wp278-82636

THE EFFECTS OF SAFE DRINKING WATER AND
SANITATION ON DIARRHOEAL DISEASES
AMONG CHILDREN IN RURAL ORISSA
Pradeep Kurnar Panda
Working Papcr No. 278
May 1993
THE EFFECTS OF SAFE DRINKING WATER AND
SANITATION O N DIARRHOEAL DISEASES AMONG
CHILDREN IN RURAL ORlSSA
Pradeep Kumar Panda
Centre for Development Studies
Thiruvananthapuram
May 1997
This is a revised version of a paper presented at the National
Seminar on Iiural Water Supply and Sanitation organised by the
Centre for Development Studies, Thiruvananthapuram, during
20-22 June, 1996. For constructivecomments and suggestions, the
author is grateful to all the participants of the seminar, and
especially to Henk van Norden, UNICEF, New Delhi and to
JagadishChander, Rajiv Gandhi National Drinking Water Mission,
Government of India. The author alone is responsible for errors,
if any.
Abstract
This papcr investigates rhc ct'fects o f safc drinking water and
sanitn~ionon diarrhocul discascs alnoiig chiIdren in rur;il Clrissn. Safe
drinking watcr i ~ n t lgimd sanitnlion facililios favour the crcation of a
hygienic cnvimnment, which helps ro pwvcnt the incidcncc of vi~rious
infcct ious childhood diseases such as diarrhtwn anti cnzthlcs Ihc child to
survivc. In hc!, cnnsirlernhlc litcraturc in developing cc~untriesin the
lasr two dccades documents this ~'cla~ionship.
This issue i s of' parlicular
itbrercst En Oriss;~.which is charautcriscd by high lcvcls ol' poverty. low
iWcCS lo safe drinking watcr and sanitatiaa. and high rvatcsof diseases
i11lCJ deaths a1111)ng children.
Data for this stlrdy comc h)rn ir fielrl survcy cnnrluctcd in 1989-
'20 ia thc Bnlnngir disiric~of Orissa. Thc analysis providcc strum2
conl'irmation rcgnrding thc imp~rrarccof safc drirlking walcr and
sani~a~ion
when conside~.ingchildren's diilrrhtwil cpiso(lc. The rtsults
suggesl rhnt s a k drinking water and snni~ulionfxililics have a strong
ncgativc asst~cirtrianwith chilrlhnud cliac~~hr~ca,
cvcn afler conifillling
tor tllc clTects
relcvnnt soulo-cconomic variables. Howevcr. mother'h
educa~ionand pcr capita income
occurrence of diarrtiocal cpisodc.
iIrC
also invcrscly rclnled lo the
Thc policy implications or this stutly. therefore, ;Ire quile olenr.
With a view lo i~chicvlnga steatly dccIinc in diarrhocal diseases among
children, piu-zicularly among certain socially and econainically
disadvantngcd groups, hasic thcilitics such as access to safe drinking
I'acititics nus1 hc dcvclopcd in addition lo the
provision or direc~hcalth care and cduciltional opporlunitics.
walcr anti sanitation
JEL Classification: 132, 138, J 13
Key words: walcr supply. sanirnrion. childhood diarrlioe:1. health
policy. culnnion property rcsuurcc, cliild survival
1.
Introduction
With suhstaatinl irnpmvemcnr in lifc expectancy. child mortality
and complctc eradication 01' small pox, world hcallh condilions llnvc
improvcd more in the past four decades than in a1I of previous h u m a n
history (World Bank. 1493). For inclancc, in 1950, life cxpectaucy in
developing countries was 40 years; by 1990, il has increased to 63 years.
[n 1960.22 out ol'eve~y1 M d~ildren(lied hcfore rhcir first hirlhday; hy
1990, thc number had thllcn to 1 I).
Srnallpx. which killcd ova- 5 million
pcoplc anrlually i n the early 1950s. has been eradicnted entirely.
Despite thcsc rcmal-kahle impi+c~vements,however, cnotnlous
hcallh prob!ans remain, cspccially in low incume populations. Moreover,
r llc inciderlcc and nature of discascs lend ro hc dilTerenr in duvelopirig
economics. Infectious diseases, many nf which are prevcntahle. undernulrfrinn and inalnutri!ion arc far rnore prevalent
in
low incornc
environinenls (Wo~*ldBank, 1993: Jamison et al., 1993; PinslrupAndcrscn ct al., 1993). It is esrimatct! that 45 per cent of all dcaths in
devebping ccunomies in 1985 can he attributed to iuli~riausand parasitic
discascs such
diarrhoea and malaria: these discrlscs accounr For 4.5
percent of denrhs in industrial mnrkct cconomies (Lopz, !493 ). Ahsfllutc
levels of mortality in dcveluping cauntl-ics are still unacceplnbly high;
child mortality rateq arc nhour I0 tirnes higher than those in the industrial
murkct cco~lomics.if is estimated Ihat i l dcalh rates among children in
developing countries were educed ito those prevailing in thc rich
countries. I I inillion fcwerchildren would die each year: Almost halfof
these prevcnrablc deaths are a resull of diarrhoea! and rcspiraroiy illness,
exacerbated hy nlalnutrilion (Jamison, 1993).
