The implementation is mostly not the biggest challenge, rather the sustainable maintenance of a certain project or practice. The successful establishment and finally reproduction is linked to the interest of the people in it. If having a toilet makes people feel that they reached a higher living standard they will be willing to maintain it. If dried faeces from UDDT or co-composted faecal sludge become marketable products that farm workers are happy to work with, a demand is created - especially when they had to handle sludge coming directly from the honey sucker before...

In Nexus project we establish showcases for learning and dissemination, but will also think of an exit strategy in which we focus on developing the institutional framework that will remain after successful implementation during the project period.

Thanks Megan and Hanna for placing integration on the continuum. This is a really important point for WASHplus when we define integration because as several people have noted, integration means different things to different people. It is also not possible to wait for perfection before acting...so we encourage programs to be "opportunistic"...find ways to integrate wherever possible even if it is not the ideal.

At WASHplus we recognize that the ideal would likely be a jointly conceptualized and implemented program that incorporates elements of WASH and nutrition. This is what we did in our program in Mali. The core element of the program was community led total sanitation (CLTS), but built around that was a range of behavior change activities on handwashing with soap, treating drinking water, exclusive breastfeeding and dietary diversity. We incentivized communities that were certified as open defecation free by building or rehabilitating a water point for the community. We were able to implement such a program because USAID/Mali requested it and provided funding for it.

In other countries, we did not have this specific mandate, so we had to find other entry points to integrate WASH into nutrition programs that were ongoing. In Bangladesh we linked with some of USAID's infant and young child feeding programs such as SPRING and SHIKHA--helping to add a WASH component that emphasized a fixed handwashing station at the food preparation area in addition to the latrine and how to safely dispose of infant poo. In Uganda we were able to develop materials to emphasize food hygiene. Neither of these were coordinated WASH-nutrition programs, but we seized opportunities where we could to infuse WASH into nutrition programs.

Dan Campbell posted the WASHplus Learning Brief on WASH and Nutrition....I am adding a few other documents related to WASH and nutrition...I would also like to draw your attention to the most recent issue of the Emergency Nutrition Network's Field Exchange . This issue is devoted to nutrition sensitive approaches of which WASH is one of several. There are some great articles in this.

Finally, WHO, UNICEF and USAID published Improving Nutrition Outcomes with Better Water, Sanitation and Hygiene: Practical Solutions for Policies and Programs in 2015.

The WASHplus website has other resources on WASH and nutrition and will be adding more over the next few months before the project ends in July 2016.

Renuka Bery
Integration Manager, WASHplus project, FHI 360

I am writing on behalf of Tofayel Ahmed, Deputy Country Representative of the Japan Association of Drainage and Environment (JADE) in Dhaka, Bangladesh. Thank you, Tofayel, for sharing this!

I would like to share that the vision of JADE is to improve the living environment for better living which refers to healthy living. Where WASH has been recognized well as one of the important factors.

However, to improve a particular society if we consider a family as a unit of development where mother is the center of that development. Therefore, without balance development of mother a family cannot be well developed. Hence, for the balance development integration of WASH and Nutrition is necessary.

Malnutrition itself is responsible for many diseases particularly for pregnant women to new born and to child where only WASH intervention is not able to cope with such family health. At this instance, if a mother is knowledgeable about the necessity of WASH and Nutrition as well as she practices by herself and her family then a healthy family we can expect. Thus, knowledge and facilities to practice WASH and Nutrition is crucial factors.

Now a days in Bangladesh knowledge and facilities gap comparatively reduced for WASH than Nutrition. But still now, there are many societies in Bangladesh they thought that nutritious food is expensive which is beyond their buying capacity, or they do not know well the function of nutrition to supply their body need. So, considering mother as the center of development JADE has integrated WASH+ and Nutrition and trying to minimize those gaps.

By this time many education sessions have been conducted with the participation of married women and adolescents girls (future mother) focusing on nutrition, indoor air pollution and WASH along with menstrual hygiene management (MHM). However, MHM is another key factor for reproductive health. But due to social taboo as well as knowledge and facilities gap adolescent girls are dropping out from school and women of all reproductive age suffering a lot from various diseases.

