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WASH/NTD ROUNDTABLE DISCUSSION
Finding Synergies between Water, Sanitation, and Hygiene (WASH) and the Control of Neglected Tropical Diseases (NTDs):
Practical Considerations to Collaboration between the WASH and NTD Sectors
Discussion Report, Jan. 2013
EXECUTIVE SUMMARY
Thirty members of the WASH and NTD sectors convened for a two-day roundtable discussion
hosted by the Bill and Melinda Gates Foundation in December 2012. The objectives of the
Roundtable were to identify common goals, acknowledge past challenges, identify barriers to
collaborative efforts, and discuss practical opportunities for collaboration and mutual benefit. This
dialogue was a part of an ongoing series of discussions between the WASH and NTD sectors in 2012
to identify opportunities for engaging jointly to ensure “communities have adequate and equitable
access to WASH and are disease free.”
Challenges to past collaboration between the two sectors were acknowledged, including: different
assumptions and approaches, different relationships with donors, and conflicting operational
characteristics such as implementation timelines and cost structures. Participants worked in small,
mixed groups and collectively defined practical opportunities and realistic next steps in the short-,
medium-, and long-term, in the following areas: advocacy, policy, and communications; capacity
building and training; mapping, monitoring, and data collection; and research
Immediate and actionable next steps between the WASH and NTD sectors, determined at the
conclusion of this Roundtable discussion, include: publication of Roundtable outcomes in an
academic journal as well as in various policy forums; inventory of overlapping sector key
messages; creation of a virtual space and electronic information hub to facilitate future dialogue
between the WASH and NTD sectors; a survey of research priorities; and continued dialogue in
upcoming and future sector discussions. This report details specific opportunities discussed.
I. INTRODUCTION
The Bill & Melinda Gates Foundation (BMGF) hosted a roundtable discussion in Seattle, Washington
on December 6-7, 2012 to engage diverse perspectives on the subject of “Finding Synergies
between Water, Sanitation, and Hygiene (WASH) and the Control of Neglected Tropical
Diseases (NTDs): Practical Considerations to Collaboration Between the WASH and NTD
Sectors.” Thirty participants, representing research institutions, private philanthropy, bilateral aid,
and non-governmental organizations (NGOs), attended the roundtable, which was organized jointly
by BMGF, Emory University’s Center for Global Safe Water, and The Task Force for Global Health’s
International Trachoma Initiative and Children Without Worms programs. A full participant list
can be found as Appendix A. This Roundtable was an in-depth follow-up to symposia held at the
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UNC Water and Health Conference in Oct 30th, 2012, and at the American Society of Tropical
Medicine and Hygiene Conference on Nov 12th, 2012.
The neglected tropical diseases (NTDs) are a group of chronic, disabling infections that affect over
one billion people worldwide - primarily poor populations living in tropical and subtropical
climates. Children are particularly vulnerable to infection. The WHO lists 17 diseases within the
NTD group. These diseases have been largely eliminated in areas of the world with improved living
conditions (i.e., access to basic sanitation, drinking water, and adequate housing) and hygiene.
The primary strategy for controlling the NTDs has been the use of preventive chemotherapy (PCT),
delivered via mass drug administration (MDA) campaigns in highly endemic areas. However,
treatment alone is unlikely to break the cycle of transmission; improvements to WASH are essential
to achieving sustained control of disease in the medium and long terms. Hence, the need to identify
the most effective, sustainable, and scalable methods of integrating WASH and NTD control
activities, as well as the need to build a strong evidence base for collaborative programming. This is
especially true for programs dedicated to the control of trachoma, schistosomiasis, and soil-
transmitted helminths, whose transmission is dramatically impacted by WASH conditions.
The World Health Organization’s 2020 goals for NTD control emphasize the need for progress
towards both treatment and prevention of the NTDs. There are some efforts to incorporate WASH
infrastructure and messaging into NTD control programs, and disease-specific guidelines do include
recommendations for WASH implementation to be conducted in conjunction with MDA. However,
there has historically been little collaboration between NTD control programs and the WASH sector
at either the national or international levels. With some notable exceptions, WASH organizations
do not typically complement their programs with MDA, while a majority of NTD control programs
do not explicitly incorporate WASH improvements.
The objectives of this Roundtable discussion were twofold: 1) to identify programmatic synergies
between the WASH and NTD sectors, including opportunities for mutual benefit and next steps
toward practical collaboration; and 2) to identify and prioritize knowledge gaps, and define
operational research that contributes to a common vision between both sectors.
