There are multiple gaps, experienced in the first 1000days of life of an individual, especially among those residing in Africa and Asia.

Experiences had shown that parents and caregivers lack the wherewithal and the correct knowledge and attitude towards good care in water supply, basic sanitation, sustainable hygiene, of course which herald nutritional deficiencies and diseases that further impoverish the poor, in their quest to sustain the life of their loved ones, especially the vilnerable under 5 children.

Therefore, the approach should be focussed, and holistic aimedat bringing about a positive change in the foci of care, especially among the lower wealth quartiles in developing countries.

Dear Emily

I certainly agree with you and the academic that ' the simplest way of preventing under nutrition was to keep the child healthy in the first place'

According to my experience, and I would like to respond to your question. ' in what level should these messages be agreed upon'. I would suggest two levels. That is the local level and the global level.

This is because at the local level we are encouraging and have set one of the 10 criterias in our WASH project site is the criteria 'nutritional back yard garden'. Touching The Untouchables (TTU) is using the 10 health promoting home criteria to be selected to receive gravity fed water supply projects.

The rewarding result is that children have access to fruits and vegetables throughout the day.We have seen obvious nutritional improvements in children in our project sites.We have total of 88 project sites (villages).

At the global level. A research can be conducted to see best nutritional practices in WASH. We (TTU) may have case to present at the research for global level to use has a common message.

In my context the regional and national level will cooperate in these messages. Because this practise is happeing at the local level and it is researched justified by research to be global message.

This my opinion and I hope my response helps to answer your question.

Cheers from Jesse

Thanks Emily.There are already institutions at the local,district, regional and global levels.Mapping out these institutions and their stakeholders can result in an array of wonderful experiences. There are bodies who lead these sectors and can be of immense help.

I am new on this platform and like to share my thoughts on integration.My brother, who should go to who and say lets work together or this system works.If the centre does not hold together no good thing can happen and be sustained.We have done a lot in coordinating with all the various stakeholders for effective integration. Everybody expects somebody to lead.Funding is a challenge for those who can make this happen. The political will is there but making it a priority and budgeting for it is another thing.Lets put in our best for we know who the intended beneficiaries/target is.

I heard about the term 'silos' a few months back and by my understanding of the term l think it is a major stumbling blocks to promoting effective integration. Development practitioners are very aware of what they can achieved if they follow the path of integration, however the mentality of grabbing rather maximizing resources and efforts had not make practitioners to commit themselves to it. Until this silo mentality is killed we will have serious challenge in realizing this effort. Promoting effective integration has policy implications and thus if it is not clearly dealt with at the policy level, actualizing it will always be challenge. Some development entities have made some modest gains in their operations with very good success story to share. However lack of will by policy makers and practitioners to work together to push the integration agenda is posing serious developmental set back.

Integrated working between departments was fundamental to the WAMMA WASH programme in Tanzania which started in 1991 and to the best of my knowledge is still continuing 25 years later. The integration was implicit in the name WAMMA, which took its name from a combination of the organisations represented in it: WA for WaterAid, M for Maji (water dept), M for Maendeleo (Community Development Department), A for Afya (Health Department). Subsequently the education dept has also joined WAMMA. The secret behind the success of WAMMA, which brought WASH to over a million people in the Dodoma Region of Tanzania, was 'plateau management', that allowed middle level staff from the departments involved to plan and work together. For this to happen there needs to be faith from the heads of each department at district level that their staff can be trusted to deliver. Initially in the early years there was need for 'hands on' support from WaterAid in the form of advisor support at district level. After a few years of such support however, the teams were capable, assured and able to continue their work, with support coming from other team members rather than from an outside source. The pride in their work was palpable and was passed on to new team members as they joined the teams. Integration should thus be empowering and enthusing to the staff to promote effective implementation, and I would argue that it has to be if serious progress is to be made in the sector. For those who would like to read more on this proven approach please go to: www.ircwash.org/resources/ensuring-susta...mes-developing-world Thank you. Dr Brian Mathew

Though GDP contribution of Agriculture in India reduced to 16 %(from 46 % in 1947). Still 48 % people are still dependent on agriculture and 68 % of people are living in India. Production of crop in India has also reduced in comparison to other part of world.25 % of hunger affected people resides in India. Food insecurity in increasing with increased climate vulnerability. Hence , neglected and termed un-viable- Agriculture could be place in centre ( atleast I can say about India), health , nutrition, WASH and climate change around it.

From where I sit on the communications and advocacy side, I definitely agree that the lack of an enabling environment is a gap and part of the work we do at DefeatDD is try to generate more momentum around integration; we're still one of the few voices out there with an inherent mission to be a convener of different sectors around a single issue. I think part of the problem is that the strength of integration -- combining many things -- can also be a weakness because there's often no clear owner or driver of the process; Emily Mates referred to this challenge as well.

