Water and Sanitation Program: technical Paper 102935 Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Claire Chase and Francis Ngure February 2016 The Water and Sanitation Program is a multi-donor partnership, part of the World Bank Group’s Water Global Practice, supporting poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. The authors thank Nkosi Mbuya, Luis Andres, and Guy Hutton, who served as peer reviewers. Leslie Elder, Andrea Spray, and Emily Rand provided comments on earlier versions. We also thank seminar participants at the 2014 World Bank Water Week session: “Maximizing Nutritional Impact of WASH Investments.” This Technical Paper is conceived as a work in progress to encourage the exchange of ideas about development issues. For more information please email worldbankwater@worldbank.org or visit www.wsp.org. The Water and Sanitation Program is a multi-donor partnership, part of the World Bank Group’s Water Global Practice, supporting poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP’s donors include Australia, Austria, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. WSP reports are published to communicate the results of WSP’s work to the development community. Some sources cited may be informal documents that are not readily available. The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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For more information, please visit www.wsp.org. © 2016 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Claire Chase and Francis Ngure February 2016 Contents .............................................................................. v Abbreviations. I. Introduction................................................................................. 1 II. Objective and Background. ......................................................... 6 Why Is WASH Important for Nutrition?................................... 6 Why Is Nutrition Important for WASH?................................... 7 III. Pathways Linking WASH and Nutrition and Available Evidence............................................................... 8 Pathway 1: Improved Nutrition through Reduction in Diarrheal Disease Due to Reduction in Fecal Contamination of the Environment......................................... 8 Pathway 2: Improved Nutrition through Reduction of Enteric Infections Due to Reduction of Fecal Contamination in the ­ Environment. ......................................... 9 Pathway 3: Improved Nutrition through Reduced Exposure and Infection with Protozoa and Helminths Due to Improved WASH................................................................. 9 Pathway 4: Improved Nutrition through Reduction in Anemia Due to Improved WASH....................................... 10 Pathway 5: Improved Nutrition through Reduction in Time Spent Fetching Water and Caring for Sick Children, and Time and Costs of Seeking Treatment........... 11 Pathway 6: Direct Links between WASH and Undernutrition................................................................ 11 IV. World Bank Group’s Water Program......................................... 13 V. World Bank Group’s Nutrition Program..................................... 14 VI. Challenges to Multisectoral Approaches in the WASH Sector. .................................................................. 15 VII. Opportunities for Nutrition-Sensitive WASH............................. 16 VIII. Principles for Nutrition-Sensitive WASH Investments and Policies............................................................................... 17 1. Improve Geographic and Demographic Targeting to Reach Populations Where Water and Sanitation Coverage Is Low and Undernutrition Is High........................ 17 2. Utilize Best Practices in Behavior Change and Insights from Behavioral Economics to Maximize the Impact of World Bank Group Operations on Nutrition...................... 19 www.wsp.org iii Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Contents 3. Leverage the Program-for-Results Lending Instrument and Other Institutional Incentives to Align WASH and Nutrition Objectives. .............................. 20 4. Incorporate Nutrition-Sensitive Objectives and Indicators into WASH Investments and Policies. ........... 21 IX. Addressing WASH through Nutrition Projects. .......................... 23 X. Summary and Next Steps......................................................... 24 Figures 1: Global Prevalence of Stunting among Children Under Age Five. .................................................................. 3 2: Global Proportion of Population Using Improved Sanitation........................................................... 3 3: Global Proportion of Population Using Improved Drinking Water Sources. ..................................................... 4 4: Drinking Water Coverage Trends by Developing Regions and the World, 1990–2015................................... 5 5: Sanitation Coverage Trends by Developing Regions and the World, 1990–2015................................... 5 6: Direct and Indirect Determinants of Malnutrition............... 7 7: Pathways Linking WASH and Nutrition.............................. 8 8: Stunting Rates and Open Defecation in Vietnam............. 18 Annex  Building the Evidence and Knowledge Base................... 25 References................................................................................ 27 iv www.wsp.org Abbreviations BCC behavior change communication CCT conditional cash transfer CDD community driven development CI confidence interval CLTS Community-Led Total Sanitation COD cash on delivery DAC Development Assistance Committee DHS demographic and health survey DLI disbursement linked indicator GDP gross domestic product GPOBA Global Partnership for Output-Based Aid HAZ height-for-age Z-score HDN Human Development Network HIV/AIDS human immunodeficiency virus/acquired immunodeficiency syndrome HNP Health, Nutrition and Population HRITF Health Results Innovation Trust Fund IEG Independent Evaluation Group MDG Millennium Development Goal MoH Ministry of Health OBA output-based aid ODF open defecation free PDO project development objective P4P pay for performance PforR Program-for-Results PM practice manager RBF results-based financing SBM Sawatch Bharat Mission SDG Sustainable Development Goal SHINE Sanitation Hygiene Infant Nutrition Efficacy Project STH soil-transmitted helminthiasis SUpRWSS Scaling Up Rural Water Supply and Sanitation Program TTL task team leader UNICEF United Nations Children’s Fund WASH water, sanitation and hygiene WAZ weight-for-age Z-score WBG World Bank Group WHO World Health Organization WSP Water and Sanitation Program www.wsp.org v I. Introduction Key POINTS • Global momentum around emerging evidence of the linkages between water, sanitation, and hygiene (WASH) and undernutrition, and high-level policy dialogue advocating for nutrition-sensitive WASH, has created a “window of opportunity” to influence how the World Bank Group approaches lending for WASH projects, and how policies are designed for greater impact on nutrition. • Achieving nearly universal coverage of the most effective nutrition interventions in high burden countries would only reduce stunting by 20 percent globally, suggesting a critical role for nutrition-sensitive interventions such as WASH to address the remaining burden. • Increased use of geographic and demographic targeting of WASH projects can help reach populations where water and sanitation coverage is low and undernutrition is high. • Incorporating state-of-the-art behavior change methods and insights from behavioral economics into World Bank Group operations in the WASH sector, and documenting behavioral outcomes, can provide plausible evidence of impact on nutrition. • Institutional levers can be used to align incentives of task teams and senior management toward multisectoral approaches, while results-based incentives can align objectives at the project level. • WASH interventions can increase nutritional impact by measuring and monitoring outcomes beyond access to services, such as usage, maintenance of infrastructure, and behavioral change. Undernutrition is estimated to cause 45 percent of all child deaths (Black et al. 2013), and is responsible for 11 percent of the global disease burden (Black et al. 2008). It results in productivity losses1 to individuals estimated at more than 10 percent of lifetime earnings, and gross domestic product (GDP) losses as high as 2 to 3 percent. Reducing undernutrition is at the core of the World Bank Group (WBG) mission to end poverty. However, nutrition interventions are not sufficient to tackle the problem of undernutrition: even at 90 percent coverage the core set of proven nutrition interventions in high nutrition burden countries would only decrease stunting by 20 percent globally. 