Opinion: How to integrate water, sanitation and hygiene into nutritional policies

In 2015, world leaders pledged to end malnutrition by 2030. But with 155 million children under age 5 still suffering from stunted growth, this goal will not be met in time at the current rate of progress. It can also never be achieved through traditional nutritional interventions, such as micronutrient supplements, alone. The truth is that food is not a sufficient means by which to end malnutrition. We have to address its underlying causes too. Clean water, adequate sanitation and good hygiene are therefore vital ingredients.

It’s estimated that half of all cases of undernutrition are linked to infections, including repeated episodes of diarrhoea, caused by a lack of clean water and poor sanitation and hygiene practices.

The Lancet also suggests that direct interventions to address malnutrition, such as nutrient supplements and exclusive breastfeeding, can only reduce stunting — or “inequality baked into the brains of children,” as World Bank President Jim Yong Kim refers to it — by at most, 20 percent, even if they are reaching 90 percent of the population most at need. Stunting is one of the most troubling consequences of malnutrition.

Despite these alarming figures, the link between WASH and nutrition has, until recently, been given relatively low priority. But as nutrition-specific interventions alone have proved insufficient, and evidence mounts of prevailing undernutrition even in regions where food is plentiful, the fundamental role WASH plays in nutrition is slowly becoming better understood.

These insights now need to be put into practice, and fast if we’re to meet the ambitious goal of ending malnutrition in 13 years. The “Recipe for Success” report — released jointly by WaterAid, Action Against Hunger and the SHARE Consortium for Stockholm World Water Week — highlights there is much that can be done by the governments of affected countries, nutrition policymakers, practitioners, donors, and those within the WASH sector itself.  

Tip 1: Get the policies, plans and delivery right

Ensure policies strengthen WASH-nutrition collaboration and coordination. While most nutrition plans recognize the importance of WASH, many lack details about which WASH actions should be prioritized and how. So putting a detailed plan in place to work and coordinate with WASH stakeholders, with the necessary resources, is crucial.  

Nutrition plans must also include improved provision of WASH in health care centers and schools, hygiene behavior change programs, and BabyWASH interventions designed to prevent babies from being exposed to pathogens — for example, safe children’s play areas, complementary food hygiene and safe disposal of child faeces. Specific WASH objectives and measurable targets should also be embedded into existing health and nutrition programs and initiatives.

Tip 2: Get high-ranking politicians on board

Ensure there is the political will and high-level engagement in place to foster a supportive and enabling environment on which collaboration across multiple sectors can emerge. Effective cross-department coordination needs to be championed and driven by heads of state, who can ensure ministers collaborate effectively.

Tip 3: Collaborate, share and educate  

Share information across sectors, ministries and government departments and encourage them all to take an active role in the development and implementation of nutrition and WASH policies and plans.  

Collaborate wherever possible; form partnerships; share knowledge and ideas and get others’ input on the programs in return. Establish joint sector reviews, regular information exchanges, technical working groups, and focal points and knowledge brokers. Working collaboratively with coalitions such as Sanitation and Water for All or Scaling Up Nutrition will allow countries to learn from each other’s experience.

Frontline health workers, teachers and caregivers can also be educated on the relationship between WASH and nutrition, education and health.

Tip 4:  Design collaborative interventions

WASH can be integrated into both the prevention and treatment of malnutrition. Nutrition programs that focus on behavior change, such as the promotion of exclusive breastfeeding, could be modified to include key WASH behaviors. Similarly, the treatment and management of severe and acute malnutrition could integrate relevant WASH interventions, such as household water treatment kits and hygiene promotion.

Co-locating WASH and nutrition programs to areas of joint vulnerability — those with high prevalence of undernutrition and low access to WASH — will ensure we reach those most in need of assistance.

Tip 5: Fund what works best

National governments need to ensure adequate financing is in place to turn words into action. Integrated nutrition and WASH policies are of little use without the budget allocated to deliver on multisectoral approaches. Donor agencies, meanwhile, have a key role to play: use funding to incentivize national governments to focus on integrated approaches; invest in nutrition-sensitive WASH programs; and fund research that documents and shares best practice to persuade sceptics.  

Successfully integrating WASH into nutritional policies and programs across the globe will require national governments ,donors, and both nutrition and WASH stakeholders to shift mindsets, develop ambitious policies and plans, create effective coordination mechanisms, scale up flexible funding, and share lessons and experiences globally. But most of all, it will require focused intent — a determined, coordinated drive toward working together to ensure that nutrition and WASH are delivered side by side to everyone who needs them.

Cambodia leads the way

The Cambodian government has already proven this approach can work. They prioritized WASH in their National Strategy for Food Security and Nutrition, advocating for its inclusion in all child and maternal nutrition programs, including behavior change campaigns and school curricula. This led to the creation of the government-led WASH and Nutrition Sub-Working Group — made up of ministry officials from health and rural development and core partners such as WaterAid, UNICEF and Save the Children — which has driven integration forward. For the first time, sub-national health, rural development and agriculture representatives are discussing integration; government and development partners are bringing joint WASH and nutrition programs to the Cambodian villages, districts and provinces they support; and more and more donor agencies are building upon their early successes.

It is now time for the rest of the world to follow Cambodia’s example and integrate WASH into their own nutritional plans. Because without clean water, adequate sanitation and good hygiene, the world will fail to end undernutrition, and the SDG on nutrition will become just one more unachievable dream that never came to fruition.

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