Water, Sanitation and Hygiene for accelerating and sustaining progress on Neglected Tropical Diseases: A new Global Strategy 2015-20

Abstract

Neglected tropical diseases (NTDs) affect over 1 billion people. Safe water, sanitation and hygiene (WASH) contribute to prevention and management of most NTDs. Linking WASH and NTDs has potential to impact on multiple NTDs and can help secure sustainable and equitable progress towards universal access to WASH.

The need to address the determinants of NTDs has been acknowledged. In response, the World Health Organization has published a new Global Strategy: “Water, Sanitation and Hygiene for accelerating and sustaining progress on Neglected Tropical Diseases”. The Strategy focuses on cross-cutting actions that benefit disease control and care efforts, and strengthen health systems. Implementation of the Strategy and accompanying action plan can help ensure that the health and development agenda leaves no one behind.

Introduction: Why is a new strategy needed?

Neglected tropical diseases (NTDs) affect over 1 billion people worldwide, causing chronic disability and death, primarily among the poorest populations (WHO 2015a, Nakagawa et al, 2015) – the same populations who often lack access to even the most basic water and sanitation services. Provision of safe water, adequate sanitation and hygiene (WASH) is one of five key public health strategies to control, eliminate or eradicate NTDs (WHO 2012). WASH plays a critical role, to varying degrees, in both prevention and management of all NTDs. The importance of sanitation and hygiene in preventing transmission of soil transmitted helminth infections, schistosomiasis or trachoma, or the role of safe drinking-water in guinea worm eradication efforts are well-known examples. Access to water in sufficient quantities and hygienic conditions in healthcare facilities and at home is one of the most basic requirements for adequate provision of care to individuals affected by NTDs, such as leprosy and lymphatic filariasis (for a detailed overview of the importance of WASH for NTDs, see WHO, 2015b p24).

WASH interventions have broad public health benefits, and linking WASH and NTDs has potential to impact on multiple NTDs through a single domain of intervention.

The success of the Guinea worm eradication programme points to the benefits that can be derived from a comprehensive approach, combining water filtration, case management, education, and interventions to protect and improve drinking water sources (Cairncross, Muller and Zagaria, 2002). Only 126 cases were reported worldwide in 2014, and only five between January and May 2015. In Morocco, implementation of a comprehensive, multi-sector programme, delivered at all administrative levels resulted in reductions in the prevalence of trachoma to the point that the Ministry of Health was able to claim its elimination as a public health problem (Ministry of Health Morocco, 2006).

The need to address the determinants of NTDs and define an integrated approach has been repeatedly acknowledged (Hunter et al, 1993; Utzinger et al, 2003; Ehrenberg and Ault, 2005). The drive for elimination and enhanced control set out in the NTD roadmap has been accompanied by renewed momentum for intersectoral collaboration and calls for normative guidance on improved programmatic practice (Utzinger et al, 2009; Freeman et al, 2013).

Despite the recognition of the need for action on WASH for NTDs, to date WASH components of global and national strategies have received insufficient attention and the potential to link efforts on WASH and NTDs has been largely untapped. Existing plans and strategies rarely offer specific guidance on the way in which collaboration between WASH and NTDs stakeholders can be strengthened and there is no global monitoring mechanism that tracks and incentivises collaboration.

The lack of collaboration is perhaps not surprising; while the WASH sector has focused primarily on increasing access to water and sanitation services, the NTD community has led successful mass drug administration in highly-endemic communities. Focusing on these ostensibly unconnected activities had led to limited communication between the two communities and consequently a dearth of knowledge on effective collaboration needed to achieve the common health goals of the two communities (although, as noted above, there are some exceptions). This situation is set to change, with both WASH and NTD actors increasingly focused on the broader goals of health, equity and sustainability of health outcomes.

The rationale for collaboration is clear. The challenge now is to foster a strong working relationship between the sectors that benefits from WASH actors’ in-depth knowledge of what works in practice and to refine that knowledge for better use in NTD control and elimination.