Diarrhoea remains one of the, commonest illnesses of children,
and one of Ihc Ici~ldiagcauses of chi ldhoorl mortality ia devcIoping
corrnlries. It is estimatcd that over IIHW) million cpisadcs and 3 rnillion
dcaths c l ~ c u i .ench year in childrcn under five years or age in he
dcvcluping coualrics (World Health Orgnnisa~ion, I992; Rcm ct al.,
1992). Many 01' thcsc children die from dehydration: dysentery arid
n~alnulrilionare also important causes of death. Dimrhocnl rIiscase also
rep~rscntsan emnomic hudcn for rhcse countrics, since childrcn with
diml-hoca arc IIRCII rrcln~irredlo hospital and !reued with cxpensive
inlraveflous nuids and ineffeclivc drugs. evcn though si~nplcand cl'l'ective
trcut ncnl ~nmkurcsarc avnilahle such as OMI rehydralion theralry(0RT)
(World Health Organisation, 1992). Dcspite the indication of n {Iccline
in diurrhocul nwtality ovcr the pask dcu:~dcin many dcvclo1)ing countries
(Murlines
a al.,
199 I : Snndilbrd et a!.. 1991). there arc also rccenl
small scalc studies 1h2toKer clcur cvidcncc of continuing high morloliry.
especially itmctng infants: nwrly 2U-30 infan1 dcnths pcr I UOO livc births
(Kutilar. 1987:
Bcgc~~holm
el ill.. 1089: Bailcy el al.. 1990).
01'thc sevanl inrervcnliansthat may rcducc rliarrhrxn morbidity
and mortnli!y !ares (Fcirhcm cl al.. 19831, ihe i~np~nvcmcnl
of water
supply atid sanitalion has attracltd particular inlercsl (Esrey ct al., 1985).
Wit11 he anlicipakiatk that thr improvetncntof water supply and sanitation
will have a substantial impact on diarrhoea ~norhidity and morlaliry ram.
especially in clevcluping rcgions, the [notivation for thc lntcrnational
Drinking Wa~erSupply und Sanitation Decade ( 198 1-91)) came into
cxistencc. Howevcr. in 1990. ncarly 855 million peoplc werc still without
accusc l o
side drinking water and ncarly 1.7 billion p p l c do not have
i r C c s S to
sanitnlioa facilities worldwide (World Bank. 1992).
Thc ~.l'ticctivcncss or inlprovcd waler supply ant1 snnitniion on
diarrhoea and othcr wiitcr rcln~eddiseascs in developing cr~untricshave
hccn cxte~~si
vcl y disc~~ssal
and dchatcd O \ ~ C ihe
~ - past iwcl dccades ( Whitc
el al.. 1972: Saundcrs a~irtNtrlbrd,
1976; World Sank. 1980: McJunkia.
1082; R a c h c n ~ct al., 1983: Rlum and Fc;lchwn. 1983: Merrick, 1983:
Esrey and FEshichr. 1985; Zuidi, 1985). Esrey ct :r1.(1985)rcvicwcd 67
srudics t'rom 28 countries in c~rclerto analysc thc irnpacr of walcr supply
amd sanitation on diarrhoea. Thcy found thi~
thc mcdii~nreductions in
dial rhnea morhidily wlcs are 22 percent finoma1l studics and 27 pcr cenl
I'run~a few hetlcr-dcsigned stuciics. Swondly, all studies ol' thc impqct
on Iota1 ~nortnli ~ rates
y
show a n~ctlianreduction oi' 2 1 pcr cent, whilc
the few hertcr-designcd sttulics givc a merliun rcducticln 01'30 pcr cent.
t-acrly. ~hcgalso Found ;~h;~r
improvemeau in wiltcr qui~lilyhave Iess of
an impt1c1thiill in~provci~~cnls
in watcr availahilizy or excrcta tlisposal.
SimiCi~rly.thc World Bank cuimiltes rh;u lhc cllkct or prnviding ncccss
EO safe
walcr anrl adequafc swiraion lo all whn currcntly lack wuuld
result in l w o nill lion kwcr deaths cach ycar From diihrrhoca amang
ct~ildrenundcr t'ivc yeias ol' agc ar~d2IM ~ i ~ i l l i o~nC
W C
cpis~des
~
01'
diiii rhnea a11nu;tlly ( WolnltlBank, 1992).
Hcccnt cmpirica! work on the positive clfects of'waler supply and
sanilation schcmcs o n the hcalth of the populalions. although exists, thc
wlationships have no1 k c n w l ~ ~ u a ~dr~urnenrd
cly
(Briscm a al., 1986;
BI-iscoc,
19R7;Plnnas. 1988: Wane CI al.. 1989). Moreover. ir i s nnl
possible ro i 1 1 . a ~a causc-and-ellkcl relationship from lhese studics.