Discussion was designed to be interactive - to stimulate debate between participants and promote
exchange across sectors. Brief introductory presentations were conducted to ensure that all
participants had basic knowledge of the neglected tropical diseases, the NTD control programs,
WASH program priorities, strategies, and challenges. Plenary group discussions focused on case
studies of past successes and challenges to collaborative efforts between the WASH and NTD
sectors, and subsequent small group discussions focused on identifying specific opportunities and
next steps that provide benefits to both sectors.
On Day 1 of the workshop, participants acknowledged barriers to collaboration between the two
sectors. Participants then worked in small, mixed groups and collectively defined practical
opportunities and realistic next steps in the short, medium, and long terms. The list of these
opportunities is provided as Appendix C.
On Day 2 of the workshop, opportunities previously discussed were grouped by theme.
Participants self-selected into one of four main groups to further explore opportunities and next
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steps in the following areas: advocacy, policy, and communications; capacity building and training;
mapping, monitoring, and data collection; and research.
The following report describes specific discussion outputs and next steps. Sections II (A) and II (B)
of this report detail lessons learned from past collaborations, as well as a common long-term vision
defined between the two sectors as discussed on Day 1. Section II(C) describes opportunities for
collaboration, arranged thematically, as discussed on Day 2. Section II (D) lists immediate and
actionable next steps as agreed during the Roundtable conclusion. The Roundtable agenda and
participant list are provided as appendices.
II. DISCUSSION OUTPUTS AND NEXT STEPS A. Case studies: Challenges must be recognized and overcome
Past collaboration between the WASH and NTD sectors at various levels has met with mixed results.
Participants discussed five case studies of past and current collaboration between the WASH and
NTD sectors, and developed a number of key lessons learned (below). Overall discussion suggested
that inherent challenges to collaboration will have to be better articulated, and concrete
mechanisms developed to overcome them.
1) Several collaborations at the district level have helped the WASH sector to target implementation
in communities where disease burden is highest, thereby increasing the visible impact of the WASH
sector. However, these collaborations have been largely ad hoc and minimally formulated and have
not led to more sustainable collaborations.
2) Schools have proved to be valuable venues for collaboration between the WASH and NTD
sectors; in Kenya, coordinated deworming and WASH interventions in schools have created
opportunities for shared resources and oversight. However, competition for time and resources
from the Ministry of Health has proved a formidable challenge.
3) Increasing funding for and support of joint WASH and NTD control relies, in part, on raising
awareness among donors, as well as increasing global awareness. Innovative outreach projects in
U.S. public schools have been successful in raising the awareness of the WASH role in preventing
disease worldwide. However, little investment has been made to consistently sustain these efforts.
4) Collaborative research in Ivory Coast, Kenya, and Bangladesh highlight the potential for more
effective and rigorous impact assessment of WASH interventions on NTDs, but have been
constrained by slow movement of WASH implementation and community-based development.
B. Group discussion: Defining common vision and mutual benefits
Successful collaboration between the WASH and NTD sectors depends on commitment towards a
shared vision between the two sectors, as well as measurable benefit towards each sector’s
principle goals. The group defined a common long-term vision as the following; both sectors
envision disease-free communities that have adequate and equitable access to water, sanitation, and
hygiene.
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In order to sustain collaboration, benefits for both sectors must be clearly articulated and concrete.
While the NTD sector is dependent on WASH improvement for the control of the NTDs, the WASH
sector is not mutually dependant on the NTD sector; WASH organizations rarely justify their work
based on disease control. Many WASH organizations emphasize a rights-based approach. The
question was raised by discussion participants: why should the WASH sector implement in areas
designated by the NTD sector, rather than other marginalized areas?
C. Small group discussion: Specific Opportunities and Next Steps
Ideas raised in discussions on Day 1 were organized by theme with direction from the plenary.
Participants self-selected into one of four main groups to further discuss the top short and long-
term priorities and next steps. The joint vision was defined as “communities that have adequate
and equitable access to WASH, and are disease free.” Groups defined specific opportunities and
next steps, and defined how opportunities contributed to the overall vision. The sections below
summarize the opportunities and next steps in each thematic realm.
1. Advocacy, Policy, and Communications
Contribute to the overall vision by helping to: engage policy makers and donors; and create platforms
for continued dialogue, harmonized messages, joint advocacy, and shared knowledge on issues of joint
WASH and NTD concern.
