Advancing WASH In AfricaA Review of WASH in ACSD and

A Plan Forward

Progress Towards the Water and Sanitation Targets of MDG 7

Sanitation Drinking Water

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All Africa Representatives Meeting – 2January 2009

Johannesburg, South Africa

Stocktaking of WASH in ACSDThe Accelerated Child Survival and Development (ACSD) programme – a package of quick impact, low-cost interventions – is recognized as a key strategy for achieving the goals set out in AARM in 2006. An estimated 1.5 million children under five die from diarrhoeal diseases each year, more than half of which are undernourished. When a child’s health has been compromised by malnutrition or HIV/AIDS, preventing diarrhoea is crucial to increasing survival and development. Handwashing with Soap, Household Water Treatment and Safe Storage (HWTS) and Sanitation can drastically reduce these staggering numbers.

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[1] Coates, S., Luyendiijk R, and Delienne D. (2007) Water, sanitation and hygiene (WASH) Accelerating action in country programmes in Sub Saharan Africa: An internal discussion paper for the RMT Autumn 2007, UNICEF.[2] UNICEF Africa Child Survival and Development (ACSD) Stocktaking Review Final Report, 3 November 2008. Prepared by Marc Bolduc, Riham Faqih, Jean Michel Ndiaye, Nancy O’Rourke, Margaret Perkins.[3] The four key community based interventions are 1. promotion of exclusive breastfeeding, 2) provision of Vitamin A, 3) distribution of ITNs and 4) promotion of hand washing using soap.

For WASH, the key findings of the Stocktaking Review are:

1. Integrating WASH (specifically the promotion of handwashing with soap) with Health, Education, Nutrition and HIV/AIDS proved to be one of the biggest challenges. Less than half of the plans developed included WASH.

2. Advances in community based interventions were slow in all four areas[3], but notably slower on the promotion of hand washing using soap.

3. Communication for Development (C4D), essential for promotion of hand washing with soap, is weak.

1. WASH is a donor priority and UNICEF’s unique positioning as a trusted partner with Governments has led donors to channel large-scale funding to UNICEF in support of the sector.

2. National programme instruments are ‘open’ to WASH, thus making way for policy dialogue and use of the evidence to go to scale.

3. The evidence base has been strengthened, clearly linking WASH promotion (handwashing with soap, household water treatment and safe storage, sanitation promotion) with improvements in health, nutrition and HIV/AIDS. WASH is a pre-requisite for child survival and development.

4. Within UNICEF, there is a strong global and regional commitment to ensure WASH contributes significantly to child survival and development.

5. UNICEF is the IASC WASH Cluster Lead in emergencies and humanitarian situations.

In preparation for AARM2, UNICEF undertook a Stocktaking Review[2]. The report shows some progress but is also critical of the pace of advancement. Specifically referring to the WASH component of ACSD, there is a notable absence of programming and resources allocated.

A recent UNICEF paper[1] outlines five opportunities in WASH that UNICEF must take advantage of in order to achieve MDG 4.

Since 1990, the number of Africans without sanitation

increased by 153 million

The WASH component of ACSD is lagging behind other ACSD interventions.

One in four Africans practises open defecation

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To achieve success, UNICEF can:• Build WASH human resource capacity at country, regional and

global levels.• Prioritize WASH interventions in programming, notably

behavior change interventions.• Create country-specific packages based on input by WASH

teams, Country Representatives, relevant Ministries, and other sector partners.

• Improve coordination amongst programming units, especially nutrition and HIV/AIDS.

• Increase allocation of Regular Resources for WASH in order to provide programme stability over time.

Priority WASH Interventions

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WASH interventions are highly effective inreducing diarrhoeal diseases The evidence is compelling that integrating promotion of

handwashing with soap, sanitation promotion and household water treatment & safe storage – alongside other low-cost, high-impact health interventions – is critical for ensuring child survival and development.

The following three WASH interventions should be prioritized in all UNICEF programming.