Utiacuc et ul., ( 198b. 19881 addresses the ~nclhodolagicaldif icultics
involvcd in cvaluiltiiig ~ h cl'l'cct.;
c
of willcr supply and saniwion. and
suggcs1c.d i~npmvemcntsin the d c ~ i g nof hculth iinpacr evaluations,
inchding thc iiicrcascd usc of thc case-con21-ol lllcrhod and rapid
ilsscssrncnrs to provide infonnaliur for policy decisions. Ir is, rhercfore.
reuogniscd hat thc dcvclopmcnr of w;hrcr supply policics th;bk can
suh.ct:~nliully in~pr.cwehcdth conlii tions will dcpend on hcttcr rchcarch
10
rlcterminc kcy l'aclors lllal could tndke such policies ctjxt-ulf'cct~vc
ant! siistaiiinhle (Weil CI a!.. 1990).
This sludy invc.c~i,oatesthe cffccls of ~ a l cdrinking warel. and
sanilatitrn o n riirt~.rliucaldiscuccs among childrcn
ill
a rural sctriiig In
Orissa. Intlia. It asks two qrreslions: IGrst. 10 w h a ~cx~cntdocs safe
drin kin? w:hlcr alitl sanitation efl'euf childt~ocxlrlinrrhwa :ISccond. how
irripur(ant ir; this l;~ctosin relation to othcr socio-econorl~icL~utnr.s.such
a s wt~men'sctl~~culiun
and pcr uaplla income ?
?he rnuin body ol'the paper isc~rgntli\cdinlo lour sections: Scction
11 hrictl y prcsc~its\umc background l'euiurcs ol' Clris\i~, Section II1
describes ihc survey dula ant! provides I l ~ e~iiclhodolofiyuscd in this
study: Scc~ion I V cxaniinc.; thc crnpil-ical cvitlencc linkin: sali: drinking
w a ~ e rant1 sanil:~tionas wcll as iVomcn'scduca~ioniilld PI. cilpi~;iinc.omc
to childhood diarrhoca; and Section V concludes rhu pnpcl wilh a t't&
1.cmat.k~on pas1 expcl iencc wirh thc public polrcy o n wa~ei*supply and
sanitation
scherncs in India aiid iinplicalioli~rol* thr: 1'11Iurc.
(Irisah. which 1ic.c oa ihr: caslern coast along ~ h Bay
c 01' Betigal,
tias 3.7 pel- ccnr of' Lhe tolal population and 4.7 pcr cetlt
o f thc land urea
ol- the counItqy. 'lhc ccononiy vl' Olhissaic pi-ccl~~li~iiiar~tly
:~gricul~ui-al.
Thc agriculluial scclor at~\orlssR9 pcr cent of tlm total work ibrcc and
c+ontrihules 50 per cetlr ol' the statc's dn~i~cstic
pinducl. Ahoul 87 pcr
ccnt ot'rhe population ofOriss;i livc in rural areas, ctli~~piir~cl
wilh 74 per
cent in India as a whotc. According ro the 199 1 Census, the literacy rates
arc 63 per cenl l'or males and 35 percent for tcrnalcs in Orissa compared
with 64 per ccnl and 39 per cenl for males and females respcclively in
India (Census of India, 199 1 ).
On the ecorrn~~ic
I'ronl, 48.3 per ccnt of' Orissa's rural population
compmetl lo 33.4 per cent nationally livcd helow the poveriy line in
i987-XS. according 10 thc ol'f'icially relcnsed Planning Commission
estimates. According In tllc Exper1 Group on Poverly (1993). thc
incidcncc ol' povcrty in run1 Orissa was even much highcr than rural
India (6 1.5 pcr cent and 37.6 per cent respcctivclly). Rcgal~ilcssoC lhc
dchatc on the methodology of poveriy eslimation, it is clear that rural
povcrry in Orissii is the highest in the country. In 1990-91 , Orissa's real
annual pcr capila incoinc w:a Rs. 16 I S compared lo Rs.2239 S'nr India
ns a whole (Cctltrc foi- Monitoring Indian Economy, 1993). Orissa is
chariicteriscd, breralio. hy low agiicullurai produclivity and thc highest
incitlcnce or rural prlvcrty in India. Agricultural modernisation and rural
inCrasrructural dcvctopmcnr including water supply and siiniladon lag
behind nrosl of India (World Bank, 1991).
The hcalth conditions of thc pcoplc 01' Orissa, mcasured in tenns
or ~nunalityand morhidi~y,are cxlrcmely pmr. For instance, in 1992.
lhe in fan1 morl:rl ily ralc was 1 14 per 1000 live births in Orissa (highcs~
among all ?;lates).cornpurcd with 74 in all India. As rcgards morhidily.
the rneuenrlycclnductcd Nnt ional Family Health St~rvcy(NFHS)estimates
!ha( in India, during 111c two weeks preceding the survcy, scven per ccnl
of childrcn undcr agc Ibur had synlplrlms of acute rcspimlory inl'eclion
(cough accompanied hy fasl breathing). 20 pcr cent wcre sick wiih a
revcr, and I O pcr ccnl had diarrhoea ' . As apainsl all India. Ihc childhood
I
For a uxful discuwion
011~ l i m h n e a
mo~bidityand
norl la lily among childrcn in
India, scc Bhmi cr 31.. ( 1989).Kumarct a!..( 1987). Mothurct at.. ( 1 985). and Sircar
rt
al.. ( 19841, Visw;~narhanand Rhodv ( l99t)).
morhidi~yin Orivsa is lliglier for all the ~ h r c ctlis~itscsrncnlionud above:
I O per ccnt of childrcn under agc I'irur had symplum~;ol'acute r~spiriltnry
inkclion. 32 pcr ccnt wcre sick w i ~ ah icvcr. and 2 1 pcrccnt had d i i ~ n h w a
(National Family IIcalth Survcy, 1995).