1 Including lost physical productivity, cognitive deficits and school days lost, and lost financial resources due to higher healthcare costs. www.wsp.org 1 Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Introduction Inadequate dietary intake and disease are directly Multisectoral Approaches (Alderman et al. 2013). The report responsible for undernutrition, but there are multiple provided the intellectual and theoretical rationale for a indirect determinants that exacerbate these direct causes, multisectoral response to malnutrition and presented a including food insecurity, inadequate childcare practices, series of self-contained guidance notes for task team leaders low maternal education, poor access to health services, lack (TTLs), World Bank Group staff, development partners, of access to clean water and sanitation, and poor hygiene and community implementers responsible for the design practices. Political, cultural, social, and economic factors and oversight of projects and programs in agriculture, social likewise play a role. Given the range of drivers of nutrition— protection, and health. The overall aim of the report was spanning multiple sectors of agriculture, social protection, to mainstream nutrition activities into multisectoral action health, WASH, and education—tackling undernutrition (Alderman et al. 2013). demands a multisectoral response. Water, sanitation, and hygiene (WASH) was recognized Children who are stunted (having low height-for-age) suffer in the report as a key sector for maximizing nutritional from a long-term failure to grow, reflecting the cumulative impact, but was not covered in depth as part of the self- effects of chronic deficits in food intake, poor care practices, contained guidance notes originally produced. Emerging and illness. Wasting, defined as low weight-for-height, is the evidence in the WASH sector suggests the linkages between result of recent shocks to lack of calories and nutrients from WASH and nutrition may be stronger than previously famine, or a severe and sudden illness. Underweight (low understood. This has generated a great deal of momentum weight-for-age) serves as a composite measure that captures in both the WASH and nutrition sectors about how the both stunting and wasting. Globally, the prevalence of two can work more closely to achieve better outcomes. stunting, wasting, and underweight among children under This paper addresses this objective from both the WASH five years of age in 2011 was 26 percent, 8 percent, and perspective, on how nutrition-specific programs (as well 16 percent, respectively (UNICEF, WHO, World Bank as nutrition-sensitive social protection, livelihoods, and 2012). Undernutrition is associated with severe long-term community-driven development programs) can provide an consequences such as poor cognitive development, lower alternative platform to deliver services at scale and more school attendance, reduced human capital attainment, and cost-effectively; and the nutrition perspective, on how potentially a higher risk of chronic disease in adulthood WASH interventions can be adapted to include nutritional (Victora et al. 2008). considerations, making them more nutrition-sensitive, and more impactful on nutrition. In response to the global development community’s request for operational guidance to maximize the impact of Child undernutrition and poor conditions of WASH investments on nutrition outcomes for women and young coexist in many low- and middle-income countries. Sub- children, the Health, Nutrition and Population (HNP) Saharan Africa and South Asia together account for the department of the Human Development Network (HDN) highest burden of child undernutrition (Black et al. 2013) commissioned the report, Improving Nutrition Through and poor WASH globally as demonstrated in Figures 1–3. 2 www.wsp.org Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Introduction Figure 1: Global prevalence of stunting among children under Age five Ͻ20.0% 20.0–29.9% 30.0–39.9% Ն40.0% 0 1,250 2,500 5,000 km Data not available Source: Adapted from de Onis et al. 2013. Map reprinted with permission from the publishers, John Wiley & Sons, Inc. Figure 2: Global proportion of population using improved sanitation 91–100% 76–90% 50–75% <50% INSUFFICIENT DATA OR NOT APPLICABLE Source: Adapted from WHO and UNICEF 2015. Reprinted with permission from Progress on Drinking Water and Sanitation: 2015 Update and MDG Assessment, page 12. © 2015. www.wsp.org 3 Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Introduction Figure 3: Global proportion of population using improved drinking water sources 91–100% 76–90% 50–75% <50% INSUFFICIENT DATA OR NOT APPLICABLE Source: Adapted from WHO and UNICEF 2015. Reprinted with permission from Progress on Drinking Water and Sanitation: 2015 Update and MDG Assessment, page 6. © 2015. Ninety-one percent of the world’s population had access through which WASH impacts nutritional outcomes, to an improved drinking water source by 2015, surpassing discusses the challenges and opportunities for nutrition- the MDG target (WHO and UNICEF 2015). Despite sensitive WASH, and proposes a set of practical strategies this progress, an estimated 663 million people relied on and enhancements to existing project design that offer unimproved water supply—half of these live in Sub- promising opportunities to impact nutritional outcomes. Saharan Africa and one-fifth live in South Asia (Figure 4). Despite well-known challenges to effective integration, an emerging interest in and attention to the role of WASH, and Globally, an estimated 2.4 billion people did not have sanitation in particular, on nutritional outcomes provides a access to improved sanitation in 2015 (WHO and “window of opportunity” to influence policy and program UNICEF 2015). Of these, 946 million still practiced open design for greater impacts on nutrition. defecation. Two-thirds of those without sanitation live in South Asia (WHO and UNICEF 2015). Figure 5 shows This paper explains why WASH is important for nutrition trends in sanitation coverage between 1990 and 2015 by and vice versa, and draws on past experience with developing regions and the world. multisectoral approaches in the World Bank Group to outline practical steps for making the WASH sector more This document outlines the rationale for nutrition-sensitive nutrition-sensitive, and ways that the nutrition sector can WASH, summarizes the scientific evidence on the pathways effectively integrate WASH interventions. 4 www.wsp.org Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Introduction Figure 4: Drinking Water Coverage Trends by Developing Regions and the World, 1990–2015 0 0 2 4 1 1 5 2 1 3 1 1 3 2 1 2 9 7 6 7 8 7 10 3 5 4 4 8 6 3 8 6 12 7 8 5 11 19 8 6 8 6 26 23 7 25 17 19 31 31 22 12 16 23 22 28 22 28 33 30 33 26 40 13 32 57 63 19 38 39 96 54 89 89 92 55 52 86 31 57 23 74 73 69 33 61 59 44 58 54 49 44 33 30 30 31 27 25 17 19 15 16 12 7 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 tr ed fr n A ern a ia a si d a a be nd on g on d ld si si ic si A ara lA n gi in gi e an or un op re lop a a a an s s s ra a rib a a A A fr A re op t ie ic si W as ce nt sus A h n n rn co vel Ca ic e Sa el er er -E n O ev te e er ev er Ce a e th st th b- es uc td th m D th D Ea u u Su W A Ca So So or as tin N Le La PIPED ON PREMISES OTHER IMPROVED UNIMPROVED SURFACE WATER Source: WHO and UNICEF 2015. Reprinted with permission from Progress on Drinking Water and Sanitation: 2015 Update and MDG Assessment, page 8. © 2015. Figure 5: Sanitation Coverage Trends by Developing Regions and the World, 1990–2015 0 7 1 3 16 2 8 1 3 2 2 8 3 11 3 2 13 13 12 17 2 4 16 17 7 2 20 31 7 10 31 24 23 34 7 7 2 36 11 45 7 10 40 6 65 5 12 5 10 17 9 48 48 15 20 25 10 27 5 7 3 6 94 96 26 89 90 6 96 25 94 12 83 80 20 72 77 17 7 71 4 5 67 14 6 62 50 10 58 48 47 43 54 38 30 35 35 24 22 20 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 1990 2015 tr ed fr n ia a A ern a be nd a a si d on g on d ld si si ic si A ara lA n gi in gi e an or un op re lop a a an a s s s rib a a ra a A A fr A re op st ie ic si W ce A nt sus ah n n rn co vel a Ca ic e el er er -E n O ev -S te e er ev er Ce a e th st th es uc b td th Am D th D Ea u u Su W Ca So So or as tin N Le La IMPROVED SHARED UNIMPROVED OPEN DEFECATION Source: WHO and UNICEF 2015. Reprinted with permission from Progress on Drinking Water and Sanitation: 2015 Update and MDG Assessment, page 14. © 2015. www.wsp.org 5 II. Objective and Background The objective of this paper is to support task teams The solution is not as straightforward as including nutrition and senior management to integrate WASH into in project development objectives (PDOs), for which task nutrition-specific programs (as well as nutrition-sensitive teams would be held accountable. Instead, guidance is social protection, livelihoods, and community-driven needed on how to incorporate nutritional considerations development programs), and to make WASH interventions into WASH projects, while at the same time avoiding more nutrition-sensitive, and thus more impactful on unnecessary complexities, to ensure that the contribution nutrition in the following ways: of WASH interventions to reducing undernutrition is accounted for. 1. Enhance the design of policy and lending operations in the WASH sector to maximize the impact on Why Is WASH Important for Nutrition? nutrition outcomes for the poor Undernutrition is both a major cause and an effect in 2. Provide guidance on effective ways to integrate the cycle of poverty triggered by inadequate WASH. WASH with nutrition-specific and other nutrition- Through the various theoretical pathways described below, sensitive intervention 3. Measure the potential impact of activities on nutrition through meaningful outcome indicators, such as infrastructure quality, usage (behavior), and maintenance The role of WASH, in particular, in improving nutritional outcomes has received greater attention in recent years. The attention has centered on a hypothesis that environmental enteropathy may be a key cause of chronic child undernutrition, and the primary pathway linking poor WASH to poor nutrition outcomes, rather than through diarrhea. A burgeoning body of evidence is finding strong linkages between poor sanitation, and open defecation in particular, and stunting. Finally, the strong association between income poverty, child stunting, and lack of access to water supply and sanitation highlights the critical need for interventions that will benefit this target group and increase prosperity among the bottom 40 percent. Despite global momentum around this emerging evidence and high-level policy dialogue advocating for nutrition- sensitive WASH, practical guidelines on how to work cross- sectorally are currently lacking. This is particularly the case for WBG lending operations, which focus to a large extent on infrastructure investments, rather than the “softer” side of WASH, which includes behavioral change. To achieve greater impact, approaches to integration need to go beyond the traditional realms of handwashing with soap and safe Woman and children washing hands, Indonesia. Photo: Ray drinking water and sanitation behaviors. Witlin / World Bank 6 www.wsp.org Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Objective and Background Figure 6: Direct and indirect determinants of Malnutrition Malnutrition Diet Disease Food Care Health WASH Source: Adapted by the authors from UNICEF 1990. poor WASH leads to infection and disease, resulting in caring for sick children and time and costs associated with undernutrition. In this weakened state, the body becomes seeking health