HANDWASHING WITH SOAP

Handwashing with soap, a relatively low-cost intervention, has the biggest impact on reducing incidences of diarrhoeal disease – by over 40% according to several studies[4]. Because it has the biggest impact, handwashing with soap must be a priority in ACSD programming.

In Ghana, a Public Private Partnership for the “Handwashing with Soap Programme” has resulted in a 41-62% increase in handwashing with soap before eating. This joint effort involves many partners, including the government's Community Water and Sanitation Agency (CWSA), the World Bank, UNICEF, WaterAid, and Unilever.

HOUSEHOLD WATER TREATMENT AND SAFE STORAGE

Studies have shown significant deterioration of water quality between the time water is taken from the source to the time it reaches the mouth. Household Water Treatment and Safe Storage (HWTS) is significantly more effective in reducing diarrhoeal disease compared with conventional, costlier source-based interventions[5].

Technologies such as chlorination, filtration and solar disinfection are all low-cost, effective and manageable at the household level. Proven market-based solutions can be utilized, possibly in conjunction with limited free distribution of filters and chlorine.

In Guinea, UNICEF has developed a strong partnership with PSI to produce chlorine for household treatment of water. The partnership has resulted in a nationwide publicity campaign, including hygiene messages, the creation of a national network of sales points and the sale of more than 350,000 bottles of “SurEau”.

SANITATION PROMOTION

Ethiopia, 51.7

Nigeria, 28.5

Sudan, 13.9

Niger, 10.9

Mozambique, 10.1

Burkina Faso, 9.9

Madagascar, 7.1

Chad, 6.9

DR Congo

Benin, 5.7

More than half of the 228 million people in Africa who practised open defecation in

2006 lived in ten countriesExperience around the globe shows that a Community Approach to Total Sanitation (CATS) leads to unprecedented numbers of households constructing their own latrines, without the use of hardware subsidies. This outreach-based approach, which emphasises stopping all open defecation in the community, rather than just the construction of household latrines, holds great promise. Worldwide application of the approach even brings the MDG sanitation target – previously thought of as one of the hardest to reach –within sight, as CATS provides the opportunity to reach a dif

ferent order of magnitude of children and families than the more traditional subsidy-based investments for sanitation.

In Zambia, in just eleven months, approximately 90,000 people gained access to improved sanitation. Of the 517 villages involved, 402 villages were verified as Open Defecation Free (ODF). In some villages, coverage increased from 0 to 100% within a month!

[4] Coates, et al. (2007)[5] UNICEF Promotion of Household Water Treatment and Safe Storage in UNICEF WASH Programmes. January 2008.

What Country Programs can do to improve WASH in ACSD

EMBRACE ESSENTIAL WASH INTERVENTIONS

Household water treatment and safe storage, the promotion of handwashing with soap and sanitation promotion should be key aspects within ACSD programming. Ramp up community outreach and community based interventions by strengthening support Communication for Development (C4D) and Community Health Worker (CHW) programs. Well-trained CHWs who are properly resourced with training, logistics and resource materials can maximize impact by delivering essential WASH messages to communities.

INTEGRATE PROGRAMMING & IMPROVE COORDINATION WITHIN UNICEF PROGRAMME TEAMS

Improved WASH is essential to the achievement of MDGs in nutrition, health and HIV/AIDS. Evidence shows that 85% of diarrhoeal deaths are WASH-related. Children weakened by frequent diarrhoea episodes are more likely to be seriously affected by malnutrition and opportunistic infections. Open-defecation free communities, access to safe clean drinking water and handwashing with soap are among the most effective means of reducing instances of diarrhoea, respiratory infection and worms.

Strategies for WASH, health, nutrition, education and HIV/AIDS have strong synergies and can be linked. Effective cross-programme interventions may include:

• Equip Community Health Workers with knowledge and educational materials to advocate for handwashing with soap

• Target WASH interventions to areas of high nutritional vulnerabilities to reduce childhood undernourishment and stunting

• Ensure primary school curricula include hygiene promotion modules• Promote household water treatment and safe storage as essential for maintaining

good health in people living with HIV/AIDS.

