Water is invaluable: A health perspective from the global program to eliminate trachoma

21 Mar 2021 
“Clean Face: Healthy Eyes!” A young girl in Amhara, Ethiopia washes her face with soap and water, because facial cleanliness is key to fighting trachoma. With support from the Lions/Carter Center Sight First Initiative, the Amhara Regional Health and Education Bureaus have implemented a state-wide school-based health education program, teaching the next generation how to prevent trachoma. Photographer: Kenya Casey

Access to clean water is invaluable. It is essential to almost every aspect of human life, from food and culture, to education, the natural environment, and, of course, our health. Sadly, water scarcity and poor access to clean water is common, affecting 2.2 billion of the world’s poorest populations. This exacerbates the consequences of poverty, including the spread of neglected tropical diseases (NTD), such as trachoma, the world’s leading infectious cause of blindness.

The trachoma community has long advocated for comprehensive cross-sectoral approaches to achieve and sustain the elimination of trachoma as a public health problem. Since 1993, increased efforts have been made to scale up all components of the World Health Organization-endorsed SAFE (surgery, antibiotics, facial cleanliness, and environmental improvement) strategy. The facial cleanliness and environmental improvement interventions include building clean water sources and toilets as well as promoting healthy hygiene behaviours alongside the delivery of surgery and antibiotics to achieve and sustain trachoma elimination targets.

In addition to the focus on promoting healthy hygiene behaviours, national trachoma programmes have also strengthened cross-sectoral collaboration in recent years, through an increased focus on using water, sanitation and hygiene (WASH) and NTD data for decision making. Notably, new efforts have been made to transform data into knowledge by aggregating data across the WASH and NTD sectors thus enabling better coordination, integration and opportunities across the two sectors. This includes improved prioritization of resources and targeting WASH and NTD implementation to areas with the highest burden of disease and low access to water and sanitation services.   

Cross-sectoral collaboration has been supported by increased political will across a range of countries. Notably, in 2019, Ethiopia published Tackling neglected tropical diseases through water, sanitation and hygiene: A national framework to guide integrated programmes in Ethiopia. Through this framework, Ethiopia has transformed its approach to NTDs by integrating WASH data into the NTD databases, recognising that NTDs are often a marker of the challenges in providing universal access to improved water and sanitation services.

A boy in Ethiopia washes his face. Photo by International Trachoma InitiativeCombined WASH and NTD data presented to Ethiopia’s ONE WASH National Coordination Office in highly accessible, visual formats, contributed to NTDs being considered as part of several criteria used for allocating WASH resources to districts. This means that the NTD burden now has a level of influence on where WASH infrastructure projects will take place, helping direct resources to support districts that are most in need of NTD support. 

In Nigeria, an alternative approach has been taken to include NTD data into the national WASH database - the WASH Information Management System (WAHIMIS). This has contributed to the development of combined WASH and NTD indicators for inclusion in the data collection tools in the WASH National Outcome Routine Mapping Survey (WASH-NORM) - a routine WASH data collection tool in Nigeria. Having these combined indicators supports advocacy of WASH and NTD coordination, prioritization of enumeration units for investment and implementation to further promote desired hygiene behaviours. 

In January 2021, the World Health Organization launched ‘Ending the neglect to attain the sustainable development goals: a road map for neglected tropical diseases 2021–2030’. The road map calls for the intensification of cross-cutting approaches by integrating interventions for several NTDs and mainstreaming them into national health systems, coordinated with related programs, including WASH. The road map includes specific indicators for WASH, including 100% of population using at least basic water supply by 2025, and 100% of population with hand-washing facilities, including soap and water by 2030. 

A community member in a village in the Indian state of West Bengal washes her face in the courtyard outside her home, while her neighbor sweeps the communal area. Photographer: Avijit GhoshTo mark World Water Day, today the World Health Organization launched an updated global strategy for WASH and NTDs, to help countries achieve WASH and NTD targets via targeted, multi-sectoral collaboration between the WASH, NTD and other aligned sectors, including education. The strategy includes four key action areas: 1) increasing awareness of co-benefits of WASH and NTD partnerships, 2) joint use of WASH and NTD data to highlight inequalities, target investment and track progress, 3) strengthen evidence and establish best practice on integrated approaches to NTDs, and 4) joint planning, delivery and evaluation of programs.

The NTD and WASH communities have several key resources and preferred practices to facilitate the development and strengthening of new and existing partnerships to achieve shared targets across WASH and NTDs. “All you need for F&E”, a toolkit published by the International Coalition for Trachoma Control in 2015, aims to strengthen coordination and maximize impacts in the field by supporting program managers working on tackling trachoma to engage water, hygiene and sanitation partners. Building on the use of the F&E toolkit, in 2019, WHO and the Neglected Tropical Disease NGO Network released “WASH and health working together: A how to guide for NTD programmes”, which provides step-by-step advice on how to engage and work collaboratively to improve the delivery of WASH interventions to underserved populations. The toolkit has now been implemented in a number of countries including Benin, Ethiopia, Liberia, Uganda, Kenya, Nigeria, Sierra Leone, and Tanzania.

The interconnectedness between WASH and health has received increased attention over the past year. The COVID-19 pandemic has catapulted interventions, such as handwashing, back into the mainstream public discourse. However, without universal access to clean water and sanitation, we will not achieve universal health coverage, which will impact our ability to control and eliminate diseases from COVID-19 to trachoma and beyond. Going forward, we must continue to advocate for better coordination across sectors, through country-led, impact-orientated programs to ensure that we tackle the environmental determinants of health and ensure that we both achieve and sustain the elimination of trachoma as a public health problem.

This blog was developed with contributions from:

  • Leah Wohlgemuth, Sightsavers, NNN WASH Working Group
  • Kelly Bridges, Global Water 2020, NNN WASH Working Group
  • Tim Jesudason, International Coalition for Trachoma Control