Introduction
Undernutrition is a major public health concern because of associations with adult health and disease risk later in life, including among others, diabetes, hypertension and cardiovascular disease (CVD), and furthermore acts as a predictor of physical, mental and cognitive child development.Reference de Onis, Blössner and Borghi1–Reference Piper, Chandna and Allen5 Experiencing poor nutrition in utero or during early childhood is furthermore associated with chronic diseases later in life. During the first 1000 days of growth and development, specific cells, organs and systems may be differentially affected by undernutrition.Reference Hoffman6 Among the three primary forms of undernutrition – stunting, wasting and being underweight – stunting is the most prevalent in children under 5 years of ageReference Black, Victora and Walker7 and is defined as having a height-for-age z-score less than two standard deviations (SDs) of the median of the World Health Organization (WHO) Child Growth Standards.Reference Said-Mohamed, Micklesfield, Pettifor and Norris8,9
Undernutrition emanates from a variety of circumstances and determinants, including antenatal, intrauterine and postnatal malnutrition. The realisation that physical growth cannot completely be improved by optimised diet and reduced burden of infection has led to the hypothesis that linkages between different forms of undernutrition and environmental conditions, including water, sanitation and hygiene (WASH), may contribute towards persistently poor child growth and nutritional status.Reference Mbuya and Humphrey10 Specific pathways are proposed by the so-called 5-F diagram, which describes the faeco-oral transmission route whereby faeces and associated pathogens are transmitted via fluids, fields/floors, flies and fingers to foods, and then to the infant which causes disease and infection which in turn leads to growth faltering.Reference Cumming and Cairncross11 Exposure to poor WASH during early childhood has been associated with higher risks of infections and poor nutritional status, including stunting.Reference McDade12,Reference Guerrant, DeBoer, Moore, Scharf and Lima13 Repeated infections in early life is associated with chronic low-grade inflammationReference McDade, Hoke, Borja, Adair and Kuzawa14,Reference McDade, Leonard and Burhop15 and associated CVD risks in adulthood.Reference Burgner, Cooper, Moore, Stanley, Thompson and De Klerk16
Data from 140 Demographic and Health Surveys (DHS) in 65 countries reported that over half of the variation in child height between countries was explained by the frequency of open defecation. Another analysis of 171 surveys in 70 low- and middle-income countries (LMIC) found that increasing access to and use of improved water sources reduced the risk of stunting.3 ,Reference Spears, Ghosh and Cumming4,Reference Fink, Günther and Hill17 The situation is most critical in sub-Saharan Africa (SSA), where at the closing of the Millennium Development Goals cycle in 2015, the portion of people relying on untreated surface water for drinking was eight times higher than any other region. Furthermore, over 70% of the SSA populations were living without adequate sanitation and the absolute number of people practising open defecation actually increased.Reference Markle and Donnenfeld 18
In response to these observations a number of trials, in various phases, have explored the effects of WASH interventions on nutritional status in children.Reference Arnold, Null and Luby 19 – Reference Brown, Cumming and Bartram 22 Initial results have indicated that there is only a marginal effect of WASH interventions on linear child growth.Reference Pickering, Djebbari, Lopez, Coulibaly and Alzua 21 ,Reference Null, Stewart and Pickering23,Reference Dangour, Watson and Cumming24 In 2012, the WHO set ambitious global nutrition targets to reduce the number of children under the age of 5 that are stunted by 40% by 2025 with particular emphasis being placed on the role that WASH, financing and policy interventions will need to play in achieving these targets. 25
The United Nations (UN) formally declared the right to water in November 2002 and noted that the right to water was indispensable to leading a life of human dignity and was furthermore a prerequisite for the realisation of other human rights. The human right to water entitles everyone to sufficient, safe, acceptable, physically accessible and affordable water for personal and domestic use. This also provided the first implicit reference to the responsibilities that governments and stakeholders have in delivering clean water and sanitation to everyone.Reference Mwebaza and Kotze 26 In the post-2015 agenda Sustainable Development Goals (SDGs) have been established, most notably in this regard SDG 6: Universal and equitable access to safe water and adequate sanitation (WASH); and SDG 2: End all forms of malnutrition, by 2030. 