Opportunities and Next Steps in Advocacy:
Develop coherent and aligned WASH and NTD messages for specific audiences: create a subgroup to create advocacy action plan and conduct an inventory of existing material and gaps
Better engage with Pharma: include WASH/NTD information in calls and reports to Pharma donors
Develop a Congressional briefing on WASH/NTDs
Reach out to non-traditional donors
Pilot demand generation strategies in 2-3 countries
Reframe the needs between WASH and NTD sectors based on cost and impact, and communicate appropriate evidence base
Create a list of messages donors would like to be able to impart and linking appropriate research
Provide programmatic guidance to USAID WASH and other organizations
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2. Capacity Building and Training
Contribute to overall vision by identifying and addressing capacity gaps within stakeholders from each
sector and creating information exchange mechanisms between the WASH and NTD sectors.
Opportunities and Next Steps in Capacity Building and Training:
Conduct inventory of existing training materials to determine gaps as well as common messages
Create an open-source format for sharing data, materials, resources, and research
Co-produce and share resources between the sectors: one manual on WASH in Schools authored by all partners.
Establish forums at the national level in endemic countries to identify specific needs and take advantage of existing initiatives
Begin dialogue at the national level in select pilot countries to identify and address specific capacity gaps
Revise indicators for success in capacity building and training to reflect quality, relevance, and integration with existing mechanisms and forums
Provide input into the creation and dissemination of WASH/NTD manuals currently being developed jointly by International Trachoma Initiative, Children Without Worms, and Emory University
*Wins for the WASH and NTD sectors are shared operational costs invested in training and capacity
building. The need to use existing infrastructures, rather than form new structures for collaboration,
was highlighted.
3. Mapping, data collection, and monitoring
Contribute to the overall vision by helping to more effectively target program interventions, measure
impact, and monitor progress.
Opportunities and Next Steps in Mapping, Data Collection, and Monitoring
Create a centralized resource for all available maps and data related to WASH and NTDs, e.g., a website to host mapping resources and provide links to the disparate sites where data already exists regarding WASH and NTDs separately or together
Compile a list of indicators currently used by the WASH and NTD control programs respectively, and determine gaps
Establish common indicators for WASH and NTDs, realistic to mapping efforts
*Challenges of scale (unit of analysis), availability, and access to maps of NTDs and WASH must be
overcome, and current WASH and NTD indicators share limited usefulness and overlap. These issues
quickly to take advantage of current NTD mapping efforts such as trachoma and schistosomiasis
mapping in Ethiopia, and incorporate WASH indicators.
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4. Research
Contributes to the overall vision by linking research to advocacy, helping to identify gaps and barriers
to collaboration, improve impact of WASH and NTD control programs.
Opportunities and Next Steps in Research:
Conduct survey of research priorities, and publish findings in public domain
Identify donors for collaborative research
Match research questions with advocacy needs
Determine costs of WASH and additive value for NTD control, nutrition, etc.
Adjust the quality of research to the audience/end use
Conduct more research regarding drivers of WASH behaviors and impacting behavior change
* An inventory of research priorities among discussion participants and programs is planned as follow-
up to this Roundtable Discussion.
D. Plenary: Next Steps
Specific opportunities within the thematic realms must be further explored during subsequent
discussion. Overall next steps focus on enabling continued dialogue, and broadening the discussion
to include relevant stakeholders at national and international levels. Immediate next steps were
determined to be the following:
1. Publish Roundtable findings in one academic journal (i.e. PLOS NTDs) and various
policy forums
2. Expand dialogue between the WASH and NTD sectors at the national and
international levels
3. Create a community of practice and a virtual space for continued dialogue.
4. Foster national-level dialogue and pilot collaborative efforts in select countries such
as Ethiopia, Kenya, or India
5. Inventory, develop, and consolidate overlapping key messages from each sector
III. CONCLUSION This Roundtable dialogue was a part of an ongoing series of discussions between the WASH and
NTD control sectors in 2012. The goal of the dialogue was identify opportunities for collaboration
and ensure progress towards overlapping goals. Challenges to past collaborations were
acknowledged. Different assumptions and approaches, different reporting structures, different
levels of donor dependence, and conflicting operational characteristics are potential barriers to
future collaboration. To overcome these barriers, the benefits of collaboration for each sector need
to be clearly established and communicated.
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Roundtable participants collectively defined practical opportunities for collaboration between the
WASH and NTD sectors in key areas, in the short, medium, and long terms. The following
immediate next steps were identified:
Publication of Roundtable outcomes in an academic journal article as well as in various
policy forums;
Inventory and consolidate overlapping sector key messages;
Creation of information exchange mechanisms between the WASH and NTD sectors and a
virtual space for continued dialogue;
Survey of research priorities;
Continued dialogue in upcoming and future sector discussions.