treatment. more susceptible to infection and disease, creating a vicious cycle of poor health and, ultimately, development. The dual Why Is Nutrition Important for WASH? burden of poor WASH and undernutrition is common in Undernutrition is associated with poverty and is an areas with high rates of poverty, such as Sub-Saharan Africa indicator of nonincome poverty. One of the major pathways and South Asia, which together account for the highest through which WASH can affect poverty is child nutrition. burden of child undernutrition (Black et al. 2013) and poor Children who get sick less often and who eat a better diet WASH globally. grow taller and stronger over time (Evans and Marcynyszyn 2004, Walker et al. 2007). Children who suffer from The direct cause of undernutrition is inadequate dietary undernutrition during childhood fail to reach their human intake and disease (Black et al. 2008, UNICEF 1990). capital potential, which keeps not only them in poverty, but Underlying these immediate causes are household food future generations of children as well (Engle et al. 2007, insecurity, inadequate care and feeding practices, poor Victora et al. 2008). household environment, and inadequate health (Figure 6). Improved conditions of environmental health—good The global development community has focused on hygiene practices, safe water, and sanitation—influence eliminating income poverty, but evidence suggests that undernutrition primarily by reducing infection and improving income does not guarantee improved nutrition disease. Evidence also suggests that improved WASH outcomes unless explicit actions are taken to improve access may influence nutrition outcomes by increasing the nutrition. In other words, poverty reduction goals cannot productivity of home gardens, leading to more nutritious be met without addressing nutrition. Investments in food intake, and enabling more time and resources for WASH are one avenue to improving nutrition outcomes caregiving by reducing time spent fetching water and and therefore poverty. www.wsp.org 7   III. Pathways Linking WASH and Nutrition and Available Evidence Inadequate WASH can impact child nutritional status that 58 percent of annual deaths caused by diarrhea are through multiple pathways. These pathways and the attributable to poor WASH conditions (Prüss-Üstun et al. strength of each, based on current evidence, are illustrated 2014). in Figure 7. This section describes the evidence supporting each pathway. Water and sanitation interventions in turn are associated with lower risk of diarrhea and better nutrition outcomes (Esrey Pathway 1: Improved Nutrition through 1996, Checkley et al. 2004, Fink et al. 2011). Meta-analysis Reduction in Diarrheal Disease Due of intervention studies shows handwashing with soap reduces to Reduction in Fecal Contamination diarrhea by 40 percent (Freeman et al. 2014), improved of the Environment sanitation reduces diarrhea by 28 percent, and improved water supply reduces diarrhea by 34 percent. However, There is good evidence that fecal contamination of the there is wide variation in risk reduction for different service household environment (Curtis et al. 2000, Marquis et al. levels, with high-quality piped water reducing diarrhea by 1990), soil contaminated with human and animal feces 79  percent but improved communal sources achieving only (Curtis et al. 2000, Pickering et al. 2012), and unsafe an 11 percent reduction. Similarly, sewerage connections can disposal of infant and child feces, all conditions found reduce diarrhea by 69 percent, whereas on-site sanitation only in areas of poor WASH, contribute significantly to the reduces the burden by 16 percent (Wolf et al. 2014). Within diarrheal disease burden (Mara et al. 2010). It is estimated the category of on-site sanitation there is still little scientific Figure 7: Pathways linking WASH and nutrition Latrines Diarrhea Child feces disposal Fecal contamination (hands, soil, Enteric Animal water & food) infection penning Undernutrition Inadequate WASH Protozoa/ Septage helminth Anemia (Stunting/ Poverty management infection underweight) Water Standing Malaria resources water Time Caregiving Household food Food production consumption Water Water supply access Water expenditure 8 www.wsp.org Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Pathways Linking WASH and Nutrition and Available Evidence evidence on the protective effect of different sanitation service by frequent exposure to and ingestion of fecal pathogens in levels. Sharing of facilities by more than one household has places with poor hygiene and sanitation, is the main cause been shown to be associated with higher rates of diarrhea in of child undernutrition (Humphrey 2009). a review of demographic and health surveys (DHS) from 51 countries; however, this analysis fails to account for other Household environments in low-income contexts are factors correlated with poor child health that might explain highly contaminated with fecal matter from poor-quality this association, such as poverty. sanitation and open defecation practices. Freely roaming animals are common in such settings, especially where Although the relative contribution of diarrhea to small-holder poultry farming is the norm (Marquis et al. undernutrition remains unclear, since poor nutrition itself 1990, Harvey et al. 2003, Ngure et al. 2013), contributing is a cause of diarrhea, there is good evidence that repeated to high concentrations of animal feces in the environment. episodes of diarrhea in young children contribute to growth Both humans and animals tread on feces in the open, stunting (Checkley et al. 2008). bringing pathogens into the domestic environment (Curtis et al. 2000) where infants and young children crawl, Pathway 2: Improved Nutrition through explore, play, and feed. Flies serve as another vector carrying Reduction of Enteric Infections Due pathogens from one place to another, especially onto food. to Reduction of Fecal Contamination Handwashing with soap is often not adequate in these in the ­Environment settings (Curtis et al. 2000), so it does not prevent the spread and ingestion of fecal bacteria. A recent hypothesis suggests that enteric infection (or environmental enteropathy) is the primary cause of child Recent research efforts have focused on testing the undernutrition, and the main route through which poor environmental enteropathy hypothesis and elucidating WASH causes stunting (Humphrey 2009). these causal pathways. Observational research has shown associations between household environmental Studies on children over the past two decades in the Gambia cleanliness, such as access to water and sanitation have demonstrated an association between enteric infection infrastructure, biomarkers for environmental enteropathy, and stunting independent of diarrheal disease or poor diet and standardized child height and weight scores (Lin et al. (Campbell et al. 2003, Lunn et al. 1991). Enteric infection, 2013). Yet, in other research, cleaning up the environment and environmental enteropathy more specifically, is a through improved handwashing behavior was not enough subclinical condition of the small intestine, characterized by to reverse enteric infection and growth stunting, although reduced nutrient absorption surface area, increased intestinal it did reduce diarrheal morbidity (Langford et al. 2011). permeability, and subsequent systemic inflammation (Haghighi et al. 1997). Whether gastrointestinal mucosal Pathway 3: Improved Nutrition through damage was a cause or a consequence of undernutrition Reduced Exposure and Infection with was not addressed by these studies, and despite having been Protozoa and Helminths Due studied for decades, the cause of environmental enteropathy to Improved WASH is still not well understood. Protozoa and helminth infections are transmitted through The idea that environment rather than diet may be the soil (soil-transmitted helminthiasis, STH) and water major cause of growth stunting was originally postulated (schistosomiasis) contaminated with feces. These infections by Solomons et al. (1993). Yet research efforts to eliminate are rarely fatal but cause poor appetite, nutritional child undernutrition have largely focused on dietary deficiencies, and anemia, and exacerbate malnutrition solutions, such as complementary feeding, none of which (Stephenson 1987, Stephenson et al. 2000, Stoltzfus et al. have been able to eliminate stunting. A more recent 2004, O’Lorcain and Holland 2000). Studies have shown hypothesis suggests that environmental enteropathy, caused Giardia and helminth infections to be associated with www.wsp.org 9 Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Pathways Linking WASH and Nutrition and Available Evidence stunting (Crompton and Nesheim 2002, Simsek et al. Pathway 4: Improved Nutrition through 2004). Reduction in Anemia Due to Improved WASH Where helminths are highly prevalent, deworming Anemia is a blood disorder that most commonly results medication is administered as preventative chemotherapy from insufficient dietary intake and absorption of iron. through organized campaigns. This is a cheap and effective Iron can be absorbed through diet, but malnutrition can strategy to reduce infections, but cannot prevent future inhibit its absorption. Iron deficiency anemia is the most reinfection, especially in places with poor sanitation. Meta- common nutritional deficiency in the world and highly analysis has shown improved sanitation to be effective in prevalent in low- and middle-income countries. Blood reducing the risk of soil-transmitted helminth infection loss and inflammation due to WASH-related infections, (Ziegelbauer et al. 2012, Moraes et al. 2004, Barreto et al. including malaria, acute respiratory infections, diarrhea, 2010) and Giardia infection (Goto et al. 2009). Sanitation and hookworm infection (Stoltzfus et al. 1996) are a promotion is recommended as a complementary strategy to major cause of anemia (Weiss and Goodnough 2005). deworming and health education. Without treatment, anemia can lead to chronic conditions Students wash their hands before eating a prepared meal at the Hope Kindergarten Elementary School in Tarbarr Community in Buchanan City, Liberia, on June 25, 