Public Health and Sanitation Policies in India: Historical Analysis and Reforms

Long before India had a unified health policy, the seeds of modern public health were being planted in the most unlikely of places – military barracks, port cities, and plague-stricken neighbourhoods of Bombay. The story of sanitation and public health policy in India is not a clean, linear march of progress. It is a history shaped by colonial priorities, deadly epidemics, political reforms, and a growing recognition that the health of a nation cannot be separated from the conditions in which its people live. Understanding this trajectory helps explain why our current public health system looks the way it does – and where its blind spots still lie.

Early sanitation efforts under British rule 🔗

When the East India Company first established its presence in the subcontinent, public health was not a priority. The colonial administration’s earliest sanitary concerns were narrowly focused on protecting European troops and officials from the so-called “tropical diseases” that decimated their ranks. The civilian population – overwhelmingly rural and poor – remained largely outside the scope of these early measures.

A turning point came after the 1857 uprising. The high mortality among British soldiers, especially during the years of the rebellion, alarmed the British Parliament enough to set up the Royal Commission on the Sanitary State of the Army in India in 1859. The commission recorded shockingly high death rates among British troops and, crucially, recognised that the health of the surrounding civilian population posed a direct danger to the army. This was the first formal acknowledgement that military health and civilian health were inseparable.

Sanitary commissioners and cantonment-centric measures 🔗

Acting on the commission’s recommendations, sanitary commissioners were appointed in the three major provinces of Bengal, Madras, and Bombay during the 1860s. The first chair of Professor of Hygiene was established at the Calcutta Medical College in 1865, marking the beginning of formal hygiene education in India. In 1869, a Public Health Commissioner and a Statistical Officer were appointed to the Government of India, signalling the slow institutionalisation of health administration.

However, the practical reach of these efforts was severely limited. Sanitary measures were concentrated in military cantonments, European civil lines, and a handful of port towns. Civilian sanitary work was sporadic and underfunded. Local self-government reforms under Lord Ripon attempted to change this. The Local Self-Government Act of 1885 made local bodies responsible for sanitation, but as a review of colonial sanitary administration notes, the Central Government failed to provide the necessary staff or sustained funding. The result was a patchwork of underpowered municipal bodies struggling to address sanitation in rapidly growing cities.

Epidemics as catalysts for change 🔗

If sanitary reform moved slowly during peacetime, epidemics forced the colonial state into rapid, sometimes draconian, action. Recurring outbreaks of cholera, smallpox, and fever throughout the 19th century repeatedly exposed the inadequacy of the existing system. But no single event reshaped Indian public health policy as decisively as the Bombay plague of 1896.

The Bombay plague and the Epidemic Diseases Act of 1897 🔗

In September 1896, the first case of bubonic plague in Bombay was diagnosed by Dr. Acacio Gabriel Viegas in the Mandvi area. Within months, the disease was killing thousands. By March 1897, an estimated 20,000 people had died in Bombay alone, and almost half the city’s population had fled to the countryside, accelerating the spread of the disease across the country. The epidemic had a mortality rate of 75-85% at its peak, and ultimately killed millions across India over the next two decades.

The colonial response was both medical and legislative. The Indian Plague Commission was constituted in 1896 under Professor T.R. Fraser of the University of Edinburgh. Its 1904 report concluded that the disease was highly contagious, that human transit played a major role in its spread, and that effective control required mass disinfection, evacuation of infected areas, regulation of travel, and a long-term strengthening of public health services and laboratories.

Even before the commission submitted its report, the government rushed through emergency legislation. The Epidemic Diseases Act of 1897, a short 773-word law, was enacted in February 1897 to give authorities sweeping powers to contain the plague. The Act was modelled in part on the Venice Sanitary Convention of March 1897 and gave the government wide-ranging powers including the inspection of travellers, segregation of suspected cases, prohibition of religious gatherings and pilgrimages, and the destruction of infected dwellings.

Implementation in Bombay was harsh. An all-European Plague Committee under Brigadier General W.F. Gatacre was given near-martial authority. Teams of soldiers and volunteers entered homes by force, burned belongings, and inspected residents. These measures triggered fierce backlash in the vernacular press – Bal Gangadhar Tilak’s Maratha newspaper became a prominent voice of dissent – and contributed to the political mobilisation of nationalist sentiment.

A law that has outlived its century 🔗

What is striking about the Epidemic Diseases Act is its longevity. The Act, originally drafted to handle a plague outbreak in a single presidency, remained the principal legal instrument for epidemic control in India for more than a century. It was invoked during outbreaks of swine flu, dengue, cholera, and most recently, the COVID-19 pandemic. Researchers studying the EDA have repeatedly highlighted that the law neither defines what counts as an epidemic nor clearly demarcates powers between the Centre, states, and local authorities – gaps that became painfully visible during recent public health emergencies.

Key reforms and the slow march to decentralisation 🔗

The early 20th century saw a structural rethinking of public health administration. Three developments stand out: the Montagu-Chelmsford Reforms of 1919, the establishment of the All India Institute of Hygiene and Public Health in 1932, and the Bhore Committee Report of 1946.

The Montagu-Chelmsford Reforms of 1919 🔗

Until 1919, medical and public health departments were controlled by the central colonial government. The Government of India Act of 1919, which gave effect to the Montagu-Chelmsford Reforms, introduced a system of dyarchy in the provinces. Subjects were divided into “reserved” and “transferred” categories. Public health, sanitation, and vital statistics were moved to the transferred list, meaning they came under the control of elected Indian ministers in the provincial councils.