Each of these actions will be reported back to the Roundtable group and extended community
throughout 2013. The Task Force for Global Health will develop and moderate a virtual space for
continued dialogue between the two sectors, and between Roundtable participants.
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APPENDIX A: Participant List, WASH/NTD Roundtable Discussion Dec. 6-7, 2012 Bill & Melinda Gates Foundation Campus, Seattle, WA
Name Organization Contact
1 Alan Fenwick Schistosomiasis Control Initiative, Imperial College London
2 Alix Zwane Bill & Melinda Gates Foundation [email protected]
3 Anupama Tantri Global Network for Neglected Tropical Diseases
4 Brooks Keene CARE [email protected]
5 Chad McArthur Helen Keller International [email protected]
6 Colin Beckwith International Trachoma Initiative [email protected]
7 Dan Abbot Save the Children: School Health and Nutrition
8 Darren Saywell Plan International [email protected]
9 Dr. Asrat Amnia Emory University and formerly Bureau of Health, Amhara, Ethiopia
10 Gagik Karapetyan World Vision [email protected]
11 Helen Petach USAID [email protected]
12 Jack Colford UC Berkeley/WASH Benefits [email protected]
13 Jack Grimes Imperial College London [email protected]
14 Jan Willem Rosenboom
Bill & Melinda Gates Foundation [email protected]
15 Julie Jacobson Bill & Melinda Gates Foundation [email protected]
16 Juerg Utzinger Swiss Tropical and Public Health Institute
17 Kerry Gallo Children Without Worms [email protected]
18 Lisa Schechtman WaterAid USA [email protected]
19 Matthew Freeman Emory University [email protected]
20 Patrick Lammie CDC [email protected]
21 Peter Lochery CARE [email protected]
22 Rafael Callejas Millennium Water Alliance [email protected]
23 Rebecca Fishman WASH Advocates [email protected]
24 Rosalyn Rush Bill & Melinda Gates Foundation [email protected]
25 Sandy Cairncross London School of Hygiene and Tropical Medicine
26 Sarah Herr Bill & Melinda Gates Foundation [email protected]
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27 Sarina Prabasi ORBIS, previously WaterAid [email protected]
28 Shaheen Kassim-Lhaka The Hilton Foundation [email protected]
29 Sharon Roy CDC [email protected]
30 Stephanie Ogden Emory, Children Without Worms, International Trachoma Initiative
31 Yael Velleman WaterAid UK [email protected]
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APPENDIX B: Agenda ROUNDTABLE DISCUSSION Finding Synergies between Water, Sanitation, and Hygiene (WASH) and the Control of Neglected Tropical Diseases (NTDs): Practical Considerations to Collaboration between the WASH and NTD Sectors
Roundtable Objectives:
1. To identify programmatic synergies between the WASH and NTD sectors, opportunities for mutual
benefit and support of common goals, and next steps toward practical collaboration.
2. To identify and prioritize knowledge gaps and operational research questions that will directly impact
programs, as well as innovative research that contributes to new ways of approaching WASH and NTD
sector goals.
Agenda:
December 6, 2012
Time Topic Items Format
9-9:30 am Introduction • Impetus for this conversation • Overview of past conversations and outputs • Roundtable goals and protocol
9:30 – 10:30 NTD Sector: What do we do
and how do we operate?
• Briefly review NTD impact, & WASH impact on NTDs • Review elements of NTD control programs
Presentation
Activity
10:30-11:00 Coffee Break
11:00 – 11:45 WASH Sector: What do we do
and how do we operate?
• Briefly review primary WASH sector goals, approaches, and indicators
Presentations
Activity
11:45 – 12:30 Setting the Stage: Defining
visions of success
• Describe commonalities and common goals as framework for discussion
• Define assumptions and what constitutes ‘collaborative opportunities’
Large group
facilitated
discussion
12:30 – 1:30 Lunch
1:30 – 2:30 Illuminating gaps: What don’t
we do? What don’t we know?
