SuSanA - Forum Kunena Site Syndication Tue, 01 Sep 2015 20:16:20 +0000 Kunena 1.6 SuSanA - Forum en-gb Re: No evidence that this sanitation programme in rural Odisha prevented diarrhoea, soil-transmitted helminth infection, or child malnutrition (study led by Emory University) - by: joeturner
I'm not sure this is saying much that the other report didn't say, but it is quite shocking that the presence of latrines has no particular effect on the diarrhea and helminth infection - even when latrines coverage changed from 9 to 63% of households.

With that big an engineering intervention, one would have expected some measurable change. ]]>
Health issues and connections with sanitation Fri, 28 Aug 2015 16:38:25 +0000
Re: New Lancet study concludes no assumed improvement from TSC (Total Sanitation Campaign, in Odisha, India) - by: muench
This has been an interesting thread which is closely related to another thread called:
"The elusive effect of water and sanitation on the global burden of disease":

(one could even think about merging the two threads but maybe it's better to keep this one separate as it started off with a very specific piece of research in Orissa - I have adjusted the thread title to make it clear what the starting point of the thread was)

I was brought back to this thread today by seeing another publication coming out from the same research team:

Does building more toilets stop the spread of disease? Impact evidence from India

A 3ie-funded impact evaluation research team used a cluster-randomised controlled trial to evaluate the government’s Total Sanitation Campaign in Odisha, India to see if latrine coverage did indeed reduce exposure to disease. The intervention mobilised households in villages characterised by high levels of open defecation to build and use latrines. The study was conducted between May 2010 and December 2013, involving more than 50,000 individuals in 100 villages.

Key policy messages

The study results show that the assumption that more latrines will reduce exposure to faecal pathogens, and therefore disease, does not necessarily hold true.
During the study period, latrine coverage in the intervention villages increased from 9 per cent of households to 63 per cent, compared to an increase from 8 per cent to 12 per cent in the control villages.

The increase in latrine coverage did not prevent diarrhoea or reduce soil-transmitted helminth infection in the intervention villages. The seven-day prevalence of reported diarrhoea in children younger than 5 years was 8.8 percent in the intervention group and 9.1 percent in the control group.

This research was also co-funded by the Bill & Melinda Gates Foundation and you find it here in our project database together with some links:

One of the links takes you to the SuSanA library entry for this project:

Here you find a presentation from January which I find useful and easy to read:

Two very important slides towards the end:

As the Gates grant still goes until 2017 (and perhaps they have more funding from other sources, too), it will be very interesting to see what else is discovered there. Wondering what is meant with "Gram Vikas evaluation"? Gram Vikas is explained here: **

In a way, it is (in hindsight) not really so surprising that just building toilets alone (even if they are used consistently, which they may not), is insufficient to have much of an impact on health indicators.* I guess it should always be coupled with other hygiene measures (e.g. handwashing, dealing with animal faeces in the sourroundings) as well, and probably also with mass deworming.

Kind regards,

* Makes me think of Peter Harvey's question at the WEDC conference to the audience at his keynote: "Even if it was proven that having a toilet has no health benefits whatsoever, would you give up your toilet tomorrow?" - No!

** "Gram Vikas is an Indian non-governmental organization based in Orissa, and founded in 1979.[1] It uses common concerns for water and sanitation to unite and empower rural communities, including adivasi communities."]]>
Health issues and connections with sanitation Fri, 28 Aug 2015 16:21:19 +0000
Re: Link between poor sanitation and higher risk of Adverse Pregnancy Outcome - by: Gendersan1
As we are working on related research interests(see "Genderized WASH" Eaawag/Sandec;
"WASH in the context of maternal health and menstrual hygiene in Uganda and India", this is of special interest to us and proves once more the importance of the connections between sanitation and maternal health.

Petra Kohler]]>
Health issues and connections with sanitation Mon, 24 Aug 2015 13:24:37 +0000
Appeal to SuSanA members for input - by: karobb
A. Suggestions about where we can deploy the SaniPath Rapid Assessment Tool?
We're looking for 1) partners working at the city level interested in deploying tool to inform sanitation interventions, 2) partners who can use this type of data to inform their work, and 3) institutions that would be good candidates to learn to use the tool.

B. Suggestions for candidates for the advisory committee?
We're are in the process of assembling an international advisory committee that can provide input on the following questions:
1) What are the greatest challenges facing sanitation decision makers?
2) What scale are decision makers most interested in (city vs. neighborhood level)?
3) How can we best engage potential users of the tool?
4) How can we best convey risk results visually?
5) How can we facilitate the translation of the tool recommendations into actionable interventions.