On Ihe wl3olc, Orissa is cco~lo~nically,
socially and clculo~rapl~ically
a hackward slatc in India (Panda, 1994n). Thercli~i.~,
Cjrisca presents an
intercs~ingcuse study for [his I-cseiu-ch.
ILI.
Data And Methodology
Data for this study corilc l'~+trmu fcl(l survcy conrlucled i n 198990 in Civc villngcs in the 13olangir dislricr or Orissa. All zhc 1 107
households wcrc cuvercd I'l-onl thc 1'ii.c villagcs with similar socio-cultural
milieu hut dil're~enrlcvels oCdcvclopmcnl. mer~sulrdin tcmu of usc of
eicclr~city,extcnr of nun-agricuIturitl work and ngricul~urrd
rnodenr isation.
Villages wcrc selec~edsn as to hc rcpresentntivc of di If'crcl~idevelopment
pal1c1.n~lihi~ndin rural Orism. Access to inft-;~struciu~;~l
I'acilities was
standardised by selecting villagcs which wcrc s i ~ t i ~ l ator such cl-itcria ;1s
tr:inspcrlAlIbcilitics, i~viiilahll~
ty o f schools and hcvl~hserviccs and dist:incc
Crorn rlle neilrcsr [own. A l l the villzigcs are having drinking warcr points
(tube wcll/hore wcll) provitlcrl by Ihe gavcrnmcnt. hut public provisic~n
OF sanital~on1kili1iesi s complctcly non-exialcnt in ihcsc ~ ~ l l ; i g cThe
h.
survcy was carricd oul dtiriny the nlnnrhs of' Scprcnlbcr 19R9 ant!
I:chauary 1990.
Thu survey u~iliserla household ques~innnaircIhat ctioi~ed
informalion I'rom ~ l i head
c
or'thc I ~ o u ~ c on
h ~thc
~ ddcmopraphic iiebails
o f each r c s ~ d c nas~ well as the houschnld's socral and ecanomic
ch;uavlcris~ics.Thc stlrvey also coltoc!od inforniotinn on ~ h occutrcncc
c
nl'thc symploma of the diari.hoeal dihcnscs. In lact. in India a5 wcll as in
Orissa, d i a n * l ~ m
is a leading cause of death ainang chi tdrco (Cenu:~l
Burcnu at' Health Intclligcnce, 190 1 ). I n thc survcy, the sccond
quesrionnairc on maternal and child hcalih, elicitcd information from
thc currcntty married women in thc itgc group 15-49 on childhood
diarrhoea. Specifically. thc notherb of children horn during the pas! four
years wcre askcd a series of quesrions on the incidcncc ol' diarrhoea
during the lasr one week as well as last
IWO
weeks. In order to obtain
correct infunnation on diarrhoea1 cpisode, the watnen were asked if any
of thcir children undcr ilgc four had a passagc o f threc or more Imse or
walcry or b l d y stools in a 24-hour period. For this paper, thc incidence
of childhood diarrhoea during lhc PSI
rwo weeks preceding ~ h survey
c
has been analyseci.
Siwe the ohjcctive o f this research is to cxarnine thc determinants
of childhood diarrhoea. rhc sanlplc i?;reslricld to householdswherc the
woman h;~dat leas1 onc child horn during the last four years. Restricling
rhe sample ia this nlanncr yicldetl4 16 houscho!dson which the analysis
in this papcr is hascd.
I n this paper, logisiic regression analysis is carried out to identity
the factors that influcncc childhood dia~~hoca.
Thc logislic modcl does
not require any distrihulionnl assurnptivns wnccrning indcpcndenl
variables (Cox. 1970). and it can hc used not only to identify thc risk
Facto15buk ills0 to predic~rhc probability o f succcss. Thc general Iogistic
Irgrcs\lon n~odclexpicsses a quali~ntivcdependent variable as a iuncrion
of' scvcr;ll
cxplanato~yvnriahles, holh quali t i l t ivc as wcll as quanril;~live
(Fox. 19x4).
[F P is thc prohahility oTaccurrcncc <)I
childhood diarrhoea, then
wherc O is a vcctor of rhc unknown coeficicnt and X is a vector
01' covariii~firhar i~ffcctthe accurrcnce of childhood diarrhoea. Thus,
the genera! logistic model can further he expressed as:
P;.
.I
..
,A
which expresses (he lug orids o f chil(ihood diarrl-toea as
;t
line
function of the explanatory variables.
In this paper, we have defined the binary dependent varinhlc th
is asslgncd Lhc valuc of I if a child had diarrhoea in n houreholti durii
the past lwo wceks preceding the survey and O for the non-occurrence I
a diarrhoea1 cpisode in the houschold. A s c o~r li)u~-explana~oi.y
variahll
thougt~llo inllucncc thc dcpcndcnt variahlc arc carcl'ully sclcc~cda1
ca~egoriscti.Thc sclecled explanatory varirtbles and their categories us<
in his papcr are prescn~edbelow:
Mulhcr's education ['illiterile', 'primary' and 'middle & above
Pcr capita annual inuome(low:'lcss ~ h u nRs. 1200', middl
'Rs. 1200 lo Ks.2399' and high:'Rs. 2400 ar~dabove']
Source of' drinking water{ Unsale:'pond/rj verlopen dug well' ar
S;~fe:'puhlictr~hewell/bore well' )
Sanila~ion{ Unhygienic: 'Opcn space' for humun excreta dispos
atid Hygienic:'household toiletllatrinc F~cility'1
IV.
