Abstract
Improvement of water and sanitation conditions may reduce infant mortality, particularly in countries like India where open defecation is highly prevalent. We conducted a quasi-experimental study to investigate the association between the Swachh Bharat Mission (SBM)-a national sanitation program initiated in 2014-and infant (IMR) and under five mortality rates (U5MR) in India. We analyzed data from thirty-five Indian states and 640 districts spanning 10 years (2011-2020), with IMR and U5MR per thousand live births as the outcomes. Our main exposure was the district-level annual percentage of households that received a constructed toilet under SBM. We mapped changes in IMR and U5MR and toilet access at the district level over time. We fit two-way fixed effects regression models controlling for sociodemographic, wealth, and healthcare-related confounders at the district-level to estimate the association between toilets constructed and child mortality. Toilet access and child mortality have a historically robust inverse association in India. Toilets constructed increased dramatically across India following the implementation of SBM in 2014. Results from panel data regression models show that districts with > 30% toilets constructed under SBM corresponds with 5.3 lower IMR (p < 0.05), and 6.8 lower U5MR (p < 0.05). Placebo, falsification tests and robustness checks support our main findings. The post-SBM period in India exhibited accelerated reductions in infant and child mortality compared to the pre-SBM years. Based on our regression estimates, the provision of toilets at-scale may have contributed to averting approximately 60,000-70,000 infant deaths annually. Our findings show that the implementation of transformative sanitation programs can deliver population health benefits in low- and middle-income countries.