Sanitation and health: what do we want to know?

Experts meet to discuss reaching a consensus on what the evidence tells us.

Radu Ban

Jan Willem Rosenbom

This is the first of two blogs written about the “Sanitation and health evidence consensus meeting”, convened by the World Health Organization (WHO) in Seattle on May 24 and 25 of 2018. It was written by Jan Willem Rosenboom and Radu Ban, who are both Sr. Program Officers on the Water, Sanitation and Hygiene (WSH) team at the Bill & Melinda Gates Foundation. This first blog will describe the process used to arrive at the consensus, while the second blog will describe the outcome of the consensus and will come out once the results of the consensus meeting have been published. Also, mark your calendars for a session during the 2018 UNC Water and Health conference dedicated to this consensus!

Two sides of sanitation: rubbish and cleanliness. Credit Bill & Melinda Gates Foundation, Cambodia/India

Introduction: What is this about?

It is hard to imagine that making improvements in sanitation wouldn’t play a role in improving health. After all, we know that shit spreads disease and the F diagram shows us that sanitation is an important tool in blocking the transmission of pathogens from one person to the next, thus lowering exposure. And sure enough: we have strong evidence about the effectiveness of sanitation interventions and improving health and human capital outcomes from rigorous historical studies, from high- as well as low- and middle-income countries.

At the same time, looking at the specific impact of programmatic sanitation interventions, it can be hard to figure out what the evidence is really telling us. On the one hand, a systematic review of the whole body of evidence on sanitation and health (carried out by Freeman et al. in 2017) suggests that sanitation protects against diarrhoea, active trachoma, some soil-transmitted helminth (STH) infections and schistosomiasis. It also improves height-for-age scores of children (i.e. it decreases stunting, which is an important measure of human capacity). On the other hand, several recent sanitation intervention studies have found limited or no impact on different health outcomes. The table below (copied with permission from a presentation by Tom Clasen), provides a summary of key findings from the most recent sanitation studies:

1. Fewer observed flies and feces; no change in fecal contamination of water
2. Fewer observed soiled hands and less fecal contamination of water
3. Except in the study arm considering just water quality improvements

This seeming lack of agreement is confusing, and partly in response to questions from practitioners, on May 24 and 25 of this year WHO convened a meeting of experts to review the existing evidence and reach a consensus about what it is telling us. The group of experts consisted of researchers across multiple disciplines who had written extensively on the topic of sanitation and health. We thought it was necessary to reach consensus among researchers before engaging, in a unified voice, the practitioner community.

At the same time, to make sure that the concerns of practitioners would be considered in the meeting, we published a “request for input” online (through the SuSanA network as well as the Sanitation Updates blog) and we will summarise the responses here. But first…

Seeking inputs for “consensus” meeting on sanitation interventions

Following the publication of results from a number of recent studies investigating links between improvements in sanitation and health (such as the WaSHBenefits study, studies in Tamil Nadu, Madya Pradesh and Orissa in India and others) some of you have contacted the Gates Foundation WSH team with questions and concerns about the seeming lack of consensus about the relationship between sanitation and health demonstrated in those studies.

Looking at a number of historical studies, it is hard to imagine that improvements in sanitation did not play a significant role in improving population health. And indeed, older as well as more recent historical evidence from US, Europe and developing countries establish causal relationships between sanitation and health. However, when considering more granular evidence considering the effects of individual and categories of interventions, there is less alignment.

Understandably, this has led to concerns about the meaning of this evidence, and questions about how it should be interpreted and used by practitioners, working to design and implement sanitation programs.

Partly in response to those concerns, WHO is convening an expert meeting in May this year, to develop a “consensus statement” around two specific questions:
• Are particular sanitation interventions more likely to have protective effects?
• What pre-conditions are likely to impact the effectiveness of these sanitation interventions?

The meeting will bring together researchers, from both life and social science backgrounds from around the world for two days of deliberations, informed by evidence and identifying points of agreement and contention. The Water, Sanitation and Hygiene team at the foundation strongly supports the organization of this meeting, and to make sure that issues relevant to practitioners are considered (and hopefully answered) during the discussions, we would like to invite you to share with us the most important questions you (and your teams) face when considering the use of evidence in program design.