At this situation along with education program, homestead garden for nutrition facility and improve cooking stove (ICS) to reduce indoor air pollution has been introduced to the project beneficiaries. Now they are able to know that nutritious food is not expensive, they can produce those foods using their homestead and even instead of buying those foods they can sell it to earn money. Frequency of eating those foods has been increased in their families. Even, adolescent girls came to know the importance and availability to eat nutritious food to be healthy mother in future. Apart from the project beneficiary families many surrounding families are now practicing homestead gardening to fortify their family nutrition. Otherwise, ICS has been well accepted due to make the kitchen smokeless, require less cooking fuel and reduce cooking period for its heating efficiency. As a result, local entrepreneurship for ICS production has been development. In addition, women and adolescent girls are happy to know and practice the easy and healthier way to manage menstrual hygiene. Overall, development of a mother should consider as the philosophy of development for a healthy family which will contribute to build a healthy society and a nation.

We are at the mid level of the project period and shared some of the findings we observed. Hope in future we may able to share more interesting findings of this integrated project.

With Regards
Tofayel Ahmed

Dear colleagues,

thank you very much for your interesting and thought-provoking contributions!
I encourage you to continue discussing in this section 2 (e.g. on WASH-Nut in the emergency context) but also to move to section 3 where we discuss policies, advocacy and the way forward.

Jona provided a good overview of points discussed and remaining questions which the WASH and Nutrition community still need to answer. I like to highlight and comment on a few points of the discusion here:


1. We learned that integration means different things to different people (experts). Hence there is still a need to explicitly state what we mean by integration and at what level when talking about integration. However, there has been some work done already. Claire highlighted a minimum WASH package in the context of nutrition crisis which clearly defines what interventions ought to be implemented. We can built on this work in the development area and expand it to establish long term benefits for the families and communities we work with.
2. Schools have been mentioned as kind of a “natural” entry point for integrating WASH & Nutrition. Yet, much still needs to be done to achieve that WASH is naturally considered when, for example, implementing a school lunch programme.
3. A need for a bottom-up approach and a need to create demand for WASH and nutrition from the community were highlighted.
4. It was suggested that mothers and future mothers (adolescent girls)should be seen as the center of development who are responsible for family health. They can then be used as “integrators” of WASH & Nutrition. Results of an integrated project in Bangladesh was mentioned to highlight that for family health, multiple interventions in nutrition (education) intervention, indoor air pollution (improved cooking stove) and WASH along with menstrual hygiene management can and should be implemented.
5. The need for more data on which specific WASH interventions affect nutrition outcomes and which indicators to use for M&E was expressed. While others also highlighted existing indicators which can be used. Hence, it seems that specific “WASH-Nutrition indicators” need to be agreed upon and recommended for use to practitioners.
6. A need to expand the traditional WASH interventions with environmental interventions to break the fecal-oral transmission (e.g animal feces). This means that we should expand the WASH –Nutrition idea to a more holistic WASH Nutrition- Environment – Food Security approach.

We also received a message from a participant asking for “real” cooperation between the WASH and nutrition experts meaning a development of an action plan. This action plan could lay out a certain number of projects in different regions. I personally like this call for an action plan and I believe that this would be a way forward. The Bonn WASH Nutrition Forum was a good start to bring the WASH and Nutrition community closer together, this online discussion is another step, the World Water Week in Stockholm could be an opportunity where the development of an action plan can materialize. If others have suggestions on how to get started on an action plan, then this would be much appreciated.
We know we have to work together to reach the goals set in the SDGs. Let us continue to break the silos!

Thank you

nutritious clean (hand-washed with soap) wishes

Theresa

That's one of the challenges we heard about in our last Think Tank at AfricaSan--that integration is clearly important, but the financing of it can be insufficient at best in many contexts. Integration should not be done when it makes sense, from an outcomes perspective as well as a financing perspective. That said, I also think that there are many instances when we do integrate where some costs can be streamlined.

