"No to fragmentation and isolated action" – integrating child health and water, sanitation and hygiene in Madagascar

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8 May 2018
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"No to fragmentation and isolated action, Yes to synergy, harmonisation and complementarity" – this was the call to action from the head of the Bongolava regional nutrition office when I visited Madagascar a few weeks ago.

He was speaking at a stakeholders meeting to discuss the progress made in Bongolava, a region to the west of Madagascar’s capital Antananarivo, in trialling an integrated project combining interventions in water, sanitation and hygiene (WASH), nutrition, health, agriculture, and a village savings and loans scheme. The five-year project, led by WaterAid Madagascar and Caritas in support of the regional and commune authorities, was marking its final year during my visit to Madagascar.

The island of Madagascar is a beautiful country, rich in biodiversity, minerals and internationally-renowned exports like vanilla, and with a fascinating culture, both a part of Africa and separate from it. Yet at the same time, it is a country with huge challenges. 77.8% of the population lives on less than $1.90 a day. A combination of prolonged political instability and vulnerability to frequent destructive extreme weather events have damaged the prospects of economic growth. 3,870 children less than five years old die every year because of preventable diarrhoeal diseases caused by poor water, sanitation and hygiene, and almost half of children under five are stunted, their cognitive development and growth damaged irreversibly by malnutrition. Sadly, this is unsurprising when only 1 in 10 of the population have access to basic sanitation, 44% of people are forced to defecate in the open and only half of the population has access to a basic water source.

Despite these dire circumstances, communities in Madagascar have shown incredible resilience and innovation in their search for solutions. While I was in the country, WaterAid Madagascar launched the new joint report by WaterAid and PATH’s Defeat Diarrheal Disease Initiative 'Coordinate, Integrate, Invest: how joint child health and water, sanitation, and hygiene (WASH) can deliver for your country’s future'. The report showcases examples of progress in combining child health and WASH interventions to achieve greater impact and cost-effectiveness.

The report praises Madagascar for the progress the government has achieved in strengthening coordination between authorities responsible for nutrition and WASH. In particular, it highlights the National Action Plan for Nutrition Phase III launched last year. The plan aims to take a multi-stakeholder and multi-sector approach to accelerating reduction of stunting in children under five, from 47% to 38% by 2020. It prioritises ‘nutrition-sensitive’ as well as ‘nutrition-specific’ interventions, with targets to improve access to drinking water to 65% of households and sanitation to 30% by 2020, and to promote good food and hand hygiene.

This coordinated effort will require investment and political ownership from all levels of government – certainly not a given in a country with frequent political turbulence and change. Only recently the Ministry of WASH was dissolved, along with the national multi-stakeholder platform Diorano WASH, and a new Ministry of Water, Energy and Hydrocarbons created with a new Minister. Such uncertainty is not conducive to embedding new, more integrated cross-government ways of working. But the stakeholders I met in Madagascar, from the communities to the regional authorities to partners such as WaterAid Madagascar, are determined to move forward together.

At the launch event for ‘Coordinate, Integrate, Invest’ in Antananarivo, the report sparked a lively discussion between representatives from government ministries and development partners focused on health, nutrition and WASH. Who should lead coordination of joint efforts? Given the decentralised structure of government in Madagascar, which level of government should be responsible? Who holds the budget for integrated actions and how is that budget allocated? None of these are easy questions to answer, but it is equally clear that these tough conversations must continue if the situation for Madagascar’s people is to improve.

As our report makes clear, people do not live their lives in sector-specific siloes. From giving birth in an unhygienic health facility without running water, to having no choice but to eat and drink food and water contaminated by faeces, the challenges people living in poverty face cross issues and sectors – and so must the solutions. For the Sustainable Development Goals to become reality requires bold action and new thinking, beyond traditional siloes. The children of today and the economies of tomorrow depend on governments and donors like those in Madagascar acting urgently to strengthen coordination, integration and investment in child health and WASH.

Read the report >

This blog was first published on 8 May 2018 by Defeat DD.