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| Lipy, a mum from Bangladesh, helps her child wash her hands. |
By Esther Indriani, MPH (Regional Health and Nutrition Advisor for World Vision South Asia and Pacific)
It is estimated that 50% of the health burden of malnutrition is attributable to the environment, and in particular to poor water, sanitation and hygiene (WASH)[i]. Yet, even though there are strong links between undernutrition and WASH, integration of health, nutrition, early childhood development and WASH is not always a “common recipe” for programmes and projects in high burden countries. In this blog, we will explore the importance of the integration of WASH and nutrition as evidence of why integration is so important.
The Scaling Up Nutrition (SUN) movement has included WASH as one of its objectives since 2012, with increased access to affordable nutritious food, clean water, sanitation, health care and social protection as vital aspects in reaching the targets set at the World Health Assembly. WASH is deemed as a major nutrition-sensitive intervention in the SUN framework.
So why is WASH not always taken as an integral part of nutrition programmes? Although the idea that water is vital to life is very well understood, clean water can be expensive, challenging, or require specific technical skills, which some nutrition programmes may not be able to afford.
According to WHO[ii], a recent WHO/SEARO study concluded that no country in Southeast Asia has an adequate national programme of drinking water quality and surveillance. For example, in the highly populous country of Bangladesh, water supply coverage in Bangladesh is at approximately 97%, but the safety of water for human consumption is questionable. Ground water is often contaminated with arsenic, which puts a large number of people at risk because they don’t have alternative safe water supply solutions. On top of the water issue, only 40% of the population have access to sanitation, with wide disparity between rural and urban areas in Bangladesh.
In other countries, such as the arid region of East Nusa Tenggara Province in Indonesia, bringing clean water to villages requires expensive drilling, piping, or dam building. This province experiences an annual water crisis, making the poor communities poorer and at higher risk for malnutrition and mortality. The impact of climate change on the dry season is a major factor; it forces local communities to consume unhygienic water if they are not able to purchase local tap water. Children are commonly mobilized to walk many kilometres to fetch water, causing children to miss school. Lack of water also influences agriculture and food security, making the root causes of malnutrition more complex than at face value. In the end, access to water is about power and survival.
To address these issues requires significant funding and technical support, which can be seen as the territory of the “WASH” sector, instead of an integral part of a nutrition programme. Therefore, nutrition programmes that take on WASH elements need to have a partnership with the WASH sector and share expertise as well as the burden of funding.
Another issue is WASH in urban contexts. Most urban areas in Asia are highly populated, and some areas are crowded with illegal settlements. It is complicated for governments and/or NGOs to provide sanitation facilities and access to clean water in the urban slums. Many times, NGOs face challenges to build even shared latrines in urban areas because there is no available land. At times, shared latrines might be built on someone’s land and later locked by the land’s owner. Urban dwellers living in slums in Jakarta, Dhaka, and Metro Manila are used to having to buy clean water and pay for public toilets. A report titled “Urban Poverty in Asia” by the Asian Development Bank (ADB)[iii] quoted a global study done by the World Bank in 47 different countries and 93 locations on small-scale private service providers (SPSPs) of water supply and electricity. It shows that the average water prices are 1.5 to 12 times higher for the poor households and those households who are outside the network compared to the networked households. The same ADB report also quotes research by Ballesteros showing that slum dwellers pay more for basic services, such as clean water and electricity, than residents living in adjacent neighbourhoods with networked connections to utilities. In Metro Manila and Cebu City, residents of non-serviced neighbourhoods pay 9 to 13 times more for delivery of clean water than those households in serviced areas. Because of poor urban planning, it is very challenging to solve this issue without relocating people to better housing. Unfortunately, relocation costs money and can create resistance from several actors who are benefitted through the business of selling water or renting houses to poor urban slum dwellers.
The 2016 Global Nutrition Report describes further the importance of WASH in reducing undernutrition, highlighting the importance of WASH in preventing faeces from getting into the child’s environment or preventing the ingestion of pathogens from the environment. Hence, hand-washing with soap is of critical importance and a feasible intervention, a “soft” behaviour change message which can be included easily in nutrition program.
In fact, hand-washing with soap has been taken as integral part of the Positive Deviance/Hearth (PD/Hearth) approach – an effective and sustainable community-based nutrition rehabilitation and prevention approach using positive deviant practices and community resources. To date, World Vision International has been implementing PD/Hearth in more than 41 countries and is currently implementing in 30 countries. In Bangladesh alone, there are more than 50 sites using the PD/Hearth approach. One of the most frequent positive messages recalled by mothers and children who participated in the PD/Hearth approach is hand-washing with soap; children continued to practice hand-washing with soap at home, and asked their parents to wash their hands too. The education on hand-washing with soap has been delivered through many interesting ways, including teaching children to sing a happy birthday song, or a hand-washing jingle while washing their hands with soap. This is to ensure they rub their hands long enough to make it an effective hand-washing.
