Building latrines and keeping water clean decreases diarrhoea and under-nutrition in Mali

This story first appeared on the WHO website here and has been reblogged.  

November 2015

Two years ago, Hamidou Samakan, chief of the village of Yarou Plateau in Mali, noticed significant changes in the neighbouring village of Gouna. The village was clean and there were no faeces to be seen. People were building affordable latrines, sweeping common areas, and chlorinating their drinking water.

Mali story

Back in Hamidou’s village, people were still defecating in the open. Few households had latrines, and diarrhoea and under-nutrition were common.

Gouna was participating in a community-led total sanitation activity, aimed at stopping open defecation. The WASHplus project, funded by the United States Agency for International Development (USAID) and led by FHI 360 and in partnership with CARE and Winrock International, is working with communities in Mali to improve water, sanitation and hygiene (WASH) and reduce diarrhoel diseases and under-nutrition.

It turned out that the community-led total sanitation approach, designed to trigger feelings of shame and disgust, was working beyond the village of Gouna.

“Having seen what was happening in our neighbour’s community, we decided to improve the sanitation condition in our village,” says Hamidou.

In nearly a year, Yarou Plateau has built more than 60 latrines and rehabilitated ones that had never been used.

The role of WASH in nutrition

Despite progress in recent years, defecating in the open is still a common practice in Mali. More than 1.5 million Malians – or 10% of the population – defecate in the open, which means that diseases like diarrhoea and intestinal worms can spread quickly.

“When people were defecating in the open in many of these villages, flies were taking the diseases from the faeces onto the food they were eating,” says Sahada Traore, WASHplus project leader at CARE International Mali.

Faecal matter was also contaminating villagers’ hands, water jugs and homes.

While inadequate dietary intake and disease, including diarrhoea, are the primary causes of under-nutrition, lack of access to safe drinking water and sanitation, along with the absence of good hygiene practices are some of the key underlying causes of under-nutrition globally and especially in Mali.

When children have diarrhoea, they eat less and are less able to absorb and use nutrients from their food. In turn, under-nutrition makes them more susceptible to diarrhoea and the cycle repeats.

Improving nutrition outcomes

To help combat this issue, WHO, in collaboration with USAID and UNICEF, are calling for nutrition and water, sanitation and hygiene (WASH) programmes to work together to maximize nutrition gains and meet important global targets.

A new report, “Improving nutrition outcomes with better water, sanitation and hygiene: practical solutions for policies and programmes”, recommends high-impact WASH interventions, such as improving access to latrines, be integrated into nutrition programmes around the world.

“Both WASH and nutrition are the basis for primary prevention. We now have the evidence and emerging examples of successful integrated approaches that improve people’s health,” says Dr Maria Neira, Director of WHO’s Department of Public Health, Environmental and Social Determinants of Health.

Additional WASH and nutrition interventions recommended include increasing water supply, handwashing with soap, ensuring safe household water management through treatment and storage, screening children for under-nutrition, exclusive breastfeeding and diversifying children’s diets with local products.

One village at a time

In Mali, community members in 180 villages, supported by USAID’s WASHplus, have built their own latrines – more than 9000 in 2 years. Each village identified the best ways to reduce open defecation and received guidance to construct the right latrines for their environment.

To date, 128 of these villages have been certified free of open defecation, meaning every household in the village has access to a covered latrine to reduce flies, and soap and water for handwashing.

“There is no more open defecation in these villages, and we’re starting to see a reduction in cases of diarrhoeal diseases as well as undernourished children,” says Traore.

Beyond building latrines, behaviours have also changed. People are now using latrines, washing their hands, and treating and safely storing their drinking water.

Working together

Prior to implementing the WASHplus project, experts in WASH and nutrition in Mali worked separately. The water programmes built water points often next to fields where people defecated, and nutrition programmes focused on teaching breastfeeding and preparing nutrient-rich foods.