27 ,28 A key challenge to achieving the above SDGs is the unique combination of governance systems, stakeholder dynamics and institutional structures found in each country which manifest various problems and subsequent priorities.Reference Jiménez, Kjellén and Le Deunff 29 Governance of WASH in this regard is the set of systems that are involved in decision-making about management and service delivery. Investigating the governance of WASH by disentangling the various actors, role players and stakeholders at various levels, while unravelling the policy environment is imperative to the understanding, design and implementation of WASH initiatives targeted at addressing the burden of childhood undernutrition. 25 ,27,30 The authors chose to conduct the review from 1990 onwards primarily due to the introduction of the United Nations Children’s Fund (UNICEF) conceptual framework 31 which proposed a causal framework for maternal and child undernutrition which included WASH. In addition to this, the dramatic geopolitical shifts that occurred as a result of the ending of the Cold War, as signalled by the fall of the Berlin wall in 1989 had far-reaching consequences for the provision of basic services and healthcare, and transformed the dynamics of economic and health development at global, regional and national levels.Reference Somerville, Fawcett and Sayigh 32 ,Reference Omaswa33 The rise of civil society and the movement on social justice, equity and rights significantly reshaped governance of health at all levels.Reference Omaswa 33 ,Reference Irwin and Scali34 Furthermore, the Lancet Series on Maternal and Child Nutrition in 2013 provided an updated framework for maternal and child nutrition, as well as recommendations for inter-sectoral approaches to the challenges of malnutrition in LMIC settings, including WASH.Reference Black, Victora and Walker 7 ,Reference Bhutta, Das and Rizvi35 In order to explore this nexus, this systematic review aims to examine the literature linking WASH, childhood nutritional status and governance in sub-Saharan African settings.
Methods
Protocol and registration
A systematic review has been conducted to examine the governance of WASH in sub-Saharan settings and associations with nutritional status in children under 5 years of age. The PRISMA StatementReference Moher, Liberati and Tetzlaff 36 was utilised, while this systematic review has also been registered with PROSPERO (CRD42017071700). 37
Eligibility criteria
Peer-reviewed articles published between January 1990 and October 2017 reporting governance or policy, WASH and associations with nutritional status in children in SSA were included. Studies pertaining to children with known chronic and acute diseases or abnormalities affecting growth were excluded along with publications not in English or French. In addition, a survey of government websites, the Global Database on the Implementation of Nutrition Action (GINA) 38 and, where possible, the Global Analysis and Assessment of Sanitation and Drinking-Water (GLAAS) 39 was conducted to investigate whether countries in SSA had water and/or sanitation policies and if they included any links to health and/or nutrition.
Study identification and selection
Data were sourced from electronic databases. All combinations of the following keywords were used to select publications from PubMed Central, Science Direct and ProQuest Social Science databases published between January 1990 and October 2017: Governance, Policy, Management; Water, Sanitation, Hygiene, WASH; Undernutrition, Under-Nutrition, Under Nutrition, Malnutrition, Stunt-ed/ing, Underweight, Wast-ed/ing; Children, Infant, Under Five Years of Age, Preschool, Pre-school; Africa. The authors opted for selecting papers that reported governance, WASH and nutritional status irrespective of links between the various components. With regard to water and sanitation policies in SSA, government websites, the GINA, 38 and where possible, the GLAAS 39 were searched for relevant policies. The authors searched grey literature databases including the Grey Literature Report in Public Health, 40 African Index Medicus, 41 the WHO Virtual Health Sciences Library, 42 as well as conference proceedings and websites, and furthermore reviewed reference lists and where appropriate contacted experts and authors.
Data extraction
Using a standard data extraction sheet for all studies included in the systematic review, data pertaining to the governance or policy mechanism were extracted along with nutritional status as defined by the WHO Multicentre Growth Reference Study, 9 and WASH metrics as defined by the United Nations Joint Monitoring Programme (JMP). 43 Study design, date of data collection, country, participant age and sex, as well as sample size, aims and results or outcomes were also extracted. In terms of the policies that were sourced, excerpts pertaining to the country, policy and date, as well as links to health and/or nutrition were extracted using a standard data extraction form.