We welcome and thank you for your input!]]>
Health issues and connections with sanitation Mon, 24 Aug 2015 11:18:23 +0000
Re: The elusive effect of water and sanitation on the global burden of disease - by: muench
Right now we have a big debate going on about mass deworming and its long term health benefits (also difficult to prove with randomized controlled trials, which are supposedly - but maybe not - the gold standard in evaluating health benefits). This is the topic of this thread here:

Coming back to the more general question, I wanted to point out a keynote presentation by Peter Harvey (UNICEF) at the recent WEDC conference which was a real conference highlight for me (and - going by the number of tweets - also a highlight for many others at the conference).

Invited Speaker: Peter Harvey
WASH, Nutrition and Health: A futile quest for evidence?

Peter is Regional Adviser - Water, Sanitation and Hygiene
UNICEF, Eastern and Southern Africa Regional Office
Nairobi, Kenya

Peter has kindly made his presentation available for sharing here:

These two slides caught my particular attention:

Very interesting account of UNCIEF's path with regards to WASH since 1946:

Clearer image:

Limitations to randomized controlled trials (slide 11):

The references that he mentioned on this slide are:

Robert William Sanson-Fisher, Billie Bonevski, Lawrence W. Green, Cate D’Este, Limitations of the Randomized Controlled Trial in Evaluating Population-Based Health Interventions. American Journal of Preventive Medicine Volume 33, Issue 2 , Pages 155-161 , August 2007

Porzsolt, F., Kliemt, H., Ethical and empirical limitations of randomized controlled trials Med Klin (Munich). 2008 Dec 15;103(12):836-42. doi: 10.1007/s00063-008-1132-x


Some points from my notes:
  1. At UNICEF, WASH has always been looked at from a child health perspective... We know that health has an important connection with WASH but there is more to it. It's not (only) about health, it's about burden and convenience as well (Peter asked: "would you give up your toilet tomorrow if someone told you that it had no health benefits?" No!). There are also the human rights aspects.
  2. In the 2014-2017 Strategic Plan, WASH is included and one new element is the link with nutrition
  3. How is evidence applied: Donor priorities, organizational priorities, implementation strategies, geographical targeting

Some tweets that were made py participants during his presentation:

Stephen Jones ‏@stephen_djones 30. Juli
#WASH & nut evidence has implications for donor priorities, geog targeting, units of intervention - Harvey #wedc38

Susan Davis ‏@improve_intl 30. Juli
Harvey:Why do we need to talk about links of #WASH to health? #wedc38

Stephen Jones ‏@stephen_djones 30. Juli
Need to distinguish btwn evidence 4 benefits of #Wash on health & evidence for diff approaches to achieve #WASH + health #wedc38

Stephen Jones ‏@stephen_djones 30. Juli
Harvey: non-health #WASH benefits can be at least as important, or more, but hard to quantify - Harvey #wedc38

Susan Davis ‏@improve_intl 30. Juli
Harvey: #water is a fundamental right, nothing about health, about burden & convenience #wedc38

Cheryl ‏@Cheryl_McD 30. Juli
Peter Harvey @UNICEF - tackling SDG 6 on #WASH will help achieve the other SDGs #WEDC38

Susan Davis ‏@improve_intl 30. Juli
Harvey: sustainability of #water & #sanitation services is an important part of rights based approach #wedc38


If you have comments or questions about Peter's presentation, please put them here. I will alert him to them.

Health issues and connections with sanitation Mon, 17 Aug 2015 15:38:24 +0000
Re: Sanitation in Hospitals - WASH in Health Care Facilities for better health care services (WHO report) - by: RobynChristine
The Soapbox Collaborative is an evidence-based charity focused on improving hygiene practices around childbirth in low and middle income countries. A colleague of mine at WaterAid working on Health started working with them when common goals, yet different and complementing value adds / skills were identified. The rationale for bridging Soapbox's research capacity with WaterAid's policy and programming capacity was strong.

You can find more reading materials on the project here. The main report I wanted to direct you to just recently had to be taken offline for an amend but will be made available again soon. I didn't work on developing the toolkit so I am probably not best suited to field many questions on methodology. I can say though that the tools used in Zanzibar were adapted from the original tools developed for use in India (you can download the toolkit for use here).There may be a case for adapting existing tools as needed. I think soapbox intends to develop some recommendations around how this can be done. As I get more information for sharing externally I will let you know.

So why Zanzibar - The government of Zanzibar had prioritised improvements in maternal and newborn health, which really facilitated and supported this work. The ministry of Health was fully engaged in the project. This, coupled with us having access through our WaterAid Tanzania office contributed to the decision for working in Zanzibar.

