Applying health impact assessment to watershed development projects in semi-arid areas in India: identifying prospects for health-sensitive food systems

Background
Undernutrition and dietary risks are amongst the top risk factors for morbidity and mortality globally. Consequently, food systems can be considered a major determinant of population health. Action towards improving nutrition and inter-sectoral coordination for health have been strongly emphasised in contemporary developmental discourse. These approaches are especially relevant to India, where health is currently characterised by a “double burden of malnutrition”, with prevalent child undernutrition, maternal anaemia, obesity and cardiovascular diseases.
Majority of India’s population is dependent on agriculture for food and livelihood. A large proportion of these households sustain themselves on wage labour. In most regions, farmers are reliant on rainfall for cultivation, and some of them, based on their ability to afford it, have turned to exploiting groundwater. Climatic models have predicted poorer rainfall and reduced crop yields in India. In this context, watershed development (WSD) projects have been supported by the government and philanthropic institutions. These projects enhance soil and water conservation, enrich the local environment and foster livelihood activities, with the aim of improving agricultural productivity, food security, access to water and income. Livestock rearing has also been promoted through WSD projects for improving livelihood security among poor households. However, few studies have been conducted to understand the types and distribution of health impacts due to WSD projects. In addition, the potential of WSD projects to improve rural health, especially nutrition, was indicated by experts, but no efforts have been made to systematically incorporate health considerations as part of WSD project-planning.
Health impact assessment (HIA) has been used to incorporate health concerns in development planning in several countries. While impact assessments are conducted in India under the broader umbrella of environmental impact assessment (EIA), the practice of HIA is negligible due to the: (i) poor focus on health assessment as part of environmental impact assessment; (ii) narrow scope of projects covered under the EIA regulation, e.g., large mining projects, thermal power plants and chemical industries; and (iii) low accountability for the quality of impact assessments, and for implementing recommendations in assessment reports. The author did not find even one published case study of a comprehensive HIA from India, and none on WSD projects from anywhere worldwide. In addition, the national health policy has strongly encouraged a “Health in All” approach for addressing cross-sectoral concerns such as nutrition and sanitation. However, it is unclear to what extent this paradigm has been operationalised in policy documents addressing food systems in India.
Objectives
The overall aim was to deepen the understanding on how health has been considered as part of food systems decision-making, and develop a case study on how health can be systematically incorporated in the planning process of a food systems-related project. The specific objectives were to, at the policy-level, (i) examine how health has been addressed in food systems policy documents in India; and then, at project-level, (ii) study the perceived health impacts of WSD projects; (iii) conduct an HIA of a proposed WSD project; (iv) describe the baseline health conditions in the WSD project area; (v) study the association of livestock ownership with household dietary quality in a WSD project area.
Methods
A qualitative study design was used to examine food systems policy documents (n = 29) and relevant health policy documents (n = 6), and the data were analysed through thematic and content analysis to identify which health concerns have been addressed in policy, and mechanisms instituted in policies to incorporate health concerns.
The field-based studies were located in Kolar district, southern India. A qualitative study with data collection through semi-structured interviews (n = 40), focus group discussions (n = 2) and transect walks (n = 4) was undertaken to document perceptions of local people, project staff and key informants about the health impacts of completed WSD projects. The data were collected from across four WSD projects in various sub-districts of Kolar, and analysed thematically.
The HIA was conducted for a WSD project that was planned for a cluster of four neighbouring villages, using methods validated by Winkler and colleagues for projects in tropical settings, e.g., a biofuels plantation project. The health concerns included in the HIA were informed by our earlier qualitative study and the wider literature. Due to gaps in secondary data for relevant health concerns, primary data were also collected from these four villages through a household survey (n = 195 households) and an anthropometric survey (n = 83 children under the age of 5 years). All available households and children from these villages were included in the surveys. Comparison villages (n = 138 households from 2 villages for household survey; and n = 77 children from 4 villages for anthropometric survey) were also part of the baseline surveys to help with the eventual impact evaluation. The data collected from the project and comparison villages on key health concerns were described using proportions and means. The data were also used to study the association of dairy animal ownership on household dietary quality using a multivariable logistic regression model.
Results
At national policy level, undernutrition received relatively high attention, being explicitly mentioned in many food-related policies across sectors (agricultural, environmental, health, industrial and social). Non-communicable diseases were only addressed in health policies, and were largely missing in food policies. Agricultural injuries and mental health concerns of farmers received limited consideration. Several advisory and executive groups instituted for food systems governance by the analysed policies were found to include representation from the health ministry (nine of the 17 identified inter-ministerial groups), but the effect of this representation on health consideration in decision-making would require further research. Overall, the data revealed that health was not systematically considered in food policy-related decision-making.
At the local project level, the main health impacts of WSD projects were perceived to be on household nutrition, potential for mosquito larval breeding and impacts resulting from opportunistic activities (e.g., improved water access leading to reduced mental stress). Perceived impacts varied between sub-groups of the local population (e.g., greater agricultural benefits for farmers with larger holdings; increased income through dairy for poor woman-headed households).
The HIA on the planned WSD project found several opportunities for risk mitigation (e.g., larval control in water bodies to reduce vector-borne diseases, and fencing of farm ponds to prevent drowning) and health promotion (e.g., improving nutrition through provision of fruit tree saplings and awareness). The baseline survey data revealed that the local health concerns included nutritional status among children under the age of 5 years (undernutrition prevalence of 23.8%), vector-borne disease (over one in ten households reported occurrence of malaria, chikungunya and dengue during the previous year), food insecurity (experienced by over one in five households during the past 2 years) and access to potable water (almost three in five households consumed unpurified groundwater which is high in fluoride content). It was also demonstrated that, at project baseline, household ownership of dairy animals (43.1% at project baseline) was associated with household milk consumption (adjusted odds ratio (OR) 2.1, 95% confidence interval (CI) 0.9, 5.5). Households owning dairy animals were found to be richer (land ownership, access to irrigation, ownership of motorised vehicle), larger, male-headed and belonging to dominant castes. This indicated the need for context-specific understanding and reflection on livelihood support initiatives, and their potential to improve income and health in the household.
Conclusions
Through the case study of WSD projects, we demonstrated approaches to further understand health impacts of food systems interventions, conduct comprehensive HIAs of food production projects in semi-arid rural areas, and utilise data from baseline surveys conducted for HIAs to answer empirical research questions on linkages between agriculture and nutrition. We also showed the cross-cutting concern regarding undernutrition from local project level to national policy level. Food systems projects and policies were demonstrated to be relevant to several health concerns. Gaps were identified in health considerations of food systems policies and projects, and the utility of HIA to identify potential health impacts and facilitate risk mitigation and health promotion was exhibited.
We discussed approaches to increase adoption of HIA in India by using non-controversial projects such as WSD projects to build local capacity, experience and interest. The important role of partnership with experienced non-governmental organisations, the key actors of WSD and other rural development projects, was highlighted. The potential role of academic institutions in evidence generation, capacity building and knowledge translation was also emphasised. This PhD thesis can be considered a contribution towards the operationalisation of the “Health in All” approach, mentioned in the National Health Policy of 2017, for developmental policies and projects in India.