2015. Photo: Dominic Chavez / World Bank 10 www.wsp.org Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Pathways Linking WASH and Nutrition and Available Evidence that include poor fetal development, delayed cognitive Evidence from observational studies also suggests improved development, higher risk of infection, fatigue, weakness, water and sanitation have synergistic effects on weight-for- dizziness, and drowsiness. Dietary interventions that age Z-scores (WAZ) (Esrey et al. 1992, Esrey 1996). include iron supplementation have resolved fewer than half of the burden of childhood anemia globally (Stoltzfus Recent econometric analysis has demonstrated that cross- et al. 2002). country differences in sanitation explained 54 percent of the variation in average height of children in Africa and Pathway 5: Improved Nutrition through Asia, suggesting that open defecation, which is exceptionally Reduction in Time Spent Fetching Water widespread in India, could account for much or all of the and Caring for Sick Children, and Time excess stunting in India (Spears 2013). Open defecation and Costs of Seeking Treatment is especially harmful in areas of high population density, and is therefore a high risk factor for stunting in India. The Reducing the time that caregivers spend fetching water number of people openly defecating per square kilometer lowers diarrhea and improves nutritional outcomes in linearly accounted for 65 percent of international variation children under age five (Pickering and Davis 2012). The in child height. Indian states with more open defecation per exact mechanism is not clear, although better access to square kilometer had shorter children (Spears et al. 2013). water may enable improved hygiene practices (Motarjemi Other recent econometric studies have likewise shown an et al. 1993, Aiello et al. 2008) and make more time available association between poor sanitation and child stunting for childcare (Miller and Urdinola 2010, Burger and Esrey (Spears 2012, Hammer and Spears 2013). 1995, Diaz et al. 1995, Cairncross and Cliff 1987) or income-generating activities (Koolwal and Van de Walle Recent experimental evidence of the effect of sanitation 2013). About 44 percent of the world’s population must on child nutrition comes from a Community-Led Total leave their homes to fetch water for drinking and other Sanitation (CLTS) intervention in Mali in which children domestic uses (WHO and UNICEF 2010). The high costs were taller and less likely to be stunted in villages where associated with accessing improved WASH services and the CLTS had been implemented, leading to a reduction of open time and cost of treating WASH-related illness can crowd defecation. Improvements in weight and a reduction in the out household income for other basic necessities such as proportion of children underweight were also observed, but nutrient-rich food. these results were not significant (Alzua et  al. 2015). In addition, households further away from a water source Cross-country evidence from Lao PDR, Vietnam, and may face barriers to home gardening and other income- Tanzania show correlation between the ratio of households generating activities that have a direct or indirect effect on defecating in the open and those using unimproved sanitation improving nutrition (Moriarty et al. 2003). in a community and height-for-age Z-scores (stunting) over time. As the proportion of households without sanitation Pathway 6: Direct Links between WASH increases, children grow shorter and stay shorter over time and Undernutrition (Quattri and Rand 2014, Quattri et al. 2014a, 2014b). Several nonexperimental studies suggest that improved Other pathways, such as improvements in child nutrition water and sanitation leads to increased linear growth (Esrey due to reductions in acute respiratory infection, malaria, 1996, Checkley et al. 2004, Merchant et al. 2003, Fink and household food production have insufficient evidence et al. 2011) and observational research has demonstrated to summarize here. associations between access to in-yard piped water and child stunting. The effects are even more important for children The first available evidence of a direct link (i.e., not through of educated mothers (Mangyo 2008). diarrhea) between improved WASH and child nutritional www.wsp.org 11 Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Pathways Linking WASH and Nutrition and Available Evidence outcomes comes from a recent systematic review and meta- Zimbabwe, aim to shore up some of the evidence gaps on analysis (Dangour et al. 2013) of five cluster randomized the direct nutritional impacts of integrated interventions trials of WASH interventions (Du Preez et al. 2010, 2011; through well-designed, randomized controlled trials that Luby et al. 2004, 2006; McGuigan et al. 2011). The meta-­ address multiple pathways of fecal contamination. analysis found a borderline statistically significant effect of water and hygiene interventions on height-for-age Z-scores The SHINE study in rural Zimbabwe will evaluate the (HAZ) (mean difference 0.08; 95 percent CI 0.00 to 0.16) in effect of (i) WASH alone (latrines, water treatment, safe children less than five years old. The same meta-analysis found feces disposal, handwashing with soap, hygienic food no effect of WASH interventions on weight-for-age Z-scores preparation, and protected play areas for infants; and (WAZ), in children under five, nor did three nonrandomized (ii) WASH plus infant and young child feeding against a studies (Arnold et al. 2009, Bowen et al. 2012, Langford et al. comparison group receiving standard health and nutrition 2011) included in the review. The reviewed studies were all preventive care (breastfeeding promotion, prevention of short term (9–12 months duration), all had methodological transmission of HIV/AIDS from mother to child, and limitations, and all were based on interventions that address village health worker visits) on environmental enteropathy, only one or a few of the multiple pathways of fecal-oral child stunting, and anemia. The interventions are initiated transmission. The interventions showing an effect on HAZ during early pregnancy and continue through 18 months included solar disinfection of water, provision of soap, and postpartum to capture the initial 1,000 days of a child’s life. improvement of water quality. Experimental evidence on water supply improvement and sanitation was insufficient to In Kenya and Bangladesh the WASH Benefits studies will include in the meta-analysis. assess the individual impacts of improved water quality, sanitation, handwashing, and nutritional supplements, Because of strong biological plausibility of this link, as well as combinations of these interventions, on linear isolating the effect of WASH interventions on nutrition growth and diarrhea in children under five. outcomes is receiving increased attention in the research community. Two field-based studies, WASH Benefits In addition to these clinical studies, impact evaluations (Arnold et al. 2013) in Kenya and Bangladesh and the initiated in the WASH sector in recent years are designed to Sanitation Hygiene Infant Nutrition Efficacy Project measure nutrition impacts such as enteric dysfunction and (SHINE, http://clinicaltrials.gov/show/NCT01824940) in child growth. 12 www.wsp.org   IV. World Bank Group’s Water Program Although WASH interventions supported by World Bank Group projects may contribute to improved health and nutrition outcomes, nutritional outcomes are perceived as too far down the causal chain to be adopted as project development objectives. The 1993 Water Resources Management Strategy was the first in the World Bank Group to recognize the health benefits of water supply and sanitation (World Bank 1993). In 2004, the Water Supply and Sanitation Sector Board developed a sector program to guide WBG lending and nonlending technical assistance, which recognized improving health outcomes as one of five cross-cutting operational, policy, and institutional priorities requiring investment in WASH infrastructure as well as behavioral change and a focus on the poor as an institutional priority (World Bank 2004). The program adopted a three- pronged strategy to realize health benefits of improved WASH: (i) access to sufficient quantities of water, (ii) sanitary disposal of excreta, and (iii) sound hygiene practices. Over the past decade, a handful of water supply, sanitation, and hygiene projects supported by the World Bank Group have explicitly targeted nutrition. A portfolio review conducted for this paper examined whether and how WBG water supply, sanitation, and hygiene projects incorporate health and nutrition objectives, activities, and outcomes. The review included all water supply (WC), sanitation (WA), and general water and sanitation (WZ) approved This new latrine was built by a local sanitation entrepreneur projects from fiscal year 2005 through 2014 (n = 274) with in Bangladesh, who was supported by WSP using sanitation health (JA) and/or social services (JB) sector coding. A total marketing. Photo: Mirva Tuulia Moilanen / World Bank of 14 projects meeting these criteria were reviewed. The majority of the projects with cross-sector coding Of the reviewed projects, five referenced health and/or and considered by the review as “multisectoral” were nutrition objectives in the project development objective identified as such because they included hygiene (PDO)2 and only one project included nutrition-specific education and/or hygiene behavior change interventions activities.3 In terms of measured outcomes, one project (12 projects/86  percent), specifically handwashing with measured a nutrition-specific outcome and three measured soap, which is classified as a nutrition intervention by the health outcomes such as diarrhea incidence and incidence nutrition sector. Only four of these projects included a of water and excreta-related disease transmission. government health agency among the project’s partners. 2 Keywords included quality of life, health-specific terms, livelihood, human development, improved health-related behaviors, hygiene living conditions, nutrition-specific terms, basic services, and poverty reduction. 