Handwashing with Soap and water..the missing ingredients in India’s Mid-day Meal Scheme?
A primary school in Mall district in rural Uttar Pradesh, just an hour from Lucknow, is buzzing with activity. The mid-day meal of fresh rice and steaming daal, prepared just half an hour ago, is about to be served, and the school’s 150 children run to the single hand pump in the school premises to fill their water bottles, and to use the toilet, just ten feet away. The school’s toilet block has separate toilets for girls and boys, and a handwashing station right outside. None of the five taps has water. Children stand in line, receive their share of food and settle down on the ground to eat. None of them had washed their hands before their meal or after using the toilet during the break.
Twenty-two children attend a colourfully decorated, cheerful anganwadi in West Delhi. Two shiny steel containers, one filled with cooked matter and the other with hot khichadi, are on the side. The children settle down and begin their prayers and morning exercises. At 10 am, the anganwadi teacher instructs the children to take out their tiffin dabbas and spoons. She serves them the matter, and the children happily eat their share, tiny hands awkwardly clutching their spoons. The anganwadi has no place to wash hands, nor water or soap, and encourage the use of spoons as an alternative. Except two children had forgotten their spoons that day, and picked at their food with their unwashed fingers.
Mid-day meals in schools help combat undernutrition
India’s Mid-day Meal Scheme (MDMS) is the largest program in the world that provides hot cooked meals to school children - implemented in 12 lakh schools and reaching a staggering 12 crore children across the country. The rationale is that providing food grains or cooked food will improve enrolment, attendance, and retention in schools, as well as nutritional status among children. In addition, the country’s 13.6 lac anganwadis (early childcare and education centres) also provide hot cooked meals and take home rations for children under 6 years, pregnant and lactating mothers, with the aim to combat widespread undernutrition and anaemia prevalent among these vulnerable groups.
The implementation of MDMS, anganwadi meals and take home rations faces several challenges including coverage of the schemes, irregularity in serving meals, poor quality of food, inadequate kitchen infrastructure, and poor hygiene practices. In spite of these shortcomings, these meal schemes have tremendous potential to improve the health and nutritional status of school going children and children under 6 years, and encourage school enrolment and retention.
Mid-day meal schemes are based on the understanding of the connection between nutrition and learning. This is critical given that 38.4% of children under 5 years of age are stunted, 35.7% are underweight, 58.4% are anaemic (NFHS 4). Stunting, a condition where children are short for their age, results when they suffer from repeated bouts of diarrhoea, intestinal worm infections, both of which are associated with poor water, sanitation and hygiene. Stunting hampers physical growth as well as cognitive development, and children miss schools days because of frequent illness. Both have adverse implications for school performance.
Meals provided in schools and anganwadis are not a panacea for rampant undernutrition in the country, but do represent a much needed intervention, especially for children from homes lacking financial resources. Obvious lacunae such as irregular food supply and poor meal quality must be addressed, and efforts to do so are ongoing at the Central level and in several States. Yet critical ingredients are missing in mid-day meal programs that are fundamental to the health and nutrition benefits they intend to confer – soap and water.
Washing hands with soap at critical moments a must
The Swachh Bharat Mission has brought unprecedented attention to the health benefits of safe sanitation. Toilets are undeniably important to prevent illnesses such as diarrhoeal diseases and intestinal worm infections. Yet, handwashing with soap, a highly cost-effective public health intervention, has received far less attention. Washing hands with soap at critical moments (i.e., after contact with faecal matter and before contact with food) is estimated to reduce diarrhoeal diseases by 47% and respiratory infections by 23%, having tremendous health benefits for children.
Hand washing interventions are important for children, their caregivers, as well as those who prepare and serve food in the institutions they attend. When children do not clean their hands before eating, they risk ingesting faecal pathogens and other germs present in their hands. Along the same vein, cooks and servers can inadvertently contaminate food that children eat when they do not wash their hands while preparing and serving meals. Faecal pathogens in hands and food can cause diarrhoea, frequent episodes of which can deplete the body of essential nutrients. Other infections, for instance, pneumonia, do not cause diarrhoea but do divert the body’s nutritional reserves from fuelling growth to fighting infections.
Hand hygiene and mid-day meal go hand in hand
Washing hands with soap must be incorporated into meal programs in anganwadis and schools to bolster the nutritional benefits of consuming hot cooked meals. Mid-day meals schemes in anganwadis and schools can promote handwashing in two ways. First, they can serve as a platform to demonstrate handwashing with soap after using the toilet and before eating food to children attending these institutions. With school teachers, Anganwadi teachers, cooks, and helpers, the focus can be on ensuring safe and hygienic meal preparation and serving. Second, school meal schemes can inculcate handwashing as a routine behaviour among children, and encourage children to take these messages and behaviours back homes to their families.
Nutrition program and WASH programs have long been implemented as parallel interventions. The Swachh Bharat Mission through the Swachh Vidyalaya Abhiyan in schools changed this narrative and brought attention to sanitation, drinking water and handwashing in educational institutions, and incorporated hygiene education into the curriculum. Many schools in rural and urban India now have gender-segregated toilets with bright wall paintings and posters on toilet use and handwashing steps. Yet, while handwashing stations may exist, they often lack water and soap, undermining actual practice of this health-promoting habit. The POSHAN Abhiyan for nutrition brings renewed attention to hygiene behaviors, including handwashing. Still, many anganwadis in rural and urban India, do not have sufficient water and soap, let alone a designated handwashing space. Future investments in the mid-day meal schemes for schools and anganwadis must include provisions for food grains or hot cooked meals, as well as for soap and water, and hygiene promotion activities, to meaningfully improve the health and wellbeing of children and ensure successful outcome for this important program.