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The missing ingredients: Are policy-makers doing enough on water, sanitation and hygiene to end malnutrition?


Summary of report*

Location: Global

What we know: There are many pathways linking poor WASH with undernutrition; how ‘integration’ of WASH and nutrition interventions is defined varies considerably.

What this article adds: An analysis of nutrition and WASH plans and policies in 13 countries found that embedding WASH in nutrition plans and policies varied widely and was largely limited; very few WASH plans referenced nutrition. Lack of budget information prevented cost analysis. Working together should be considered along a continuum, ranging from simple information-sharing and shared targeting through to a more closely integrated and jointly delivered programme. Nutrition and WASH policy-makers share a common vision and goal of improving health that can help bridge inherent differences.

Comprehensive national nutrition plans are critical to detail the mechanisms and systems required to allow more cohesive operations.


Evidence shows that scaling up interventions that tackle the immediate causes of malnutrition is insufficient to overcome the challenge. A more comprehensive ‘recipe’ requiring a mix of ‘ingredients’ from multiple sectors is critical to address both the immediate and underlying causes of malnutrition. 

A report from SHARE (Sanitation and Hygiene Applied Research for Equity) and WaterAid highlights why water, sanitation and hygiene (WASH) are essential for nutrition. An estimated 50% of undernutrition is associated with infections caused by poor WASH, contributing to 860,000 preventable annual deaths in children under five years of age. Evidence from a number of trials and observational studies has identified three biological mechanisms linking WASH to undernutrition, including repeated bouts of diarrhea, intestinal parasitic infections and environmental enteric dysfunction (EED). There may be other important WASH-related social and economic pathways.

Growing evidence of the links between nutrition and WASH has contributed to building momentum for better coordination, collaboration and integration. However, the definitions that different sectors, individuals and organisations use for ‘integration’ vary considerably along a continuum. This ranges from very minimal coordination and collaboration on one side through to a more closely integrated and jointly delivered programme on the other.

Through an analysis of both nutrition and WASH plans and policies in 13 Scaling Up Nutrition (SUN) countries (Bangladesh, Kenya, Liberia, Madagascar, Malawi, Mozambique, Nepal, Rwanda, Sierra Leone, Tanzania, Timor-Leste, Uganda and Zambia), the report evaluates the degree to which national strategies in both ‘sectors’ are integrated. It identifies gaps in coordination and ways of working, and where and how improvements must be made.


Countries selected for analysis were based on SHARE’s focus countries and WaterAid’s country programmes, for which national, multi-sector nutrition action plans or strategies were freely available online. National, multi-sector nutrition action plans were the primary focus of analysis, although national nutrition policies were also reviewed for a comprehensive picture. Pre-defined criteria used for reviewing action plans included:

In addition, a keyword search of nutrition terms1 in the national WASH plans and policies of the 13 countries was conducted to allow for a basic assessment of whether the plans include nutrition considerations.

Key findings

WASH into nutrition varies widely. All the nutrition plans and policies that were analysed recognise the importance of WASH; however, the degree to which WASH is embedded within plans varies significantly across countries in terms of objectives, targets, interventions and indicators (Nepal and Timor-Leste have the strongest plans in terms of embedding WASH components). 

Nutrition into WASH is limited. Very few WASH plans reference nutrition or identify opportunities to integrate with nutrition and health programmes and campaigns (with the exception of Liberia). 

Limited budget information

Of the plans analysed, a detailed budget for activities was not generally included in the same document, limiting the ability to capture the budget for WASH activities. Where budget was available, this was provided at the level of the objectives or priority areas and not by activity; thus a detailed costing analysis was not possible within the scope of this research.

One size does not fit all. There is no single blueprint for how WASH should be embedded in nutrition plans, nor for how WASH programmes can be made more nutrition-sensitive. However, consideration of some key principles and approaches could help drive progress. For example, designing WASH programmes to target populations most vulnerable to nutrition and/or identifying opportunities to integrate activities such as those related to behaviours (e.g. personal and food hygiene and breastfeeding) could result in more joined-up approaches. 

Continuum approach. Working together should be considered along a continuum, with different degrees or approaches to collaboration. This may range from simply sharing information and targeting different programmes to the same populations to a more integrated programme, involving the same staff and a single budget. 

Challenges in working together. Inherent differences in the objectives, outcomes of interest and people involved in delivering nutrition and WASH programmes present a number of challenges to working together. Unlike those responsible for nutrition, the WASH sector is not dependent on nutrition action for achieving its primary objectives. However, both nutrition and WASH policy-makers share a common vision and goal of improving health, and evidence shows that public health aims have been a key driver of investments in WASH, particularly sanitation. Working together can also leverage investments across the two sectors to maximise health impact and improve cost-effectiveness. Plans and policies are a core part of the process of outlining the mechanisms and systems required to allow more cohesive working to advance nutrition and WASH goals.

The report uses findings from the analysis, along with existing evidence and lessons learned to date, to provide insights into the different ways of working to enhance nutrition and WASH coordination and collaboration across different stages of the policy cycle.


According to the report, comprehensive national nutrition plans are a critical first step toward ending malnutrition by 2030, but they must include all three WASH ‘ingredients’. Moreover, these plans should be underpinned by sufficient financing, effective coordination, timely tracking of results and stronger institutions. The report makes specific recommendations on how partners – governments, UN agencies, donors, technical agencies and international NGOs and academics – can play their part to ensure an integrated approach to ending malnutrition.

An infographic on how well water, sanitation and hygiene are integrated into national programmes is available at:



1Agriculture, anaemia, (breast)feeding, food, micro(nutrient) deficiency, nutrition (which also captures ‘malnutrition’ and ‘undernutrition’), stunting, under(weight), wasting.

*The missing ingredients: are policy-makers doing enough on water, sanitation and hygiene to end malnutrition? WaterAid. SHARE, Health Start. August 2016.

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Water Aid (). The missing ingredients: Are policy-makers doing enough on water, sanitation and hygiene to end malnutrition?. Field Exchange 53, November 2016. p56.



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