SUPPORT CAPACITY DEVELOPMENT OF UNICEF WASH STAFF

Today’s WASH programme may require a different skill set from previous WASH programmes. Country Offices should ensure WASH staff take full advantage of training opportunities and also look to augment the WASH team, where appropriate. A comprehensive WASH program based on community outreach and promotion will require adequate, dedicated and qualified permanent staff. Many offices have WASH staff experienced in water supply – those dedicated team members now need to be joined by staff with a different skill set to take on the challenges of the “S and H” in WASH.

Country Representatives, with their WASH and other programme staff, can map UNICEF’s strengths and weaknesses in the WASH sector and create country-specific plans which will address WASH in ACSD and beyond.

Emergencies inevitably lead to a high level of political and media focus on WASH. Ensuring access to safe water supplies, sanitation and hygiene are key elements in UNICEF's Core Commitments to Children during emergencies. This, together with UNICEF's role as the IASC WASH Cluster lead agency, gives an opportunity for raising the profile of WASH in countries experiencing emergencies.

Countries which are transitioning from emergencies to more stable situations also have a great opportunity to put WASH high on the agenda, for example during the development of early recovery plans and frameworks. Such opportunities can help strengthen national planning processes for WASH, as well as bring important resources into the sector.

UNICEF Country Offices should capitalize on the visibility and momentum of WASH programs undertaken in emergency times to refocus donor and national interest on WASH interventions.

Additional Complementary WASH Interventions

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UNICEF’s work to improve WASH in Schools has long been a core activity and should be continued. Not only are water and toilets essential services in schools for proper hygiene, school feedingprograms and as teaching tools for hygiene promotion; but are also essential for getting girls to stay in school.

In Health Centers, water and sanitation are necessary basic tools for doctors and nurses to lower neo-natal mortality, control the spread of disease and ensure a health center is, indeed, a healthy place to visit.

WATER SUPPLY

WASH IN SCHOOLS AND HEALTH CENTERS

TRANSITIONING OUT OF EMERGENCIES

ACSD interventions are low-cost and quick impact. Investing in safe drinking water supply systems does not generally fall into that category. However, with 36% of Africans still without access to a safe water supply, UNICEF must continue to tackle the issue. In order to reduce costs and increase sustainability, approaches are being explored in improving supply chains for pumps and spare parts, using rainwater harvesting, and making boreholes more cost-effective – including using low-cost drilling techniques such as manual drilling.

Donors continue to prioritise access to safe drinking water and UNICEF country offices can review programmes to see where scaling up can take place.

Four out of five Africans without an improved drinking water source live

in rural areas

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CONCRETE STEPS TO ENHANCE WASH PROGRAMS IN AFRICA

Promote Sanitation and Open Defecation-Free

Communities

Integrate WASH into Health, Nutrition, HIV/AIDS

and Education Programming

Promote Household Water

Treatment and Safe Storage

Promote Handwashing with

Soap

Enhance Staff Capacities

WHAT HEADQUARTERS AND REGIONAL OFFICES CAN DO FOR COUNTRY TEAMS

CAPACITY BUILDING

Recruiting the best WASH staff and ensuring all our WASH staff have the right skills for the job must be a priority. HQ is developing a set of WASH training modules designed for distance learning, which all CO WASH staff should be encouraged to take. HQ is also working with DHR to find the right candidates to fill WASH staff positions in country offices.

DOCUMENTATION AND KNOWLEDGE SHARING

HQ will work with country offices to produce high quality publications which showcase WASH best practice, innovations and lessons learnt; which can be used within UNICEF and by sector partners to improve WASH programmes.

TECHNICAL ASSISTANCE

Country offices can access technical support from Regional Office and HQ Advisors. EASARO and WCARO now have advisors specializing in Sanitation & Hygiene, as well as broader WASH and emergencies. Support can be requested at critical periods such as mid-term reviews and new country program design.