Results
I n the diwussion heloiv, uwcbl iefly sun~ima~.ise
the results fro
cross-lahulalion hctwecn aclccrcd hocio-ccono~~iic
vai-iahles ar
childhoud diarrhoea. Subsequently, we discuss the inter-relat~onshil
bctwccn socio-econotnic vat.iahlcs by examining zcro ordcr corrcldlic
matrix. Finally, wc discuss logistic regression results to sort nut 11
separate cffccls ot lhcsc cxplanatory vai-iahlcs on thc likelihood
occurrence o f childhood diarrhoea.
I
Thc hivariate relationships hetween the occurrence of childhood
diarrhoea and sociu-cconomic variahlcs are presented in Table I . The
table shows thal although nearly two-fifihs of the households have
cxpericnced at leas1 one episode of childhood diarrhoea, there arc
significai~tvariations in the occurrcnce of childhood diarrhoea among
thc houschdds with differen[ socio-economic charac~cris~ics.
The level
of mother's cducarion has a ncgalivc ~.ela~ion
with the occurrence of
dinrrhocal cpisode. showing the lowest occurrence of diarrhoea atnonp
Table I . Percentage distribution of households by occurrence of
diarrhoes in at least one child under four years of age,
according to selected characteristics, Rural Orissa,
1989-90
N
Totaf
Occurrcn~r
No
nF d i a r r h w
diarrhoea
41 6
39.2
60s
100.0
lllilunlc
2b3
43.7
56.3
1000
Prinwy
89
37.1
62 9
100.0
Mtddtu and :~ho'e
M
13.4
76.6
100.fl
L C S than
~ Kr. 1200
144
50.7
49.3
100.0
I ?(MI-Ks.',;W
112
62 3
100.fl
K\ 2 4 W ant1 nhow
150
377
79.3
70 7
100.0
Cbaractrristia
Todd
Molhrr7seducation
Rr rrpitn inmine
Kx.
Snurcc nf drinking water
Tube wlllhorc well
Si~nitalion
Opm space
Hou\whirld #oiicl'.
Nnee: * includes sanitary and other latrines.
children to those wonlcn who hnuc midrile level ediicnlion or ithove.
The per capita income has also a negarivc cfr'tcl on 111eoccurrence of
chi ldhocd diarrhocn. Thc hou~choldswho util ~ s public
e
'tutx we1 l'l'hure
wcl I' sourcea f r drinking
~
water have cxperie~lcedles5 diarrhoea1 episodc
among lherr chilrlren than lhoce households who u t ~ l i s eunsafe/
contaminated sources of drinking wales. The prescrlcc of sanitaiion
friciIity has a i n verce relation with the Dccurrcnce of c hr ldhuod diarrhoea.
.;bowing the lowest iiicidcncc of' a chil(lhoud dinnhoca arnong lhclse
I~ouseholclswho hdve Loilct/latrine tucil~tics.
But CI-(as-tahulat~on
can be mislcading a1 [Imes, so multivariate
analysis is npcescary lo sort nut the main Ihclors cnn~rollingfor other
cokariatcs. The f ~ r s tstep i n this rlil-cc~iclnia lo exalnlne thc
i n t c ~ ~ r ~ l i l r i u i i s hhetween
~pc
various socio-cconomic v ~ t i n b l c s .
Carl-clalions hetween the four cxplunnro~.!,vi~riithlesarc presented in Tithle
2. Kesiills sugged rhnt ( I ) nlathcr's cducaliun is doscly lirlkctl
LO per
Table 2. Zero order correlation matrix s h o w i ~ gthe relationships
between socio-economic variahfcs, Rural Orissa, 1989-90
-
Charartel-istics
.-
EDN
EDN
I
Notcs:
":
FCI
-..28"
.I3
significanl a1 .05 level 01.bcua.;
ElIN
refers to rnothcr's cduuation;
PC1
rcfcrs
WAII'
rclkrs to source o f drinking water; and
SA N
rcrcl-s Lo sanitatiotl facility.
