Seven pathways towards ending undernutrition by integrating nutrition and water, sanitation and hygiene

5 min read
Happy children enjoying their porridge at Ntondoko Early Childhood Development Centre, Zomba, Malawi, February 2019.
Image: WaterAid/ Dennis Lupenga

How can we improve policy integration to address the root causes of undernutrition and child stunting? Megan Wilson-Jones and Paul Reissi discuss the opportunities and pathways for combining nutrition and water, sanitation and hygiene work, as revealed by joint WaterAid and Action Against Hunger research in Cambodia, Ethiopia and Madagascar.

Globally, more than one in five children younger than five are stunted, irreversibly damaging their physical and cognitive development and limiting their life chances. Poor sanitation is the second leading risk factor for stunting worldwide.

To end hunger and the devastating, long-term effects of undernutrition, we must tackle its root causes. Lack of access to safe drinking water, decent sanitation and good hygiene remains a dramatic driver of undernutrition, especially among children. It is time for governments, civil society organisations, donors and the private sector to collectively implement new approaches to ensure that water, sanitation and hygiene (WASH) interventions are better integrated with nutrition policies and programmes.

Consistent lessons from Madagascar, Cambodia and Ethiopia

There is no silver bullet for creating a multisectoral approach to nutrition and actions must be context-specific. However, Action Against Hunger and WaterAid’s joint research in Madagascar, Cambodia and Ethiopia points to at least seven drivers, or enabling factors, that can support more joined-up working between nutrition and WASH stakeholders for successful integration of WASH interventions with nutrition policies and programmes. Seven pathways that can contribute to creating lasting change for communities and countries held back by chronic undernutrition.

Our experience, based on qualitative stakeholder interviews in the three countries, points to opportunities and entry points for governments and partners to strengthen multisectoral approaches. This finding is consistent with previous work and experience of the World Bank, USAID, Action Against Hunger and other international development actors. We recognise the complexity of the issue, but hope to contribute to the conversation through sharing our experience.

The seven pathways:

1. Leadership

Support and leadership must be secured at the highest level – from the prime minister or president. Undernutrition is multicausal, so strong leadership is essential to drive the cross-ministerial coordination necessary to tackle it and hold line ministries to account for integration of WASH and nutrition in development plans. Without top-level, outspoken backing, prioritisation can slip.

2. Policies

Just as leadership must come from the top, so should policies. National and regional development plans must take a multisectoral approach to integrating nutrition and WASH interventions, aiming to improve child nutrition. Specific policies for nutrition and WASH must be coordinated and cross-refer to one another, each requiring lead ministries, sufficient budget, targets and indicators.

On the ground, the corresponding interventions should deliver an integrated minimum package of health, nutrition and WASH services and messaging. Focusing on promoting key hygiene behaviours (such as handwashing at key moments, safe treatment and storage of food and water, and safe disposal of child faeces), targeted particularly at mothers, newborns and children, and combined with nutrition interventions, offers a key entry point for integration.

3. Financing and strong government systems

To enable policies to be translated to action, WASH and nutrition plans must be fully financed, with clearly defined financing strategies across ministries that support better coordination. Both domestic and international funding needs to increase, to support government systems, and ensure WASH interventions can be aligned with nutrition interventions.

4. Data

Governments and donors must prioritise investments in data systems to enable interventions to be prioritised and targeted effectively, and to enable reliable monitoring. Public policies should be based on a systematic collection of localised data in order to target WASH interventions to undernutrition hotspots, prioritising mothers, newborns and young children.

Without good data, how can actors choose where to focus efforts, and track progress? Countries need up-to-date, localised data on undernutrition, and to share data regularly across the ministries responsible for nutrition and WASH.

Raoly, 29 and her daughter, Natasha, at the water point, six months after the arrival of water in their village. Tsarafangitra village, Belavabary commune, Moramanga district, Madagascar, March 2018.
Raoly, 29 and her daughter, Natasha, at the water point, six months after the arrival of water in their village. Tsarafangitra village, Belavabary commune, Moramanga district, Madagascar, March 2018.
Image: WaterAid/ Ernest Randriarimalala

5. Sub-national coordination

In order to implement policies in a sustainable way, it is essential to ensure regular coordination meetings between stakeholders from local to national levels. The strong national coordination mechanisms established at ministry level should be replicated at sub-national level. National governments and donors should invest in building capacities of and creating incentives for sub-national authorities to jointly plan, deliver and monitor integrated WASH–nutrition approaches.

6. Knowledge sharing

Local authorities, CSOs, NGOs and donors should prioritise documenting and sharing knowledge and experience from integrated WASH–nutrition projects, to support governments to adopt and scale up models that work. This needs to happen from the local to the international level. The ongoing collaboration between the Scaling Up Nutrition (SUN) Movement and Sanitation and Water for All (SWA) Partnership is a great forum for sharing lessons.

7. Accountability

Governments must ensure transparency and accountability – key to driving multisectoral approaches. Clearly defining roles and responsibilities across sectors and stakeholders working on WASH and nutrition, and common measures of success, mean everyone knows where they stand and what they are accountable for – and to whom. Open and clear communication of new multisectoral approaches can demonstrate to citizens the intended long-term benefits, and help them to hold government to account.

As the WASH Benefits and SHINE trials showed, the relationship between nutrition and WASH is complex. But better collaboration between WASH and nutrition sectors can undoubtedly support collective progress across the Sustainable Development Goals to end undernutrition, and ensure everyone, everywhere has access to water, sanitation and hygiene.

Governments and donors must act differently by investing in integrated actions on nutrition and WASH, to make sure every child has the healthy start that is their right.