To accelerate the reduction of undernutrition, WASH is a crucial component that must be included. There is a special panel in the 2016 Global Nutrition Report[iv], which suggests ways to make WASH programmes nutrition sensitive. The Authors suggest that this does not require a paradigm shift, but rather requires programme planners to adhere to WASH behavioural objectives and align programmes with the multiple pathways of faecal-oral transmission relevant to the target population. Key principles include:
1. Focus on nutritional outcomes: WASH programmes often address underlying issues related to child nutrition and development, but they can be further leveraged to improve nutrition when they are implemented in a manner that protects women’s time – such as reducing time spent by women to fetch water freeing up time for child care and other activities to improve nutrition consumption.
2. Target the first 1000 days: As the critical point in a child’s development, WASH programmes targeted to this age group are more likely to achieve nutritional outcomes and prevent developmental deficits due to growth faltering.
3. Pay attention to the causal linkages between WASH and nutritional outcomes: The environmental enteropathy hypothesis suggests that chronic diarrhoea compromises the gut and is the primary link between WASH, stunting and anaemia. We should focus on addressing the environmental sanitation and hygiene issues in order to prevent chronic diarrhoea.
4. Align WASH interventions with these causal linkages: Preventing child’s ingestion of faecal microbes in the first 1000 days should be a key objective of nutrition-sensitive WASH programmes. Research shows that the faecal-oral transmission pathways for adults are different from those of toddling children, who engage in mouthing and exploratory play, which can lead to the consumption of animal faeces, for example, when a safe play space is not provided. This result suggests that nutrition-sensitive WASH interventions should:
a. reduce the environmental microbe load through household sanitation and hygiene;
b. reduce faecal transmission via hands through washing of caregivers’ and children’s hands with soap;
c. improve drinking water quality through improved access to protected water sources and hygienic methods of household water treatment and storage;
d. promote exclusive breastfeeding for the first six months of life to ensure nutrient adequacy and exclude potentially contaminated non–breast milk liquids and foods;
e. avoid faecal ingestion during child mouthing and exploratory play by ensuring a clean play and infant feeding environment; and
f. provide hygienically prepared and stored complementary food fed using clean utensils and hands.
Truly integrated programmes are an aspiration and a challenge for many organisations. We have some examples of integration between two or three sectors, but not many examples available on the integration of WASH with nutrition, early childhood development and maternal newborn child health. The aforementioned publications and research have emphasized the need to have better integration of WASH into crucial nutrition programmes, and we want to see even better results by integrating WASH and nutrition with maternal, newborn and child health and early childhood development. However, not all organizations are equally resourced nor experienced to do this multiple sector integration.
To overcome this, organisations should work together collectively to share expertise and create ideas that can be brought together into clear programming guidance to make integration more practical and effective. The BabyWASH Coalition is a group of organisations coming together to share, learn, document and advocate for stronger, more integrated WASH, nutrition, early childhood development, and maternal newborn child health programmes to benefit mothers and children in the first 1000 days. It is created as a common ground to leverage collective strengths to break down the barriers of policies, attitudes, and funding for improved integration. It is aimed to document and test different formulas and “recipes” to enable WASH integration and to help Coalition members achieve better impact in reducing the health burden of malnutrition due to poor water, sanitation and hygiene. As more programmes attempt to integrate, and share their successes and failures with the larger community, we will have a better sense of what integration works and what integration is not as successful.
BabyWASH is an integrated approach for maternal and young child health. It is the targeted integration of WASH, maternal newborn child health, early childhood development, and nutrition programmes across the first 1,000 days of life to reduce stunting and improve the health and well-being of children and their caretakers. For more information, visit www.babywashcoalition.org
Esther Indriani is the Regional Health & Nutrition Advisor for World Vision South Asia and Pacific Region. She works closely with World Vision’s country programs in South Asia and Pacific in the design, implementation and evaluation of diverse and evidence-based Public Health programs, with a focus on sustainable improvements in maternal health, child health, nutrition, reproductive health, and infectious diseases. She has over 18 years of experience in the health and nutrition sector including: ten years of public health experience in Indonesia and seven years of international public health experience in more than ten countries. She holds a Master of Public Health degree with Honors from Maastricht University and Post Graduate Degree on Food Security and Nutrition with Distinction from Wageningen University.
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