The Impact of Household’s Better Access to Water on Children’s Health and Survival in Rural Rajasthan, India

​Malnutrition and lack of access to water and sanitation are responsible for one third of disability Adjusted Life Years lost in developing countries, and 62% of under-five mortality worldwide. Both factors are preventable, but persist as risks largely among the poor, 75% of whom live in rural area and depend on agriculture for livelihood. In the context of water and sanitation, Shuval suggests that a segmental approach for addressing the numerous handicaps that the poor face are unlikely to be successful, while a multi-dimensional intervention is likely to work synergistically. Income, and food security of the rural people are linked to their agricultural practices, which in turn is largely dependent on availability of irrigation. Water collection time is a good marker of thee dimensions of access to drinking water - quantity, quality and ease of availability - all of which impact health. Water, thus, is a common, distal determinant of health and income of people in rural areas of low-income countries. We studied the independent and combined effects of better access to water in rural, under-developed areas of Rajasthan, India. We also evaluated a community driven rural development project, piloted by TBS, a Non Governmental Organization, that constructed ponds to harvest rainwater and recharge groundwater, and thereby improved access to water for drinking and irrigation. Our outcomes were under-five mortality and anthropometry, which are the best indicators of population health, and are appropriate for evaluation of both agricultural and water projects. We used a combined retrospective cohort and cross-sectional design, benefiting from the high reliabilities of maternal birth histories, to evaluate the TBS project. Through a survey in 2004, we collected data on 1838 households and 1925 ever married women aged 15-49 years, weighed and measured 1715 children aged 0-59 months and their mothers. Our findings reveal the protective effects of: (i) Closer access to drinking water (i.e. 10 minutes or less of collection time) on risk of stunting among children (OR: 0.70, p<.1), (ii) Multiple cropping (a correlate of irrigation) on risk of stunting (OR: 0.53, p<.05), wasting (OR: 0.67,p<.1), and (iii) Irrigable land with the household on under-five mortality (Incidence Rate Ratio 0.78, p<.05 for one standard deviation increase). Closer access to water and multiple cropping were associated with multiplicative benefits in lowering the risk of stunting, though neither of them was protective in households with only a minimal access to the other. We identified better dietary intake by children and mothers, lower risk of diarrhea among children and low Body Mass Index among women, and higher incomes as pathways. We found weak evidence that the TBS project helped reverse the deteriorating trend in child survival, and reduced the prevalence of stunting relative to the control area. Our findings vindicate the role of water as an underlying determinant of health and income. We suggest that governments and developmental agencies should: • In rural areas, plan for improving access to water for both drinking and irrigation in a sustainable manner with community involvement; • Promote integrated delivery of inputs, drinking water and irrigation being mere examples, not only because of the likely synergisms, but also because a segmental approach is unlikely to benefit those who might need them the most. Even though water interventions are largely engineering based, public health professionals should play a proactive role in promoting access, in conjunction with other public health inputs.