A WHO Global Strategy 2015 -2020

The World Health Organization has published a new Global Strategy and Action Plan - “Water, Sanitation and Hygiene for accelerating and sustaining progress on Neglected Tropical Diseases”, to respond to the growing support for intersectoral approaches and the need for guidance (WHO, 2015b). The Strategy builds on existing plans and responds to the mandate given to WHO by Member States for action on this area, in World Health Assembly resolutions WHA64.24 (WHO, 2011) and WHA66.12 (WHO, 2013). Its vision is accelerated and sustained achievement of the NTD roadmap milestones, particularly among the poorest and most vulnerable, through better-targeted and joint WASH and NTDs efforts.

Rather than providing disease-specific recommendations, the Strategy focuses on cross-cutting actions, set out under four Strategic Objectives, by WASH and NTD actors that benefit disease control and patient care efforts, as well as strengthening health systems.

Strategic Objective 1 sets out measures to increase awareness of the co-benefits of joint WASH and NTDs action by sharing experience and evidence from improved delivery. Increasing awareness requires documenting and building on current successes, and sharing information on multiple WASH and NTDs platforms. Examples of success have been documented in the context of trachoma control efforts in Ghana (Yayemain 2009) and more recently in Ethiopia (unpublished information presented at the NTDs NGDO meeting, Abu Dhabi 2015), where ministries of health, education and water resources as well as donors and implementers have come together to better align WASH activities and NTD programmes. Examples of enhanced collaboration are also increasingly reported in the context of school-based deworming programmes (REF).

Strategic Objective 2 focuses on the need to use WASH and NTDs monitoring to highlight inequalities, target investment, and track progress. This aspect is crucial to ensure accountability as well as to incentivise collaboration. It also takes into account the focus on universal access to basic water, sanitation and hygiene services by 2030 and on universal health coverage, as set out under the Sustainable Development Goals. The WHO-UNICEF Joint Monitoring Programme on water supply and sanitation is moving towards monitoring progressive reduction in inequalities in access to WASH services, analysing and reporting on disparities between rural and urban settings, wealth quintiles, and subnational analyses; these can be used to identify vulnerable areas (WHO/UNICEF 2015) that are likely to have a high prevalence of NTDs. Existing mapping initiatives that produce country profiles with both NTDs and district-level WASH coverage estimates are also powerful tools to help decision makers and implementers with the targeting of their interventions and should be encouraged (Flueckiger et al 2015, Pullan 2014, Solomon et al 2015).

Strategic Objective 3 urges action to strengthen evidence on how to deliver effective WASH interventions for NTDs and embed the findings in guidance and practice. This will involve defining a shared agenda for operational research across the WASH and NTDs communities that will result in practical lessons for implementation, and using this information to define and update guidelines for both WASH and NTDs programme design and delivery.

Strategic Objective 4 focuses on the need to plan, deliver and evaluate programmes with mutual inputs from WASH, health and NTDs stakeholders at all levels. In practical terms, this could mean simple measures that are currently rarely applied, such as NTD actors involving WASH partners in the planning and delivery of disease programmes, and WASH actors improving the targeting of interventions towards NTD-endemic communities as well as ensuring that water and sanitation technologies and hygiene promotion are effectively used to block transmission of NTDs. Such coordination should take place at country and regional levels.Integrated delivery of behaviour change activities for disease control (such as simultaneous promotion of handwashing with soap and face washing in trachoma-endemic areas) should be factored into programme design.

Conclusion: Sustaining momentum towards 2020

The new WASH and NTDs strategy has given renewed impetus for collaboration between WASH and NTDs actors. International organisations, academics, donors, practitioners, and countries have started mobilising efforts to work together to accelerate progress on NTDs. It is time to build on the momentum in the health and development community and make sure it translates into concrete and efficient collaboration at the programme level.

Action is needed to break down existing programming siloes built around single interventions (Johnston 2015). Such action requires the heath and WASH communities to actively seek collaboration by initiating and sustaining joint processes and interventions.

The consultation process undertaken to define the Strategy has exposed a real will across WASH and NTD stakeholders to work together and a strong desire to define the shape that optimal collaboration should adopt. Implementation of the measures set out in the Strategy and accompanying action plan can and should play an important part in ensuring that the health and development agenda leaves no one behind.