3 Nutrition-specific activities were defined to include infant and young child feeding practices, prenatal/maternal nutrition, micronutrient supplementation, child growth monitoring, and nutrition and food hygiene education interventions, as well as nutrition components of early childhood development programs, nutrition components of social safety nets, home gardens and small livestock production, and targeted emergency food aid. www.wsp.org 13   V. World Bank Group’s Nutrition Program In 2008, The Lancet series on Maternal and Child • Improving institutional development and capacity Undernutrition identified a set of priority interventions to design, implement, and monitor nutrition with robust evidence of effectiveness and cost- interventions effectiveness (Lancet 2008). The Nutrition Global • Developing and integrating nutrition education Solutions Group in the World Bank Group is aligned with and behavior change communication (BCC) into these guidelines in its lending and nonlending technical nutrition interventions assistance programs. Although nutrition investments are • Targeting food supplementation to malnourished a small proportion of overall WBG lending, they are women and children often not formally coded as nutrition activities, making • Using food-based safety nets, including food stamps, them even more difficult to quantify. The World Bank food subsidies, and food for work, with nutrition Group now uses a dual reporting system for nutrition objectives projects and components of projects, which includes • Including nutrition components in early childhood Theme Code 68 for Nutrition & Food Security as well development, school health, reproductive health, as Development Assistance Committee (DAC) codes: and other programs • Ensuring that food security interventions, including • Promoting adequate infant and young child growth income generation, labor-saving technologies, improved • Improving breastfeeding practices marketing systems, and food distribution networks, • Ensuring the adequate and timely introduction of have explicit objectives to improve household food complementary foods security, food intake, and/or nutrition outcomes • Implementing programs to reduce micronutrient • Increasing crop/livestock production to benefit the malnutrition such as fortification, supplementation most malnourished and food insecure or food-based strategies, and disease and parasite • Targeting emergency food aid to the most vulnerable, prevention and control (e.g., helminths, tuberculosis, including famine relief programs malaria, HIV/AIDS) • Developing and implementing nutrition monitoring • Improving adolescent and maternal nutrition and and surveillance to improve nutrition interventions reducing low birth weight and affect policy change • Developing capacity in nutrition planning and • Developing policies and programs concerning diet- policy development, including consumption effects related noncommunicable disease prevention and of food policy control 14 www.wsp.org   VI. Challenges to Multisectoral Approaches in the WASH Sector The challenges of working multisectorally are well There is increasing attention in the research community to recognized and are not unique to the WASH sector. Lack of study and isolate the effects of WASH on nutrition, but incentives, institutional barriers, weak client demand and until this evidence is available, projects face risks proposing donor funding, risk aversion, and insufficient knowledge approaches that are not backed by strong evidence. of best practices are all limiting factors. The following are some of the key challenges and how they specifically Inherent complexity of WASH projects. Water projects influence multisectoral approaches in the WASH sector. have one of the lowest disbursement rates of the infrastructure global practices. A high number of “problem projects” (that Lack of evidence to enable prioritization of WASH is, projects facing procurement delays, slow disbursement, interventions. There is still limited knowledge as to and financial management issues) is indicative of the which WASH interventions and in what combinations technical complexity of water projects. Project TTLs trying are most effective for reducing fecal contamination of the to meet tight deadlines for project preparation and who are environment. In order to integrate WASH components accountable for delivery of the portfolio are understandably beyond handwashing with soap, the nutrition sector reluctant to introduce project components that may get needs evidence on where to focus its efforts. Similarly, the derailed during project appraisal. research community is still building the evidence base on which WASH interventions are most strongly linked with Institutional complexity is likewise a challenge. Water and nutrition. sanitation are often handled by different line ministries in client countries, which can add further complexity to Some key WASH interventions hypothesized to impact already demanding timeframes and technically challenging nutrition, such as basic sanitation and improved water projects. At the same time, in some countries, sanitation supply, have not been subject to the level of rigorous study and hygiene are under the authority of Ministry of Health, needed to generate evidence that could be used to advocate which opens avenues for closer integration between WASH for nutrition-sensitive approaches. This level of evidence is and nutrition-specific projects. generally available through the gold standard in scientific research, randomized controlled trials. However, in a recent Focus on infrastructure lending. The vast majority of Cochrane review of the impact of WASH interventions on World Bank Group loans in the WASH sector target large nutrition outcomes, neither sanitation nor water supply infrastructure: sewerage networks, wastewater treatment improvements were included due to lack of experimental plants, and water supply systems. Infrastructure lending evidence on the effects. results in large loans with easily quantifiable outcomes. On- site sanitation and fecal sludge removal are seldom financed. Similarly, there is limited evidence of the costs and cost- On the other hand, there is little lending for the “softer” effectiveness of nutrition-sensitive WASH interventions side of WASH, specifically communication, education, and compared with a business as usual approach. There could behavior change, which are required in order for WASH be a strong economic argument for integration if targeting interventions to have an impact on health and nutrition. of WASH investments brings greater returns, as measured by health and nutrition outcomes. Similarly, leveraging delivery channels could lead to cost savings, resulting in more cost-effective programs. www.wsp.org 15   VII. Opportunities for Nutrition-Sensitive WASH Despite these challenges, an emerging interest in and SDGs on eliminating open defecation shifts the focus from attention to the role of WASH, and sanitation in particular, infrastructure to behavior change, conferring more plausible on nutritional outcomes has provided a “window of nutritional benefits of WASH. The SDGs will again call opportunity” to influence how the World Bank Group attention to the nonincome face of poverty with a nutrition approaches lending for WASH projects, and how policies indicator on stunting. Investments in improved WASH can are designed for greater impact on nutrition. Some reasons contribute to reducing both income and nonincome poverty. for this are: WBG reform and the twin goals. Eliminating extreme poverty Environmental enteropathy hypothesis. Attention has and increasing shared prosperity will require eliminating recently focused on the role of environmental enteropathy nutritional deficiencies, which demands input from multiple (or enteric infection more broadly) on poor child nutritional sectors. The twin goals motivate a shift in thinking toward outcomes. Research has only just begun to try to understand the bottom 40 percent, who are most likely to lack access the contribution that poor WASH has on environmental to WASH services and be undernourished. Targeting will enteropathy, which could prove to be a major link between become more important as the WBG works toward reducing WASH and child nutrition. extreme poverty and increasing shared prosperity. Secondly, the new Global Practice structure, in particular the positions Sustainable Development Goals. With the recognition of program leader and global solutions group lead, could prove that progress on the sanitation MDG was not as fast as that to be a unique facility to (i) identify cross-sectoral solutions on water supply, sanitation is being prioritized in the post- and (ii) provide an enabling environment for multiple sectors 2015 development dialogue. The emphasis of the expected to work toward the same goal. A child drinks clean, safe water in rural Badakhshan province, Afghanistan. Photo: Imal Hashemi / Taimani Films / World Bank 16 www.wsp.org   VIII. Principles for Nutrition-Sensitive WASH Investments and Policies WASH investments and policies that incorporate nutrition- and Nutrition projects conducted between fiscal years sensitive goals explicitly into design and implementation can 2005 and 2014 were most frequently undertaken in low- increase nutritional impact. Although access to WASH services income countries with the dual burden of undernutrition has been the primary focus of the WASH sector in the MDG and poor access to WASH, indicating appropriate targeting era, issues around equity, usage, and maintenance of services is happening at a macro level. Eighty percent of these are becoming increasingly important. An emerging toolkit of projects indicate a target beneficiary group such as the poor evidence-based guidance, instruments, and incentives provides and women and children. However, project documents tremendous opportunity to capitalize on the unique synergies seldom contain information on how target beneficiaries are between WASH and nutrition to increase the development identified, increasing the likelihood that target groups may effectiveness and nutritional impact of WASH investments. not effectively be reached. The following are four key principles for action: Taking It Further 1. Improve geographic