12 November 2015

WASH and Nutrition: opportunities and challenges from farm to faeces

Yesterday I was invited to the first WASH-Nutrition Forum.  The organisers, the German WASH Network,  set it up with half of the participants from the WASH community and the other half from nutrition (SUN was well represented), with plenty of people capable of talking to both groups. 

I was presenting the Global Nutrition Report in a session that Bruce Gordon of WHO was presenting the GLAAS report, a global accountability mechanism for WASH which has been going for several years.
I wrote a paper on the non-food determinants of nutrition back in 1996, showing that food security was more strongly associated with nutrition status in the presence of better heath environments, so I was already intrigued.  But this was, I think, the first event of its kind I had been to—one that deliberately sought to connect WASH and nutrition.

I learned a lot, but I left with more questions than answers.
There are some big differences and many commonalities between the two communities.

Differences include
* The extent of big ticket WASH spending items that the engineers oversee—water and sanitation infrastructure.  This hardware provides a platform for the behavior change work that must accompany WASH infrastructure, but could easily dominate it.

* The focus in WASH is on access for everyone.  Not all nutrition interventions are like this.  Some are (e.g. exclusive breastfeeding) and some aren’t (e.g. SAM and Zinc treatment of diarrhea)
* In WASH there is no comparable age related focus window.  In nutrition we have the first 1000 days, but in WASH no particular lifecycle stage gets more focus than others.

* The political profile of WASH is much higher than nutrition: the Sanitation and Water for All Partnership (SWA) executive Director told us about the annual meetings she organizes with Finance Ministers to talk about what a great investment WASH is.  Clearly in nutrition we have to aim higher.  Also the WASH community has a World Toilet Day (wonderfully clear articulation—no weasel words there!).  There is, as yet, no World Nutrition Day.

But there are many commonalities
* The DHS and MICS surveys are vital to both communities—does this provide a place to come together to influence improved data collection, especially for analyzing inequalities?

* Both communities rely on behavior change communication interventions: for WASH especially in hygiene and toilet use.  Imagine how school feeding programmes are undermined if handwashing after defecation is not practiced. 
* Both communities are concerned with public health outcomes.  At least in theory.  I learned in practice that few WASH programmes are evaluated in terms of health metrics.

* Incentives to collaborate across sectors are not terribly strong.  For nutrition folks, you would think the incentives to collaborate with WASH folks are strong: we know if WASH is done well it will increase the chances of our nutrition interventions having a bigger positive effect. And yet collaboration is the exception rather than the rule. For WASH folks, the incentives are (at least to me) not so clear.  Yes, WASH folks want improved health outcomes from their work, but if they don’t have to report on health outcomes, then engaging with nutrition is one more cost.
So I left the meeting (one day early) wondering about incentives.  Clearly there are many opportunities, but how can they be realised? I’m afraid I don’t have any sure fire answers.   I suspect it is something to do with embedding nutrition indicators in some WASH interventions, and convincing WASH folks that if they show a nutrition impact then that is one more reason for governments and donors to invest in WASH.  Donors have a role to play in promoting collaboration (although they are often as divided).

Ultimately though it is not clear to me when this collaboration should be deep and where it should be less intense.  
Do we just want WASH programmes to be effective on their own terms (reducing disease burdens), and then locate our nutrition programmes in areas where WASH programmes are at least providing some minimum floor for nutrition interventions to operate on? 

Or are there really such things as nutrition-sensitive WASH programmes?  I believe there are (e.g. focusing on how to keep pathogens out of the mouth and gut of infants), but are they essential for WASH to have an impact on nutrition or do they simply represent an acceleration and intensification of impact on nutrition? And if so, how much?
We don’t have the answers to these strategic but empirical questions yet, but I got the sense that there is a new set of sophisticated interventions and evaluations in the field which are attempting to answer these questions. 

At a minimum nutrition and WASH communities need to keep talking and identifying and implementing modest wins all along the farm to faeces chain.  When there are enough of these, big changes can happen—and then everyone will want in.

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