Global health – new year, new decade, new challenges and opportunities
How can we tackle the World Health Organization's urgent health challenges of water, sanitation and hygiene (WASH) in healthcare facilities, superbugs and equality in healthcare? Dan Jones highlights opportunities in 2020 to strengthen integration in global health, including key moments for WASH, nutrition and vaccines.
“Public health is ultimately a political choice,” wrote Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO), when he published a list of urgent health challenges for the next decade in January.
Produced by WHO with input from global health experts around the world, the list was intended as an urgent call to action that 'reflects a deep concern that leaders are failing to invest enough resources in core health priorities and systems'. This message resonates strongly with our concern at WaterAid that world leaders are failing to prioritise the fundamentals of good health and strong health systems – water, sanitation and hygiene (WASH).
Keeping healthcare clean
It is absolutely right that WHO’s list highlights the critical issue of ‘keeping healthcare clean’ (number 13 on the list, which is not in order of priority). WHO highlights the crisis in WASH both in healthcare facilities and in communities. Roughly one in four health facilities globally lack basic water services (nearly half in least-developed countries). Billions of people are living in communities without safe water to drink or adequate sanitation services – which are major drivers of disease.
We were pleased to also see WASH explicitly mentioned in tackling the threat of antibiotic-resistant 'superbugs' (number 12) and, in this year of the 10th anniversary of the UN’s recognition of water and sanitation as human rights, as an issue of fairness and equality (number 3).
The emergence of a novel coronavirus in China and its spread reinforces the crucial importance of WASH, with WHO’s advice reiterating that practising good hand and food hygiene is a key defence against infection and transmission of illnesses.
Can we break out of our silos?
It is clear that the global health challenges the world now faces cannot be solved through narrow approaches divided by traditional sectors. Perhaps they never could. I don’t say that glibly, or to suggest that I or WaterAid have all the answers (the WASH sector is as bad as any other at breaking out of its silo), but it is striking to me as we look at the year ahead that the urgency of finding new, more collaborative and integrated approaches has never been greater.
In many of the conversations I’ve had with health ministries, donor agencies and INGOs focused on health issues, there is little real push back against integrated cross-sectoral approaches. In principle, everyone agrees and nods vigorously. But making the case for ‘why’ is much easier than securing commitment to ‘how’.
Our research with Action Against Hunger in Cambodia, Ethiopia and Madagascar on the extent of integration of WASH and nutrition highlighted barriers including the political territorialism of ministers, and the perverse incentives of donor funding for countries to prioritise short-term, tangible wins over long-term, sustainable systems strengthening.
Another challenge is the difficulty of proving the effectiveness of integrated approaches when traditional gold standards of evidence and research favour singular results in carefully controlled environments.
Opportunities in 2020 to commit to an integrated approach to global health
At WaterAid, we remain committed to moving the conversation forward towards realistic, effective solutions. We see many opportunities in the year ahead for countries and donors to strengthen understanding and take important steps forward in delivering integrated approaches combining WASH and health. And, throughout this year, our country teams will be sharing their expertise, drawn from WaterAid’s Healthy Start global priority.
For example, in June the UK Government will host the next replenishment of Gavi, The Vaccines Alliance. Gavi and its CEO Seth Berkley have been important allies in the push for effective integration, helping to make the case that investment in WASH should go hand in hand with investment in vaccinations. At a joint event at the World Health Assembly in 2019 focused on ending cholera, Seth emphasised that vaccines can help with managing cholera outbreaks, but the long-term solution is investment in WASH services for all. Will donors and countries pledging new funding to Gavi this year similarly recognise the need for investment in WASH alongside vaccines as part of creating strong health systems? We hope so.
Countries looking for concrete solutions in this area could learn from an integrated approach pioneered by WaterAid Nepal on hygiene promotion through routine immunisation, which is now being scaled up to nationwide under the leadership of Nepal’s Ministry of Health, with our capacity-building support. This approach recognised that a new mother will take her baby to an immunisation clinic at least five times in the first nine months of the child's life, making this an excellent point of contact where health workers can promote good hygiene behaviours that will improve children’s and families’ health. Other countries in South Asia and Africa have experimented with similar approaches and are keen to learn, adapt and scale up.
Another key focus for the global health community in 2020 will be the Nutrition for Growth events spearheaded by the Government of Japan around the Tokyo 2020 Olympics. These will seek new financing commitments from governments and donors towards ending malnutrition.
This is another area where we at WaterAid have been working hard to contribute to understanding of how an integrated approach combining WASH and nutrition can be beneficial. We have worked closely with the Scaling Up Nutrition (SUN) Movement and the Sanitation and Water for All (SWA) Partnership to champion a multisectoral approach and to document and share country experiences. At November’s SUN Global Gathering we supported a rich discussion on this, with experiences shared from Cambodia, Ethiopia, Madagascar, Mali and Nepal (read the event summary here). Will those making commitments at Nutrition for Growth emphasise a multisectoral approach to tackling malnutrition, with WASH as a priority?
Finally, it’s worth noting that when the world’s health ministers meet in Geneva in May for the annual World Health Assembly, they will be marking one year since they adopted the first-ever formal resolution to take action on WASH in healthcare facilities. That resolution, years in the making and ultimately adopted unanimously by all member states, was championed by the Health Ministers of Tanzania and Zambia, and drew wide support from countries as diverse as Australia, eSwatini, India, Nigeria and all European Union member states (yes, including the UK). 12 months later, will health ministers have taken concrete action to deliver on this promise? We’ll see.
As WHO's list shows, the biggest global health challenges at hand – and thereby their solutions – are linked by cross-cutting issues unbounded by borders or sectors. Can we learn new ways of working effectively together, across ministries and across sectors to address them? Ultimately, as Dr Tedros makes clear, we have no choice but to do so if we are to realise the dream of health for all.
All the challenges in this list demand a response from more than just the health sector. We face shared threats and we have a shared responsibility to act.
– Dr Tedros Adhanom Ghebreyesus