantify the incremental change and explain the average effect of changes in predictor variables on the probability of outcome variable (Agresti 2019). The NSS uses a multistage sample design; therefore, appropriate sampling weight is used to correct the selection probabilities. Stata software version 15.1 is used to conduct the analysis (StataCorp 2017).

The present study uses anonymized secondary data collected by the National Statistics Office under the Ministry of Statistics and Programme Implementation (MoSPI) government of India. The confidentiality and anonymity of respondents were ensured throughout the study.

Table 1 presents households' access to sanitation (safely managed, basic, limited, unimproved sanitation services, and no sanitation facility) and hygiene services in India based on the (UNICEF and WHO) JMP service quality ladder. Overall, 51.2 and 71.8% of the households in India have access to safely managed sanitation and hygiene services. In comparison to hygiene services, socio-economic disparities are more apparent in sanitation services. In urban areas, 63.9% of the households have access to safely managed sanitation facilities whereas in rural areas 44.6% have access to safely managed sanitation services. In comparison to urban (3.8%), OD is more prevalent in rural areas (28.7%). The higher prevalence of OD in rural India is largely attributable to the ill-perceived notion of ritual purity, pollution and fear of latrine pits filling up and emptying among forward caste people (Gupta et al. 2020). Female-headed households had higher access to limited sanitation services (14.5%), while access to safely managed services was higher among male-headed households. Households with a head's level of education graduate or higher have significantly higher access to safe sanitation facilities. Among the social groups (caste and religion) a larger proportion (two-thirds) of socially privileged caste groups have access to safely managed sanitation services compared to just 36.6% among STs. ST-SC households have disproportionally lower access to any form of improved sanitation facilities and limited services. One-third of ST and 30.3% of SC do not have access to any type of sanitation facility. Among the MPCE quintiles, only 40% of the poorest households have access to safe sanitation and 42% defecate in the open.

Part 2 of Table 1 shows access to hygiene services, which is a combination of water and handwashing material availability around the toilet and whether household members wash their hands with water and soap/detergent after defecation. Compared to sanitation services, access to basic hygiene is higher across socio-economic status. However, there also exists a wide disparity among urban–rural (16% points) residences, social groups (Other vs. ST [21.7% points]), and economic classes (richest vs. poorest [8.8% points]). Sex of the household head, household size, and religion do not show significant differences in access to basic hygiene services. We find substantial state-level variations in access to sanitation and hygiene services (Appendix Figures 1 and 2).

To identify the factors associated with access to safely managed sanitation and basic hygiene services, multivariable logistic regression results are presented in Table 2. The odds ratio is reported after mutually adjusting for residence, sex, education of the head, and socio-economic status. Urban households were more likely to have safely managed sanitation (AOR 1.19; 95% CI 1.14, 1.24) and basic hygiene (AOR 1.47; 95% CI 1.40, 1.55). Contrary to this, rural residents are more than three times more likely to have no sanitation facility or OD (AOR 3.38; 95% CI 3.14, 3,64). Female-headed households are more likely to have safely managed sanitation (AOR 1.04; 95% CI 0.98, 1.09) and basic hygiene (AOR 1.09; 95% CI 1.03, 1.16) and are less likely to practice OD (AOR 0.90; 95% CI 0.84, 0.96). Household head education is significantly associated with greater likelihood of having access to safely managed sanitation (AOR 3.22; 95% CI 2.98, 3.48) and basic hygiene (AOR 2.66; 95% CI 2.42, 2.93). On the other hand, households with illiterate heads were almost five times more likely to defecate in the open (AOR 4.69; 95% CI 4.05, 5.43). Among social groups, the odds of defecating in the open are more than twice for STs (AOR 2.30; 95% CI 2.11, 2.51) and SCs (AOR 2.62; 95% CI 2.44, 2.81) compared to other socially privileged caste groups.

We estimate the marginal effects of safely managed sanitation and hygiene services to quantify the magnitude of odds ratios. Table 3 shows that after adjusting for other socio-economic characteristics, the probability of access to safe sanitation is 0.26 points, 0.16 points, and 0.22 points higher for those having heads with graduate education and above, Other social groups, and the richest MPCE quintile compared to no-education, STs, and poorest MPCE quintile, respectively. The probability of OD is 0.28 points, 0.12 points, and 0.13 points higher for the poorest households, SCs, and rural areas compared to the richest, ‘Others’ social group, and urban areas, respectively.

The present study examines the JMP service quality-based access to different sanitation and hygiene services and how social identity (caste) interacted with economic deprivation affects their accessibility in India. More than half of the households residing in rural areas do not have access to safely managed sanitation services. One-fifth of the surveyed households live without any sanitation facility or defecate in the open. A similar pattern of OD is also found in NFHS-5 (2019–21), which shows that 20% of the households have no sanitation facility (IIPS & ICF 2021). In December 2019, the government declared India as Open Defecation Free (ODF), and a close examination of the ODF claim found some definitional disconnect between the definition used in SBM and other household surveys (Seth 2021).

Another independent survey also found that despite a substantial increase in toilet ownership, OD persists in Northern Indian states. Further, the study reveals that SBM officials also took undue coercive measures to force people to build latrines and suggests that in North India, rural sanitation policy could be more effective if social attitudes toward open defection can be changed (Gupta et al. 2020). Coffey & Spears (2017, p. 222) reflect on a crucial aspect related to the lack of awareness among people about the goal of SBM and low spending on behavior change. In line with their prediction, the latest estimate from the National Family Health Survey 5 (2019–21) shows that 20% of households still defecate in the open. Our finding coheres with Prakash et al. (2022) and finds large regional and state-level rural-urban disparities in access to various sanitation and hygiene services.