As I mentioned, at WaterAid we are just starting to explore our role in healthcare settings. We recently had a webinar series to discuss this. In discussions we identified some potential next steps for starting to develop policy and programming capacity in healthcare settings. One ask coming from country programmes was to develop an inventory of existing tools. I think as we increase our capacity and policy / programming in healthcare settings we will develop a better understanding of how to get available tools routinely used. I suspect it will be largely context driven, and will require comprehensive and collaborative efforts ... and political prioritization.]]>
Health issues and connections with sanitation Tue, 11 Aug 2015 14:57:39 +0000
Link between poor sanitation and higher risk of Adverse Pregnancy Outcome - by: jbr
Has anyone seen this publication?

Padhi BK, Baker KK, Dutta A, Cumming O,Freeman MC, Satpathy R, et al:
Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study.

PLoS Med 12(7): e1001851. doi:10.1371/journal.pmed.1001851

Landmark in that it seems to be the first evidence that poor sanitation is linked to a higher risk of APO (Adverse Pregnancy Outcome).

Best regards,
John Brogan
Terre des hommes]]>
Health issues and connections with sanitation Tue, 28 Jul 2015 08:59:33 +0000
Re: WASH awareness and practice among health staff in PHCs (primary health centres) - by: joeturner

I don't think they looked at sanitation systems, but they concluded that half of the surveyed facilities lacked on-site water to wash hands and none had it available 24 h a day.]]>
Health issues and connections with sanitation Tue, 23 Jun 2015 13:58:37 +0000
Re: WASH awareness and practice among health staff in PHCs (primary health centres) - by: JKMakowka
But regarding the issues you raised: I was told that here in the Philippines health care staff turnover and absenteeism is a big problem for PHCs as nurses and other health professionals can easily find much better paid jobs abroad.]]>
Health issues and connections with sanitation Tue, 23 Jun 2015 13:22:41 +0000
WASH awareness and practice among health staff in PHCs (primary health centres) - by: samanthaswasti Hello! This is my first post on the SuSanA forum. Thank you for having me! I am currently an intern with Swasti in Bangalore, and my focus is on WaSH, specifically sanitation attitudes and sustainable technologies. I have posted a piece written by one of our staff members sharing his experience with health care professionals in primary health centres (PHCs). I look forward to this learning experience!

The promotion of institutional deliveries and funds allocated for the improvement of working and infrastructure of PHCs under the strategies of the National Rural Health Mission is not uniform for all PHCs. Many facilities are ill equipped to promote maternal and child health care. After delivery, many mothers and newborns leave the hospital with an Hospital Acquired Infection (HAI). HAIs result in illness, deaths and high treatment costs. HAIs relate directly to the water, sanitation and hygiene (WASH) situation in the PHCs.

Awareness and practices
Labour rooms in the PHCs ranged from clean and well-equipped to rusty labour tables and unclean floors. In one observation, there was a tray with clots and bloodied cotton piled on the side of the toilet from a delivery conducted the previous night. Labour room toilets at certain PHCs were locked, used for storage or were only available for staff, which made it difficult for patients to access toilets. In many of the hospitals, disposal of grey water was inadequate. Rubber sheets used over the labour table were washed in the toilet used by patients. The staff was unaware how these ‘unrelated’ situations could be connected to high morbidity and mortality among mothers and newborns.
The probability of infection transfer within the wards was high due to the lack of rules or guidelines to clean the hospital. There was a clear lack of awareness about how often the ward, labour room, or other parts of the hospital should be cleaned. There was little knowledge about the required concentration of cleaning solutions and correct materials to be used for cleaning. The same broom, mop, or cloth would be used to clean the toilet and wards in some facilities, thereby transferring infections from one place to another, rendering cleaning ineffective. Patients in the wards were mostly examined without washing hands. Since hand wash basins were situated in labour rooms or OPDs, the practice of hand washing was limited only to activities such as conducting deliveries.
Dumping of waste was observed at many PHCs on the compound (especially behind the building). The waste included needles, drip sets, medicine wrappers and sanitary napkins. Such practices were observed even when the PHCs had the correct infrastructure and sufficient staff.

Attitudes of staff at PHCs
In one of the facilities we observed, a tray with the placenta was kept in the labour room for more than 24 hours after the delivery. In contrast, there were some good exceptions; in one PHC the staff was enthusiastic about their work and the PHC had a clean ward and labour room, equipment was well arranged and the compound was clean. The difference between these hospitals is the attitude of the people who worked there. In PHCs with proactive medical officers, the staff had a positive attitude and the hospitals were clean. Conversely, hospitals with little staff or those where the staff was listless and unwilling to take initiatives were unkempt and unclean.
Lack of positive attitude towards one’s own work translated into incorrect practices and gaps in the quality of services. In addition, certain practices could be attributed to the ignorance of the staff, such as garbage littered around water sources, which may be due to lack of understanding about contamination of the water sources.