“No one was connecting the dots when it came to open defecation,” Traore explains. “The water supply people did not talk to the nutrition people when they were designing and implementing programmes, and thus we weren’t seeing any reduction in diarrhoea or under-nutrition.”

But this is now in the past, he says. “We work together more now and we’re seeing less under-nutrition because, alongside the delivery of key nutrition interventions, people are drinking safe water, using latrines and washing their hands.”

World Toilet Day = Systems Day = Nutrition Day

By Ron Clemmer, Strategy and Business Development Manager, WASH, FHI 360.

World Toilet Day is about more than toilets! It is about the whole system of the sanitation chain. This whole “system” of household latrines; school and health facility toilets; septage haulers; wastewater and septage treatment, reuse and disposal, has become more and more a focus of international development professionals. As with development practitioners in other sectors, we work in complex social systems that require organizational change, behavioral change, and personal change for transformative social change to result in sustainable impact. A systems lens helps us to see our roles in development programs to understand the impact that is needed in the big picture of the “system.”

FHI 360’s 2015 Challenge Conference Deepening Systemic Engagement addressed an important question for systems thinking: “How do we as practitioners and change agents unify systems theory and practice to bring forth healthy and inclusive human development?”

FHI 360 brought together speakers who are leaders in the area of systems thinking and also practitioners who are implementing a systems approach for international development for the Challenge Conference. The keynote speaker was Otto Scharmer from the MIT Sloan School of Management, who with Katrin Kaufer co-authored, Leading from the Emerging Future: From Ego-System to Eco-System Economies.

Being the pragmatic engineer that I am, some of the presentations that peaked my interest the most were from FHI 360 colleagues discussing the application of systems approaches in their development programs. A systems approach that FHI 360 staff has developed in conjunction with USAID is SCALE (System-wide Collaborative Action for Livelihoods and Environment). Ten years of learning through the implementation of the SCALE systems methodology to accelerate broad stakeholder engagement in sustained collaborative action to address a complex development issues has now resulted in FHI 360’s development of SCALE+.

If you want to explore more of Deepening Systemic Engagement, the Challenge Conference highlight videos and materials can be found here.

World Toilet Day is also about more than toilets because of the significant impact of good sanitation on maternal and child health, neglected tropical diseases, HIV/AIDS, education, and nutrition. World Toilet Day has a special linkage to nutrition this year, and 2015 World Toilet Day was chosen as the day that WHO/UNICEF/USAID are releasing the important publication Improving Nutrition Outcomes through Water, Sanitation and Hygiene: Practical Solutions for Policies and Programmes. My FHI 360 WASHplus colleagues managed the development of this publication in collaboration with the publishing agencies. And the integrated activities in different countries implemented by WASHplus and its partners are contributing practical knowledge and tools that will help guide WASH-nutrition integration in the future.

ABOUT THE AUTHOR: Ron Clemmer joined FHI 360 in May 2015 after working with World Vision as Senior Technical Advisor for WASH for six years. Ron is passionate about building sustainable water and sanitation services through the public and private sectors, hygiene behavior change that becomes habit, and integrated programming of WASH with nutrition, HIV, neglected tropical diseases, education, and women’s empowerment.

Improving Nutrition, One Latrine at a Time: WASH 1,000 Strategy in Ghana Takes Hold

By Christa Elise Reynolds, Knowledge Management Officer, JSI Research & Training Institute, Inc. with USAID SPRING.

Gmangun Charles, of Kubone community in Ghana, shows off his household’s new latrine. (Photo by David Nunoo, SPRING/Ghana WASH Advisor)
Gmangun Charles, of Kubone community in Ghana, shows off his household’s new latrine. (Photo by David Nunoo, SPRING/Ghana WASH Advisor)

Toilets might not be the first thing you think of in conjunction with basic human nutrition, but inadequate sanitation poses a real danger for 2.5 billion people around the world. When crops become contaminated through open defecation, communities are at risk for disease outbreaks and chronic malnutrition.

