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WaterAid response to consultation on the draft work programme of the UN Decade of Action on Nutrition 2016-2025

WaterAid welcomes the transparency of the planning of the UN Decade of Action on Nutrition 2016-2025 (hereafter the Nutrition Decade) and the opportunity to comment on the draft work programme.

We warmly welcome the draft work programme’s emphasis on the need to convene, coordinate, enhance cooperation and drive action across multiple sectors and actors. This will be critical to accelerating progress towards the goal of ending malnutrition by 2030. We particularly support and welcome the emphasis within Action area 5 (‘safe and supportive environments for nutrition') on integrating the recommendations of the ICN2 Framework for Action on water, sanitation and hygiene.

Water, sanitation and hygiene (WASH) are fundamental to ending undernutrition. The WHO estimates that 50% of undernutrition is associated with repeated diarrhoea, intestinal worm and other infections (environmental enteric dysfunction) directly resulting from inadequate WASH.[1] WASH therefore needs to be integrated into national nutrition policies, strategies and plans, with joint multi-sector action, and increased domestic and international funding for WASH as a key ‘nutrition-sensitive’ intervention. WaterAid calls for the Nutrition Decade to provide strong leadership in urging Governments to achieve much more effective integrated action on Nutrition and WASH.

1. Does the work programme present a compelling vision for enabling strategic interaction and mutual support across existing initiatives, platforms, forums and programmes, given the stipulation of Res 70/259 that the Decade should be organized with existing institutions and available resources?

We welcome the emphasis in the workplan on coordinating with and building upon existing institutions and initiatives, rather than further fragmenting global governance and accountability mechanisms. The emphasis is rightly on supporting the development and implementation of ambitious national nutrition action plans – reiterating the need for country ownership that is fundamental to the work of the Scaling Up Nutrition (SUN) Movement.

While the work programme stresses the need for action by “multiple actors from all sectors”, and specifically references Every Woman, Every Child (EWEC) as one important existing initiative, it should make clearer links to existing initiatives and platforms in other nutrition-relevant sectors. For instance, the work programme could highlight the need to build upon the early efforts to coordinate between SUN, the Sanitation and Water for All partnership (SWA) and the Global Partnership for Education (GPE). The Nutrition Decade should provide additional impetus and convening opportunities to significantly shift global governance in this more coordinated, more harmonised direction which will be fundamental to driving ‘nutrition sensitive’ investment and action.

2. What are your general comments to help strengthen the presented elements of the first draft work programme of the UN Decade of Action on Nutrition?

‘Aims and Added Value’

(para 9) The stated aims should be strengthened by a greater emphasis on not just “addressing” malnutrition (implying a focus on treatment) but preventing it. We propose an additional clear aim to “Support all countries’ efforts to prevent malnutrition through effective multi-sectoral action to address the underlying determinants”.

Action areas

(para 18) The reference to conducting “a full and thorough mapping” of existing initiatives and movements is welcome. We propose that this should explicitly include initiatives between nutrition-relevant sectors. For instance, SUN and the SWA have recently agreed a joint work plan for action on WASH-Nutrition integration – this may provide a useful model and example of cross-sectoral action at the global governance level.

Action area 1

(para 21) Water availability and water resource management are critical aspects of sustainable food systems (e.g. for adequate and consistent supplies to crops and livestock as well as people) and should be referenced.

(para 23) Improving access to WASH is fundamental to preventing Anti-Microbial Resistance (AMR).

Action area 2

(para 25) Achieving UHC requires that the fundamentals of good quality healthcare are in place. Yet the WHO estimate that 38% of healthcare facilities in low- and middle-income countries lack access to water[2]. 19% do not have adequate sanitation and 35% do not have soap for handwashing. In Sub-Saharan Africa, 42% of healthcare facilities do not have access to water. Ensuring adequate WASH in healthcare is critical to delivering quality health care, including the treatment of malnutrition. The Global Action Plan on WASH in Healthcare Facilities co-led by WHO and UNICEF is therefore a key initiative to highlight and coordinate with that will be fundamental to improving nutrition.