and demographic targeting Data visualization tools such as mapping can improve to reach populations where water and sanitation targeting by identifying the coexistence of nutritionally coverage is low and undernutrition is high vulnerable populations and poor WASH access. A recent 2. Utilize best practices in behavior change and insights initiative undertaken jointly between the Water and from behavioral economics to maximize the impact Sanitation Program and the Poverty Practice compiled of WBG operations on nutrition population census data on access to sanitation in Vietnam 3. Leverage the program-for-results lending instrument and presented this side-by-side with rates of child stunting and other institutional incentives to align WASH to highlight areas of the country where these burdens and nutrition objectives coexist. The resulting maps (Figure 8) informed the design 4. Incorporate nutrition-sensitive objectives and of a Program-for-Results (PforR) operation on Scaling indicators into WASH investments and WASH Up Rural Water Supply and Sanitation in the Northern policies. Mountain and Central Highland regions. Visual tools such as mapping can be extremely effective in dialogue with Based on these four key principles for action, the following client countries, but are not yet widely available in the are proposed strategies and enhancements to existing WASH sector. project design, monitoring, and evaluation of WASH interventions that offer promising opportunities to increase Operations can leverage large poverty reduction platforms, the nutritional impact of WASH investments. including conditional cash transfer (CCT), community- driven development (CDD), and rural livelihoods, to 1. Improve Geographic and Demographic mainstream WASH and reach the poor who lack access. Targeting to Reach Populations Where CDD programs finance a range of nutrition-sensitive Water and Sanitation Coverage Is Low interventions, including water supply, sanitation, health, and Undernutrition Is High and agriculture. Although nutrition-specific interventions are seldom components of CDD programs, the menu of Current Status options for communities may include other nutrition- Distributional analysis shows that the poor are most likely sensitive interventions, such as agriculture, and developing to lack access to WASH, and evidence shows that pro-poor demand for nutrition interventions is an important part targeting of sanitation, such as in urban slums, has greater of these programs. Moreover, CDD programs can serve potential for improving health outcomes because of higher as a cost-effective platform for delivering nutrition-related disease burden and increased susceptibility combined with services and evidence shows these programs to have an impact lower access levels (Rheingans et al. 2012). WASH, Health, on underweight, stunting (Arcand and Bassole 2007), and www.wsp.org 17 Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Principles for Nutrition-Sensitive WASH Investments and Policies FIgure 8: STuNTING rATeS ANd OPeN deFecATION IN vIeTNAM malnutrition (Olken et al. 2011). When poverty maps The Water practice through the Water and Sanitation have been used, these programs have been particularly Program (WSP), in collaboration with other practices, effective in selecting poor areas in which to operate (Wong is currently providing technical assistance to several 2012). client countries, including the Philippines, Lao PDR, Vietnam, and India to mainstream rural sanitation CCT programs incentivize preventive health and nutrition into poverty-reduction projects. In the Philippines, for actions such as prenatal visits for pregnant women, well example, sanitation demand generation, behavior change child visits, growth monitoring, immunization, and communication, and access to financial products intended family development sessions/life-skills training, which to remove financial barriers to purchasing a toilet will be often focus on changing nutrition-related behaviors of integrated into the Pantawid Pamilya CCT and outcomes families. CCT programs can be a cost-effective platform evaluated through a randomized controlled trial impact to reach target audiences as the targeting systems used by evaluation. Importantly, these approaches to integration do these programs enable both geographic and demographic not try to make WASH outcomes a conditionality of these (first 1,000 days) targeting without incurring additional programs, but rather leverage the large-scale platform that costs. the CCT program provides to reach target audiences. 18 www.wsp.org Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Principles for Nutrition-Sensitive WASH Investments and Policies 2. Utilize Best Practices in Behavior Change effective way to improve practices—people respond more and Insights from Behavioral Economics strongly to emotional appeals such as a desire to be clean to Maximize the Impact of World Bank Group and modern. Thus communication campaigns are designed Operations on Nutrition to appeal to a person’s dignity, pride, or a desire to nurture one’s children. A new genre of interventions has emerged Current Status using innovative information and marketing campaigns WASH infrastructure, such as household latrines, water to advocate for better individual hygiene behaviors and supply systems, and handwashing facilities, is necessary practices. but not sufficient for meeting nutrition objectives. Two recent rigorous evaluations of India’s flagship rural To date, behavioral economics has not been fully sanitation program have attributed lack of evidence for exploited by the water and sanitation sector. However, it health impacts to lack of use of newly constructed toilets is increasingly recognized that insights into how humans (Patil et al. 2014, Clasen et al. 2014). Similar findings have make decisions and the behavioral biases that dictate much been documented for clean water supply, where transport, of this decision making can play a large role in how likely storage (Brick et al. 2004, Shaheed et al. 2014), and poor people are to take up interventions (Coville and Orozco hand hygiene (Pickering et al. 2010) reintroduce disease- 2014). For instance, people dislike losses more than gains causing pathogens, and for handwashing facilities, which (loss aversion), so messages that highlight costs and losses are a poor predictor of actual handwashing rates (Ram et al. are likely to be more effective (Kahneman and Tversky 2014). Without adequate and consistently practiced WASH 1979). In other words, it may be more effective to tell behaviors, such as handwashing with soap, water treatment people they will be sicker and poorer if they do not wash and safe handling practices, and use of latrines, infrastructure their hands. This is counter to the predominant messaging inputs alone will not lead to health and nutrition outcomes. in the sector, which emphasizes the health benefits of Behavioral change has not been sufficiently prioritized in improved water and sanitation. World Bank Group WASH lending operations in the past. Behavior change elements of lending projects are dwarfed A new concept, termed “baby-wash,” is also drawing by larger infrastructure investments. At the same time, interest from sector practitioners. It refers to WASH there is limited capacity both within the WBG and in interventions that address child-specific or child-related client countries to conduct state-of-the-art behavior change behaviors and risk factors, such as frequent mouthing of campaigns and approaches. fingers and objects during exploratory play, and playing in areas contaminated with human and animal feces Taking It Further from poor waste disposal practices. Traditional WASH Although still not a science, evidence is emerging about infrastructure investments have largely bypassed some of how to scale up effective behavior change for water, these dominant fecal contamination pathways that affect sanitation, and hygiene. In the hierarchy of behaviors, using small children. a toilet and handwashing with soap seem to matter most for stopping the spread of pathogens. Treating water to remove Technical assistance to clients in both the Water and fecal pathogens before drinking it and using clean water for Nutrition sectors can help bring these best practices into cooking are also important, especially as there is no guarantee project design and implementation and help to achieve that these other behaviors have been practiced consistently. behavioral compliance—itself a precondition for nutrition However, experience shows that just teaching people about outcomes. Likewise, closer coordination between WASH, these behaviors is not enough since knowledge is already nutrition, and agriculture colleagues can help address high in many contexts. We also know that telling people a major source of disease-causing pathogens in some about the health benefits of these behaviors is not the most contexts. www.wsp.org 19 Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Principles for Nutrition-Sensitive WASH Investments and Policies 3. Leverage the Program-for-Results In the past, outputs for results-based WASH projects have Lending Instrument and Other been limited to water, sewerage, or sanitation connections. Institutional Incentives to Align Associating disbursement linked indicators (DLIs) with WASH and Nutrition Objectives behavioral, health, or nutrition intermediate outcomes could incentivize projects to improve targeting and implementation, Current Status with resulting impacts on health and nutrition. Lack of incentives at both the project and institutional levels has limited multisectoral collaboration. Institutional Taking It Further barriers exist in the World Bank Group in the form of staff Institutional levers can be used to align incentives of TTLs time allocation, sector-specific budgets, and project coding and managers with multisectoral approaches. Recent reforms systems that effectively disallow ownership of projects by and restructuring that aim to institutionalize and incentivize multiple sectors. Integration is viewed as cumbersome to cross-sectoral solutions to development challenges present a manage and risky to achievement of project objectives, unique