Theory of Change Pathway and Narrative forIntegrating WASH and Nutrition

ProgrammingIn Cambodia

DRAFT

Cambodia February 2016

Table of Contents

Key Challenges................................................................................................................... 3

Vision and Long-term Changes.....................................................................................4

Analysis of Stakeholder Roles.......................................................................................4

Realistic Changes by 2023.............................................................................................. 6

Key areas of change.......................................................................................................... 6

Ways of Working............................................................................................................... 8

Key Assumptions............................................................................................................... 8

Moving Forward.............................................................................................................. 10WHAT WE NEED TO DO FOR EFFECTIVE LEARNING & ACCOUNTABILITY............10HOW WE ARE GOING TO MOVE THIS FORWARD...........................................................11

Key ChallengesJoint programming in WASH and nutrition in Cambodia will be undertaken in a complex environment with numerous challenges and underlying factors that will need to be taken into consideration when planning actions.

Table 1: Key contextual challenges in CambodiaTECHNOLOGY PHYSICAL

ENVIRONMENT & CLIMATE ISSUES

SOCIO-ECONOMIC & CULTURAL ISSUES

GOV’T POLICIES & LEGISLATION

POWER DYNAMICS & BUSINESS

Physical: Affordable and appropriate technologies;WASH hardware

Information systems: reporting systems and geographic mapping

Psychological:Mass and social media affecting norms attitudes and behaviours

Scientific: testing of water and nutritional indicators, mobile technologies

Drought/flood: decrease of nutritious food and hygiene issues

Pollution and home environment

Urbanisation: migrations/slum and affects on rural communities

Seasonality

Dam construction

Disparity of wealth in geographic/ethnic areas

Migration

Gap between knowledge and practice

Availability and access to services

Aid Dependency

Lack of community cohesion

Gender inequality

Social and cultural behavioural norms

Good WASH and Nutrition policies but no enforcement.

No integrated strategy on WASH/Nutrition

Limited coordination and information sharing

Information analysis and sharing

Filtering down to the subnational level

Attaching funds to plans

Poorest are the most vulnerable

Leveraging decision makers with budget allocation power

Media

Emerging Markets

Public Private Partnerships

Competing priorities – profit & public health

Peer & family pressure

Vision and Long-term ChangesThe overall vision for integrated WASH and nutrition programming and the key success factors that would ensure that this vision could become a reality were identified.

Vision: All pregnant and lactating women and children under 2 in Cambodia live in a safe and hygienic environment, are healthy, well nourished and cared for so that the children grow to their full potential.

Long-term changes:

a) Pregnant and lactating women and caregivers adopt optimal WASH and nutrition behaviours and practices for themselves and the young children in their care.

b) Community leaders, religions leaders and others act as role models. They empower women in the community, facilitate and demonstrate healthy practices that contribute to healthier pregnancy and healthier young children.

c) Health and WASH service providers at all levels provide quality services for pregnant and lactating women, young children and their caregivers and support them to sustain hygienic and healthy practices.

d) Commune and district have clear mandates o nutrition and WASH to ensure that communities have access to sustainable WASH and nutrition services. They advocate to higher government for funds and capacity development.

e) Government administrative bodies at all levels effectively priortise budget and resources for WASH and Nutrition. They are able to leverage further funds to support new ways of working.

f) Private investors and business increase their corporate social responsibility and/or invest in efficient and affordable initiatives and/or innovation which benefit pregnancy and lactating women and young children.

g) Line ministries provide clear policies, strategies, funded action plans and guidelines to support WASH and nutrition programming. They have joint performance monitoring frameworks on WASH and nutrition.

Analysis of Stakeholder RolesAn analysis the roles and potential contributions to these long term changes of the UN agencies, Government, and NGO community maps out the stakeholder opportunities for influencing change.

The UN has a role to play to support government institutions and development/support of systems. The changes needed within the UN community

in Cambodia are, better integration of WASH and nutrition, analysis, planning, common M&E framework and bottleneck analysis through:

Emphasis is to support government institutions with shift towards less service delivery and more upstream support. When Working a service delivery area focus on capacity building, doing programming to scale and strengthening systems

New C4D, need to apply communication efforts not just at the community level but also the bigger picture.