The consensus meeting is scheduled to take place on May 24 and 25. To allow for review and incorporation into the agenda, the deadline for the submission of questions for consideration is end of day Thursday May 17.

There is no particular format for submission, although when we say we are looking for questions, we mean just that; a short sentence with a question mark at the end (no need to over-think it). If you are concerned that there is the possibility of mis-interpretation, you should feel free to provide some context and explanation.

Following the meeting, the results will be published and broadly disseminated.

We look forward to hearing from you what concerns you. If you have any questions about the process (or the scope) of this effort, please feel free to get in touch.

Jan Willem Rosenboom and Radu Ban

Contact:  janwillem.rosenboom [at] gatesfoundation.org

Lessons learned from WASH and NTD projects

Water, sanitation and hygiene (WASH) are essential for preventing and managing diseases including neglected tropical diseases (NTD) which affect over 1 billion people among the poorest communities.

Closer coordination of WASH and NTD programmes is needed to ensure WASH services are reaching the most vulnerable populations. Many WASH and NTD actors have started to work together on the planning and implementation of their projects and have documented their experiences and lessons learnt.

The World Health Organization (WHO) has published a paper that draws on examples from eighteen countries to summarise emerging successes and challenges. Several examples relate to WASH in Schools projects. Two case studies are highlighted: the Lao PDR and Cambodia CL-SWASH initiative and the CARE Integrated WASH and NTDs Programme in Ethiopia.

WHO, 2017. Water, sanitation and hygiene to combat neglected tropical diseases : initial lessons from project implementation. Geneva, Switzerland: World Health Organization. 6 p. WHO reference number: WHO/FWC/WSH/17.02. Available at: www.who.int/water_sanitation_health/publications/wash-to-combat-neglected-tropical-diseases/en/

 

Health workers must have #safeHANDS – WHO annual call to action

This year’s annual day to recognize hand hygiene among health workers commemorates ten years of the Clean Care is Safer Care programme (2005-2015) of the World Health Organization (WHO).

Hand hygiene is an important element of infection prevention and control. A recent WHO/UNICEF survey of  66,000 health facilities in developing countries revealed that over a third of them lacked soap for hand washing.

To join the campaign and learn more visit: http://www.who.int/gpsc/5may/en/

Webinar: Healing Hands, 5 May 2015, 3:00 PM – 4:00 PM CEST

Hear from experts from WHO, the London School of Hygiene and Tropical Medicine, and Johns Hopkins University on the importance of hand hygiene, the current state of practices and lessons learned from the recent West Africa Ebola Outbreak.

To join the discussion register at the site of the Global Public-Private Partnership for Handwashing.

Water, sanitation and hygiene in health care facilities

A new report by the World Health Organization (WHO and Unicef provides an “alarming picture of the state of WASH in health care facilities”.

Drawing on limited data from 54 low- and middle-income countries the report concludes that 38% of the facilities lack access to even rudimentary levels of water, 19% lack sanitation and 35% do not have water and soap for handwashing.

In addition, “training and capacity building to ensure there are sufficient resources and personnel to operate and maintain WASH facilities and enable health care staff to deliver hygiene behaviour change messages is urgently needed”, the report says.

“While the situation appears bleak, there are a number of global initiatives for which WASH in health care facilities is a foundational element and examples of national governments taking the initiative to improve standards, implementation and monitoring”, the report concludes. Through coordinated, global action, with leadership from the health sector, WHO and Unicef believe that all health care facilities can have adequate WASH services.

Besides the full report, you can also download:

• 10 key findings
• Q&A on WASH in health care facilities 
• Simple solution improves water and sanitation in Zambian health-care facilities

Cronk, R. & Bartram, J., 2015. Water, sanitation and hygiene in health care facilities : status in low and middle income countries and way forward, Geneva, Switzerland: World Health Organization (WHO) and Unicef. x, 38 p. : 8 boxes, 2 fig, 8 tab. Avaialable at:
www.who.int/water_sanitation_health/publications/wash-health-care-facilities/en/

Campaigning for better WASH in health care facilities

WHO is launching a global plan of action to improve access to WASH at all health care facilities. This kind of intersectoral collaboration is set to become a major theme in the post-2015 development agenda.