Apart from sanitation services, we also report socio-economic disparity in access to hygiene services in India. Compared to sanitation, access to basic hygiene is much higher, and socio-economic inequalities are lower (Roy et al. 2023a). However, privileged social groups have an advantage in both safely managed sanitation and basic hygiene services. The intersection of social identity and economic status shows a visible caste disadvantage in access to safe sanitation and hygiene, irrespective of economic status. These findings align with a study in Nepal on access to WASH and healthcare services where caste and social identity are significant determinants of access to these services (Balasubramanya et al. 2022). In India, Spears & Thorat (2019, p. 731) concluded that ‘when many people in rural India compare the costs and benefits of latrine use and OD, aspects of the culture of caste-related purity and pollution encourage open defecation.’ Therefore, policies aiming to change social attitudes toward ritual and physical (im)purity and pollution can play a significant role in improving access to better sanitation services across all sections of society (Gupta et al. 2020). Arora & Choudhary (2024) find that 24% of the difference in access to basic household amenities in urban India is attributable to caste-based inequality. Similarly, social identity (caste) affects almost all economic affairs of life in India (for details, see Deshpande 2011).

We find that female-headed households are more likely to have access to safe sanitation and hygiene services and lower the probability of OD. One candidate explanation that may explain this relation, partially, if not fully, is intrahousehold bargaining power and benefit perception of access to sanitation facilities. Experimental evidence from India shows that women's bargaining power and higher benefit perception of sanitation loan up-take positively influence the household's decision to invest in sanitation (Augsburg et al. 2023). Das et al. (2023) found that in peri-urban areas, the probability of using toilets exclusively for sanitation is 16% points higher in households where the decision to construct it was solely taken by women. Thus, embedding awareness about the benefits of improved WASH services in women empowerment policies may help to end open defecation in India. It may further promote gender equality as women face harassment while going outside to defecate and also disproportionately bear the burden of cleaning the feces of children, ailing family members, and fetching water from outside.

Safely managed sanitation is a public good as it serves an excreta-free living environment that has positive externalities (Ross 2017). A significant positive impact of community-level improved sanitation on child mortality and human capital was observed in India (Spears & Lamba 2016; Geruso & Spears 2018). Access to improved WASH services mediated 23% of the rural-urban differences in child stunting in China and resulted in a lower likelihood of ill-health episodes of occurrence of diarrhea among children under 3 years of age in India (Lin & Feng 2023; Roy et al. 2023b).

In terms of class and caste interactions, we find a persistent significantly lower probability of having access to safely managed sanitation services for socially deprived groups irrespective of their economic status. It indicates that to improve access to safely managed sanitation facilities among social groups, specific policies should be designed with an emphasis on social identity alongside monetary poverty. However, there is a convergence – much more robust in the case of OD – in the probability of having access to basic hygiene facilities and not defecating in the open among social groups with higher economic status. Therefore, the immediate target of eradicating OD can be achieved more effectively by economic status-based targeting alongside a long-run transition to safely managed sanitation services for all. In rural India – specifically northern states where ritual purity, pollution, and caste-based norms are responsible for a higher prevalence of OD— sanitation policy should encourage the adoption of affordable toilets alongside changing the social attitude toward sanitation (Gupta et al. 2020).

Using (the WHO-UNICEF) Joint Monitoring Program sanitation and hygiene service quality ladder, the present study examines the status of class and caste-based interactions in access to sanitation and hygiene services in India. We find a significant variation across states in access to safe sanitation, basic hygiene, and no services. There is convergence in access to sanitation and hygiene within the state. Privileged sections of society have a higher likelihood of safely managed sanitation and basic hygiene services. In contrast, the probability of not having any sanitation services (OD) is 28% higher for the lowest MPCE quintile households. It further intensifies when interacting with historically marginalized social groups. This indicates that relying on mere economic or social group targeting is not sufficient to ensure equitable access to WASH services, and socio-economic intersectionalities should be taken into consideration.

Findings imply that a special policy should be designed to achieve convergence in access to sanitation and hygiene. Further, there is a strong need to upscale the existing policies in the lagging behind states. This upscaling can be done by empowering, training, and compensating the Village Health Sanitation and Nutrition Committees (VHSNC), which are constrained by a lack of training of members, fund utilization, and poor linkages with the healthcare system (Srivastava et al. 2016). The VHSNC includes frontline workers, Accredited Social Health Activists (ASHA), Anganwadi Workers (AWW) and adequate representation of women and socially marginalized communities. By information delivery and local campaigning about the social benefits of improved WASH services, the VHSNC can play an instrumental role in behavior change. Further, a comprehensive state-level access to WASH services index can be created to measure the performance and resource allocation. Finally, to overcome the implicit barriers that emerged from social identities, basic health and hygiene materials such as soap/detergent should be provided to marginalized sections of society in WASH programs and policies.

We thank Manoj Godara for the helpful discussion in the research problem formulation.

The author(s) had not received specific funding for this work.

All relevant data are available from an online repository or repositories. The dataset used in the present work is available at the online microdata library, https://microdata.gov.in/nada43/index.php/catalog/153 of National Data Archive under the Ministry of Statistics and Programme Implementation (MOSPI) – Government of India.

The authors declare there is no conflict.