More engagement with the private sector Innovative engagements Knowledge management – document for building the evidence base and

NGO currently engages and supports in national technical working groups, provincial networks, health centre management committees and commune development planning. The opportunities for influencing change in WASH/nutrition are:

Provide a collective voice in advocacy via appropriate bodies such as SUN, CSA; build joining messaging from the NGO group

Extend multisectoral bodies (such as SUN, CSA) to provincial level Continuing good practice in health, support provincial department of

rural development (PDRDs) to learn from learn from good practice Ensure good practice is consistent from one province to another through,

amongst other, documentation and sharing Work with national committee for decentralisation (NCDD) and CCC to

ensure NGOs all understand their role in commune/district/provincial development planning and actively participate.

Individual NGOs take action to participate, share information, and support a quality process (and advocate for WASH & nutrition).

Collaborate, plan, monitor together better Co-locate WASH and nutrition projects, share information at all levels.

Government currently works with national level policy, strategy and coordination through technical working groups. There is a newly established sub-working group on WASH and nutrition but no strategy for integrated WASH and nutrition. At the sub-national level the government works through Line departments, subnational administrations, local administration and CBOS. The opportunities for the government in influencing change in WASH/nutrition are:

Developing a Joint Statement/Strategy on WASH and Nutrition Integration

Shift so that donors and other stakeholders fund and implement programme within the umbrella of Government plans

Reinforce/widely disseminate policy and strategies Joint performance monitoring framework and work plans Appoint one body to lead (such as CARD with strengthening the WASH

and nutrition SWG) Strengthen and reactive working groups at the subnational level Link commune level groups (CIP and CDP) (CCWC and HCMC)

Realistic Changes by 2023Realistic changes, or goals, that stakeholders together can achieve because of our work by 2023

a) Sector stakeholders can demonstrate how and where resources have been invested in WASH and nutrition, what worked, what the remaining gaps are, and describe the roles of all actors in the past and future. This enabled more PLW and U2s to benefit from effective interventions to improve healthy practices and receive quality services.

b) More effective and appropriate technological solutions are being implemented at scale

c) Most of the communes and social service providers are investing in key interventions and this improves WASH and Nutrition practices by PLW, young children and caregivers.

d) More community leaders who are facilitating WASH and nutrition behaviors and practices fully participate and receive recognition from higher government.

e) Pregnant and lactating women (households) fully understand and are able to adopt good hygiene and nutrition practices using safe water, positively affects child health and growth.

Key areas of changeInitially the UN and NGOs have some in-house preparatory work to enable them to move forward adequately with integrated WASH and nutrition programming. This work will enable them to work effectively with government at different levels so that government systems policies and structures are in place and ready to support and facilitate integrated programming through implementation channels. The complementary platforms will work effectively to achieve positive results for women and young children. More work needs to be done on detailing how implementation will work in practice but preliminarily implementation channels have been identified as:1. Community Channel

a. CCWC/communeb. CBO/private sectorc. Religious leadersd. VHSG

2. Health System Channela. Public Privateb. Hospital/primary care

3. Communication Channela. Mediab. Inter personal communicationc. Road shows

4. Provincial government bodiesa. Buy in

Ways of WorkingUndernutrition is determined not only by nutrient intake, but equally by nutrient loss. A vicious cycle exists between diarrhoea and undernutrition: children with diarrhoea eat less and are less able to absorb the nutrients from their food; malnourished children are more susceptible to diarrhoea when exposed to faecal material from their environment. Inadequate access to clean water and unsafe sanitationand hygiene practices increase the risk of severe infectious diseases that can contribute to undernutrition. There is strong evidence that improved water and sanitation conditions are associated with a decrease in stunting.

For long-term changes to occur the government of Cambodia has the ultimate responsibility and authority; therefore the UN and NGO community needs to support the government to enable sustainable change. The stakeholders committed to integrating nutrition and WASH programming have chosen to collectively assist the government to develop systems and structures that will enable the implementation of programming that will make a difference for the nutritional outcomes of young children.

The main points of intersection for WASH and nutrition programming within the Cambodia context is currently thought joint analysis, coordination, planning at national and sub-national level, implementation and monitoring. In addition there needs to be an enabling environment of policy and strategies and effective advocacy as needed.

Key AssumptionsA summary of the key assumptions that have been made, and how they can be tested throughout the lifetime of the programme, are below.

