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Research on multi-sectoral programming: reflections on a cash and WASH, nutrition integrated approach

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Some time ago I had the opportunity to attend a regional event for sharing multi-sectoral nutrition approaches, organized by ACF and its partners in Dakar, Senegal. This meeting was organised to share results of the "Research on Food Assistance for Nutrition Impact" (REFANI) study conducted in Niger in 2015. Apart from the Niger’s study, the REFANI Project was also conducted in Pakistan and Somalia by a consortium of partners who aimed to evaluate the impact of cash transfers and its impact pathway on the prevention of wasting in these countries. ENN was responsible (with the implementing partner ACF) for the study in Pakistan where we implemented a four-arm randomised control trial published here. The REFANI Pakistan study was amongst the first showing a reduced risk of wasting from a cash transfer programme in an area with very high levels of wasting. Interestingly, ENN also found significant reductions in stunting. At the Dakar meeting, attended by governmental and non-governmental institutions, United Nations agencies, research institutions and private companies, presentations focussed on cash and WASH impacts on nutrition as follows:

  1. Distribution of cash transfers for the prevention of malnutrition.
  2. Distribution of cash transfer during the first 1000 days.
  3. Water Sanitation and Hygiene (WASH) and nutrition Integration for improving nutritional status.

Some of the studies on the impact of cash transfer programme presented have demonstrated mixed results for reducing child undernutrition and have mainly shown improved dietary diversity as the main outcome: Mam’out project evaluation; Community Nutrition and Health Program in Kayes; the REFANI study in Niger. The Niger study did not report an effect on wasting and raised questions for participants about the likely impact of cash transfer interventions and whether, impact can be improved when combined with other interventions.

The second theme of this one day event, which concerned the impact of WASH on nutrition was of particular interest to me. The results presented during this panel showed some interesting outcomes when WASH and nutrition interventions are integrated.  

Three studies were presented

  1. Assessing the effectiveness of adding a household WASH component to the standard outpatient treatment for severe acute malnutrition (SAM).
  2. Integrating WASH and nutrition programming in field offices: WASH’Nut manual
  3. Acute malnutrition, livestock and hygiene practices around the water chain in eastern chad.

Assessing the effectiveness of adding a WASH component to the outpatient treatment of SAM

The effectiveness of adding a household WASH component to the standard treatment of SAM was studied in two districts of the Kanem region of Chad. The aim was to verify whether the "WASH in Nut" strategy, had the desired impact on nutrition outcomes. This intervention consisted of the distribution of a WASH kit (chlorine, soap, home water storage container) to caretakers of children admitted into the outpatient SAM treatment centres as well as hygiene messages. An intervention group receiving SAM treatment and the WASH kit were compared to a control group receiving only SAM treatment. This study found that the distribution of the WASH kit helped to reduce episodes of diarrhoea in the intervention group, it also reduced the non-responder rate in SAM treatment and improved cure rates. It definitely seems advisable to add a WASH package to SAM treatment programmes, especially in areas with high default and diarrhoea rates.

Acute malnutrition, livestock and hygiene practices around the water chain in Eastern Chad

An intervention implemented by Concern Worldwide called "Community Resilience to Acute Malnutrition" (CRAM), comprises 3 element Nutrition and Health; WASH and Food, Revenue and Markets (FRM). A multi-sectoral intervention package (Agriculture, WASH, Health system support, behaviour change communication, gender equality) was implemented in a group of 35 treatment villages and compared to a group of 34 control villages. The WASH intervention consisted essentially of separating water sources for humans and animals. Before the intervention, the animals (cattle) drank at the same wells as members of the community. The intervention made it possible to separate wells for the animals and wells used for drinking water, and to create better hygienic conditions for the members of the community. This intervention, which lasted from 2012 to 2016, had a significant impact on the nutritional status of the targeted population. Indeed, the rate of wasting and stunting remained stationary in the treatment groups, while they increased in the control groups. The combined WASH and nutrition approach had had more impact than nutrition intervention alone. This result confirms the effectiveness of the integrated approaches but also, provides a better understanding of the impact mechanism of this approach.

This meeting highlighted the importance of a multi-sectoral approach to reducing child wasting and stunting.  We heard how health centres treating SAM can improve their outcomes by integrating WASH components and beyond this, how nutrition actors need put in place multi-sectoral approaches for the prevention and treatment of undernutrition. While these approaches are more promising and are widely accepted by countries and implementing actors, they are often not well supported by donors. As technical experts, it can be seen that there is no problem in undertaking a multi-sectoral approach. But for donors, we need to be much clearer about how these multi-sectoral programmes should be designed, as this is not always obvious. There is a large knowledge gap around multi-sector programming i.e. what is the best way to implement such programmes? How to be the most cost and resource effective and how to achieve the greatest impact. This is the challenge for all of us working in this area.