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Linking Toilets and Nutrition for Stronger, Healthier Lives

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published
17 November 2016

The role of water, sanitation and hygiene (WASH) in tackling undernutrition has been on development and humanitarian professionals’ radar for more than two decades. Yet fully multi-sectoral approaches remain rare, despite undernutrition contributing to 860,000 preventable deaths a year in girls and boys under five. Ahead of World Toilet Day, marked each 19 November, experts and practitioners discuss how to turn this around by linking nutrition and WASH policies and implementation and overcoming barriers between sectors.

One obstacle to integrating WASH in nutrition projects is a cultural barrier. “People will agree to do a water programme – it’s about cleanliness, it’s nice,” said Catherine Chazaly, former Food Assistance and Nutrition Policy Officer at the European Commission’s humanitarian aid department (ECHO). “But sanitation is about dirt, about shit, and people have much more difficulty speaking about it and getting involved in it. There’s a big cultural barrier in terms of finding solutions, working with the community.”

Impact on children

One in three people around the world do not have access to a clean, safe toilet. One in seven do not have access to any kind of toilet. And there are few statistics available on how many people with access to a toilet prefer not to use it, and go in the open.

Children in these communities often bear the brunt, playing in contaminated areas and drinking unsafe water. This puts them at risk of diarrhoea; intestinal worms, which can lead to anaemia and impaired growth; and environmental enteropathy, which inflames the gut and hinders nutrient absorption. The result in all three cases is undernourishment and increased sensitivity to reinfection, contributing to stunting (affecting one in four children around the world) and preventable deaths.

“It’s a vicious circle we need to cut,” said Dr Jean Lapègue, Senior Advisor on WASH, Scientific and Technical Direction at Action Against Hunger. “To do that, you need to implement toilets, provide safe water access, and develop hygiene projects.” 

“Yet it’s difficult to integrate projects, for many reasons,” said Dr Lapègue. “Donors are not specifically integrated, they are still working a lot in silos. NGOs are in silos – the coordination bodies are in silos. We need to break that and learn how to work together.”

Skip to 0.05 for Dr Jean Lapègue (Action Against Hunger) on the link between toilets and nutrition; 1:23 for Catherine Chazaly (DG ECHO) on the barriers to overcome; 1:49 for Sergio Cooper Teixeira (SUN movement) on what a good nutrition policy would look like; and 2:38 for Dr Jean Lapègue on progress so far.

Linking WASH and Nutrition Policies

Work to dismantle the silos is already underway. Effective advocacy has raised the political profile of WASH and has led to increasing discussion at donor and government levels.

“A lot of our work is trying to get different ministries and departments to work better together at a policy level,” said Sergio Teixeira, Strategy and Policy Adviser for the Scaling Up Nutrition (SUN) Movement. Supported by the European Commission, the SUN Movement has 57 member countries and three Indian States committed to reducing child undernutrition, and is working to embed links between nutrition and WASH. This means: “Are WASH representatives at the table when nutrition policy is written, and are nutrition representatives there when WASH is on the table?”

There are signs that this may not be happening to a satisfactory degree. WaterAid and SHARE analysed the

 UNICEF Ethiopia via Creative CommonsCredit: UNICEF Ethiopia via Creative Commons

national nutrition and WASH policies of 13 countries, mostly members of SUN in Africa, to assess how well integrated they are. Some countries, like Nepal, Madagascar, Timor-Leste and Zambia, have nutrition plans which specify WASH-related objectives, and in Nepal’s case go as far outlining specific indicators, activities and budget, and jointly delivering WASH and nutrition interventions to the same target groups. Others, including Kenya, Tanzania and Liberia, still have some way to go, including defining activities which promote hygiene and identifying targets, budget and who is responsible for delivery.

Coordination can be complex, as nutrition and WASH are both multi-sectoral issues in their own right. In different countries nutrition might be the responsibility of the Ministry of Health or the Ministry of Agriculture (as in Liberia) or be handled by a special committee through the President or Prime Minister’s office (as in Timor-Leste and Uganda). Meanwhile water, sanitation and hygiene can be divided across several ministries, with water policies sometimes focusing more on agriculture than on human health.

Once the policies are in place, the next step is “finding ways WASH and nutrition can go well together from a delivery perspective,” said Teixeira. “Community health workers can do both WASH and nutrition actions. Are they doing that, do they know how? Are hospitals doing both? Are community development workers?”

