Spatial analysis of water sanitation and hygiene services and health outcomes in Northeast India using NFHS-5

Water, Sanitation, and Hygiene (WASH) are essential determinants of public health and human development, particularly in geographically remote and socio-economically disadvantaged regions. This study examines the spatial distribution, clustering patterns, determinants, and health implications of WASH conditions across the districts of North-East India using district-level data from 104 districts of the National Family Health Survey-5 (NFHS-5), 2019–21. A Composite WASH Index was constructed using Principal Component Analysis (PCA), with the first principal component explaining 50.04% of the total variance based on four indicators: improved drinking water source, improved sanitation facility, clean cooking fuel usage, and hygienic menstrual protection usage. Spatial analytical techniques were used to examine geographical inequalities and clustering of WASH conditions across districts. The findings reveal substantial inter-district disparities in WASH accessibility, with clean cooking fuel usage exhibiting the highest inequality. The results reveal significant spatial clustering of WASH conditions across districts. High-performing clusters were concentrated mainly in Mizoram and parts of Arunachal Pradesh, whereas low-performing clusters were observed in Assam, Meghalaya, and Tripura. The analysis further suggests that better WASH conditions are significantly associated with lower levels of diarrhoea, malnutrition, childhood anaemia, maternal undernutrition, and maternal anaemia. Multiple regression analysis identified women’s educational attainment as the strongest positive predictor of district-level WASH accessibility, followed by household electricity access. The study highlights pronounced spatial inequalities in WASH development and emphasizes the need for district-specific WASH planning, targeted investment in underserved districts, improved water and sanitation infrastructure, clean cooking fuel access, and menstrual hygiene promotion to reduce regional inequalities across North-East India.