The recently approved National Nutrition Mission provides an opportunity to integrate water, sanitation and hygiene interventions for improved nutritional outcomes for children and women.
The Government of India’s commitment to improve nutritional status of children and women is receiving unprecedented support. Recently, the Cabinet approved the launch of the National Nutrition Mission with financial support of Rs 9046.17 crore. Perhaps the most promising feature of this Mission is the explicit recognition of the need for convergence among various schemes addressing nutrition along with instituting robust monitoring mechanisms and engendering community participation.
While the Mission does not elucidate the role of other sectors in improving nutritional outcomes, the emphasis on convergence underscores the involvement of allied sectors in tackling malnutrition in the country.
Stunting, a major manifestation of undernutrition where children are short for their age, results from severe and persistent undernutrition. While the lack of nutritious food certainly and significantly contributes to undernutrition, the World Health Organization estimates that half of all undernutrition is associated with diarrhoea and infections resulting from unsafe water and sanitation, and unhealthy hygiene behaviour. Repeated diarrhoea in the first two years of life directly contributes to a quarter of all cases of stunting, with WASH responsible for about 88% of all diarrhoea cases. Water, sanitation and hygiene (WASH) contributes to diarrhoea through several key routes. The lack of basic sanitation results in faecal matter polluting water sources used for drinking, cooking, and washing purposes. Limited access to safe drinking water puts people at risk. And lastly, low levels of awareness about handwashing and the unavailability of soap and water results in poor hand hygiene practices, leading to the ingestion of faecal pathogens through dirty hands.
Inadequate WASH makes children vulnerable to diarrhoea, intestinal worm, and other infections. These conditions prevent a child’s intestines from absorbing whatever nutrients the child gets, inhibiting their physical and cognitive growth. Research suggests that a child can become stunted if they experience five or more cases of diarrhoea before their second birthday. Furthermore, stunting is believed to have long-lasting adverse impacts in terms of educational performance, health, and future potential.
The need for an inter-sectoral approach to nutrition was highlighted by a landmark article in the Lancet in 2013, which found that direct nutrition interventions, while essential, can reduce stunting only by 20% in the worst affected countries. If we are to reduce the remaining 80% of stunting, nutrition-sensitive interventions that tackle the underlying drivers of nutrition such as WASH, among others, are critical.
The National Nutrition Mission provides this platform. The Swachh Bharat Mission already focuses its energies on eliminating a critical route of disease transmission by promoting latrine use and encouraging sustained use. Efforts are also ongoing to improve access to safe drinking water, and to encourage handwashing with soap and water. Convergence, however, requires meaningful integration of nutrition and WASH interventions, and not just well-intentioned, but parallel efforts. Integration can be brought about, and there are several ways to do this. At the very minimum, nutrition and WASH interventions can co-target nutritionally vulnerable groups (such as children under five, pregnant women and mothers, adolescent girls), and co-locate nutrition and WASH interventions in the same geographies (ideally focused on marginalized rural and urban populations). Moving a step further, the WASH interventions can be made nutrition-sensitive through, for instance, concerted hygiene promotion and a focus on child risk factors and behaviours. An ideal scenario will be integrated and joint programming, where hygiene promotion and WASH security are entrenched components of nutrition programs, or WASH programs serve as a delivery platform for nutrition-specific interventions. Encouragingly, India does have examples of nutrition programs that incorporate WASH and vice versa to varying extents, providing insights, strategies, and opportunities for more impactful integration.
The National Nutrition Mission can indeed reduce stunting from 38.4% to 25% by 2022 through a comprehensive, multi-sectoral approach. By strategically incorporating nutrition sensitive interventions such as WASH, the Mission can help India’s children thrive and realize their potential.Arundati Muralidharan is Manager - Policy (WASH in Health & Nutrition, WASH in Schools) at WaterAid India. She Tweets as @@arundati_md