Quality assessment and data analysis
For studies that were included, the strength of the individual articles and body evidence were assessed using the Grading of Recommendations, Assessment Development and Evaluation (GRADE) approach.Reference Balshem, Helfand and Schunemann 44 ,Reference Guyatt, Oxman and Akl45 All studies were graded concerning their quality and summary data regarding data extraction fields, compiled. The studies included were assessed and classified to be of very low, low, moderate or high quality.
A synthesis of the eligible studies was compiled, and health policy and systems research – exploratory and descriptive frameworks utilised.Reference Gilson 46 ,Reference Walt and Gilson47 These sought to incorporate the context, content and processes surrounding knowledge production and act as a model for analysis.
Results
Description of publications
The search terms returned a total of 15,351 articles for screening as reflected in the flow diagram (Fig. 1), through which a total of 47 articles were identified for full-text review. Publications were excluded because: nutritional status was not reported (n = 3636), metric for WASH was not reported (n = 3609), comorbidities such as acute and chronic infections, congenital abnormalities or any condition that could affect growth was not reported (n = 2864), participant was >5 years of age (n = 791), publications did not geographically pertain to SSA (n = 2102), publication or date of study was not between 1990 and 2017 (n = 257), governance or policy mechanism was not reported (n = 13), publications were not in English or French (n = 3), the type of document was a newspaper, correspondence or book review (n = 1394), miscellaneous reasons (n = 635). One article could not be procured, thus 46 articles were included in the qualitative synthesis. For the purposes of this systematic review, the quality assessment yielded 3 publications of high quality,Reference Black, Victora and Walker 7 ,Reference Bhutta, Das and Rizvi35,Reference de Onis and Branca48 19 of moderate quality,Reference Said-Mohamed, Micklesfield, Pettifor and Norris 8 ,Reference Cumming and Cairncross11,Reference Guerrant, Oriá, Moore, Oriá and Lima49–Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65 24 of low qualityReference Kinyoki, Kandala and Manda 66 – Reference Syed, Ali and Duggan 89 and none of very low quality.
Fig. 1. Flow diagram.
Table 1 delineates the observational studies included in this systematic review while Table 2 indicates the reviews included. A total of 24 cross-sectional household surveys,Reference Hoffman 6 ,Reference Akombi, Agho, Hall, Merom, Astell-Burt and Renzaho50–Reference Chirande, Charwe and Mbwana52,Reference Griffiths, Madise, Whitworth and Matthews55–Reference Yarnoff, Allaire and Detzel57,Reference Derso, Tariku, Biks and Wassie62,Reference Kinyoki, Kandala and Manda66,Reference Van de Poel, Hosseinpoor, Speybroeck, Van Ourti and Vega67,Reference Kinyoki, Berkley, Moloney, Odundo, Kandala and Noor69–Reference Kinyoki, Berkley, Moloney, Kandala and Noor74,Reference Hagos, Hailemariam, WoldeHanna and Lindtjørn77–Reference Alemayehu, Tinsae, Haileslassie, Seid, Gebregziabher and Yebyo80,Reference Knoblauch, Hodges and Bah82–Reference Hangoma, Aakvik and Robberstad84,Reference Darteh, Acquah and Kumi-Kyereme87 14 reviews,Reference Black, Victora and Walker 7 ,Reference Said-Mohamed, Micklesfield, Pettifor and Norris8,Reference Cumming and Cairncross11,Reference Bhutta, Das and Rizvi35,Reference de Onis and Branca48,Reference Guerrant, Oriá, Moore, Oriá and Lima49,Reference Keusch, Rosenberg and Denno60,Reference Brown, Cairncross and Ensink61,Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65,Reference Crane, Jones and Berkley68,Reference Bourne, Pilime and Behr81,Reference Motarjemi, Käferstein, Moy and Quevedo85,Reference Salam, Das and Bhutta88,Reference Syed, Ali and Duggan89 4 cohorts,Reference Kimani-Murage, Muthuri, Oti, Mutua, van de Vijver and Kyobutungi 58 ,Reference Nabwera, Fulford, Moore and Prentice59,Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman63,Reference Medhin, Hanlon and Dewey75 3 meta-analysesReference Danaei, Andrews and Sudfeld 53 ,Reference Fernandez, Himes and de Onis76,Reference Stevens, Finucane and Paciorek86 and 1 case-controlReference Prendergast, Rukobo and Chasekwa 64 studies were included (Fig. 2). The first publication documented dates from 1993Reference Motarjemi, Käferstein, Moy and Quevedo 85 (Fig. 3). However, the period from 1993 to 2012 is characterised by a consistently low number of publications with a brief spike in 2008. There is a significant increase in the number of studies from 2013 to 2017.
