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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

a.fenwick@imperial.ac.uk

2 Alix Zwane Bill & Melinda Gates Foundation alix.zwane@gatesfoundation.org

3 Anupama Tantri Global Network for Neglected Tropical Diseases

anupama.tantri@sabin.org

4 Brooks Keene CARE bkeene@care.org

5 Chad McArthur Helen Keller International cmacarthur@hki.org

6 Colin Beckwith International Trachoma Initiative cbeckwith@taskforce.org

7 Dan Abbot Save the Children: School Health and Nutrition

dabbott@savechildren.org

8 Darren Saywell Plan International darren.saywell@planusa.org

9 Dr. Asrat Amnia Emory University and formerly Bureau of Health, Amhara, Ethiopia

asrat.amnie@gmail.com

10 Gagik Karapetyan World Vision gkarapetyan@worldvision.org

11 Helen Petach USAID hpetach@usaid.gov

12 Jack Colford UC Berkeley/WASH Benefits jcolford@berkeley.edu

13 Jack Grimes Imperial College London jack.grimes10@imperial.ac.uk

14 Jan Willem Rosenboom

Bill & Melinda Gates Foundation janwillem.rosenboom@gatesfoundation.org

15 Julie Jacobson Bill & Melinda Gates Foundation Julie.jacobson@gatesfoundation.org

16 Juerg Utzinger Swiss Tropical and Public Health Institute

juerg.utzinger@unibas.ch

17 Kerry Gallo Children Without Worms kgallo@taskforce.org

18 Lisa Schechtman WaterAid USA Lschechtman@wateraidamerica.org

19 Matthew Freeman Emory University mcfreem@emory.edu

20 Patrick Lammie CDC pjl1@cdc.gov

21 Peter Lochery CARE lochery@care.org

22 Rafael Callejas Millennium Water Alliance rafael.callejas@mwawater.org

23 Rebecca Fishman WASH Advocates rfishman@washadvocates.org

24 Rosalyn Rush Bill & Melinda Gates Foundation Rosalyn.rush@gatesfoundation.org

25 Sandy Cairncross London School of Hygiene and Tropical Medicine

sandy.cairncross@lshtm.ac.uk

26 Sarah Herr Bill & Melinda Gates Foundation sarah.herr@gatesfoundation.org

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27 Sarina Prabasi ORBIS, previously WaterAid sarina.prabasi@orbis.org

28 Shaheen Kassim-Lhaka The Hilton Foundation shaheen@hiltonfoundation.org

29 Sharon Roy CDC str2@cdc.gov

30 Stephanie Ogden Emory, Children Without Worms, International Trachoma Initiative

sogden@taskforce.org

31 Yael Velleman WaterAid UK yaelvelleman@wateraid.org

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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