opportunity. Most notably, movement toward the despite demonstrating similar performance in practice twin poverty alleviation goals aiming for reduced extreme (IEG 2009). poverty and increased shared prosperity motivate a shift in thinking toward the bottom 40 percent. Targeting will Institutional resources exist for supporting cross-sectoral become more important as the World Bank Group works work, but may not be fully utilized. For instance, the toward these twin goals, and can help bring actors together Health Results Innovation Trust Fund (HRITF) has set to develop multisectoral solutions that can best meet the aside $100 million in grants for sectors outside health that needs of this population. Secondly, the new Global Practice incorporate a results-based financing mechanism linked to structure can be a unique facility to (i) identify cross- health outputs and outcomes, but use of these funds for sectoral solutions and (ii) provide a supportive environment nonhealth sectors has been limited. for multiple sectors to work toward the same goal. Country directors and practice leads can be crucial leverage points early Incentives operate at the project level as well. Results-based in a project because of their frequent role as chair of concept approaches4 are increasingly mainstreamed for achieving note reviews, which places them in a position to ask critical desirable outcomes in development, and could be an effective questions, and their mandate to collaborate across sectors. instrument to incentivize WASH projects to incorporate Practice managers play a role in influencing TTLs (and other nutrition-sensitive objectives. Experience to date using PMs) through email and other communications. Peer-to- results-based approaches in water and sanitation is limited. peer engagement across sectors is also important, where A review undertaken by the WBG indicated that less than TTLs working alongside each other in the same country, 5 percent of its output-based aid (OBA) portfolio was in even on projects for different sectors, can come together water and sanitation (Mumssen et al. 2010). The use of to discuss respective projects and collaborate on a shared OBA in water and sanitation has since increased under the framework. Within this context, earmarking of resources Global Partnership for Output-Based Aid (GPOBA), which for cross-sectoral operations could spur further innovative currently lists 22 projects in water supply and sanitation. ideas and approaches. The WBG’s new PforR lending instrument currently has Despite reforms underway in the WBG and the opportunity three active operations in Water Supply, Sanitation, and that this presents, incentives will not necessarily change at Hygiene (India, Mexico, and Vietnam) with three more the country level. Therefore, multisectoral approaches will under preparation in Sanitation (Egypt, India, and Vietnam). continue to benefit from engagement of champions at the 4 Examples include output-based aid (OBA), results-based financing (RBF), cash on delivery (COD), pay for performance (P4P), performance-based financing/contracting, and conditional cash transfers (CCT). 20 www.wsp.org Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Principles for Nutrition-Sensitive WASH Investments and Policies country or regional level who understand both sectors and objective to improve health (IEG 2009). These findings can help identify opportunities and advocate for nutrition- were echoed, albeit more starkly, in the portfolio review sensitive approaches. Champions can help bring together undertaken for this paper, which found just four projects the appropriate knowledge and expertise to ensure that (1 percent) out of a total of 274 reviewed between fiscal nutrition-sensitive WASH interventions apply the most up- years 2005 and 2014 with a project development objective to-date methods and materials. Similarly, champions that related to health or nutrition. This further decline could be a span both sectors can help bring knowledge and innovation reflection of an increasingly lower priority that meeting health from one sector to the other. and nutrition objectives has in the WASH sector. On the other hand, it could be an outcome of the increased scrutiny Incentives need to change at the project level as well to on the formulation of project development objectives, which mainstream nutrition-sensitive WASH. Two recent large- leads to a reluctance by project TTLs to include higher-level scale operations under development will finance activities development objectives. that address the behavioral constraints to wider take-up of WASH interventions and pioneer behavioral change Taking It Further as a main project outcome. The Sawatch Bharat Mission What we know from multisectoral approaches in other (SBM) in India and the Scaling Up Rural Water Supply sectors is that it is critical for WASH interventions that and Sanitation Program (SUpRWSS) in Vietnam include intend to improve nutrition outcomes to include nutrition reduction in open defecation and increased use of improved as an objective or indicator, and vice versa. Whereas WASH sanitation as key result areas for disbursement under the PforR projects are required to report progress on core sector instrument. Both projects thus recognize that infrastructure indicators at the output level (e.g., people provided with provision alone is not sufficient to achieve development access to improved sanitation facilities, number of piped results. Although neither project intends to measure health water connections, people trained to improve hygiene or or nutrition outcomes, documented behavior change can sanitation practices, etc.) progress for nutrition-sensitive provide evidence of plausible impact. Furthermore, both WASH needs to be measured at the outcome, and in some projects will collaborate with institutional partners in the cases impact, levels. Following is a list of potential indicators health and nutrition sectors, which demonstrates the priority at the outcome and impact levels that are recommended placed on nutritional impact for these projects. for use by projects that incorporate nutrition objectives. All projects that intend to improve health and nutrition 4. Incorporate Nutrition-Sensitive Objectives outcomes should include at a minimum a checklist of and Indicators into WASH Investments behavioral proxies that are relevant for the project. Projects and Policies that intend to evaluate effectiveness or impact should go a step further to include indicators at the impact level. Current Status Although health is often cited as a potential benefit of WASH Outcome Indicators interventions, it is seldom included as an explicit objective, Self-reported behavior and behavioral proxies such as decreasing the likelihood that health outcomes are realized. infrastructure and environmental spot-checks are more For instance, a report commissioned by the Independent strongly associated with improved health and nutrition Evaluation Group (IEG) states that although half of the outcomes than access to infrastructure alone, but do not water supply and sanitation projects reviewed between fiscal require costly health measurement. years 1997 and 2006 claimed to have health benefits, only one in 10 included this as an objective, and just 3 percent had • Usage: Access to infrastructure should not be improving health among the poor as an objective. Moreover, confused with actual usage, which is a measure of the number of projects that include health objectives has behavior. Measures of usage include: been steadily declining. Between fiscal years 2002 and 2006, ºº Observation of a well-trodden path to the latrine just one in 20 water supply and sanitation projects had an ºº Observation of a water seal (for wet latrines) www.wsp.org 21 Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Principles for Nutrition-Sensitive WASH Investments and Policies ºº Observation of cover in place (for dry pit latrines) Health Impact Measures ºº Transect walks in community to identify open • Diarrhea: Evidence of diarrhea prevalence is defecation relatively easy to collect, but it is highly variable and ºº Presence of fecal matter (including child feces) in requires large sample sizes to estimate with precision. the housing compound Self- or caregiver-reported diarrhea can be biased ºº Presence of residual chlorine in water downward due to placebo effects, social desirability ºº Availability of soap and water at a designated bias, and recall attenuation bias, and therefore place for handwashing may show impact where there is none. Moreover, • Maintenance: Maintenance of infrastructure, and diarrhea is caused by multiple factors, and without cleanliness in particular can indicate use. Measures an appropriate research design to attribute causality, include: data may not be sufficiently specific to demonstrate ºº Observation of feces around pit impact. Measures of diarrhea include: ºº Cleanliness of toilet ºº Incidence of diarrhea in previous seven days (or ºº Presence of flies two weeks) for children under five and/or for adults • Behavior: Measuring behavior is challenging since ºº Symptom-based recall of watery stools and three beneficiaries may overreport desirable behaviors or more stools per day, or blood in stool (called “social desirability bias”) and are more likely • Anthropometrics: Child anthropometrics are to alter their behavior while under observation. objective measures of nutrition, but are costly to Although these measures should not be used to measure since they require special equipment and measure levels of impact due to the likelihood that well-trained staff. Moreover, they have low specificity they overestimate actual behavior, they can serve since growth can be influenced by many factors. Some as indicators of the direction of impact. Behavioral growth measures, such as height, are best measured outcome measures include: in the long term, which is not always practical for ºº Self-reported behaviors (handwashing with soap) typical project and evaluation timeframes. Systematic at critical moments (after defecation, before administrative data on height and weight is uncommon preparing food), open defecation, child feces and population-level data is typically