10
per capil;~income;
24'1:
(household toilet}; (2) pel
capita income is closely linked to h t t e r sanitation facility; (3) safe sourct
of drinking watcr (tube well/ hore well) is unrelated to mother's educatior
and hettcr sanitation facility. It i s importnnl to nolice that although thr
correlations mentioned above (cspccially I and 2) are significant anc
arc in thc expclcd direc~inn,the coefficients are not very large.
capita income and better sanitation facility
Thc resi~ltsof thc lugistic regression analysis arc prcsenrcd in Tabl
3 ? . It shows thc sirnul~anenus
effect of sacio-economic variables on th
likclihood of occurrcncc or childhood diarrhoea in a household. Th
all the [our explanatory variables are significa~
predictors of he occurrence of childhood diarrhoea.Moreuver, [he c f k
nf thc explanatory variahlcs are in the expcctcd direclioo.
rcsulrs suggesr Ihal
Howcvc~;of the foul. predictors, the cffect of' mothcr's educatic
on (hc occurrcncr: of childhwd diarrhoea is found to h the r~~ost
inrpofla
one. The likclihood rc~nainsmuch lower for women with middle ar
above level of education (odds ratio is 0.3 15). In other worcls, the worn
with the liighcsl levcl of cducation(middle and ahovc) are less than or
third as likely as illitcrdte w o m e n to have experienced Bn episode
diarrhoea in their c h i l d ~ nThcre
.
arc many routes lhmugh which mothc
2.
111:~ddi~io~i
torhe lo~isticwglerxion m u l ~ prrscn~cd
s
i11Table3. wliichis
ft>l.m, we
in addi
hail also rnie~nptedn muliplicaiive lr~gis~ic
modc! hy ~ncludingreler
intrncricln Icrlns. Wc Imrc itlrcady noric~din Tallle 7, that
want of
llle acre o.
corrtlatirm coeflcients between the cxplanntory va15abIcs x c significant. and
wlat~velyk~argerrltan others. TI~~%fore.
one would expel llle iirst order interact
thcmselx~rsto be significant
lor the highly cacrelateti variables. RUI in
~nulliplic:~tivr:
l d e l none o f thcinreractinn tams (cspccially EDNLPCI,EDN4:
nt~dPUI'SAN) nlr round ro be sipnificanz.As a result. 1lr nhrlltiplicntivcmode
not fil tllc data significanlly better than the additive model. Filially ,therefore
have retained and a n a l y ~ only
l
the d d i l i w intxlel (Tahle
:~ssunlptionof indcpcndcncc of explanatory vnri;lbles.
3). which satislie
education can influence cllild health. For instance, increased education
hrings greater awareness of heallh in general, and results in a higher
value being attached 10 health and hygiene. Moreover, mother's education
may change a whole rangc of health-improving behaviour beneficial for
[heir children as we1 l as households. Specifically. educated mothers
relative to their uneducated counterparts, are rnore likely to seck
information and adopt child care practices, such as preparation of weaning
Table 3. Logistic regression.of occlrrrence of diarrhoea on selected
characteristics, Rural Orissa, 1989-90
Characteristics
Logistic
Odds
P
coefficient (B)
ratio
va111e
-
Mother's education
{Illilerate)
Primary
Middle and abovc
-.408
-.915
1.000
.64 1
.3 15
Per capita income
{Less than Rs. 1200)
RS.I 200-RS.2399
Rs. 2400 and above
-
1.000
-.366
-.642
,698
Source of water supply
( Pond/rivcr/opcn dug well )
Tube wellhorc we1 l
Sanitation
{ Opcn space j
Household toilel"
Constanl
Mvdel chi-quare
Degrees or rreedum(d.f!
Probability
-
-.83 I
.OOO
,000
-
.5 1 7
.ono
,000
1.0W
-
,596
,000
1.000
,405
-
-.552
-
-
2.004
100.599
6
,000
Notcs: ( I ) * includes sanitary and other latrines.
(2) Rcfcrcnce category is in parentheses.
.000
i d s , boiling DC drinking watcr, and pcrsonal hygienc. All these health-
improving hehaviour of rnothcr would rcsult in decreasing incidence of
ot~ildhw~d
diseascs such as diarrhoea. I n fact, ir has long been shown
that rnatcrnal education is linkcd lo child survival in developing cnuntrie~
(Caldwcll and McDonald, 198 1 ;Cochmne el al., 1982; Hobanaftct a!.,
19114; Linenbaurn, 1990: 1,cVine ct at., 199 1 ; Jejcehhoy, 2Y95) ' .
As shown in Tahle 3, the results indicate thal ~ r capita
.
income
also has a signilicanl negalivc cffect
on
the occurrence oE' childhood
diarrhea. Hieh income households are hail' as likcly as low incorue
households to haw expel-icnccd an cpisode of dia~rhocain ~hcirchi tdren.
As thc li tcri~wresuggests. the rich houscholds rclativc to thcir poor
uountcrpal-ts are hcltcr ahlc !a buy inlilr~~lalion
and have grcalcr cnpaciry
10adopt
choiccs. wit11 low uncertainty, rhat arfcfccl childhonct diarrhoea,
o.g. a bctter living condition with hygicnic houseliold envimnmcnt.
AF expected, the ~ o u r c co f drinking watcr has ;I aigrlificent
independent cfrcct on thc occurrence of childhood diarrhoca. Ttic
hauscliolds who utilicc puhtic 'tube wcll'l'horc wcll' sources for drinking
water are threc-fi t'ths as likely as houscholds who utilisc drinking watcr
from tlnhnfe sou~~ccs
to have cxperienced an episude of childhood
diarrhoca.
