WASH intersects with all SDGs – this publication is part of an IDS Working Paper series that looks at the intersection of sanitation and other fields.

This paper explores access to water, sanitation, and health in pastoral communities in northern Tanzania.

It argues that the concept of gender, used on its own, is not enough to understand the complexities of sanitation, hygiene, water, and health. It explores pastoralists’ views and perspectives on what is ‘clean’, ‘safe’, and ‘healthy’, and their need to access water and create sanitary arrangements that work for them, given the absence of state provision of modern water, sanitation, and hygiene (WASH) infrastructure.

Although Tanzania is committed to enhancing its citizens’ access to WASH services, pastoral sanitation and hygiene tend to be overlooked and little attention is paid to complex ways in which access to ‘clean’ water and ‘adequate sanitation’ is structured in these communities. This paper offers an intersectional analysis of water and sanitation needs, showing how structural discrimination in the form of a lack of appropriate infrastructure, a range of sociocultural norms and values, and individual stratifiers interact to influence the sanitation and health needs of pastoralist men, women, boys, and girls.

WASH intersects with all SDGs – this publication is part of an IDS Working Paper series that looks at the intersection of sanitation and other fields.

This paper explores the relationship between accessible sanitation and disability-inclusive employment in Bangladesh and Nigeria.

Both countries have sanitation and hygiene challenges as well as disability-inclusive employment challenges, but the existing evidence on the intersection of these issues that is focused on Nigeria and Bangladesh is extremely limited. Building on the literature where this complex issue is addressed, this paper presents the findings of a qualitative pilot study undertaken in Nigeria and Bangladesh. It focuses on the need for toilets at work that are easy for people with disabilities to use in poor countries.

These are sometimes called accessible toilets. Accessible sanitation is not regarded as a challenge that must be addressed by people with disabilities themselves, but as a challenge that must be addressed by many people working together – including governments, employers, and the community.

WASH intersects with all SDGs – this publication is part of an IDS Working Paper series that looks at the intersection of sanitation and other fields.

Millions of people around the world do not have access to adequate sanitation facilities, undermining progress towards Sustainable Development Goal 6.2 that calls for adequate and equitable sanitation for all.

Efforts to improve sanitation outcomes have been rapidly accelerated in the past decade alongside an expansion of different financial incentives or subsidies to promote access to services and motivate sanitation behaviour. In parallel, social protection has become part and parcel of development policy, with many low- and middle-income countries now offering some form of cash transfers to those most vulnerable. Comprehensive interventions that couple financial transfers with complementary support such as behaviour change communication, training, or coaching have also grown increasingly popular.

Despite similarities between water, sanitation, and hygiene (WASH) subsidy schemes and social protection interventions, these policy areas have largely developed in silos and limited cross-sectoral learning has taken place. This paper begins to fill this knowledge gap by assessing the potential for comprehensive social protection in addressing sanitation outcomes and drawing out policy implications for the social protection and WASH communities. It does so by focusing on a social protection programme in the context of extreme poverty in rural Haiti.

The five broad findings of the report are explained in the executive summary, while the full report provides more detail on the study.

The success of national policies and plans for universal health coverage depends on implementation. Much of this implementation takes place at the local level, where health services are managed and delivered. This means district health management teams (DHMTs) play a crucial role in promoting health service coverage, quality and public health. In many countries, decentralisation has increased the role of DHMTs, and they often have key responsibilities for designing annual plans and budgets, overseeing facilities, managing staff, monitoring and reporting.

These responsibilities need to be performed well, as effective planning and management underpin progress in other areas of the health system. Sound planning is particularly important because district health budgets are often small: district managers need to identify and prioritise activities that can make the most of limited resources and bring the greatest benefit. However, district health planning is often rushed, and sometimes based on previous activities or donor interests rather than systematic thinking about district needs.

An evidence-based approach to planning

More use of district health service data can support effective planning by helping DHMTs to identify key gaps in health service coverage and their causes – for example, whether problems relate to lack of medicines, health worker skills, or community uptake of interventions. Techniques such as the ‘5 whys’ approach or problem tree analysis can then be used to understand underlying causes, and stakeholder discussions and prioritisation criteria can help to select activities that are most likely to be feasible and effective.

UNICEF has been supporting DHMTs in East and Southern Africa to use these more evidence-based approaches, using a method called bottleneck analysis, and we are working with UNICEF to evaluate progress and identify lessons that can strengthen support for DHMT planning and management.

