One WASH – the implementation of Ethiopia’s national programme Eliminating Trachoma: Accelerating Towards 2020

www.trachomacoalition.org Water, sanitation and hygiene (WASH) Water, sanitation and good hygiene (WASH) are essential for the prevention of trachoma and critical to global efforts to eliminate the disease as a major public health problem by 2020.

Trachoma, the world’s leading infectious cause of blindness, is transmitted in overcrowded communities with poor sanitation and without access to clean water for basic hygiene1.

Facial cleanliness (F) and Environmental improvements (E), which require water, improved sanitation and promotion of hygiene practices, are core components of the World Health Organization (WHO)-endorsed SAFE strategy for trachoma elimination. Alongside Surgery (S) and

Antibiotics (A) to treat active infection, F and E can prevent the spread of trachoma-causing bacteria in endemic communities2.

Regular face washing is proven to reduce person-to-person transmission while properly constructed, improved latrines reduce open defecation and in turn, the number of disease-carrying flies in communities . Health and hygiene promotion equips families with the necessary knowledge and practices for preventing repeated infections that lead to irreversible vision loss.

While WHO recommends all four components of SAFE be implemented concurrently to effectively tackle trachoma, collaboration with the WASH sector to realise the F and E components of the strategy is often challenging. Organisations focusing on the those already infected with trachoma will work on treatments such as surgery or antibiotics; the preventative components, the facial cleanliness and the environmental improvements are more complicated and often overlooked3. Organisations that focus on treatments rarely have the technical expertise or mandate to implement WASH programmes, while WASH organisations are rarely focused on disease outcomes when planning and implementing their programmes4. Integration requires trachoma and WASH actors to develop a common language, to agree on joint programme outcomes and to develop ways of working together.

One WASH - a pioneering national programme In Ethiopia, the most trachoma-endemic country in the world, an ambitious government-led WASH coordination mechanism is paving the way for greater collaboration between sectors to support trachoma and other disease control efforts.

Launched in September 2013, the US$ 2.9 billion One WASH National Programme (OWNP) brings together the ministries of Water, Health, Finance and Education with a network of development and private sector partners to tackle Ethiopia’s water and sanitation crisis5.

The huge investments in water and sanitation hardware afforded by the One WASH programme are complemented by health education in rural and remote communities through Ethiopia’s Health Extension Programme (HEP). Through the HEP, basic sanitation coverage has increased dramatically reaching around 66% of people. The improved water source coverage reached 57% during the Millennium Development Goal period, achieving target. However, the quality of the majority of sanitation facilities built is not up to standard and improved latrine coverage is only around 28%.

According to the 2015 World Bank/ UNICEF Joint Monitoring Report (JMP), less than half of all rural Ethiopians have access to improved drinking water sources, compared with 93% of people in urban areas6.

The One WASH programme aims to extend safe water supply to 98% of the country’s rural population and 100% of city dwellers; and to ensure access to improved sanitation for all by 20207. It also aims to achieve the government’s Universal Access Plan (UAP) target for 77% of the population to be washing hands with soap at ‘critical times’ (after using the toilet or before contact with food)8.

Oromia, Ethiopia, WASH

"We control our fates. We can defeat this disease simply by washing our faces and the faces of our children and keeping our compounds clean." Dr. Kebede Worku, State Minister of Health, Ethiopia

Collaboration of government ministries To realise these goals, One WASH requires the various government ministries and development and NGO partners to pool resources and expertise into four core programme streams: Rural WASH, Urban WASH, Institutional WASH and Programme management and Capacity building.

The Rural and Institutional streams are of particular importance to trachoma prevention efforts. Under Rural WASH, $US1.53 billion is set aside to construct new water points and rehabilitate existing water schemes for 27.9 million people in underserved rural and pastoral communities9. The programme aims to improve rural sanitation by encouraging the construction of household latrines through Community Led Total Sanitation and Hygiene (CLTSH) schemes. With trachoma affecting the most marginalized in rural and remote communities, improved access to clean water and sanitation in these parts of Ethiopia will significantly reduce the national disease and disability burden10.

The Institutional WASH component is an allocation of US$545.7 million to improve infrastructure in health centres and schools11. When One WASH was launched in 2013, as many as 80% of Ethiopia’s health facilities were without adequate sanitation and 97% had no hand washing facilities, posing significant health risks to the entire country and undermining disease control and poverty alleviation efforts12. Since then there has been marked improvement, but as many as 56% of healthcare centres don’t have piped water, 29% don’t have improved water (within 500m of the facility) and 22% are still without client latrines13.

Through the Institutional stream, One WASH plans to extend safe water to 7,772 health centres and to improve sanitation facilities for 7,141 health centres around the country, under the purview of the Ministry of Health14.

The Ministry of Education is responsible for coordinating work to make clean drinking water available in an additional 22,985 primary and secondary schools, and to improve sanitation facilities in 6,122 schools around the country15.

Young children are the group most affected by trachoma and are considered ‘reservoirs of infection’16. Improving water and sanitation in schools is an investment in the overall health, wellbeing and life opportunities of young children, their families and entire communities17.