only collected disposal, safe water storage, and treatment of every five years, making these indicators unsuitable drinking water for monitoring. These measures include: ºº Observation of behaviors (handwashing with ºº Height/length-for-age soap) at critical moments (after defecation, before ºº Weight-for-age preparing food), child feces disposal, safe water ºº Head and arm circumference storage, and treatment of drinking water • Anemia: Anemia is an objective measure of nutrition but requires a finger prick, specialized equipment, Environmental Impact Measures and training, which may not be practical for most • Environmental fecal contamination: Presence of projects. Moreover, anemia has many causes that are fecal indicator bacteria and E. coli in water, soil, not affected by WASH. and on hands and food is highly correlated with • Helminth and protozoa infection: Stool samples subsequent health outcomes. Measuring reduction can be collected and tested in a laboratory for presence in fecal contamination could provide evidence that of soil-transmitted helminths and protozoans. an intervention is having an effect. • Other biomarkers: New methods for analyzing stool • Fly density: Presence and quantification of flies using samples can predict long-term nutritional outcomes, fly grills or fly tape can demonstrate improvements and noninvasive saliva samples can be tested for the in cleanliness. Since flies are a major vector for presence of antibodies to common diarrheal disease the spread of disease, a decrease in fly density may pathogens. Further research is needed to establish indicate lower disease risk. validity and reliability of these measures. 22 www.wsp.org   IX. Addressing WASH through Nutrition Projects Where alleviating the burden of undernutrition has underweight, as well as nutrition-sensitive interventions for proven to be a stubborn challenge, environmental hygiene communities becoming open defecation free (ODF), access solutions could be the binding constraint to improving to school latrines, and hygiene knowledge. The project nutrition outcomes. Therefore, nutrition interventions that targets various risk factors for undernutrition, focusing on address environmental hygiene practices and behaviors, interventions where the evidence of impact on nutritional such as handwashing with soap and use of latrines, as status is strongest. key determinants of nutritional outcomes can increase nutritional impact. Taking It Further Nutrition interventions commonly include hygiene Current Status components that provide information or promotion of A review of the health portfolio for fiscal years 2005 through handwashing with soap, safe water, and sanitation. A 2014 (n = 372) resulted in a total of six projects with cross- handwashing demonstration is often included in infant and sectoral coding in water supply (WC), sanitation (WA), young child feeding interventions, including breastfeeding or general water and sanitation (WZ). WASH-specific and complementary feeding. These interventions may objectives specified in these projects included expanding also discuss the importance of using safe water in food coverage of improved water supply and sanitation and preparation. More recently, the WASH sector has been improving WASH practices and behaviors. Importantly, working with nutrition, social protection, and other these projects measured WASH outcomes as part of the poverty-reduction efforts to incorporate promotion of project results framework, including in some cases access to household sanitation and latrine usage. Incorporation of improved sanitation and water supply. sanitation demand generation into the Poverty Reduction Fund II in Lao PDR is expected to result in substantial cost Although the number of projects is small (1.6 percent of savings by using the existing platform for reaching remote all health projects over the past decade) they illustrate a rural villages. Specifically, the project will finance training, number of potential approaches to multisectoral action. For travel costs, CLTS triggering events, and ODF verification example, the Sunaula Hazar Din Community Action for to be conducted by the environmental health arm of the Nutrition Project in Nepal, which targets high population MoH National Center for Environmental Health (Nam areas with high stunting and poverty levels, will mobilize Saat). In the Philippines, the WASH sector will leverage communities to discuss nutritional challenges and commit Pantawid Pamilya, the largest national antipoverty and to achieving specific nutritional goals within a 100-day social protection program in the country, to incorporate period. A “menu of goals” includes nutrition-specific an enhanced sanitation module into family development objectives around exclusive breastfeeding for six months, sessions to provide information on the benefits of sanitation immunizations, and weight gain for children who are and incorporate evidence-based behavior change messages. www.wsp.org 23   X. Summary and Next Steps There is sufficiently robust evidence that improved WASH Coordination between the WASH and nutrition sectors, impacts nutrition, and the use of evidence-based guidance, especially at the preparation and design phases, can help instruments, and incentives can help task teams to maximize ensure that nutritional considerations are addressed, nutritional impacts. At the same time, more evidence is appropriate target groups prioritized, and where possible, needed on operational approaches that are effective and objective indicators are used to measure nutritional impact. cost-effective. For instance, there is little knowledge of the Similarly, nutrition projects can readily borrow from the duration or intensity of WASH interventions that are required software elements of WASH interventions to address key to achieve nutritional impact, whether WASH interventions determinants of undernutrition. in combination or alone can achieve health impact, and how task teams can prioritize these different interventions. There This note presents some promising approaches to make WASH is little experience to date with integration of WASH into projects more nutrition-sensitive with the overall objective to community-driven development, conditional cash transfers, increase development impact and end extreme poverty. However and other results-based financing approaches, and how these selectivity is needed—not all WASH projects can or should projects might affect nutrition outcomes. Experimental and operate with nutritional considerations. However, having in quasi-experimental impact evaluations are the best mechanisms mind nutritional considerations can help guide task teams to to answer these questions; however, tacit knowledge and adopt nutrition-sensitive approaches to project and policy design experience can help inform task teams in the short term. where appropriate. Moreover, closer coordination between the WASH and nutrition sector can facilitate identification of The annex, “Building the Evidence and Knowledge Base,” projects that would benefit from a nutrition-sensitive approach presents a preliminary list of policy and research questions or those that could increase effectiveness on nutritional outcomes to help address these knowledge gaps. by incorporating selected elements of WASH interventions. Following a handwashing program, children at a school in West Java, Indonesia, wash their hands with soap. Photo: Sheryl Sliverman / World Bank 24 www.wsp.org Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Annex 1: Building the Evidence and Knowledge Base Annex: Building the Evidence and Knowledge Base A set of initial research and policy knowledge gaps emerge ii. Effectiveness of nutrition-sensitive WASH from this review, spanning three broad areas: (i) direct and interventions on child nutrition outcomes. There indirect effects of WASH on child nutrition outcomes; are few effectiveness studies evaluating the impacts (ii) effectiveness and cost-effectiveness of nutrition-sensitive of nutrition-sensitive WASH. Further evidence is WASH interventions; and (iii) how to strengthen nutrition needed, particularly at a large scale, on the relative impacts in WASH operations. effectiveness of nutrition-sensitive approaches to business as usual: i. Direct and indirect impacts of WASH on • What is the impact of sanitation promotion child nutrition outcomes. Despite the strength combined with CCTs on nutrition outcomes? of available evidence, there are still unresolved How can financial incentives tied to program questions on the impact of WASH on stunting, low conditionalities increase adoption of weight-for-age, and anemia: sanitation and improve nutrition for program • What is the impact of improved water, sanitation, beneficiaries? and hygiene, alone and in combination, on child • What are the costs and relative cost-effectiveness nutrition outcomes? of nutrition-sensitive WASH interventions • What is the relative importance of diarrhea, compared with business-as-usual on health and anemia, environmental enteropathy, and nutrition outcomes? helminth infection caused by WASH on child • What are the costs and relative cost-effectiveness nutrition outcomes? of nutrition interventions that incorporate WASH • What are the impacts of WASH on nutrition components on child nutrition outcomes? outcomes mediated through household time • What is the impact of geographic and/or savings and productivity? demographic targeting of vulnerable populations • What are the impacts of WASH on income poverty for WASH operations with a goal of improving and how do these influence nutrition outcomes? child nutrition? • What are the pathways of fecal contamination • What is the impact on child nutrition outcomes and exposure in the household? of results-based financing approaches that link • What is the relative importance of animal and water supply and sanitation subsidies to health human feces for infection and child nutrition seeking behavior, appropriate childcare behaviors, outcomes? and growth monitoring? www.wsp.org 25 Multisectoral Approaches to Improving Nutrition: Water, Sanitation, and Hygiene Annex 1: Building the Evidence and Knowledge Base iii. 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