Bringing WASH and nutrition experts together

5 min read
Image: WaterAid/Tom Greenwood

Cambodia has made great strides in decreasing poverty and growing its economy, but how can we ensure undernutrition is reduced so its children can grow and develop? Channa Sam Ol, WASH and Health Program Manager for WaterAid Cambodia, discusses the context in which the WASH and Nutrition Working Group was created.

"From the good shoots will grow good bamboo."

In Cambodia we compare children to bamboo shoots – if we take care of the shoots, they will turn into strong green bamboo. This phrase makes me think of the nutrition and sanitation situation in my country and motivates me in my work to get clean water, decent toilets and good hygiene to everyone.

Cambodia was recently re-classified as a low-middle-income country. Yet, despite improved economic growth and a reduction of national poverty, undernutrition remains a public health threat. The rate of child stunting, wasting, and micronutrient deficiencies remains high compared with other countries in Southeast Asia. Every day, 12 children under five die because of maternal and child undernutrition;1 and one in three children under five are too short for their age (stunted),2 irreversibly damaging their long-term cognitive and physical development.

Are we missing a trick?

In our rural communities, fewer than half of households use an improved latrine,2 and around half have access to an improved drinking water source.3 For me, as a mother of two young children, the link between clean water, sanitation and hygiene (WASH) and improved nutrition status is obvious. A mother or caregiver needs a hygienic environment to feed young children and provide them with clean drinking water, and needs a clean place for them to play, free from the pathogens spread by poor sanitation. Without these conditions, our children become sick again and again, which contributes to making them lighter and shorter than they should be – the bamboo shoots can’t grow.

When I visit rural communities I often find children living in a house without a latrine, where water is taken directly from a surface or rainwater source. Good nutritious foods are lacking, and food is often prepared unhygienically, in a dusty house surrounded by livestock. I notice the same conditions in urban poor areas. I always imagine how much communities must struggle to support their children to grow strong and healthy.

Pheurn's family having lunch.
A family meal time in a rural home.
Image: WaterAid/Kim Hak

I also notice many different organisations coming to our communities to work on nutrition, agriculture, or WASH projects – normally separately. Some projects deliver really good activities for improving, for example, breastfeeding or diets, yet these take place in communities where half or even two thirds of people defecate in the open. This, unfortunately, undermines the benefits of the nutrition interventions.

The birth of the WASH and Nutrition Working Group

During its first year of operations in Cambodia, WaterAid identified better integration of WASH and nutrition as a strategic global opportunity, leading WaterAid Cambodia to discuss the missing link between WASH and nutrition. We found other key stakeholders among donors (the Global Sanitation Fund, Plan International and the World Bank) and the Government (the Council of Agriculture and Rural Development [CARD] within the Council of Ministers) who shared our view.

WaterAid worked with CARD to establish a national WASH and Nutrition Working Group to drive integrated WASH and nutrition action. The group’s purpose is to develop a shared vision of, learn about, and share experiences of integration of WASH and nutrition, and establish synergy between the sectors to improve the quality of programming and services, to achieve greater impact.4 CARD and Save the Children co-chair the group, which comprises key WASH and health sector actors.

More evidence needed

Many previous efforts to integrate sectors in Cambodia have stalled. To understand the barriers and find solutions, we commissioned the Burnet Institute to undertake research, led by CARD and co-funded by the Global Sanitation Fund and Plan International.

The WASH and Nutrition Working Group identified three top priorities for action, from which stem three action plans: (i) appoint focal people who can accumulate knowledge about WASH and nutrition; (ii) develop a cross-sectoral strategy that outlines how existing WASH and nutrition policies contribute to integrated efforts to improve nutrition outcomes; and (iii) advocate to the Ministry of Economy and Finance for increased budget allocations to nutrition, WASH and donors for increased merged funding opportunities.

A girl receiving treatment in one of the referral hospitals in Kampong Chhnang province.
A girl receiving treatment in one of the referral hospitals in Kampong Chhnang province.
Image: © WaterAid/ Tom Greenwood

Raising the profile with key decision-makers

Our next key objective was to raise the profile of WASH and nutrition integration with high-level decision-makers, and advocate for national budget changes. Last year, the working group, with strong leadership from Save the Children, organised a national conference on 'Improved hygiene and nutrition make children grow: from evidence to impact'.

The conference, led by the Deputy Prime Minister, marked National Nutrition Day at the start of November. It brought together key thought-leaders and decision-makers from national and sub-national levels. It highlighted the need to establish an enabling environment and greater resource allocation for integrated stunting prevention, working across sectors.

New analysis was presented from baseline studies related to stunting, including on nutrition, food security, WASH interventions, and access to healthcare. I presented the findings from the barrier study. In group discussions implementers from different regions talked about the barriers they faced in integrating programmes, and what to do to overcome these.

A key message I took away was that active collaboration is an important start, but successful programmes that deliver sustained impact on nutritional outcomes require joint planning and policy, appropriate financing, and strong leadership, including coordination, knowledge sharing, and monitoring and evaluation.

At WaterAid Cambodia, we use an adaptive planning approach, and we are now pausing to reflect on what has been achieved on this topic over the past few years, and planning our next steps. There is certainly greater coordination between WASH and nutrition actors, more programmatic activity, more evidence and better data than there was a few years ago. So what’s next for us? We’ll keep you posted.

Channa Sam Ol tweets as @channasam

1. UNICEF/IRD (2016) Secondary analysis of Cambodia and Health Survey 2014. Moench-Pfanner R, Silo S, Laillou A, et al. The economic burden of malnutrition in pregnant women and children under 5 years of age in Cambodia. Nutrients 8(5): 292. DOI:10.3390/nu8050292.
2. National Institute of Statistics, Directorate General for Health and ICF International (2015) 
Cambodia Demographic and Health Survey 2014. Phnom Penh, Cambodia and Rockville, Maryland, USA.
3. National Institute of Statistics (2015)
 Cambodia Socio-Economic Survey 2014. Phnom Penh, Cambodia and Rockville, Maryland, USA.
4. The WASH and Nutrition Working Group is accountable to the Technical Working Group – Rural Water Supply Sanitation and Hygiene (RWSSH) chaired by Ministry of the Rural Development and Chair of Development Partners; and the Food Security and Nutrition Technical Working Group is chaired by the Council for Agricultural and Rural Development (CARD).