Megan,

I like that you differentiate integrated programming into different contexts. I think oftentimes those of us who work in behavior change think about linking behavior change messages but you rightly point out that it could also be co-location of services.

Integration and coordination of WASH and NUTRITION is about allocation of reasonable financial resources to both components on public spending. In my view, it is not always possible to allocate resources for nutrition in WASH projects or for WASH in nutrition projects.

There might be some specific places like preschools,primary schools and health care facilities to address both components at the same time. It is also obvious that without creating access to safe and adequate WASH services it is not possible to achieve the nutrition out come .

The Global Public-Private Partnership for Handwashing (PPPHW) has been working with the Clean, Fed & Nurtured community of practice to bring together experts of the WASH, nutrition, and early childhood development (ECD) sectors. Collaboration among these three sectors has resulted in integrated efforts to address gaps in delivery of programming and research. Clean, Fed & Nurtured has developed and proposed a
list of indicators for integration so that integrated interventions can have a greater impact. Each of the three sectors represented in CF&N have their own indicators with varying degrees of strength.

The PPPHW put together a list of key WASH and nutrition resources, which can be found here . This list of resources features the latest research, technical briefs, learning briefs, and evidence of integrated WASH and nutrition programs that provide insights to effective programming. These resources can serve as a tool for implementers and advocates in the WASH/Nutrition sector.

WASH and Nutrition integration will be a great step in the correct direction. I also think we need to apply LiST software to get the correct mix of interventions for investment. School feeding programs are good target but in with the limited parent participation like here in Uganda; sustainability is highly questionable

Dan,

Regarding your last point,"integrated program should have a monitoring and evaluation framework with corresponding WASH and nutrition indicators. However, when WASH activities are integrated into an existing nutrition program, WASH indicators need to be added to the monitoring framework", I am also thinking that ideally when it is faisible and achievable, the project which target the decrease of undernutrition prevalence have to include nutrition indicators (at objectives level) and WASH indicators at result level. Therefore, this will allow to speack about nutrition sensitive projects by exemple for a WASH program in development context with a good coverage, which will have clearly an impact on nutritional security (see Rachel Lozano post: forum.susana.org/forum/categories/244-th...k-of-under-nutrition).

Absolutely agree with you Nripendra!
A good exemple to share regarding multisectorial response to undernutrition at school, could be the WASH in schools project (washinschoolsmapping.com/).
In Burkina Faso, Tapoa Province, ACF is leading a WASH in Schools project which include Water access, sanitation acces (with EcoSan component), valorisation of Ecosan product in a school garden, support to school canteens, inclusion oh hygiene promotion and food diversity in classroom teaching and advocacy to include this thematics at national level in education curricula.
Do not hesitate if you have questions or want to share!
www.pseau.org/outils/lettre/article.php?...ticle_lettre_id=1323

The USAID WASHplus project has looked at the Integration of WASH and Nutrition and a 2015 Learning Brief states that:

Link to the Learning Brief

- Policy engagement is a vital step for integrating WASH and other interventions that impact nutrition programs.
- Having a national nutrition policy that recognizes the importance of WASH for nutrition outcomes paves the way for the development of integrated programming at all levels. Donors, governments, and implementers should endorse and support an integrated approach.
- Staff in both sectors needs skills and knowledge to effectively implement integrated programs. While enough evidence exists to support WASH and nutrition integration, more data is needed to demonstrate how and in which ways specific WASH mechanisms affect nutrition outcomes and determine which implementation modalities are most likely to lead to strong and sustained impact.
- An integrated program should have a monitoring and evaluation framework with corresponding WASH and nutrition indicators. However, when WASH activities are integrated into an existing nutrition program, WASH indicators need to be added to the monitoring framework.

Also, Traditional WASH interventions focused on human excrement may need to be supplemented with new approaches to break the fecal-oral transmission cycle from animal feces, particularly in infants and young children.