Thc snt~itationfacility has ;I signi f'icnnt ncl e l l ' i l on [heoccurrcncc
of childhood diilrrlxrca. TRc l~ouscboldswho have toilet l'acili~icsarc
Iwo-liiihs ;IS likely ;IS households who have no such f'acili~ics
fopen space)
to have cxpcricnccd an incidctlcc orchiIdhd diarrhoca. I n ~
3
C I ,in tcnuis
The linksk!wccn ~nalcrnnlctluc:~~ion
and chili1 heiiltll ir wcII c<t3hfihhtxl111 Indi;~,
and zspevially ill Kcr;kla E!,IIC. For ;i ~
~ C C U S on
Y ~the
L ~rolc of rmten1:kl cducnrion rn
dc~lwg~.aph~cl
hcallh rr;~nsilirr~i
in Kr~aln.srt. Bhal and Ilaj:lnt lWO): Kabir ant1
Ktisllni~n(1992): and Krislt~~:tlt(
1976. 1'191. I9921
of'the magnitude of the eft'cct, Ihc cf't'cct ufsslnitn~ionon the oucumcace
ol' child hood diarrhocn is next to won~ct~'s
education.
W;~tcr supply and s a ~ ~ i t a t i ocondi~ions
l~
directly at'fecl
uonta~ninnlionof thc household cnvirt~nritcntarltl rhus may facilitalc llic
disscminarion ant! incidence ol' various rliscascs, suck as diurrhocn. i b r
inslance, safc disposi~lof human Llects or ilrotcction ot' water supply
I ' I - ~ I I I cnnlaminalioa will rcw11 in 1l1c recfucriol~01' t hc iricide~~cc
of
di;ktrhoea. Thcrcfure, p~rvenlir>n
01 diarrhoca is linkccl to ~ h rluali~y
c
as
wcll 3s llle quantity or water supply and 10 good sanitation ([Jriscoc.
1984. 1987: Mfnlcy arid CIhen. 1984).
'Tt,
sumlnibnse. Ihc logislic ~,cg~rssinn
ar,alysis s l ~ n \ ~r11;ll
s acccss
10 \arc drinking watcr(tuhc welllhorc well) i:nd sanita~ion(hou~chnld
loilcl/l:~tl-ine)arc nsstbciaicd will1 lowcr risks ol' chilrlhwjd rlinn.hoca,
cvorl al'la' c o ~ i ~ r o l l iroi~ ~ gnot ha-'s cclucalion and pcr capita incotirc.
H(~wcver.i t is importnnl ro note th;lt n~othcl-'scducatior~and pcr capiia
i ncrxilc ;lrc also signil'icnnt ilclcsn~rt~i~nix
o f chi lrlhnoil diurshot.;~.The
~ c ~ ' i o - ~ c o ~ l oClilf'c~.cn~i~Is
miC
ill illc ~nc~dcnce
ot' diarrhoc;~ldisc;~scniay
hc tluc
1 0
dil'Ccrcnces in child cnrc p~+;rlicch,such
21%
prcpalariou ol'
wc;lning I'oo~lx,boiling of drinking wulcr, or pclrsnntll hygicnc (Black ct
19x3).
V.
I)iscussion and Conclusions
A l thrwgh Ihc nl~tiondhc:~llh pnlicy p4ac.c~;I major cmph;~sisoil
cnsuring hcalth care lo :III by thc ye;w 2IlOO. ;~ncl wntcr supllly anrl
aailil;~~it,n
is idcnl ilicrl as clac of thc key arc;is which need s p i : ~:~~rcntion
l
to reach w~chgoill, thc otljectivc
of providing sill2 drinking wiltcr' and
adctluaic sarlitalion I9 all scctiot~sorthe peopIc rcmains, a distiul! goal. It
;~lso
;jppars aln~ostc~rr:~in
rhnr rvc?auh~ng
he FO;II of health fir all hy the
ycitr 2(HX) i r ~tr~cliiris
J.IJ
i~rrpossihility.In India, its of IVY$. d' rlrc 860
for the supply of waler through spot sourucs, and rhe water supply poi11ts
arc physically accescihlc by the households in tcnns of proximity. In
fact, the distancc to t hc watcr supply points I'rom the households, on an
avcragc, 1s nnl ruorc than 300rnetres in all the five villages. En the survey,
we also elicited
informalinn regarding 11on-useo f drinkiny waler through
water %upplypoints. Clf the 159 households, who were no1 utilising
drinking water from lhc spot sources, lhree-fourths of the respondenls
mcntictned 'heavy rush at the point' as the main reaqon for no1 using
watcr froni spot sourccs. In Fi~ci,whxle collecling the dnta, the author
ohscrvcd ihiu, il took o n an averaye 2-3 hours to collect jusl two buckcl:,
of ~c'ltcrfrom ~ h l spoi
:
solu.ces by a rypical woman (who usually collccts
WRlCr in villages). Clearly, 1l1creli)rc.there is an unmct nccd for drinking
waicr f~orrispol sources. Therefore, a11 iinpol.tan1 public initiative should
aim at incrciising dl-inking waler puir~tsin the villdgcs so as to caplurc
the present nun-uscrs 01 spot SOUI.CCS ofdrinking waler. In l'act. the study
shows that if iriorc drinking waicr poinls are provided In these viIlagcs,
thc utili ulion rate nf anre drinking wilier could increase to 90 pcr ccnr
froru 1hc prcscnl r:k o f o111y0 1 pel cent.