It's also tough to know which levers to pull and when. What comes first: integrated technical policies or integrated funding mechanisms?

It's a long way of saying I don't have answers, just more questions.

“Integration” is quite possibly the most commonly thrown around buzzword in international public health these days—well, aside from capacity-building... After all, what’s not to like about integration? In its broadest definition, integration implies being able to use the same service delivery touch-point and the same service provider to deliver multiple services. Such combinations of services and messaging should ideally extend all the way up to the enabling environment—policies, guidelines, training curricula, etc.—as well as the manner in which service providers and service delivery touch-points are resourced and supervised. Ideally, integration should lead to cost savings (from the use of a single service provider or service touch-point to provide multiple services) and better health and well-being outcomes of children (as a result of children receiving a complete package of services, rather than discreet services that may not address her/his holistic needs).

In the real world, integration suffers from several shortcomings. First and foremost, there is the issue of overloading service providers and service delivery touch-points. Everyone will appreciate that excessive/unmanageable workload is a fact of life in most low-resource settings. When more and more “additional” services and messages are added to what is considered to be the core/essential package of services, there exists the very real risk that service providers will start “mixing” messages and that there will be a dilution in the quality of service delivery. In a worst-case scenario, service providers may choose which messages/services to prioritize and others to de-emphasize, based on such subjective criteria as: (1) personal interest, (2) perceived difficulty or easiness of content of certain services/messages; (3) which development partner is paying them an additional stipend to “encourage” them to integrate certain services/messages; and (4) the intensity of supervision/mentorship/coaching provided by certain development partners with regards to specific services/messages.

The second gap is around the lack of a strong enabling environment to support integration. Country policies and guidelines are siloed around vertical technical areas and donors and development partners implement projects in similarly contained silos. Therefore, integration of services/messages is not emphasized from the level of pre-service training, which usually sets the tone for subsequent service delivery. As long as integration of services/messages is not explicitly mentioned in guidelines (and critically, pre-service training curricula), service providers, supervisors, and managers will continue to look at any addition of new messages/services as construing “extra” work, rather than reinforcing content that was weak in the first place.

Continuing on the theme of a weak enabling environment to support integration, gaps also exist in the lack of meaningful intersectoral coordination at national and subnational levels. While the Scaling Up Movement has achieved promising results in bringing together disparate stakeholders from both nutrition-sensitive and nutrition-sensitive programming areas, such multisectoral engagement is often the exception rather than the rule. Moreover, even when individual agencies agree to meet and talk in a common forum, rhetoric is not reflected in actual activities in a work plan or specific allocation of resources.

More thoughts to come later... To start the discussion, here are some initial questions:

What do you think about these gaps? Do they capture what you have seen in the course of your own work with integrated service delivery?

What is the best way to overcome them?

Are there other gaps that you have seen during the course of your work?

Because I work in the nutrition world, I naturally have to start by talking about nutrition.

I was talking to an eminent academic just this morning about how to address the very high rates of stunting in humanitarian contexts and he reminded me that the simplest way of preventing undernutrition was to keep the child healthy in the first place! This is a very obvious statement, but it is also very true – preventing illness from occuring by improving the conditions the family are living in – particularly for the most vulnerable members, pregnant and lactating women, infants and young children; and thereby avoid heading into the vicious cycle of infection and undernutrition. But how difficult that is to do even in ‘stable’ contexts - in emergency situations the difficulties multiply.

The vital role WASH has in preventing undernutrition is well known – but only lately are we getting to grips with how to link our two sectors – more studies providing much needed evidence are coming out each year. While we are making some progress at being more ‘joined up’ at global and national level, we still have a long way to go to ensure coordinated responses during crisis situations. For me, the critical part to ‘get right’ in integrated programming is right down at community level – whoever the first line workers are in any given situation, a set of simple, clear and harmonised messages, whether delivered from food security, WASH, social protection, nutrition or health workers, can go a long way to embedding integrated programming from the bottom up.

Common messaging could help keep children healthier – but I wonder at what level these messages should be agreed upon; global, regional, national, local? Is it possible to have a set of messages agreed at global level, or do contexts vary too much? Which sector should take the lead? Thoughts welcome!

Now that we have discussed examples of integration, and have started to list possible tools that can be used when integrating programs, it is time to think about what gaps still exist. What are the barriers to more integration between sectors? How do we reduce those barriers and which stakeholders are essential to involve in those conversations? What tools have yet to be created? All of these thoughts and more are welcome on this thread.

For this topic we have two great experts to help guide our discussion. Emily Mates is the technical director at the Emergency Nutrition Network. Debjeet Sen is the Regional Specialist for ECD and Nutrition for PATH. Both have invaluable experience largely outside the WASH excited and will use their experience to help determine the gaps that are key to fill. They will both start off this conversation with their expertise and some thoughts for this community to ponder and expand upon.