• Utilize case studies of past collaborations to understand success, barriers to collaborations, program and knowledge gaps that need to be addressed
Small group
discussions
2:30 – 4:00 Brainstorming opportunities,
strengths and weaknesses
• Describe opportunities for collaboration within the context of sector strengths and weaknesses:
- Short-term, medium-term and long-term opportunities
Small groups
4:00 -4:30 Break
4:30 – 5:15 Reporting back and prioritizing • Small groups report back to larger group. Prioritize short term, medium term and long term opportunities
Large group
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opportunities
5:15 pm Closing Day 1
6:30 – 8:30 pm Dinner and Drinks Hosted by International Trachoma Initiative
December 7, 2012
Time Topic Description Format
9:00 -9:30 Introduction • Summary of Day 1 and refocusing
9:30 -11:00 Practical considerations to
opportunities: WASH can
contribute/NTDs can contribute
• Brainstorming opportunities in different thematic realms: Short and long term opportunities and clearly articulating benefits to each sector
Small Groups
11:00-11:30 Coffee Break
11:30-12:30 Reporting Back: • Propose detailed programmatic and research opportunities to the larger group
• Prioritize opportunities as a group according to feasibility and interest
Group
presentations, and
Large group
discussion
12:30 – 1:30 Lunch
1:30 – 2:30 Defining practical next steps • Describe next steps for each of the prioritized opportunities in the short and long terms.
Group
presentations, and
large group
discussion
2:30 – 3:30 Conclusion • Summary of programmatic next steps and relevant research questions
• Define overall next steps, venues for continued dialogue, and metrics for success
3:30 pm Closing and departure of guests
with pm flights
3:30 – 5:00 Coffee break and Discussion • Continued discussion with remaining participants
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APPENDIX C: Day 1 Discussion Output: Opportunities in the short, medium, and long-term
Opportunities in the short-term
Advocacy
Encourage dialogue between stakeholders at the national level.
Choose 3 countries where WASH and NTD sectors can support pilot dialogue: (e.g..
Ethiopia, India, Kenya)
Continue the WASH and NTD dialogue at upcoming and future meetings
Revise the WHO NTD resolution to include WASH, and update the WASH sector’s health
strategy to explicitly include NTDs
Jointly engage the sectors in ‘hook’ days of mutual importance, such as Global
Handwashing Day.
Capacity building and
training
Create consolidated and consistent messages for practitioners: WASH sector should
together agree on NTD messages, and NTD sector should together to agree on WASH
messages
Mapping and data
collection
Conduct joint mapping where possible to leverage on-the-ground resources and minimize
costs
Create mutual indicators to track progress towards mutual goals
Donor Advocacy Educate donors of the benefit and importance of WASH and NTD collaboration
Advocate for structural changes and revised reporting mechanisms within the WASH
sector, supported by donors, to better incentivize WASH sector inclusion of NTDs (and
change of approach).
Communications Develop key messages for each sector
Provide input into the online manual and course for integrating NTDs into WASH
(currently in development: to be available December 2013).
Integrate messages into existing resources rather than creating new resources
Incorporate WASH dialogue into upcoming NTD events and meetings, and vice versa
Opportunities in the medium-term
Research Gather new evidence of impact of WASH on NTD control
Better communicate existing evidence
More clearly direct the evidence to the intended audience
Gain a better understanding of how current WASH and health promotion is being
conducted
Take better advantage of natural experiments; conduct research where both WASH and
NTD control are happening on the ground
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Opportunities in the medium-term
Local Coordination More effectively coordinate at the district level to utilize existing structures for both
WASH improvement and NTD control
Mapping and data
collection
Make WASH and NTD mapping and other data available through a central repository
Establish the right indicators, and collect the right data
Conduct routine data collection and monitoring
Policies and programs Match up goals and timing of WASH and NTD interventions to identify quick wins towards
mutual goals
Ensure that NTD programs have/utilize baseline WASH data from their onset
Pilot and investigate step wedge implementation so that impact can be measured against
natural, temporary control groups
Leverage funds from other sectors, (i.e. agricultural sector in the development of water
supply systems and water management institutions)
Create a strategy for incorporating nutrition into WASH/NTD control to better ensure
holistic health gains
Communications Collaborate on joint/consolidated hygiene messages; hygiene education is both an area of
overlap, but also an area of relative neglect
Advocacy More effectively disseminate data to inform advocacy and create awareness at the
national level
Participate in WASH/NTD advocacy networks
Opportunities in the Long-term
Policies and Programs Define an overlapping long-term vision. “We as the WASH and NTD sectors envision a
world where everyone has equitable and adequate access to water and sanitation, and is
free of disease.”
Create a single plan that includes both development and health that shows links between
the WASH and NTD programs
Start in schools, where WASH and NTD interventions can utilize the same platform to
reach the shared target of school-age children. Define medium-term vision as: all schools
have quality sustained WASH facilities with NTD control activities (treatment and health
education)
Broaden the concept of WASH to consider agricultural uses of WASH; linking agriculture
with health
Research More strongly link poverty and economic development to WASH/NTDs and advocate
accordingly
Mapping and data
collection
Conduct appropriate monitoring to ensure progress towards short, medium, and long-
term visions