Understanding Current Approaches,
Gaps, and Opportunities in the
Undernutrition in children is a major problem in low- and middle-income countries, which puts
the age group younger than 2 years, in particular, at risk of dying from diarrhea and other infectious
diseases (1). In 2016, of all the 159 million children under 5 years old living with stunting, 56%
lived in Asia and 38% in Africa, and of the 52 million children under 5 with wasting, 69% lived
in Asia and 27% in Africa (2). An estimated 45% of all deaths of children in the age group of under
5 was attributable to undernutrition in 2011(1).
On the other hand, diarrhea alone is equally a significant health threat to children. According to a
recent estimate of global data published in The Lancet, despite the reduction of diarrheal mortality
rates in children by 34.3% and incidence by 10.4% (3), diarrhea killed about 499,000 children
younger than 5 in 2015, making it the fourth leading cause of mortality among young children in
the world (4).
About 88% of deaths from diarrheal diseases is attributable to unsafe drinking water, inadequate
water supply for maintenance of hygiene, and lack of access to sanitation together (5).
Most importantly, diarrhea in combination with other Water, sanitation, and hygiene (WASH)
related factors affects the nutritional outcome as shown in Fig. 1 (6).
Fig. 1 Underlying components of WASH that affect nutritional outcomes in children.
Diarrhea leads to loss of appetite, malabsorption of nutrients from
the gut, and increased metabolism (7). Hookworm infections can
lead to anemia, in both pregnant women and children, which in
turn increases the risk of preterm delivery and low birthweight
babies (7). Women who have already experienced malnutrition
are more likely to become malnourished mothers and give birth
to underweight babies. Such babies are susceptible to
undernutrition and infectious diseases (including death),
establishing an intergenerational cycle of undernutrition (1), as
illustrated in Fig. 2.
About 80% of deaths from diarrheal disease occur in children less than 2 years of age (8), as
children between 6 months and 2 years have relatively more exposure to enteric pathogens once
they start crawling and putting things in their mouth (7). Undernourished children in this group are
also more prone to suffering from frequent, severe and prolonged episodes of enteric infections
which can lead to irreversible stunting and impaired cognitive ability (7).
While nutrition specific interventions alone do not seem to improve the overall nutritional outcome
in children (9) integrated nutrition interventions with prevention and control of infections have
indicated more benefits in terms of improving nutritional outcome in children (10).
WASH interventions reduce the pathogen load in the environment, which reduces the incidence of
diarrheal disease and intestinal worm infections in children. This ensures healthy gut function and
better nutrient absorption, and decreases susceptibility to other infectious diseases, thereby
facilitating healthy development and growth of children (11). Considering the importance of the
first two years of life as a window of opportunity for growth promotion (12), and the impact that
WASH and nutrition interventions alone have had so far, an integrated approach of
WASH/nutrition program targeting children in this age group could be more beneficial.
Source: Save the Children. Nutrition in the First 1,000 Days: State of the
World’s Mothers 2012.
Fig. 2 The intergenerational cycle of
The overall objective of this study was to explore existing integrated WASH/nutrition
programmatic approaches, leading evidence/results, barriers/challenges, and areas for future
research through desk research and interviews with subject matter experts.
Semi-structured, in-depth interviews with WASH and nutrition experts were conducted. The
interviews explored approaches taken in integrating WASH and nutrition programs, barriers and
challenges to integration, and recommendations for integration ideal for addressing the needs of
children younger than 2 years. Secondary data collection involved a review of published data.
The study was designated as a nonhuman study by the Research Determination Committee of
PATH. Interviewees were purposively selected based on their professional experiences and
expertise. Six interviews were conducted, five on Skype and one in person. Five people declined
the request, but one of them provided helpful documents and links for further study. The interviews
were coded and analyzed for emergent themes.
Existing evidences for integration from literature
A retrospective analysis of data from 145 countries conducted in 2014 concluded that improved
water and sanitation in low- and middle-income settings could prevent 361,000 deaths annually
from diarrheal disease among children less than 5 years of age, which is 58% of total diarrhearelated
deaths and 5.5% of deaths in that age group (13). A multi-country study showed that an
exposure to a higher cumulative burden of diarrhea owing to poor sanitation during the first 2 years
of life was associated with 25% of stunting (14). A study in Peru showed that children at 24 months
of age, living with the worst conditions for water source, water storage, and sanitation, were 1 cm
shorter and suffered 54% more diarrheal episodes as opposed to children of the same age group
living in the best conditions (15). The same study showed that a height deficit of 0.9 cm at 24
months of age could be attributed to inadequate sewage disposal (15).
A cluster randomized trial of 121 villages in Mali showed that severe stunting in children could be
reduced by 22% and the risk of severe underweight by 35% with reduction of open defecation
(16). In Bangladesh, children from clean households were found to have 22% lower stunting
prevalence than children from contaminated households (17).
A study done in 2012 in Niger concluded that therapeutic food alone does not address malnutrition
unless adequacy of the water supply is considered. The association between adequacy of water
supply and the length of stay in a therapeutic feeding center of Medicins Sans Frontiers for 1518
children from 20 villages showed that children exposed to adequate quantity and quality of water
supply had the shortest stay in the feeding center (OR=0.97). Furthermore, both quantity
(OR=0.64) and quality (OR=0.44) of water were independently associated with shorter stay in the
feeding center (18).
A systematic review of fourteen studies from 10 LMICs published in 2013 evaluated the effect
various WASH interventions on nutritional status of children under age 18 years of age and
concluded that solar disinfection of water, provision of soap, and improvement of water quality,
significantly contributes to increased height in children less than 5 years of age (19).
