Background
The Burden of NTDs and the Link to WASH
Disease | World Health Assembly (WHA) Resolutions and Global Programs |
---|---|
Soil-transmitted helminths (STH) | WHA 54.19 (2001): Goal of a minimum of 75 % of school-aged children receiving regular chemotherapy by 2010; encouraging member states to promote access to safe water, sanitation and health education through inter-sectoral collaboration. |
Schistosomiasis | WHA 54.19 (2001): Goal of a minimum of 75 % of school-aged children receiving regular chemotherapy by 2010; encouraging member states to promote access to safe water, sanitation and health education through inter-sectoral collaboration |
WHA 65.21 (2012): Encouraged member states to provide necessary and sufficient means and resources for water, sanitation, and hygiene interventions in order to achieve elimination. | |
Trachoma | WHA 51.11: Established goal of eliminating blinding trachoma. Includes call for implementation of facial cleanliness and environmental improvements as part of SAFE strategy |
Lymphatic Filariasis | WHA 50.29 (1997): Elimination of LF as a public health problem. Includes a call for increased access to safe water, sanitation, and health education through intersectoral collaboration. |
Global Program to Eliminate LF (GPELF) (2000): Launched to eliminate LF by 2020. Strategy based on interrupting transmission through MDA and alleviating suffering through morbidity management and disability prevention. | |
Guinea Worm | WHA 64.16: Calls on all Member States to expedite the interruption of transmission and enforce nation-wide surveillance to ensure eradication of Guinea World disease. |
Type of Intervention | Specific Intervention | Diseases Impacted |
---|---|---|
Water | Increasing access to sufficient amounts of safe water for personal hygienic purposes (e.g., washing hands, face, or body; bathing; and doing laundry) | Soil-transmitted helminthiasis, Schistosomiasis, Trachoma, Lymphatic Filariasis, Guinea worm disease |
Increasing access to sufficient amounts of safe water for environmental sanitation (e.g., cleaning latrines) | Soil-transmitted helminthiasis, Schistosomiasis, trachoma | |
Increasing access to safe water for drinking/food preparation | Guinea Worm disease, soil-transmitted helminths | |
Monitoring impact of water resource development, waste water management, and sanitation programs on vector breeding levels | Schistosomiasis, Lymphatic Filariasis | |
Sanitation | Reducing open defecation | Soil-transmitted helminthiasis, Schistosomiasis, Trachoma |
Disposing of infant/child feces properly | Soil-transmitted helminthiasis, Schistosomiasis, Trachoma | |
Increasing improved sanitation coverage | Soil-transmitted helminthiasis, Schistosomiasis, Trachoma | |
Promoting maintenance and cleaning of latrines | Soil-transmitted helminthiasis, Schistosomiasis, Trachoma | |
Type of Intervention | WASH Messaging | Diseases Impacted |
Hygiene | Hand washing | Soil-transmitted helminthiasis |
Face washing | Trachoma | |
Wearing shoes outside | Soil-transmitted helminthiasis | |
Daily washing, with soap, of swollen limbs, feet, and between toes to prevent bacterial infections | Lymphatic Filariasis | |
Washing of soiled clothing/bedding | Trachoma | |
Avoiding physical contact with contaminated surface water | Schistosomiasis | |
Use of safe water for bathing, clothes washing, and swimming | Schistosomiasis | |
Avoiding physical contact with or entering bodies of water used for drinking | Guinea Worm disease |
WASH objectives for disease control | Enabling activities | Desired behaviors | NTD-specific outcomes |
---|---|---|---|
Reduced amount of human feces in environment | Construction and maintenance of latrines | Elimination of open defecation practices | Reduced breeding sites for the M. sorbens fly, which spreads trachoma |
Reduced transmission of STH and schistosome eggs | |||
Daily practice of personal and environmental hygiene activities | Increased access to water in homes, schools and communities | Increased daily hand washing behaviors at key times | Elimination of bacteria and eggs from hands |
Behavior change communication | Increased daily face washing | Reduced reservoir of trachoma bacteria transmitted via flies, fingers, and fomites | |
Decreased contact with contaminated surface water bodies | Separation of people from water infested with schistosome parasites | ||
Increased use of safe water for washing clothes, bathing, and swimming | Separation of people from water infested with schistosome parasites | ||
More frequent washing of clothes in safe water | Reduced transfer of trachoma bacteria via dirty fabric | ||
Cleaning and upkeep of latrines | Reduced breeding sites for the M. sorbens fly, which spreads trachoma | ||
Increased washing of lower limbs and feet affected by lymphedema | Removal of dirt and bacteria that can cause skin infections |
Methods
Area of expertise | N ( %) |
---|---|
NTDs | 11 (45 %) |
WASH | 7 (29 %) |
Environmental health | 2 (8 %) |
School health | 2 (8 %) |
Behavior change | 1 (4 %) |
Community health | 1 (4 %) |
Location | |
Headquarters | 16 (66 %) |
Field | 8 (33 %) |
Position | |
Technical advisor | 9 (37 %) |
Operations / Managing director | 9 (37 %) |
Research associate | 2 (8 %) |