Maternity ward, Gazipur, Bangladesh. © DFATD-MAECD/Wendell Phillips. https://www.flickr.com/photos/dfait-maeci/10057359875

Better access to water, sanitation and hygiene (WASH) in health care facilities is crucial for mothers and babies to stay healthy. It is just as important as curative measures says Dr Maria Neira, the Director of Public Health and Environment at the World Health Organization (WHO) [1]. She announced that WHO will launch a global plan of action by March 2015 on improving access to WASH at all health care facilities [2].

Save Lives: Clean Your Hands – 5 May 2013

Photo: WHO

This annual global campaign on 5 May supports the World Health Organization’s (WHO) effort to improve hand hygiene in health care and thus prevent often life threatening healthcare-associated infections (HAI).

It was launched in 2009 as a follow-up to WHO’s First Global Patient Safety Challenge: Clean Care is Safer Care work.

WASH by numbers: the latest on cost benchmarks, economic returns and handwashing

One of the most quoted WASH statistics was recently “downgraded”. For every $1 invested in water and sanitation, not $8 but “only” $4 is returned in economic returns through increased productivity. This recalculation [1], says the World Health Organization, is mainly a result of higher investment cost estimates and the more complete inclusion of operation and maintenance (O&M) costs.

Providing a better insight into O&M costs has been one of the achievements of the WASHCost project of the IRC International Water and Sanitation Centre. WASHCost has published minimum benchmarks for costing sustainable basic WASH services in developing countries [2]. The project collected data from Burkina Faso, Ghana, Andhra Pradesh (India) and Mozambique.

The main message is that spending less than the minimum benchmarks will result in a higher risk of reduced service levels or long-term failure. NGOs claiming that “US$20 can provide clean water for one person for 20 years” have clearly forgotten to include annual recurrent costs for operation and maintenance, capital maintenance and direct support.

The real cost for 20 years of basic water supply from a borehole and handpump would be, per person,  between US$ 20 and US$ 61 for construction plus US$ 3-6 every year to keep it working. In total for the 20 years this would amount to  US$ 80 to US$ 181 per person.

Similarly, for the most basic sanitation service, a traditional pit latrine, the combined costs would be US$ 37 – 106 per person over 20 years.

Al Jazeera’s Inside Story discusses new WHO/UNICEF report on water and sanitation MDGs

The UN announced that the Millennium Development Goal (MDG) target to cut the number of people who do not have access to safe drinking water by half, has been met five years before the 2015 deadline. In contrast, the sanitation MDG target will not be met.

The report issued by UNICEF and the World Health Organization (WHO) says that between 1990 and 2010, over two billion people gained access to improved drinking water sources such as piped supplies and protected wells.

Does this really show an early success for the MDG? How reliable is the UN report on safe drinking water?

Joining presenter Adrian Finighan on Inside Story are guests: Patrick Moriarty, in charge of the International Programme for the IRC International Water and Sanitation Centre, a Netherlands-based NGO; Joakim Harlin, a senior water resources advisor at the UNDP; and Muhammad Jahangir, the founder of Better Tomorrow, an NGO focusing on water sanitation.

More information:

• Al Jazeera – Inside Story
• Rebecca Zerzan, Millennium Development Goal target on drinking water met, UNICEF, 06 Mar 2012
• WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (2012). Progress on Drinking Water and Sanitation: 2012 Update. www.unicef.org/media/files/JMPreport2012.pdf
• Stef Smits, Is the glass half full or half empty?, Water Services That Last, 09 Mar 2012

64th World Health Assembly approves three WASH resolutions

The 64th World Health Assembly (WHA) has adopted a resolution on drinking-water, sanitation and health, and two other related resolutions on cholera and Guinea worm (dracunculiasis).

Yael Velleman at the WHA in Geneva with a copy of the WaterAid report "The sanitation problem - What can and should the health sector do". Photo: WaterAid

WaterAid had issued a call to leaders participating in the WHA in Geneva to prioritise sanitation and water in the fight against diseases including cholera and dracunculiasis. In support of their campaign, WaterAid published a new report
The sanitation problem: What can and should the health sector do?. WaterAid’s Senior Health Policy Analyst Yael Velleman wrote an opinion piece in the Guardian and posted daily updates from the WHA.