Assumptions Testsa) There will be political will to push

WASH and nutrition at top of agenda. If we produce a strong argument with evidence, costing and budget, the MEF will allocate more budgets.

Further analysis of budget allocation, process, practices of MEF, national development plans

Assessing the quality of argument/costing

b) Sufficient human resources are available at sub-national level to implement interventions.

Capacity for gap assessment for sub-national and community level

Assessment of the planning for decentralization and deconcentration of MRD and MoH and level of alignment with our interpretation of the roles and responsibilities of these actors.

c) Community level actors are motivated and incentives

Review of real motivation of community leaders/actors and how these match with our proposed interventions

Assessment of existing incentive schemes for village level actors and their efficacy, efficiency and sustainability.

d) Communication messages will lead to behavior change

Ensure regular and rigorous monitoring of the quality of our communication messages and research impacts.

e) Monitoring systems are effective and functioning.

f) Integration yields better results on stunting

Design and evaluate integrations versus convergence versus business as usual.

g) Private sector is an active participant across the country

Private sector solutions prove viable and profitable through FGDS and interview

h) Piloted models are sustainable and can be scaled up.

Analysis of resources needed, political commitment at various levels and cost-effectiveness of various components of the piloted methods.

i) The stakeholders around which the long-term goals are built are complete

Revisit the ToC on a regular basis for validation at all levels in relation to all parts of the country (systemic review)

j) Assume that the government increases the budget for WASH and nutrition

Look at budget allocation

k) There is capacity at subnational government bodies level

Screening capacity of sub-national structure and staff

Planning translated into budget Joint M&E mechanism

l) We assume that there are clear coordination platforms to coordinate cross-sectoral stakeholders

Clear TOR Clear action-plan

m) Timely synchronization of supply and demand is taking place.

Define framework with benchmarks;

develop operational guidelines with what who when and how

Follow on the implementation and feedback/fine-tuning to

n) Commitment, political will and funds agreed and on the priorities o from government and development partners

Coordination with strong timelines USE CARD as a

mechanism/platform to engage higher level participation and stimulate dialogue

Consolidate workplan developed by gov’t and development partners and review progress quarterly

o) Active participation and support from Commune Council and Health Workers community

Use existing group to provide feedback on the interest to be engaged (select communities)

Support case studies Identify synergy/success stories Check the increase of dynamic

groups engagement

Moving Forward

WHAT WE NEED TO DO FOR EFFECTIVE LEARNING & ACCOUNTABILITY Benchmarks developed SWG made accountable to benchmarks Defined parameters for how we work together Development of monitoring frameworks together Need formal mandate for SWG Regular schedule for reviewing and annual review Assigned focal points for reviewing and reporting back Feed in the review into the regular joint planning/review of SWG annual

workplan Continue elaboration of ToC and priority actions Annual review of ToC Connect the annual ToC review with benchmarks and indicators From now until 2019 further develop and test the ToC Funds needed for CARD to lead on the development and ownership of the

ToC Guidelines/outline for how to operationalize joint WASH & nutrition

programming to be developed Committee of key players to new ways of working

HOW WE ARE GOING TO MOVE THIS FORWARD Further map out why the WASH and nutrition programming currently on-

going in Cambodia isn’t working through methods such as bottleneck analysis. This will provide a stronger platform of evidence to build from.

Understand what implementation channels are needed for integrated WASH and nutrition programming so as to map the challenges and develop plans.

Need to develop benchmarks/milestones and indicators to measure progress along the pathways sequence.

Consider how to bring the private sector into the conversation Use government indicators/platforms (JMI) as an opportunity to bring efforts

together UNICEF and CARD to work on the draft Theory of Change from the workshop

and present to SWG for more consultation (open to other motivated people/org who want to contribute and/or representative of NGO/CSOs)

CARD proposes a training of trainers of ToC to adopt and propagate the methodology, even for application to other sectors.

In 2019 (when the next national cycle begins and more local evidence and results are available) would be a good time to establish a results framework.

Identify individual actions (as agencies/individuals) that will contribute to progressing joint programming with reference to the framework of the ToC.

Develop active plan for engagement of more partners Next meeting of the SWG (February 19) the ToC learning and process will be

shared with partners Document experiences with integrating WASH and nutrition programming so

that Cambodia can ‘show by doing’.

Annex 1: Assessment Matrix for Quality ToC