Action area 5

(para 37) We strongly welcome the inclusion of an area on water, sanitation and hygiene. Poor WASH is linked to nutrition in multiple ways, beyond diarrhoeal disease. The direct biological pathways through which poor WASH is linked to undernutrition includes diarrhoeal diseases, intestinal worms, and environmental enteric dysfunction, a sub-clinical condition which affects the structure and function of the small intestine, resulting in the poor absorption of nutrients. The paragraph would be strengthened by including a more thorough overview of the key links between WASH and nutrition, and a greater emphasis on the role of hygiene behaviour change as a critical intervention to break the common routes of faecal-oral transmission.

Means of Implementation

(para 45) We strongly support the proposal for “a publicly-accessible repository” of commitments made by Member States in support of the Nutrition Decade, which will help to drive transparency and accountability. This is particularly crucial for commitments to ‘nutrition sensitive’ action, which are often less easy to track and carry greater risk of ‘double-counting’ of existing commitments in other sectors without sufficient thought and effort to enhance nutrition-sensitivity.

3. Do you feel you can contribute to the success of the Nutrition Decade or align yourself with the proposed range of action areas?

Yes, WaterAid stands ready to contribute towards the success of the Nutrition Decade. Our advocacy on the need for integration of WASH and Nutrition in policies and practice will be key. We have already established relationships and initiatives with the aim of enhancing coordination and integration, working closely with SUN, SWA, the Global Nutrition Report team, EWEC and WHO, among others.

We propose that WASH-Nutrition integration could be a specific topic for the development of commitments and the establishment of action networks, adding to those suggested in Table 1. We would argue that to have one topic on “Nutrition sensitive investments” as currently listed may be too broad a topic to allow the in-depth sharing of experience and knowledge necessary to enhance effective multi-sectoral action.

4. How could this draft work programme be improved to promote collective action to achieve the transformational change called for by the 2030 Agenda for Sustainable Development and the ICN2 outcomes? What is missing?

The work programme must drive a step-change in multi-sectoral coordination for effective Nutrition-sensitive investments and actions. The Global Nutrition Report in 2016 highlighted that scaling up nutrition-specific interventions to 90% coverage in 34 of the countries with the highest burden of child undernutrition, will only reduce stunting by 20%.[3] Therefore effective nutrition-sensitive action will be absolutely vital to meeting the goals of the Nutrition Decade and SDG 2. This should be reflected in the work programme by:

• (para 13) Making explicit within the ‘guiding principles’ the need to ensure ambitious funding for ‘nutrition-sensitive’ as well as ‘nutrition-specific’ action, and the role of the Nutrition Decade in convening high level stakeholders across nutrition-relevant sectors.
• (para 49) Ensuring that ‘Action Networks’ have the active participation of government representatives from across nutrition-relevant ministries such as Ministers or senior officials for WASH, Education, Agriculture, Health, Planning and Infrastructure.
• (paras 55, 56) Emphasising that funding modalities and the mobilisation of new financial resources must include ambitious commitments to nutrition-sensitive investments. While the World Bank / R4D estimates of the cost of achieving global nutrition targets is an important benchmark, it should not be treated as definitive. Their conclusion that an annual additional $2.2 billion of financing is required to deliver a ‘priority package’ of interventions clearly states that this estimate is predicated on the assumption of “ambitious commitments in water and sanitation”[4], among other nutrition-relevant sectors. Further urgent work is needed to improve the costing and tracking of nutrition-sensitive investments by governments and donors, including improving resource tracking of ODA via OECD DAC measurement.

5. Do you have specific comments on the section on accountability and learning?

We welcome the proposals for transparency and accountability. A focus on shared learning is particularly critical for integration and effective nutrition-sensitive action, where the evidence and cost-effectiveness of interventions is still being researched. It is vital that governments and donors do not only invest in and report on the more limited set of nutrition-specific interventions – since this will not result in meeting the goal to end malnutrition by 2030. Rather, the Nutrition Decade must act to galvanise rapid experimentation, evaluation and learning to strengthen the global nutrition community’s understanding of what works in effective multi-sectoral action.