Thc hlrldy also points lo lhc ~mporlanccol'womcn's education in
rcd~lcing1hc occuncncc oi'chiIdhood diarrl-loea. I n fact, it is rhe strorigcsl
p ~ c d i c i oofchildhood
~
dial-rhoc;~.
Therelbre, increasing l'crnalc cducdiion
should form a part of new hctllth and puhlii. pc~licy.Sinuc the infant
mortality r a ~ ci n 01-issai\ Ihc highest i n rhe counlry, and diarrhoea is a
leading cause of thesc dcntbs, a more cffcctivc cduca~ionpfO~raln111eon
thc prcvcntion and licatrucn~of dial-I-hoeashould be dcsigncd to reach
~ h pool.
c
anrl i lli~cralemot hel-k 'I .
4.
A i l l ~ u r ~ gin
h l i ~ d i iIlle
~ paltcl-ns uf dicrnse llnvr. utldcr~onca f~~ausi~uon
I1-urn
c-u~u~nu~licuble
diseases l o r~on-co11~1nu1~ica1~1~
discncc~tlurir~gr l ~ t .I ; L dcc;rde.
~
the
i[\kcliflui and paraulic disc:jce+
dr;~lhs [F';intl;~,1994b).
xlill pretloinin;ll~t.; I I I ~ole 1nn.jor cnuscs 01'
In short, the policy implications o f the stud) are cluitc clear. With
a view lo prcvcnt dialrhoeal discases a~nongchildren. parlicularly among
ccrvain socially and economically disadvan~agedgroups, acccss to basic
inrraslructural hcilities such as clean drinking watcr and hygicnic
sanitation must hc developed, in addition !othe provision o f direct health
cnrc and educulional opportunities.
Bcfnre cu~loludingthc paper, hi few rcmarks on tllc public policy
regarding provision of wuler supply and sani~ationin India are in ordcr.
Thc rural-urban disparities in acccss to (11-inkingwater supply and
sanitation continues tu he substantial. A rt~i?jurportion (about 80 pcl.
cent) or subsidised walcr is used by the urban rich (housc conneclion) to
Ihc negfecl of urban poor and rural arcas (Kundu, 1'39 I; Rerldy and
Ruthore, 1993). It is redly disturbing hccause nlorl of t h e social
consumptiun such as drinking watc~'and sa~litalionair heavily subsidisod
through
government grants to
favour the poorer scctions ol' thc sacicty.
I n practice, lhcrc seems lo hc a strong bias in favr~uror thc high inconle
g~uupsresulting in further disparities in he lcvcl and quality o f husic
amenities. A further dirncnsion of rural-urban bias is lhai while in the
case of urban nreas the stlass is on providing safe and adequaze water, in
the case of rural areas Ihc objective is simply in lcrrns OF coveling number
ol' villagcs with drinking waler facililics (Govtmmcn t of India, 1900).
As thc results ot' this study show ilicre avuilnhility of drinking water
points do not transl;~leinto cffcctive ulilisalion.
Public policics may alsu ~~cducc,
rather than improve, poor pcoplc's
health and livelihood conditions. For inslatlcc, lack of acccss to cooking
fuel as a result of privwtisation of common property resources such as
fol-est lands in some parls of lhe country. indirectly affect henlth by
rcducing the ability of poor I'rlmilics to regularly hail drinking water, by
comprcnnising the full cooking of foud, and by reducing the frequency
of cooking, resulling in increased risk o f bacterial conlaminat ion of food
and w;lter (Asarwal. 1986) . This has serious implicalions for child
health in poor families. Still anolher dimension of puhIic policy which
rnay affect child heaIth adversely is that of oral rchydration therapy,
which lins frcqucntly bccn favourcd over improvements in wntcr supply
and s a n i ~ i o i (Uni
i
tcd Nations, 1990). although thc lirlks bctwccn quality
a n d quantify or water supply and prevalence of diarrhoea1 discn%esam
wcll known (Wrld Bank. 1992). Howcver, it
shoultl
he rcalised that
or:!] rchydration is s~mplyun in-in~cdiatcresponse to diarrhoea, while
water supply and sanitarian
iuvcstmc~~ts
arc cssentinl to prevent tliarrhoca
to slart with (Ucsai, 19'34) (' . Dcspile major di ficrences En idcology 2nd
approach, thcgovernlnlcnts should canlinue financing c tricienlly cxecuted
and elfcctivcly mrgcrcd water supply and sanitation projects In dcvcloping
coutltrics.
Thc inapprt~printepubIic pdicies in Tndia such as privalisalion of
conlmutl properly resource. rural-urhan disprtri~iesin the access to and
utiIisation of water and sanitalion, highly subsidised drinking watei- and
baniration schcmes
favouring thc rich, h a w ~obc rcmodi fied lhrnueh
di\tributive policies. Thc distributive policies that me cSfcc~ive?y
targeted
a1 the pool; ullin~atcly.
can $0 a lorig way i n ensuring prospec~sfor child
survival in lndia.
5
for;^ cIiscussiilii vn privarisation ofconllnan prupclly
in wlnc
b
~ ~ s o ~ r rsuch
u e s a%furrst lands
uf India. hcc. Guha (19x3. 1985).
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~ ~resullk
n
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r
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