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Combining WASH and nutrition activities within a multisectoral package to improve young children’s diets and reduce child stunting in Sindh province, Pakistan

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Dr Sahib Jan Badar is the Programme Coordinator of the Accelerated Action Plan, Department of Health, Government of Sindh province.

Eric Alain Ategbo (PhD Nutrition) is Chief, Nutrition, UNICEF Pakistan.

Thewodros Mulugeta is Chief, WASH, UNICEF Pakistan.

Dr Saba Shuja is a medical doctor and Nutrition Officer with UNICEF, Pakistan. 

Dr Wisal Khan is a medical doctor and Nutrition Specialist with UNICEF, Pakistan. 

Ziggy Kugedera is a Knowledge Management Specialist, WASH, UNICEF Pakistan.

Dr Umar Khan is a medical doctor and Nutrition Specialist with UNICEF, Pakistan. 

Introduction

The province of Sindh, located in the southeast of Pakistan, has one of the highest prevalences of stunting (45%) in children under five years old in the country. It also has considerable differences in stunting prevalence between districts, ranging from 60% in Tharparkar district to 29% in Karachi Central district¹. Moreover, 23% of children under five years old are wasted¹. 

Key drivers of stunting and wasting in Sindh province include poor infant and young child feeding (IYCF) and hygiene practices, and inadequate access to improved water and sanitation facilities. Only 29% of infants aged less than six months in Sindh are exclusively breastfed and just 18% of children aged 6-23 months are fed a minimum acceptable diet². The water, sanitation and hygiene (WASH) conditions in the province are the poorest in the country. Just 36% of households have access to both improved water and sanitation facilities; fewer than half of mothers or caregivers have knowledge about safe disposal of child faeces; and only 60% report practicing hand washing after handling a child’s faeces and before feeding a child³.

Addressing these challenges requires alignment of policies and programme actions across the sectors responsible for interventions to improve IYCF practice and WASH conditions so that they support the integration of services by targeting the same communities, households and individuals at greatest risk of stunting and wasting. To this end, Sindh province was selected by the Government of Pakistan to implement the Maternal and Child Stunting Reduction Programme (MCSRP, 2015-2018) in three districts with high stunting prevalence, those of Ghotki, Khairpur and Nowshero Feroz districts. This large-scale multi-sector programme was designed to improve the nutritional status of women and children across the 1000 days between conception and a child’s second birthday. Programme objectives were to strengthen the enabling environment to improve awareness of and access to nutrition services delivered by the health system and WASH services in the target communities.

This article describes how joint WASH and IYCF interventions were first integrated in Sindh province in the MCSRP between 2015-2018, then scaled up by the provincial Government of Sindh, with UNICEF support, across both the health and WASH sectors under a large-scale Accelerated Action Plan (AAP) to tackle multiple underlying causes of stunting.

Planning and implementing a multi-sector response

The MCSRP was jointly planned and implemented collaboratively by the Department of Health (the Maternal Nutrition and Child Health Programme, the Nutrition Support Programme for treatment of severe acute malnutrition, and the Lady Health Worker Programme⁴) and the Planning and Development Board of the Government of Sindh. 

The Provincial Nutrition Steering Committee and the District Coordination Committee provided the overall leadership for planning and implementation. These structures are now provincial multi-sector government coordination platforms that include representatives of eight sectors or line departments and civil society organisation partners.

To facilitate integration of nutrition and WASH services in the target areas, a joint WASH and nutrition action plan was developed for 2015-2018 to cover all three districts covered by the programme. This plan identified the points of integration and included joint micro-planning at district, taluka (sub-district) and union council level as well as joint monitoring. 

Optimising service delivery packages – health and WASH system interventions

The health system in Sindh province has delivery platforms that reach pregnant and breastfeeding women and children under two years of age at both health facility and community level. However, prior to the MCSRP, these platforms were not used effectively in the targeted districts to inform and counsel women and other caregivers on IYCF and WASH practices. Meanwhile, the potential of WASH to support healthy growth and development was not fully realised. WASH has a critical role in ensuring access to safe food, water and clean environments in the promotion of hygiene practices, including during food preparation and the feeding of young children. These actions can help ensure that complementary foods are free of pathogens and are fed safely to the child, thereby preventing against loss of precious nutrients due to WASH-related infections. 

To address these gaps, the programme developed a social and behaviour change communication (SBCC) strategy that combined community engagement, group and individual counselling and mass media approaches to inform and counsel caregivers and other influential community members on breastfeeding, complementary feeding and WASH practices. The strategy was based on formative research conducted in all three districts, and education/counselling job aids and tools were developed.

