From Ideas for Development, January 7, 2016
The links between the lack of sanitation and hygiene and nutritional status are increasingly well documented.Yet in the field, few development actors include nutrition in their water and sanitation operations. Why do they fail to take it into account? What are the barriers? Would building stronger links between sanitation and nutrition significantly reduce malnutrition? Is there not the risk that wanting to address all topics in the same development action would lead to none of them being addressed?
The debate was coordinated Emmanuelle Bastide, journalist at RFI. The speakers were Joséphine Ouédraogo, Ministry of Agriculture, water Resources, Sanitation and Food Security, Burkina Faso (in visioconference) ; Cassilde Brenière, Head of AFD’s Water and Sanitation Division at AF ; Jean Lapègue,Technical Advisor for Water, Sanitation and Hygiene at the Scientific and Technical Department of Action Against Hunger (ACF) France; Frédéric Naulet Head of Drinking Water and Sanitation Programs at GRET.
Please find below the Conference synthesis
While one person in three does not have access to basic sanitation facilities, the question of sanitation is “a public health issue that is not properly addressed” (Emmanuelle Bastide). Yet sanitation is critical for preventing undernutrition “a deadly disease which causes 45% of deaths in children under 5” (Jean Lapègue). However, the capacity to interconnect the two issues comes up against the specificities of each sector.
Nutrition, water and sanitation: Interdependent issues
“The link between the health environment and nutritional symptoms” stems from “a vicious circle that needs to be broken”. Indeed, “undernutrition destroys the immunity of the person” who suffers from it and then becomes “susceptible to all infections, and especially water-borne infections”. Yet the lack of hygiene and access to drinking water creates a breeding ground for the emergence of diseases – diarrhea, intestinal worms, environmental enteropathy – which maintain the undernutrition: “A person who is suffering from diarrheal infections will lose their appetite, become dehydrated and suffer from catabolism (meaning that nutrients pass directly into the stools).” (Jean Lapègue)
All the field observations confirm the vicious circle: in Burkina Faso, “it is estimated that 50% of malnutrition is related to infections, poor hygiene conditions or unsafe water and the absence of sanitation.” (Joséphine Ouedraogo) In a region in South Kivu in DRC, AFD has seen that there is “a clear and even temporal link between the number of cases of cholera in the city and the deficiencies in water supply.” (Cassilde Brenière)
Promote the multisectoral approach: An effective solution…
The identification of these causalities has led to a paradigm shift in the perception of undernutrition: while for a long time the only response to this phenomenon was to supply food aid, “today, there is a trend that is conducive to increasing the role of the water-sanitation sector in preventing undernutrition”. Indeed, at Action against Hunger, “34% of projects work on water, sanitation and nutrition in an integrated way” (Jean Lapègue). For example, the association develops comprehensive strategies, such as WaSH-in-nut, where a “water, sanitation and hygiene” component is systematically coordinated with all the programs to combat undernutrition.
In Burkina Faso, the pilot phase of a WaSH-in-nut action program has just been launched: to treat “children under 5 suffering from acute malnutrition, pregnant women and breastfeeding women”, “we have distributed WaSH kits to families, built latrine in homes, raised awareness on handwashing”. The results are satisfactory: “The operations for access to water-sanitation-hygiene have an impact of almost 45% on reducing malnutrition.” (Joséphine Ouedraogo)
…but which comes up against structural specificities
“The planning of sanitation and nutrition needs to be linked and coordinated in both the field and in institutions” (Cassilde Brenière), like what is being established in Burkina Faso: “With the Ministries of Health, Social Action and Education, we are trying to develop a common strategy for operations in order to improve the fight against malnutrition” (Joséphine Ouedraogo). But this approach is still insufficiently widespread: GRET notes that “there are very few exchanges between the public authorities responsible for national strategies and policies”, as is the case with NGOs and financial partners, who “also [work] a lot in silos.”
What are the reasons for this segmentation? The two sectors do not involve the same type of economic circuit: access to water and the sanitation activity involve “market-based relations between service providers and the beneficiary users”, whereas nutrition falls within a different sphere that does not require so much heavy infrastructure. The two sectors also work with different actors: sanitation involves working “with municipalities and the technical services of local governments [….] and nutrition “more with healthcare institutions than with municipalities.” (Frédéric Naulet)
Furthermore, there is not total consensus on the degree to which water, sanitation and nutrition issues should be integrated. AFD advocates for a case-by-case approach, depending on the projects: “Otherwise there is a risk of blurring the lines, which partly prevents a scaling-up” (Cassilde Brenière). For GRET, integrated programs are relevant: “which is especially the case in territories that suffer from a combination of handicaps (extreme poverty, high nutritional prevalence, isolation”. However, in these areas where institutions are often weak, “it is extremely difficult to guarantee the permanence of sanitation services and sustainability of hygiene and nutrition awareness-raising programs”. GRET therefore advocates for “cross-fertilization”, which involves “identifying in each sector […] the common issues and innovations that can benefit one another/” (Frédéric Naulet)
Specific handicaps in the sanitation sector
Finally, it should be noted that certain issues remain specific to the sanitation sector. The first is financing: “Very few sanitation projects are submitted to donors” since priority was for a long time given to access to water (Frédéric Naulet). Indeed, “if we look at total development assistance in the water-sanitation-hygiene sector, 75% is allocated to water, 24% to sanitation and 1% to hygiene” (Jean Lapègue). There is a pressing need to come up with sustainable financing solutions for sanitation if we want to scale up: “It will not be possible to provide 2.5 billion people with access [to basic sanitation facilities] with small-scale integrated projects in villages.” (Cassilde Brénière)
The other main challenge is to involve communities. Issues such as latrines and hygiene are still taboo: for the time being, sanitation “is not subject to a strong enough demand from communities”. There is a “need to change behavior” (Joséphine Ouedraogo). At the same time as developing infrastructure, actions need to be conducted to raise public awareness, especially because the most basic actions can have very significant effects: for example, the researcher Lorna Fewtrell has shown that to reduce morbidity and mortality, especially from diarrhea, “the first action to take is handwashing with soap”. However, due to the lack of resources, “priority needs to be given to effective and inexpensive actions.” (Jean Lapègue)