The Strengthening Household Ability to Respond to Development Opportunities (SHOUHARDO)
Project of United States Agency for International Development (USAID) in Bangladesh (2006-
2010), which focused on WASH and nutrition interventions for children between 6 and 23 months
of age and pregnant and lactating women, showed that stunting decreased from 56% to 40% in the
6- to 24-month age group, and none of the children under 5-year age group experienced increases
in stunting over three years. USAID’s Good Start Program in Peru (1999-2004), based on a
participatory community-based program integrating WASH, nutrition, and early childhood
development over four years, successfully reduced stunting from 54% to 37%, while decreasing
anemia prevalence from 76% to 52% and serum retinol, an indication of vitamin A status, from
30% to 5% (11).
Programmatic barriers and challenges
Lack of funding, collaboration/coordination, and donor support; siloed working mechanism;
knowledge gaps; and poor governance, plans and policies/strategies, paucity of convincing
evidences, emerged as the main themes in terms of barriers for program intergration.
All participants expressed that lack of funding for multi-sectoral integrated programs is the major
barrier. A similar finding was reported from a study in which funding for WASH and nutrition
programs was mentioned to come either from different donors or from a donor but with different
goals and expectations (20). Interestingly, another report mentioned the existence of competition
for funding between WASH and nutrition programs (21).
II. Governance and policy
Vertical and segregated government implementation structures for WASH and nutrition,
especially at the ministry level, were discussed as the other main challenge. WASH and nutrition
stakeholders consult with the respective ministries and program coordination mechanisms often
lack across ministries. Most participants mentioned that integration is often weakest at the policy
This is not different from what participants mentioned in another study, which also cited the need
for supportive institutional arrangements and funding at both national and subnational levels for
effective implementation of policies (21).
III. Knowledge and learning
All participants agreed that lack of training and knowledge-sharing among sectoral experts is
another barrier to integration. Experts are preoccupied with their assigned responsibilities and
training outside of their own field is not prioritized.
IV. Lack of evidence
Majority of the participants agreed that there are limited data to show that an integrated
WASH/nutrition approach can result in better health outcomes. Similar view was noted by relevan
experts in a study done by Teague et al. and a study conducted in Cambodia (18, 20).
Additionally, many participants also mentioned that the choice of indicators for the outcome
measurement is equally challenging. Observation of physical changes takes time, while invasive
techniques to determine gut health might not be feasible in all settings.
The majority of participants mentioned that technical specialists are needed in different roles no
matter how integrated the program is. Usually people have limited technical capacity beyond their
sector of primary responsibility. Interestingly, one report mentioned that WASH practitioners are
engineers with little connection to health at all (22).
Most study participants believed that an integration is easier at subnational levels, especially at the
community level. In contrast to this it has been reported that from a practical point of view, it is
challenging for community beneficiaries to participate in multiple activities, or learn information
about multiple topics at the same time when programs are integrated (20, 22). The need of certain
kind of incentives has been mentioned to encourage staff participation in the integration process
at the subnational levels (18, 19).
VI. Planning, design, and strategy
Many participants stressed that focus on sector-specific objectives is a barrier to integration when
it comes to planning co-location of a program. WASH programs often target entire communities
since the measurable impact requires that communities have 100% access, while nutrition
interventions often target the most vulnerable population (22). This notion was shared by a few
participants who believed that targeting whole communities versus the most vulnerable population
is another challenge in the integration process.
All participants noted that measurement of any impact in general requires more time than what is
available within short project cycles, as noted in the two other studies (21, 22). It was also noticed
that generating evidence regarding specific changes attributable to WASH or nutrition requires
special study, which is beyond what routine project monitoring and evaluation does (21).
Participants also mentioned about Action contre la Faim’s WASH Nutrition practical
Guidebooka which encourages integrated service delivery for the “mother/caretakermalnourished
child” dyad. Programmatic approaches like “Baby WASH”, “SUAHARA”
“Clean Household,” are discussed in the book and were also mentioned by the experts.
Recommendations from participants
Participants made the following recommendations for targeting children under 2 years of life,
based on their experiences with successful programs.
I. Strengthening of cross-sectoral coordination and collaboration is necessary to bring ministries,
researchers, and stakeholders together to rethink the implementation model.
II. Integrated programs are successful only when accepted at the policy level and internalized by
the government; therefore, it is important to engage government from planning point through
all stages of implementation.
III. Programs should be integrated in such a manner that neither of the one gets overshadowed by
IV. In situations where a single donor is unwilling to support an integrated program, seeking fund
from multiple donors for an integrated program was hinted as a possibility.
V. Messages to prevent children from coming in contact with environmental pathogens should
cover both WASH and nutrition aspects like promotion of breastfeeding, and consumption of
locally available nutritious foods.
VI. Staff training and capacity-building should take place at the subnational level, with particular
focus on the community level.
VII. During project design, sufficient time should be planned for impact evaluation and ensuring
sustainability of programs.
Most integrated programs focus either on nutrition or WASH as the first priority, and the other
component is either overshadowed or considered as a complementary program. There is a lack of
rigorous evidence regarding the outcomes of integrated WASH/nutrition interventions on children
a Available from: http://www.actioncontrelafaim.org/sites/default/files/publications/fichiers/manuel_wash_nutrition_online.pdf.
younger than 2 years. This is because most programs have been vertical. Lack of funding for multisectoral
programs, effective cross-sectoral coordination, and comprehensive strategies to address
the integration process are the main barriers to the integration process.
Strategies to address these barriers and challenges could be the subject of future research involving
a larger sample size, which was beyond the scope of this study due to time constraints.