Reasons for bad practices and attitude of staff in PHCs
Inadequate staff affected the functioning of the PHCs and left little time and resources dedicated to sanitation and infection control at the hospital. As the staff struggled to complete the mandatory services provided, they tended to skip those which they did not value much or did not need to send reports for, skipping these tasks caused insufficient hygiene and sanitation. Lack of knowledge and awareness in WASH created gaps in following correct procedures and safety measures. As a result, there was no ownership, indifference towards safety of patients, and an approach towards reaching targets rather than a good WASH situaiton.
Staff tended to shift the blame on the public saying they dirtied the hospital, did not follow rules in the premises, and generally created nuisance. The senior staff held cleaning staff responsible for unsanitary conditions in the hospital, yet they only supervised cleanliness at their hospital by making morning rounds. No standard procedures or checklists were used to assess the cleanliness of the hospital. Problems occurred through absence of policies for infection control or adequate training for the cleaning and sanitation of the facilities in infection control.

Implications and next steps
The current monitoring system has very little focus on the status of infection control, review of the enabling factors (infra structure, staff, equipment, policies), and the overall maintenance of hygiene to ensure patients safety. In most of the facilities there is no point person who is responsible for infection control in health care facilities. The safety of the environment and patients against HAI is compromised.
The focus should aim to prevent the newborn baby and the mother from acquiring infections while being admitted in the hospital in the pretext of receiving skilled delivery support. Priority should be given to the provision of water at PHCs, without which it is difficult to maintain infection control. Supervision is required with a focus on the actual hygiene and sanitation situation in the facilities and not just if targets are reached. HAI should be added as a performance indicator. Capacity building, systems to improve performance and incentives to promote good practices in WASH are required.
With numerous efforts being made towards addressing maternal and child health, there should be focus on the safety of mothers and newborns at hospitals, including PHCs. In order to achieve the Millennium Development Goals (MDGs) post 2015, let the mantra be: WASH in health care facilities!

What are some sustainable solutions to ensure adequate WASH practices in PHCs?
Other experiences?]]>
Health issues and connections with sanitation Tue, 23 Jun 2015 08:58:21 +0000
Health trends: burden of diarrheal disease decreasing (Global Burden of Disease Report, 2015) - by: joeturner is a digest of data from 188 countries for 301 diseases and injuries between 1990 and 2013.

These show some interesting trends of various diseases of relevance to sanitation, in particular it suggests that diarrheal disease is down, intestinal nematodes are down and ascaris infections are down.

It is a long report, so it is a lot to download.

Another report from last December looking at the data says that overall global life expectancy for women is up 7 years to 71 and the WHO says that for women in low income countries it is up 10 years to 64.

This is the other report (also long)

And the World Health Organisation health statistics have also been updated for 2015, here:

If you don't want to wade through all these, I wrote an article on some of the key messages here:]]>
Health issues and connections with sanitation Mon, 22 Jun 2015 14:11:58 +0000
Re: Sanitation in Hospitals - WASH in Health Care Facilities for better health care services (WHO report) - by: muench
Interesting conversation. (jbr is John Brogan from Terre des Hommes in Switzerland)

Robyn, could you please explain a bit more about these tools? The website that you linked to states that:

The tools are to be used to perform a situation analysis of the state of hygiene (outcomes) on the maternity unit, as measured by visual cleanliness and the presence of potential pathogens, and individual and contextual/systems level determinants.

And SoapBox is a small NGO from the UK, did I understand that right from their website?

How did the connection with WaterAid come about and how have the tools been used in Zanzibar? Why Zanzibar in particular?

There are generally lots of tools around, but the hard part is to get them into practice and to get them used routinely by the intended target audience. How have you achieved this step?

Kind regards,
Health issues and connections with sanitation Tue, 16 Jun 2015 13:42:58 +0000
WASH in the context of maternal health and menstrual hygiene (research project by Sandec, Switzerland and others) - by: Gendersan1
Sandec/Eawag contributes also to the topic of Menstrual Hygiene Management (MHM) in an
interdisciplinary two-year (2014-2016) research project, which combines social anthropology and gender studies with sanitary engineering. We aim to provide solid information about users’ needs for WASH infrastructure in public health care facilities in Uganda and India. The project focus is to deepen our understanding on how to respond to women’s special needs during special times (menstruation, pregnancy, and childbirth). The expected research outcomes are a WASH indicators checklist for health care facilities, supplemented with a gender perspective, allowing for the assessment of the infrastructure, as well as providing practical guidance on necessary improvements. The data will provide evidence for possible interventions that are needs-based, technically appropriate and socially acceptable.

