E-dialogue Series Ep. 1: Equity & Context in WASH

PC: Christopher Michel

On Wednesday, 2nd August 2023, UKRI GCRF Action Against Stunting Hub launched the Connected E-dialogue series highlighting the power of interdisciplinarity in solving stubborn challenges, such as stunting, facing the world. The first episode, “Equity & Context in Policymaking for Water, Sanitation & Hygiene (WASH)”, hosted panellists Caroline W. Mutari, Public Health Promotion (WASH) advisor, OXFAM International and Hugh Sharma Waddington, Economist and Environmental Health Specialist, London School of Hygiene and Tropical Medicine (LSHTM). Through contextual analysis, a human rights-based approach, and intersectionality, Caroline and Hugh discussed policymaking in WASH.  

The importance of context in policymaking 

Mutari opened the dialogue emphasizing the role of institutions, organisations, government and the private sector in setting the context and promoting equitable access to WASH services. She shared her deep concern for more than 2.2 billion people who lack access to basic hand-washing facilities, vital for disease prevention.

“If we want to see a change globally, we need to exaggerate the kind of response that we are doing and make sure that we increase service provision to all people.”

She stressed that simply having access to water is insufficient, but “sufficient, safe, acceptable, physically accessible, and affordable water for personal and domestic use” fulfils one’s right to water. While “physical and affordable access, in all spheres of life, that is safe, hygienic, secure and socially and culturally acceptable” with privacy and dignity satisfies the right to sanitation.

Government entities should incorporate such a Human Rights Based Approach (HRBA) encompassing the Sustainable Development Goals (SDGs) and examine how gaps in the right to water and sanitation can be addressed. 

Understanding the context  

Mutari placed contextual analysis as the pinnacle of response work. It comprises of: 

1. Community diversity: to determine the type of systems and structures in place.  

2.  Demographics, ethnicities, vulnerabilities, and power versus gender analysis among community members.  

“We need to understand the people that we are serving because you cannot serve people in an African context the same way that you would serve in the Middle East or Europe,” added Mutari. 

3. Putting knowledge into practice to create behaviour change while addressing specific groups’ enablers and barriers.  

4. Considering existing capacities such as educational levels, access to information and availability of WASH and health services.  

WASH Inclusion   

To ensure inclusion, Mutari emphasized deciphering the vulnerabilities at multiple layers of gender barriers, age, and physical disability. Instead of operating with generalised assumptions, an intersectional multi-pronged approach integrating context, vulnerability, and capacity building can help avoid excluding people from WASH services. Working with advocacy groups can help strengthen and empower community leadership, provide adequate resources and opportunities to learn from the communities and improve coordination with relevant actors.  

Mutari recommended that rigorous evaluation can ensure policies are guided by evidence. A solid feedback loop centred around the communities remains vital for this evidence to be accurate. It can help design policies that reflect the needs and comfort of the community. Lastly, Mutari recommended involving the community in the risk analysis and creating context-specific solutions tailored to their needs. 

Impact evaluation: Are we measuring the right way? 

Waddington’s presentation questioned the right ways of measuring WASH impact evaluation. He pressed upon the importance of learning from the past to design better WASH infrastructure and behaviour for the future.  

“The SDGs are for everybody, which means in many areas going the last mile (is necessary) to ensure that everybody has access to adequate water, sanitation and hygiene, including the most vulnerable and the hardest to reach, which may be the same groups.” 

While presenting the indicators showcasing a reduction in childhood stunting over 30 years amongst under-fives in China with a simultaneous increase in basic sanitation services, he demonstrated the impact of an improved sanitation facility.  

Up to what extent are the changes in living standards reflected in improving sanitation? He indicated a possible interplay of several reasons: 

Direct factors such as less exposure to excrete in the domestic environment, which at the community level can translate into fewer open defecations in public, resulting in children being less exposed.  

Indirect factors such as financial burdens influence expenditure priorities in a household, shifting from safe access to water and sanitation to food.  

To evaluate how improving the standard of living helps enhance the quality of life outcomes, he discussed the triple R assessment rating.

Triple R assessment 

The Triple R assessment for quality encompasses rigour, relevance and representation.  

Triple R  Evidence of improvement Recommendations 
Rigour Reporting standards matter for relevance as they need to report to consort standards. Registration of study protocols Editorial standards 
Relevance Funder initiatives, e.g. team composition requirement for studies to have more involvement in design, analysis and reporting. Policy-research initiatives Theory-based evaluations being conducted Systematic reviews 
Representation Representation of the authors Funder initiatives e.g. team composition requirement for studies to have more involvement in design, analysis and reporting. 

He emphasized the significance of the gap maps in measuring and understanding a range of outcomes, including changes in behaviour, access to WASH services, health impacts (such as diarrhoea and infection), nutrition, and socioeconomic effects. With significant improvements in the rigour of studies over time, there has been a focus on minimizing confounding factors, increasing sample sizes, and exploring causal mechanisms beyond measuring impact. 

Is there evidence of improvement? 

While there have been improvements in reporting standards, mainly through initiatives like CONSORT, he also pointed out that social science studies in development economics often lack proper reporting, affecting quality and relevance. Proper reporting standards are not just a quality issue but also a relevant issue, as they impact the inclusion of studies in systematic reviews and meta-analyses. 

One such aspect involves the representation of the study authors. The location of corresponding authors and co-authors has evolved. Initially, many studies were led by authors from low and middle-income countries, but there has been a shift away from this trend. Better representation of lead or corresponding authors from these contexts is needed.  

Co-authorship has improved, but the lead or corresponding author often lacks representation from LMICs. To improve research quality and relevance, incentives such as registering study protocols, writing studies even if they don’t find an effect, conducting theory-based evaluations, and providing direct support to institutions in low and middle-income countries can help.

Leading the way with dialogue

The presentations were followed by a fruitful discussion moderated by Dinesh Malleshwar. Mutari expressed the willingness in policy from governments to be “pro-poor”, but lacking in implementation; the challenge lies in “bringing a synergy” between the varying sectors; therefore, the question is “how do we come together and find solutions that provide?” commented Mutari. Dinesh added to her point, stating how, in some instances, “policy is viewed as a success if it attains a certain percentage, but we are missing out on the most vulnerable”.

Waddington responded from an evaluation perspective. Stating in line with the SDGs, he said that “nobody can be left behind” by going the final mile in providing use and not simply access, as without use, there is no impact on quality of life. Hugh went on to stress the importance of infrastructure in terms of access as an area which needs more focus within the discussion. 

To conclude, equity and context are inseparable components of WASH. To ensure service provision to all, we must recognise people’s unique challenges. Through understanding the intersectionality of societies, we can address contextual nuance. It is a step towards an inclusive future where everyone can enjoy their right to clean water, proper sanitation, and improved hygiene.  

You can rewatch the discussions below:

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