Policy analyst | 1 (4 %) |
Program associate | 1 (4 %) |
Program manager | 1 (4 %) |
WASH/NTD coordinator | 1 (4 %) |
Ethics statement
Results
Barriers
Barriers | N ( %) |
---|---|
Different Programmatic Objectives | 17 (71 %) |
Indicators and Metrics | 14 (58 %) |
Over Emphasis on MDAs | 12 (50 %) |
Funding Discrepancies | 11 (46 %) |
Coordination & Information Sharing, Lack of | 10 (42 %) |
Siloed Funding | 10 (42 %) |
Evidence Base, Lack of | 9 (38 %) |
Timeline Discrepancies | 9 (38 %) |
Behavior Change | 8 (33 %) |
Joint Mapping, Lack of | 7 (29 %) |
Ministerial Coordination, Lack of | 7 (29 %) |
Political Will, Lack of | 7 (29 %) |
Ill Committed Partnerships | 5 (20 %) |
Government Ownership, Lack of | 4 (17 %) |
Difference in Results Timelines Between Sectors | 3 (13 %) |
Joint Messaging, Lack of | 3 (13 %) |
Differing programmatic objectives
Participant 23: That is a challenge, the WASH organizations have their own objectives, they have their own donor goals.
Participant 16: It’s clear how WASH is important to the NTD community, but the issue is making NTDs a priority to the WASH community.
Participant 24: They are sectors that come from very different backgrounds, water and sanitation being very much based in engineering and ourselves being based in more of a biology-medicine area. I think that actually working across sectors and really understanding the motivations of different programs is quite challenging. And I think we perhaps underestimate the kind of work you have to do to create meaningful relationships and collaborations.
Indicators and metrics
Participant 12: WASH organizations usually don’t measure health indicators.
Participant 7: WASH interventions are the most sustainable way to prevent NTDs. It’s the work they are already doing; they are just not evaluating the impact of that work on NTD outcomes, which is a great lost opportunity.
Participant 9: I agree that metrics are probably the biggest hang-up and probably the most difficult conversation to have, not because it’s sort of a question of intractable differences between the two sides in that respect, but more just what would those shared metrics be and how would you find a common metric between them?
Participant 10: It’s really hard to come up with an integrated indicator.
Participant 13: The NTD community needs to do a better job of defining those indicators and also making them practical for other sectors to access and understand.
Over-emphasis on mass drug administration
Participant 3: I think the big challenge within the whole NTD sector is that until fairly recently all you would hear about in these meetings is preventive chemotherapy. Again it sort of goes in the sense that a lot of public health is overseen by medically trained people and the idea of giving medication is right up their alley, they understand it better, it's reinforced by donors like USAID, and its much easier to say that X number of tablets were distributed than looking at some of the more difficult aspects to define, like behavior change.
Participant 19: We need to make sure that WASH is part of the overall plan for NTD elimination in a country, and we need to move away from thinking of NTD programs just as Mass Drug Administration programs.
Participant 15: Integration needs to be more than just collaborating MDAs with multiple drugs.
Participant 3: I think in a nutshell one of the major problems we’ve had is that we’ve been taking a very medical approach to very much a public health problem… and not looking at those elements that are really going to sustain the progress we’ve made through the preventive chemotherapy.
Funding
Participant 23: WASH is very, very resource intensive.
Participant 21: Disparities in budget in WASH projects versus NTD projects make it difficult for both sectors to work together in a specific location.
Participant 11: We get money for Neglected Tropical Diseases, we don’t get money to build toilets. That’s not our mandate. So we coordinate with people that build toilets, but that’s not the same as having our own money to build toilets, which means we can’t really have comprehensive programs on the ground.
Participant 1: You see because the thing is that’s why this is an interesting topic, this whole WASH and NTD integration because its not easy, and one of the problems that we have is, you know, very specific funds. We get funds from Congress to do very specific things.
Lack of coordination and information sharing
Participant 6: We’re not doing any mapping or targeting between those two initiatives. With our pharma procurement we’re not looking at the countries where we have significant WASH programming and trying to build that investment on top of that programming, which is again a huge lost opportunity.
Participant 7: We are procuring a tremendous quantity of deworming medication…and distributing that with our Ministry of Health partners, but as an investment it is not being purposely leveraged together with our WASH programming.
Participant 21: In terms of countries and areas [within countries] that are highly endemic, we don’t necessarily always match up with areas that have been targeted for prioritization of infrastructure and water and sanitation projects by other organizations, which is a huge barrier.
