By Bijan D. Manavizadeh
Imagine a two-year old child is sitting on a three-legged stool. If one or two legs are stronger than the other, the stool would not be stable and the child would be at risk of harm. Yet, if the stool has been properly constructed, with resources to ensure all three legs are strong and secure, then the stool would be durable and the child would be at a reduced risk of harm. The same principle is applicable to key factors of growth and development in early childhood—such as water, sanitation, and hygiene (WASH), nutrition, and early childhood development (ECD).
This metaphor was the crux of the Clean, Fed & Nurtured (CF&N) side session at the George Washington University Global Health Mini-University on March 4. Presentations by CF&N members Merri Weinger (USAID), Monica Woldt (FANTA III), and Julia Rosenbaum (USAID WASHplus) outlined the “why” and the “how” of developing and measuring indicators for integrated global health programs to better promote essential multi-sector collaboration of WASH, nutrition, and ECD.
In the first part of the session, the speakers shared evidence supporting the link between the three sectors of WASH, nutrition, and ECD and promoted cross-sectoral collaboration. In the second part, they addressed integral questions, such as: Which indicators need to be defined? How do we evaluate them? What kind of research is needed to develop more appropriate indicators for successful integration?
As a program officer for the Global Public-Private Partnership for Handwashing, I know the implications that WASH interventions can have on health and development, but I did not know the full extent to which poor WASH practices can inhibit nutrition and ECD. This what I learned and what needs to be done.
What we do know? The first 1,000 days of life—from conception to age two—is the most critical period of cognitive and motor function development in a person’s life. Evidence shows that WASH interventions can prevent diarrhea, which if left untreated can lead to undernutrition and poor physical and cognitive growth. Frequent bouts of diarrhea tend to lead to a reduced appetite and poor absorption of nutrients from the food children do consume. This leads to a vicious cycle. Undernourished children are more susceptible to contracting parasites, viruses, and bacteria that lead to diarrhea. This cycle of diarrhea and undernutrition leads to stunting, which can have lifelong implications as it prevents children from reaching their full potential, both physically and mentally. In the long term, this can lead to negative outcomes in school, in professional settings, and in society.
Why cross-sectoral collaboration? Growing evidence indicates that through integration we can harness synergies. Multifaceted problems need multifaceted solutions. Integration provides the opportunity for streamlining messages and greater efficiency in program delivery. However, there are challenges. Funding, staff motivation and workload, coordination among agencies and organizations are some of the many hurdles that must be overcome. Another hurdle is the lack of common indicators, which inhibit the measurement of program effectiveness.
Why focus on integrated indicators? Properly defined indicators for integration mean that we can learn which interventions worked and which failed to meet expectations. Each of the three sectors represented in CF&N have their own indicators with varying degrees of strength. Indicators that correspond with integrated programs will allow us to better know if our hypothesis—that integrating WASH, nutrition, and ECD will have a greater impact—is correct. We know that indicators developed and utilized must be SMART: specific, measurable, achievable, reliable, and time bound. But, we also know that there is more work to be done. The evidence base for three-way integration is growing, and the development of indicators is a crucial step as we move forward.
How do we move forward? During the second segment of the session at the Mini-University, the audience engaged in a discussion of what is needed to move forward by sharing ideas on ways to identify and develop indicators for integration, as well as methods for overcoming gaps and challenges of delivering integrated interventions.
Increased advocacy with donors is needed, integration must be incorporated at the service delivery level to not overburden families, and a broader range of partners, stakeholders, and implementers must be brought into the conversation. Simply put, more dialogue and a greater emphasis on developing frameworks with indicators that function along a continuum are both needed.
Robust, comprehensive, measurable, and integrated indicators will generate more evidence that will allow us to better hone our work. Ultimately, as the WASH, nutrition, and ECD sectors further collaborate and forge stronger bonds, a broad set of health, nutrition, and child development indicators will be essential to demonstrating impact. Certainly, the challenge is great, but we believe that through our joint efforts we can make a greater impact than we could alone.