Linking messages with education Under the HEP, more than 38,000 community-based health extension workers (HEWs) and an ‘army’ of male and female health volunteers (the Health Development Army) deliver preventive health services that include education about basic hygiene, latrine use and waste disposal. The One WASH programme is supporting the training of Health Development Army volunteers who act as role models and give advice to further promote behaviour change for disease-free communities. The group uses a system of one-to-five networking – one individual learns new information and then passes this on to five others in their community18. Linking face washing messages with these existing health education packages could greatly support trachoma

elimination efforts across Ethiopia; sustaining health gains achieved through mass antibiotic campaigns, surgery and improved infrastructure.

Importantly, the One WASH programme is helping to bring the right people together to ensure water and sanitation services in Ethiopia reach those most in need.

Already, 70% of Ethiopia’s trachoma endemic regions have been prioritised by regional health bureaus for One WASH interventions19.

In 2015, the State Minister of Health, Dr. Kebede Worku, called for the expansion of One WASH to all trachoma endemic districts and for it to become the central strategy to fight trachoma20. At an event to celebrate the 500 millionth donated dose of the antibiotic Zithromax, Dr Worku urged Ethiopian citizens to take trachoma elimination into their own hands by adopting healthy hygiene practices in their communities.

"We control our fates. We can defeat this disease simply by washing our faces and the faces of our children and keeping our compounds clean," said Worku.

Fetching water, Gurage, Ethiopia

Photo Credits: The Fred Hollows Foundation, Sightsavers

Last updated 31 August 2016

_____ 1 World Health Organization. (2015) Water sanitation and hygiene for accelerating and sustaining progress on neglected tropical diseases: A global strategy 2015-2020. Geneva: World Health Organization. http://www.who.int/water_sanitation_health/publications/wash-and-ntd-strategy/en/ 2 World Health Organization. (2016). Trachoma. [online] Available at: http://www.who.int/mediacentre/factsheets/fs382/en/. 3 In conversation with Yared Tadesse, Senior Hygiene and Environmental Health Expert, Federal Ministry of Health, Ethiopia August 2016 4 NTDs and WASH Programmes: How NTD programmes can work with WASH programmes for common goal of improved public health, Chad MacArthur, Envision, accessed April 2016: http://www.ntdenvision.org/spotlight/ntds_and_wash_programs 5 Carter Centre Review Meeting, 2016 6 World Health Organization and UNICEF Joint Monitoring Programme (JMP) 2015, ‘Progress on Drinking Water and Santitation,’, 2015 Update and MDG Assessment. www.who.int/water_sanitation_health/monitoring-jmp-2015-update/en/ 7 Federal Democratic Republic of Ethiopia, One WASH National Programme (OWNP) Programme Document, August 2013 8 Federal Democratic Republic of Ethiopia, One WASH National Programme (OWNP) Programme Document, August 2013 9 One Wash National Programme leaflet http://www.unicef.org/ethiopia/OWNP_LEAFLET.pdf 10 World Health Organization. (2015) Third WHO report on neglected tropical diseases: “Investing to overcome the global impact of neglected tropical diseases”. Geneva: World Health Organization. http://www.who.int/neglected_diseases/9789241564861/en/. P.62 11 Carter Centre Review Meeting, 2016. 12 National WASH Inventory report, 2012 in Federal Democratic Republic of Ethiopia, One WASH National Programme (OWNP) Programme Document, August 2013. 13 The Ethiopian Public Health Institute. Ethiopia Service Provision Assessment Plus Survey 2014. http://www.ephi.gov.et/images/pictures/FINAL%20Key%20finding%20SPA+%20%20-%20Aug%2017%20-%202015.pdf 14 Federal Democratic Republic of Ethiopia, One WASH National Programme (OWNP) Programme Document, August 2013 and One Wash National Programme leaflet: http://www.unicef.org/ethiopia/OWNP_LEAFLET.pdf 15 Federal Democratic Republic of Ethiopia, One WASH National Programme (OWNP) Programme Document, August 2013 and One Wash National Programme leaflet: http://www.unicef.org/ethiopia/OWNP_LEAFLET.pdf 16 World Health Organization (WHO), ‘Blinding Trachoma Fact sheet N°382", updated May 2015: http://www.who.int/mediacentre/factsheets/fs382/en/ 17 Federal Democratic Republic of Ethiopia, One WASH National Programme (OWNP) Programme Document, August 2013 18 BBC Media Action. ‘How listening groups are adding value to the Ethiopian Health Development Army and impacting the wider community’http://www.bbc.co.uk/mediaaction/publications-and-resources/research/summaries/africa/ethiopia/listening-groups [online] 19 Mengitsu B et. al,‘Ethiopia and its steps to mobilize resources to achieve 2020 elimination and control goals for neglected tropical diseases: Spider webs joined can tie a lion’, Int Health 2016; 8 (Suppl 1): i34–i52 doi:10.1093/inthealth/ihw007. 20 Sarah V. ‘Ethiopian leaders inspire with empowering messages on WASH for trachoma elimination,’ International Coalition for Trachoma Control (ICTC). 2015:http://www.trachomacoalition.org/news-blogs/ethiopian-leaders-inspire-empowering-messages-wash-trachoma-elimination