Participant 15: So something needs to change higher up and when I say higher up it includes the big aid agencies, it includes the pharma companies, it includes foundations, it includes everybody.
Ideal conditions
Ideal conditions | N ( %) |
---|---|
Educational Advocacy | 17 (71 %) |
Joint Indicators | 13 (54 %) |
Ministerial Involvement | 12 (50 %) |
Integrated Strategy Development | 12 (50 %) |
Task Force or Committed Partnership | 12 (50 %) |
Donor Environment for Funding Integration | 12 (50 %) |
Appropriate Programmatic & Results Timelines | 11 (46 %) |
Government Ownership | 11 (46 %) |
Information Sharing & Message Integration | 11 (46 %) |
Program Design Integration | 11 (46 %) |
School Curriculum Integration | 11 (46 %) |
Evidence-based Best Practices | 10 (42 %) |
Joint Mapping | 9 (38 %) |
Funding Advocacy | 8 (33 %) |
Geographic Overlap Targeting | 8 (33 %) |
Linking NTDs & WASH to Nutrition | 7 (29 %) |
Educational advocacy
Participant 10: WASH, especially sanitation, and NTD sectors are both neglected issues that usually include the same demographic and same population so there is a lot of incentive for both sectors to come together.
Participant 13: I think that honing in on the fact that we’re all working to improve the health and lives of the same communities, essentially…so it’s improving those communication channels, awareness levels and knowledge and information sharing across the sectors. I think we’re seeing success with this and we should continue to build on that.
Participant 7: Really I think for us to be most successful with this integration our WASH implementers and people involved in the design of our WASH programs need a greater understanding of the NTD issues and NTD indicators need to be standardized in our WASH log frames.
Participant 22: We need to engage them. We need to make them feel that what they are contributing is really valuable.
Joint indicators
Participant 19: I don’t think we’ve gotten our messaging right. We’ve never given a convincing case to the WASH sector about why they should be looking at these diseases. I’m not a WASH expert, but I believe that they are really looking at things like access to water, improved hygiene, and the general impact on health rather than looking at indicators specific to disease, and I think that one of the reasons why the trachoma and broader NTD communities have found it difficult to work with them.
Participant 24: For the water sector their measure of impact have been primarily focused on coverage rather than utilization, and also very few use health markers and if they do they often focus on diarrheal disease rather than NTDs so I think we have some sort of advocacy work there to do to try to convey that actually measuring NTDs as an output or indicator of effective sanitation is very useful.
Participant 5: NTD and WASH programs need to be designed and evaluated simultaneously. So you can call it a WASH program, but NTDs need to be integrated at each step of the way.
Participant 7: NTD indicators need to be standardized into WASH log frames, and WASH issues should be standardized into NTD programming.
Participant 13: We’re looking to the WASH community as well to help us to identify what would be the most useful indicators that both sectors could use, and that we’re not collecting data that is only useful to one side or the other. I think it’s important for us to hone in on what those joint indicators would look like.
Ministerial involvement
Participant 17: Ministers on the ground really need to facilitate with each other better.
Participant 11: Sometimes it’s kind of like none the two shall meet, they don’t even know where the other person’s office is so then you’re kind of starting from zero.
Participant 11: In some of our countries, the Ministry of Health, the Ministry of Education and the WASH department are totally different, but they know each other and they work together on a regular basis. Those are the places where putting a little more effort would have the biggest impact because they already are coordinating. Those are the places that have the biggest potential for integration and success.
Participant 10: School based programs that include hygiene education, pill distribution and behavior change efforts are really ideal, but this brings up the issue of being able to coordinate with the Ministry of Education along with the Ministries of Health and Water.
Integrated strategy development
Participant 15: If we’re talking about integration and the need for it to happen across the board for NTDs then having something like the SAFE strategy for other NTDs would be a good starting point even though it won’t solve everything it at least it brings people together.
Participant 13: There needs to be specific articulation of how and why NTD prevention should include WASH; this is why they trachoma community has the upper hand compared to the STH community.
Task force or committed partnerships
Participant 10: The people that were working together to run those programs know each other very well and they are working in the same communities, so its very easy [for them] to see their shared objectives.
Participant 2: Time and financial commitments [between partners] should be very equal.
Donor environment for funding integration
Participant 14: Even if integration is the ideal in order to reach that ultimate goal and common vision of ‘disease free communities’ 2 it is from a practical standpoint not even possible until there’s a larger commitment among donors.
Participant 14: A lot of it really goes back to donors and governments driving that integration in the first place, driving both goals at once.
Participant 22: In most countries these neglected tropical diseases are diseases of marginalized people are not on the highest agenda of the government. Even though they are really, really ugly diseases that cause people to lose their dignity they are not really killing people like malaria and HIV and TB so government tends to put more emphasis on those.