This was the first major step in the decentralisation of health administration in India. In 1920-21, Municipality and Local Board Acts were passed in several provinces, providing legal infrastructure for local public health work. The Government of India Act of 1935 went further, giving provincial governments greater autonomy and categorising health activities into federal, federal-cum-provincial, and provincial domains. In 1937, the Central Advisory Board of Health was established to coordinate public health activities nationally, with the Public Health Commissioner as secretary.

Yet decentralisation came with a hidden cost. Provincial ministries were given responsibility for public health without proportionate financial resources or trained personnel. Many of the structural problems of underfunded state health departments – a persistent issue even today – can be traced to this incomplete transfer of authority.

The All India Institute of Hygiene and Public Health 🔗

If the 1919 reforms changed the administrative architecture, the next leap was institutional. The need for a dedicated centre for training Indian public health professionals had been recognised since the early 20th century. Sir Leonard Rogers proposed a School of Tropical Medicine for Calcutta and an Institute of Hygiene for Bombay as early as 1914. The School of Tropical Medicine opened in Calcutta in 1920, but a full-fledged institute of hygiene remained elusive.

With substantial financial and intellectual support from the Rockefeller Foundation, the All India Institute of Hygiene and Public Health (AIIH&PH) was established in Calcutta on 30 December 1932. It was the first school of public health in the South-East Asia region and became the nucleus of public health teaching, research, and field training in India. The institute trained generations of public health officers, epidemiologists, and sanitarians, and conducted India’s first general health survey in 1944.

The Bhore Committee and the vision of integrated health services 🔗

The most consequential public health document of the colonial era – and arguably of independent India’s first half-century – was the report of the Health Survey and Development Committee, popularly known as the Bhore Committee. Appointed in 1943 under the chairmanship of Sir Joseph Bhore, a former Diwan of Cochin and an experienced civil servant, the committee was tasked with surveying the existing health conditions in India and drawing up a blueprint for the future.

The committee submitted its four-volume report in 1946. Its major recommendations were strikingly progressive for their time and have shaped Indian health planning ever since:

• Integration of preventive and curative services at all administrative levels – a rejection of the colonial separation between sanitary departments and clinical medicine.
• A three-tier health system for rural areas, with Primary Health Centres at the base, secondary health centres providing supervision and specialist support, and district hospitals at the top.
• As a short-term measure, one Primary Health Centre per 40,000 population, each staffed with two medical officers, one nurse, four public health nurses, four midwives, four trained dais, two sanitary inspectors, two health assistants, one pharmacist, and additional support staff.
• Major reforms in medical education, including the training of “social physicians” oriented toward preventive and social medicine, and the introduction of refresher courses for practising doctors.
• Special emphasis on maternal and child health, including regular check-ups and health education.
• A recommendation that health expenditure should rise to at least 15% of total government spending – a target India has yet to achieve.

The Bhore Committee’s vision was essentially that of a state-led, universally accessible health system grounded in primary health care – an idea that anticipated the Alma-Ata Declaration of 1978 by more than three decades. As later scholarship on Joseph Bhore’s legacy has noted, India’s current three-tier public health architecture, with its emphasis on PHCs, is a direct descendant of the 1946 report.

Continuities and contradictions in the colonial legacy 🔗

Looking at the colonial period as a whole, three contradictions stand out. First, public health interventions were almost always reactive – driven by epidemics, military concerns, or political pressure – rather than proactive and population-wide. Second, sanitary policy was selectively implemented, prioritising European quarters, cantonments, and elite urban spaces while leaving rural India largely untouched. Third, even when progressive policies were drafted, the gap between recommendation and implementation remained vast, due to limited funding, fragmented administration, and a colonial state that was reluctant to invest in the welfare of its subjects.

Independent India inherited this mixed legacy. The Bhore Committee’s blueprint provided the philosophical foundation for the Primary Health Centre network and successive Five Year Plan health investments. But many colonial-era instruments – including the Epidemic Diseases Act of 1897 – also continued in force, sometimes uneasily, into the 21st century. The challenge for contemporary policy has been to retain the integrative, preventive vision of the Bhore report while modernising legal and administrative tools that were never designed for a sovereign, democratic, and rapidly urbanising nation.

What do you think? If the Bhore Committee’s recommendations on health spending and integrated services had been fully implemented in the decades after independence, how different might India’s public health landscape look today? And do colonial-era laws like the Epidemic Diseases Act still deserve a place in our legal toolkit, or is it time for a complete legislative rethink?

References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2763662/
2. https://aiihph.gov.in/history/
3. https://www.ijfmr.com/papers/2024/2/15480.pdf
4. https://en.wikipedia.org/wiki/Bombay_plague_epidemic
5. https://www.nam.ac.uk/explore/bombay-plague
6. https://nmji.in/the-epidemic-diseases-act-1897-a-study-of-international-and-domestic-pressures-on-british-epidemic-policy-formation-in-india/
7. https://en.wikipedia.org/wiki/All_India_Institute_of_Hygiene_and_Public_Health
8. https://www.nhp.gov.in/bhore-committee-1946_pg
9. https://www.academia.edu/5096471/Bhore_Committee_1946_and_its_relevance_today
10. https://pmc.ncbi.nlm.nih.gov/articles/PMC11414765/