Our findings highlight a range of issues that can help or hinder DHMTs’ use of evidence, their approach to planning, and implementation of annual plans. Important issues include accurate health systems data that can indicate bottlenecks; planning guidelines that support DHMTs in identifying local priorities; help and collaboration from political decision makers, NGOs and other development agencies; predictable and adequate resources to implement plans; and capacity to adapt plans and budgets around unexpected shocks such as COVID-19. Several of these issues have been highlighted by others, including limited DHMT decision space due to lack of funds and associated reliance on donors, and the influence of power relations with political structures, but here are some other, perhaps more overlooked issues that we’ve found so far.

Do district managers see planning as a useful investment of their time?

One area evident in many districts was the importance of DHMT motivation and interest in detailed planning. In the past, district plans have often not been implemented – sometimes because of insufficient budgets, or because plans were not regularly reviewed and followed. Many DHMT members appreciate the use of evidence incorporated in the bottleneck analysis approach, but this approach also requires more effort. DHMT members may not immediately see value in investing time for this given their high workloads and past experience of plans not being used.

Even if we have a beautiful plan those activities will still not be implemented, because funds are never enough. … The plans are not serving any purpose. (district planning committee member, Malawi)

DHMTs’ interest in planning is also affected by budgeting systems: if the system that determines allocation of national funds to DHMTs is not linked to the annual plans, DHMTs may focus on the system that brings the resources and see less value in planning.

Planning is hard work and district managers are busy

Another important issue highlighted by several DHMT members relates to the complexity of the planning processes and time requirements: DHMT staff are busy, planning and budgeting deadlines are tight, and planning processes can be lengthy – in some cases requiring completion of numerous online forms and tables. This can mean planning is rushed, particularly at the crucial later stages of selecting priorities and budgeting. Workshops for planning can provide dedicated time for DHMTs to focus, but funding for workshops may not be sustained once donor support ends, and it can be hard to complete all stages of planning within the workshops – and to retain enough concentration for later steps.

Planning takes a very long time – there are times when we stay in the office until 22:00 hours to meet the deadlines. (district health management team member, Tanzania)

Building the value of planning

These issues are not easy to overcome: they involve stakeholders and systems at national and district level; links between ministries and departments; activities and interests among a range of development partners; engrained approaches; wider health system capacity; and tricky balances around providing support while ensuring sustainable systems.  While fully embedding evidence-based planning requires action on multiple fronts, steps to ensure planning has value for DHMTs, and leads to action may help to sustain more systematic approaches. This might include, for example, encouraging DHMTs to identify activities that can be developed within existing resources so that plans are affordable, supporting regular review of plans during the year to promote attention to their implementation, and working with national and sub-national stakeholders to align budgeting and planning systems

UNICEF is continuing with DHSSi and taking steps to further enhance the value of planning for DHMTs. We are now starting round 2 of the evaluation, and will continue working with UNICEF to see how these activities progress and to identify lessons that can inform district management capacity interventions.

As a first step in this process, this review paper synthesises and assesses the quality of the evidence landscape available in Cox’s Bazar and how the Rohingya seek and access healthcare services in Cox’s Bazar and presents the findings from key informant interviews on the topic. Findings are structured in five discussion sections: (1) evidence quality; (2) major themes and variations in the evidence; (3) learnings drawn and recommendations commonly made; (4) persistent bottlenecks; and (5) areas for further research. This synthesis will inform a roundtable discussion with key actors working for the Rohingya refugees to identify next steps for RCCE and research efforts in Cox’s Bazar to improve health outcomes among the Rohingya.

With a slow vaccine rollout and overwhelmed health infrastructure, there is a critical need to examine India’s response and recommend measures to further arrest the current spread of infection and to prevent and prepare against future waves. This brief is a rapid social science review and analysis of the second wave of COVID-19 in India. It draws on emerging reports, literature, and regional social science expertise to examine reasons for the second wave, explain its impact, and highlight the systemic issues that hindered the response. This brief puts forth vital considerations for local and national government, civil society, and humanitarian actors at global and national levels, with implications for future waves of COVID-19 in low- and middle-income countries.

This review is part of the Social Science in Humanitarian Action Platform (SSHAP) series on the COVID-19 response in India. It was developed for SSHAP by Mihir R. Bhatt (AIDMI), Shilpi Srivastava (IDS), Megan Schmidt-Sane (IDS), and Lyla Mehta (IDS) with input and reviews from Deepak Sanan (Former Civil Servant; Senior Visiting Fellow, Centre for Policy Research), Subir Sinha (SOAS), Murad Banaji (Middlesex University London), Delhi Rose Angom (Oxfam India), Olivia Tulloch (Anthrologica) and Santiago Ripoll (IDS). It is the responsibility of SSHAP.