While there is no blueprint for how WASH should be embedded into nutrition plans and vice versa, as it depends heavily on context, a few ways which have worked in the SUN countries are: 

Ministerial level
  • cross-ministerial committees to ensure WASH and nutrition policies complement each other
  • active involvement of the WASH ministry in developing the nutrition plan
Policy level
  • including WASH-related objectives, activities, targets and indicators in nutrition action plans and vice versa (e.g. In WASH programmes, prioritise hand-washing, food hygiene and breast-feeding)
  • targeting WASH programmes at nutrition-vulnerable age groups and geographical areas 
  • combining behaviour change interventions for nutrition and hygiene 
  • increased focus on children, including safe disposal of child faeces and hygiene of children’s hands
Implementation level
  • memoranda of understanding between implementing partners 
  • pooling expertise and resources to maximise health impact and cost-effectiveness
To read the recommendations in full, see the report ‘The Missing Ingredients’


For these recommendations to work, investment is needed in the coordination itself.

“Coordination across sectors and multi-stakeholder platforms – they’re often seen as just a meeting of people which should happen naturally,” said Teixeira. “Actually, coordination requires significant funding, as does transforming a coordination unit across WASH and nutrition into a functional team. It takes capacity strengthening, monitoring, time, facilities, transportation, all kinds of expenses. Many countries from our experience report not always having enough funds to coordinate properly.”

DEVCO’s contribution

This is something DEVCO, the European Commission’s Directorate-General for International Cooperation and Development, puts at the heart of its water programmes, with a budget for coordination in each country which selects water as a focal sector for cooperation. “We try to make sure that coordination is government-led,” said Antoine Saintraint, Head of Sector for Water in DEVCO. “It has to be integrated and taken up by the partner countries – that’s paramount in having successful sector integration.”

One example comes from the Solomon Islands in the Pacific, where around 80% of the population practice open defecation and many do not have access to safe water.

“I went to visit a school in Honiara with 600 students, and not a single latrine,” said Saintraint. “They were all going to [attend to] their needs behind a football pitch. So if they were playing football, you better not put the ball outside the pitch… In addition, the lack of sanitation facilities is the first cause of girls dropping out of school.”

DEVCO has invested €1.9 million to address this situation with a water supply and sanitation programme. It is implemented by UNICEF and World Vision in partnership with communities, with the national and provincial health authorities involved in planning and coordination.

 “The EU Delegation is very committed to supporting the government in this sector, really trying to improve access to water and sanitation in removed rural areas, with a priority of providing facilities for schools and health posts,” said Saintraint.

 WSCC via Creative CommonsCommunity Led Total Sanitation, near Lake Malawi. Image credit: WSCC via Creative Commons

The Solomon Islands will continue to work on water and sanitation with the EU, along with 12 other countries which have chosen WASH as a focal sector this EU funding cycle (2014-20). Saintraint outlined three key lessons from DEVCO’s experience which can be built into future cooperation in the Solomon Islands and beyond.

“Firstly, water supply projects have to go hand in hand with sanitation. Secondly, they have to be sustainable: the water operator has to have management independence and financial independence,” said Saintraint. “There has to be no political interference with the water operator, and they need to be able to cover their operation and maintenance costs. This can come from several parts – tariffs, taxes, subsidies, but it has to be planned for.”

And thirdly, “a latrine has to be built by the people because they realise they need one,” said Saintraint. No matter how good the coordination between sectors, change depends on behaviour change within communities.

Toilets & behaviour change

When introducing latrines to communities, a “build it and they will come” approach does not always work – especially where perceptions that it is more natural to go outdoors persist.

Earlier approaches to sanitation often involved providing subsidies to build toilets, leading to only partial use and dependence on subsidies. DEVCO supports the Community-Led Total Sanitation (CLTS) approach, a zero-subsidy policy which helps a community to analyse their sanitation and waste situation, recognise the health and nutrition impact, and decide collectively how to end open defecation.

In the following short video, Antoine Saintraint explains the approach and two techniques to encourage behaviour change:

 
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Public Group on Water & Sanitation

Further reading & viewing:

 This collaborative piece was drafted by the capacity4dev Coordination Team.

DISCLAIMER: This information is provided in the interests of knowledge sharing and capacity development and should not be interpreted as the official view of the European Commission, or any other organisation. Image credits: UNICEF Ethiopia via Creative Commons license 2.0 - hand washing; Water and Sanitation Collaborative Council via Creative Commons license 2.0 - 'The walk of shame'

DISCLAIMER: This information is provided in the interests of knowledge sharing and capacity development and should not be interpreted as the official view of the European Commission, or any other organisation.

Comments

This is a really great read: very informative and interesting. However if I could suggest one small correction: WASH actually stands for 'Water, Sanitation and Hygiene' not water, sanitation and health.
Thank you

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