This November 19, designated as World Toilet Day, we are reminded of the people lacking access to toilets and improved sanitation. About 1.1 billion people defecate in the open, according to UN-Water. Diarrheal disease, which can prevent nutrients from being absorbed, is a common outcome of improper human waste disposal. This is an issue in Ghana, where approximately 19,000 people die yearly from diarrhea. Nearly 90 percent of those deaths can be attributed to poor water, sanitation, and hygiene (WASH), according to the Water and Sanitation Program.

At the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project, funded by the U.S. Agency for International Development’s (USAID), we are working to improve nutrition through our “WASH 1,000 strategy,” a multifaceted approach stresses the importance of key household behaviors during the first 1,000 days, spanning the mother’s pregnancy to the child’s second birthday. Numerous factors influence a child’s well-being during this time. Our WASH 1,000 strategy focuses on four key behaviors: ensuring the child has a safe and clean play space, safely disposing of human and animal feces, handwashing at critical times, and using only boiled or treated water for the child’s consumption.

Mobilizing communities to build latrines is one of the first steps toward improving sanitation. Working with country partners, we facilitated discussions about the importance of latrines and sanitation in communities in the northern and upper eastern regions of Ghana, and participants have been receptive to the ideas. Installing tippy taps, or simple handwashing stations, near latrines and in households promotes handwashing after using the latrine and before meals, another WASH 1,000 goal.

“I am happy that I and my family do not defecate in the open again. I have restored my lost dignity,” said Gmangun Charles, a resident of the Kubone community in the Mion District of Ghana, who recently constructed a latrine for his household’s use.

Since February 2015, 47 household latrines have been built in the Kubone community. After learning about the benefits of using latrines, residents are increasing community awareness of open defecation’s health risks and shaming those who refuse latrines.

The link between open defecation, hygiene, and nutrition is not obvious and many community members may not be aware of the connection. Because people in the northern and upper eastern regions of Ghana often defecate on farm fields and near water sources, crops can become contaminated. Children might be exposed to human and animal feces while playing, which can lead to infection and diarrhea. Eating with unwashed hands can cause further contamination. Properly built latrines and use of tippy taps reduce this health risk. These latrines are a source of pride for the community members who build them, 14-year old Emmanuel Loteba said.

Though the idea of feces getting into our foods is disgusting, I also felt guilty because we all defecate openly in this village. We were told that the best way to avoid contaminating our food and to live healthy lifestyles is to build household latrines,” Loteba commented.

Loteba lives in Boagnab Yare, a community in Ghana’s upper east region, where diarrheal disease and low nutritional absorption are common. He learned about the WASH 1,000 strategy through one of our trainings. In the Kugbar-Bulug community, another of our WASH 1,000 Ghana sites, 19 of 28 households have already built household latrines. Kwame Awin, a local farmer, is happy with his new latrine because he and his family can finally eat fresh beans from their fields without risking contamination.

World Toilet Day highlights the sanitation needs of billions of people around the world who can’t wait for better hygiene. By encouraging a more holistic understanding of nutrition as it is impacted by WASH, our work in Ghana has begun changing perceptions of latrines and sanitation in the country’s northern and upper eastern regions. SPRING continues to promote WASH 1,000 behaviors to communities and trainers so that they may improve sanitation access, nutrition, and health.

ABOUT THE AUTHOR/ PROJECT: Christa Elise Reynolds is a Knowledge Management Officer working on the USAID SPRING project at JSI Research & Training Institute, Inc. Funded by USAID, the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project strengthens country efforts to scale up high-impact nutrition practices and policies. To learn more about SPRING visit the project website at and follow @SPRINGProject2 on Twitter.

DISCLAIMER: The contents of this blog post are the responsibility of JSI, and do not necessarily reflect the views of USAID or the United States Government. SPRING’s work is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-11-00031 (SPRING), managed by JSI Research & Training Institute, Inc. (JSI).