Training frontline workers to deliver WASH and nutrition

Frontline workers, including Lady Health Workers (LHWs) and Community Resource Persons (CRPs) were trained on IYCF and WASH using ‘stunting reduction’ training modules. Training involved a mix of skills, such as technical knowledge and counselling skills to facilitate community engagement and support groups. The LHWs and CRPs used a range of community-based platforms to inform and counsel caregivers, including mother-to-mother and father-to-father support groups. Key messages focused on what, when and how to feed children, hand washing with soap and safe disposal of a child’s faeces. Across all these platforms, special attention was paid to ensuring consistent messaging and the reinforcement of key messages. 

Identifying common touch points

A first step in the community-based approach was a mapping exercise to identify common contact/touch points for nutrition and WASH at community and household level, so that the community was approached in an integrated manner: through individuals (LHWs and CRPs) and institutions (health facilities and schools). The programme’s outreach component was further strengthened through the formation of village-based structures (village WASH and health committees and mother-to-mother and father-to-father support groups) for sustained awareness and communication efforts. As a result, members of the community were empowered to raise their voices, and this helped in generating demand for nutrition and WASH services, as evidenced by monitoring and evaluation (M&E) of the programme, including qualitative data from interviews with community members and monitoring of SBCC. The creation of action plans to facilitate joint activities and District Coordination Committees to improve coordination at the district level was another bottom-up approach to strengthen synergies between nutrition and WASH. 

Strengthening the WASH component

In addition to the SBCC actions on WASH behaviours that were integrated with the promotion and support of IYCF, the WASH sector focused on maintaining an adequate water supply, in terms of both quality and quantity; improving sanitation through community-based approaches for ‘total sanitation’ that seek to eliminate the practice of open defecation; and built on the capacity of service providers (mainly CRPs) to counsel on improvement in hygiene practices, such as handwashing etc. Policies and plans such as the Sindh Government’s WASH sector master plan and the Safe Drinking Water Policy and Sanitation Policy were developed under the leadership of the provincial government, with technical support from UNICEF, to underpin the programme. 

Joint reporting on WASH and nutrition

Both WASH and health/nutrition sectors had been collecting data separately in a primary data tool and then sending the data to the provincial level. The creation of an integrated database provided an opportunity for joint reporting on the main programme indicators across nutrition and WASH. 

Nutrition-specific interventions (including IYCF counselling) in the MCRSP programme reached a total target population of 646,590⁵. This included 334,443 children under two years of age, 178,370 pregnant and lactating women, and 133,777 women of reproductive age. A total target population of 800,000 people in all three districts benefited from improved sanitation and hygiene and 480,000 people benefited from sustainable water supplies.

Strengthening sustainability of convergent and integrated efforts through enhanced Provincial Government ownership 

Since completion of the MCSRP in 2018, the Government of Sindh has continued to integrate WASH-nutrition programming into its Accelerated Action Plan (AAP) to address malnutrition in the province, and has plans to expand the coverage of multi-sectoral interventions by 2026⁶. WASH-nutrition interventions have been scaled up from the initial three districts in the MCSRP to an additional 23 AAP-targeted districts with high burdens of malnutrition. The original programme’s model of creating a District Coordination Committee for WASH-nutrition interventions has now been replicated by the provincial government in all of the AAP districts. WASH-nutrition SBCC elements are now incorporated into the revised manual for LHWs to strengthen their role in nutrition and WASH programming. An integrated database for monitoring WASH and nutrition indicators within the multisectoral M&E framework has been adopted and implemented by the Government of Sindh to promote greater monitoring and accountability.  

The cost of the initial joint WASH-nutrition programme implementation between 2015-2018 was USD 20 million with funding from the United States Agency for International Development (USAID). However, since the launch of the AAP in 2018, the Government of Sindh has taken ownership and responsibility for funding of multi-sectoral programming, ensuring sustainability of the WASH-nutrition approach as it is scaled up in the province. 

Challenges and lessons learned

Collaboration between government, various sectors and civil society is crucial to the successful implementation of activities. However, identifying key implementing partners from multiple sectors and non-governmental organisations was time-consuming and took longer than originally anticipated. Lessons learned include ensuring the functioning of a coordination forum at provincial and district level prior to implementing an integrated programme. 

Limited implementing-partner capacity to plan and implement multi-sector interventions and employing multiple partners also had cost implications and created coordination challenges. The under-representation of women in district-level coordination committees was a further issue, with only around 15% of them attending the meetings. 

Next steps 

Implementation of integrated WASH and nutrition interventions is new in Pakistan, and findings from the Sindh programme evaluation will be crucial in informing inter-provincial learning to bring out the synergistic benefits of integration. Process documentation and rigorous costing of ongoing projects in Sindh (such as the APP) are planned to inform the process of moving to a larger scale. 

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Dr Sahib Jan Badar, Eric Alain Ategbo, Dr Saba Shuja, Dr Wisal Khan, Dr Umar Khan (). Combining WASH and nutrition activities within a multisectoral package to improve young children’s diets and reduce child stunting in Sindh province, Pakistan. Nutrition Exchange Asia 2, June 2020. p19. www.ennonline.net/nex/southasia/2/pakistansindh

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