Preliminary evidence from Expertise France’s Health Recovery in Northeast Syria (HERNES) project has revealed the need for a better understanding of the gaps in the availability and level of RMNH.

The study, which took place between September – December 2020 assessed the availability, quality, and accessibility of RMNH services at both the facility and community level in Ar Raqqa and Deir-ez-Zor Governates to support effective RMNH programming.

Long term planning

The study used a mixed-methods approach – including a desk review, key informant interviews with a range of stakeholders at the community, facility, (I)NGO and governmental levels, surveys, facility observations, and exit interviews. The findings showed that available RMNH care suffers from many of the general weaknesses affecting the health systems in Ar Raqqa and Deir-ez-Zor. Gaps in available care, clinic practices and equipment reflect shortages in trained medical personnel and medical supply chains. As few public facilities in either governorate have the capacity to provide the essential components of different levels of required care, women often face significant barriers to accessing adequate services – particularly emergency care.

Based on these findings, the study calls for long term planning to ensure the reconstruction of the health system and the provision of accessible and quality RMNH services, including:

• Large-scale investment in existing health infrastructure
• Addressing gaps in the medical supply chain including for equipment, essential drugs and vaccinations
• Improving access to health education and medical training as well as working conditions for medical personnel Mitigating financial barriers to ensure health access for the most vulnerable without exacerbating their current financial vulnerability.

Within this context, the study suggests that RMNH actors operating in this region should consider:

• Making use of and strengthen existing health infrastructure, rather than working in other properties such as private homes or industrial buildings.
• Conducting an urgent review and improvement of the supply chain in relation to RMNH essential equipment, consumables, and supplies. This includes developing relevant procurement strategies, warehouses, distribution practices, and consumption tracking.
• Conducting a comprehensive mapping of existing RMNH facilities across the two governorates to strengthen referral systems and women’s ability to access different levels of care.
• Pairing short and medium-term projects to provide certified medical trainings, competency-based short courses, ‘on-the job’ clinical training and supportive supervision with longer-term programmes focused on restoring formal health education in universities and other pre-service training institutions.
• Coordinating with the local health authorities to identify allocation strategies to ensure sustainable services.

The full report from this programme can be accessed here.

The aim of this project has been to produce technical recommendations for the Indonesian government, ‘Ensuring a strategic focus on data protection and cyber security within telemedicine regulation and standards, to ensure the protection of users’ is prioritised.’

The report, along with an associated conference (which will take place virtually on June 15 & 16 2021), are the main deliverables of this engagement which began in November 2020. The work has relied on quantitative and qualitative research through extensive stakeholder engagement, and as such, we would like to thank the Indonesian government for their full cooperation. In particular we would like to thank the Ministry of Health (MoH), the National Cyber and Crypto Agency (BSSN), the Ministry of Communication and Information Technology (KOMINFO) and the National Social Security Administration for Health (BPJS Kesehatan) for their open and prompt responses to our requests for information and meetings, all conducted with congenial goodwill and professionalism, which has been much appreciated by the CCU team.

In addition, we also thank all those stakeholders that have contributed to this study from the private sector, academia and other professional healthcare bodies (a full list of stakeholders can be found at Annex A), again without their assistance this study would simply have lacked integrity and credibility.

Finally, we thank the FCDO DAP team based in Jakarta, who operating under very difficult COVID circumstances (as have all stakeholders), have provided constant and unwavering support to the CCU team, who are based entirely remotely.

Please note that this is the draft version of the recommendations paper to be reviewed by delegates prior to publication

5 large-scale surveys are included with over 12 million respondents in 22 central, eastern, western and southern African countries (note: one major study accounts for more than 10 million participants); data from 14 peer-reviewed questionnaire surveys in 8 countries with n=9,600 participants and 15 social media monitoring, qualitative and community feedback studies. Sample sizes are provided in the first reference for each study and in Table 13 at the end of this document. The data largely predates vaccination campaigns that generally started in the first quarter of 2021. Perceptions will change and further syntheses, that represent the whole continent including North Africa, are planned.

This review is part of the Social Science in Humanitarian Action Platform (SSHAP) series on COVID-19 vaccines. It was developed for SSHAP by Anthrologica. It was written by Kevin Bardosh (University of Washington), Tamara Roldan de Jong and Olivia Tulloch (Anthrologica), it was reviewed by colleagues from PERC, LSHTM, IRD, and UNICEF (see acknowledgments) and received coordination support from the RCCE Collective Service. It is the responsibility of SSHAP.

This document is structured as follows: 1) the themes arising in the data and 2) operational and methodological considerations, 3) the full synthesis.