For more information please see:

Petra Kohler\sesp]]>
Health issues and connections with sanitation Mon, 01 Jun 2015 09:37:13 +0000
Re: Water, Sanitation and Hygiene – WASH - by: pkjha
Thanks for the informative post.
Sanitation is always lagging behind water. One of the reasons is both the sectors are clubbed together under the same budgetary head and water sector always get higher share than sanitation. Secondly Public health engineers are more interested with water than sanitation as it not considered as a dignified work.
In India there is a separate Ministry for water and sanitation for rural areas having separate Joint Secretary with separate budget for the water and sanitation. The result is good.
Sanitation has direct linkage with health. However, it has been observed that Health Department is rarely involved with sanitation program. If a patient suffering from water borne diseases go to Doctor, he gets some antibiotics. Doctor never advise such patients not to go for open defecation and use only toilets. The sanitation program can be more effective in achieving its goals when Health Department / Doctors in villages get involve into the program.
Health issues and connections with sanitation Mon, 25 May 2015 11:39:07 +0000
Water, Sanitation and Hygiene – WASH - The neglect of hygiene promotion in developing countries - by: F H Mughal Water, Sanitation and Hygiene – WASH

The mindset of politicians and decision-makers in the developing countries is such that they always give priority to water – when it comes to giving priority. They avoid talking about sanitation. Sanitation is given a low priority. However, in India, the government is giving high priority to sanitation.

Hygiene component, however, has not yet received the priority in developing countries. It has failed to receive the attention of decision-makers in developing countries – even to this day.

Recently, I happen to lay my hands on the paper: The neglect of hygiene promotion in developing countries, as shown by the Global Analysis and Assessment of Sanitation and Drinking-Water survey. The paper is authored by Alejandro Jiménez, Sue Cavill and Sandy Cairncross.

The abstract reads:

“The UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water (GLAAS) report is one of the three periodic UN reports dealing with water supply, sanitation and hygiene. This paper analyses the data on hygiene promotion which were collected for the 2012 edition, but not included in the report. Despite the limitations of the information, this is the best picture available of the global status of hygiene promotion in developing countries. Results show the low priority given to hygiene when it comes to implementation. On average, the staff in place meets 40% of the estimated needs to achieve national targets. Countries report that over 60% of their population is reached by hygiene promotion messages, but we estimate that there are barely enough hygiene promoters to reach 10% of the people. Government officials’ greatest concerns are the lack of human resources and funds, but they also point to the absence of strategy, responsible agency and basic coordination and monitoring mechanisms as challenges. This has serious implications for the poor working conditions and low recognition of hundreds of thousands of hygiene promoters, who in most cases are women capable of playing a crucial role for public health. There is an urgent need for further development of capacity for hygiene promotion in developing countries.”

The abstract clearly indicates that low priority given to hygiene. Only 10% of the population is impacted by hygiene promotion.

A recent blog post by Hanna Woodburn, Deputy Secretariat Director for the Global Public-Private Partnership for Handwashing, has an eye-catching caption: Harnessing the “H” in WASH: The need to ensure hygiene’s place in the SDGs.

In her post, Hanna highlights the importance of including targets and indicators on hygiene, into the post-2015 development agenda under the Sustainable Development Goals (SDGs).

She points out that, while the proposed goal for water under the SDGs is a step in the right direction, there is a need to develop global level indicators that more accurately assess progress on hygiene. She calls hygiene as an overlooked area. Hanna underlines the need to develop global level indicators on hygiene.

An important comment in her post reads:

“Some of the world’s greatest development challenges have the simplest solutions. If you are reading this blog, you likely know the facts about water, sanitation, and hygiene (WASH). You probably know that diarrhea and pneumonia are the top killers of children under the age of five, and that WASH can make a big difference in saving these lives. You might be able to cite statistics about how many days of school children miss due to diarrhea (272 million per year, in case you were wondering), or be able to describe the impact that a lack of facilities have on menstruating girls’ education.”

Hanna’s post can be seen here:

These two references show importance of hygiene. But, the key point is how to motivate and sensitize the politicians, decision-makers and key government functionaries, so that priority is given to hygiene. At the moment, I think, the top-brass of the government, and the officials working in the relevant department in the developing countries, are miles away from hygiene.

F H Mughal]]>
Health issues and connections with sanitation Sun, 24 May 2015 06:01:09 +0000