Table 1. Studies included in systematic review
Table 2. Review articles included in systematic review
Fig 2. Study design.
Fig. 3. Publications by year.
Of the observational studies included, 30Reference Akombi, Agho, Hall, Merom, Astell-Burt and Renzaho 50 – Reference Nabwera, Fulford, Moore and Prentice 59 ,Reference Derso, Tariku, Biks and Wassie62,Reference Prendergast, Rukobo and Chasekwa64,Reference Kinyoki, Kandala and Manda66,Reference Van de Poel, Hosseinpoor, Speybroeck, Van Ourti and Vega67,Reference Kinyoki, Berkley, Moloney, Odundo, Kandala and Noor69–Reference Van de Poel, Hosseinpoor, Jehu-Appiah, Vega and Speybroeck72,Reference Kinyoki, Berkley, Moloney, Kandala and Noor74–Reference Alemayehu, Tinsae, Haileslassie, Seid, Gebregziabher and Yebyo80,Reference Knoblauch, Hodges and Bah82–Reference Hangoma, Aakvik and Robberstad84,Reference Stevens, Finucane and Paciorek86,Reference Darteh, Acquah and Kumi-Kyereme87 aimed at assessing nutritional status and associated factors, while 2Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman 63 ,Reference Hathi, Haque, Pant, Coffey and Spears73 were concerned with assessing the association between WASH and child growth. Water, either in terms of source, type of infrastructure or access, was reported as a significant risk factor in 21Reference Akombi, Agho, Hall, Merom, Astell-Burt and Renzaho 50 – Reference Chirande, Charwe and Mbwana 52 ,Reference Yarnoff, Allaire and Detzel57–Reference Nabwera, Fulford, Moore and Prentice59,Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman63,Reference Kinyoki, Kandala and Manda66,Reference Kinyoki, Berkley, Moloney, Odundo, Kandala and Noor69–Reference Alemu, Ahmed, Yalew, Birhanu and Zaitchik71,Reference Kinyoki, Berkley, Moloney, Kandala and Noor74,Reference Fernandez, Himes and de Onis76–Reference Alemayehu, Tinsae, Haileslassie, Seid, Gebregziabher and Yebyo80,Reference Knoblauch, Hodges and Bah82,Reference Hangoma, Aakvik and Robberstad84,Reference Stevens, Finucane and Paciorek86 of the observational studies, and access to sanitation, or type of sanitation infrastructure, as a significant risk factor in 15 of the studies.Reference Pongou, Ezzati and Salomon 51 ,Reference Danaei, Andrews and Sudfeld53–Reference Habaasa56,Reference Kimani-Murage, Muthuri, Oti, Mutua, van de Vijver and Kyobutungi58,Reference Derso, Tariku, Biks and Wassie62–Reference Prendergast, Rukobo and Chasekwa64,Reference Hathi, Haque, Pant, Coffey and Spears73,Reference Medhin, Hanlon and Dewey75,Reference Hagos, Hailemariam, WoldeHanna and Lindtjørn77,Reference Anand and Roy79,Reference Hangoma, Aakvik and Robberstad84,Reference Stevens, Finucane and Paciorek86 Hygiene, considered here as multiple forms of hygiene, or hygiene as an integrated concept was reported as a significant risk factor in one study.Reference Prendergast, Rukobo and Chasekwa 64 All significant risk factors are in the expected direction, that is, associations in the direction typically hypothesised, for example, improved wash conditions predict reduced stunting. No association between WASH and nutritional status was reported in four papers.Reference Van de Poel, Hosseinpoor, Speybroeck, Van Ourti and Vega 67 ,Reference Van de Poel, Hosseinpoor, Jehu-Appiah, Vega and Speybroeck72,Reference Balk, Storeygard, Levy, Gaskell, Sharma and Flor83,Reference Darteh, Acquah and Kumi-Kyereme87 With regard to the observational studies assessing the association between WASH and child growth, in unadjusted models, that did not control for child, household, parent and community characteristics, household access to improved water and toilets was associated with reduced stunting risk. After adjusting for child, household, parent and community variables, access to improved water was associated with reduced stunting at 1 and 5 years of age (relative risk ratios from 0.55 to 0.57).Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman 63 In adjusted models, those that controlled for child, household, parent and community characteristics, open defecation externalities were important for child height-for-age z-scores where people lived in close proximity to one another. One study found that a one log-unit increase in population density was associated with lesser height-for-age z-score by about 0.04 SD.Reference Hathi, Haque, Pant, Coffey and Spears 73
In terms of the 14 review articles included, 3 papersReference Cumming and Cairncross 11 ,Reference Bhutta, Das and Rizvi35,Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65 aimed at assessing WASH interventions, while 4Reference Black, Victora and Walker 7 ,Reference Said-Mohamed, Micklesfield, Pettifor and Norris8,Reference de Onis and Branca48,Reference Salam, Das and Bhutta88 were concerned with assessing trends in nutritional status. A total of seven articlesReference Guerrant, Oriá, Moore, Oriá and Lima 49 ,Reference Keusch, Rosenberg and Denno60,Reference Brown, Cairncross and Ensink61,Reference Crane, Jones and Berkley68,Reference Bourne, Pilime and Behr81,Reference Motarjemi, Käferstein, Moy and Quevedo85,Reference Syed, Ali and Duggan89 aimed at reviewing evidence between environmental enteric dysfunction (EED) and nutritional status, with EED as a mediating factor between poor WASH conditions and nutritional status. Results of the reviews highlighted water either in terms of source, type of infrastructure or access was reported as a significant risk factor in 12Reference Black, Victora and Walker 7 ,Reference Said-Mohamed, Micklesfield, Pettifor and Norris8,Reference Cumming and Cairncross11,Reference de Onis and Branca48,Reference Guerrant, Oriá, Moore, Oriá and Lima49,Reference Keusch, Rosenberg and Denno60,Reference Brown, Cairncross and Ensink61,Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65,Reference Bourne, Pilime and Behr81,Reference Motarjemi, Käferstein, Moy and Quevedo85,Reference Salam, Das and Bhutta88,Reference Syed, Ali and Duggan89 of the papers, while the importance of access to sanitation or type of sanitation infrastructure was emphasised in 13Reference Black, Victora and Walker 7 ,Reference Said-Mohamed, Micklesfield, Pettifor and Norris8,Reference Cumming and Cairncross11,Reference Bhutta, Das and Rizvi35,Reference de Onis and Branca48,Reference Guerrant, Oriá, Moore, Oriá and Lima49,Reference Brown, Cairncross and Ensink61,Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65,Reference Crane, Jones and Berkley68,Reference Bourne, Pilime and Behr81,Reference Motarjemi, Käferstein, Moy and Quevedo85,Reference Salam, Das and Bhutta88,Reference Syed, Ali and Duggan89 articles and hygiene in 9Reference Cumming and Cairncross 11 ,Reference Bhutta, Das and Rizvi35,Reference de Onis and Branca48,Reference Guerrant, Oriá, Moore, Oriá and Lima49,Reference Brown, Cairncross and Ensink61,Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65,Reference Motarjemi, Käferstein, Moy and Quevedo85,Reference Salam, Das and Bhutta88,Reference Syed, Ali and Duggan89 of the reviews.
Geographical coverage
Nineteen publications dealt with SSA as a region, while three articles dealt with more than one country in SSA.Reference Hoffman, Cacciola, Barrios and Simon 54 ,Reference Griffiths, Madise, Whitworth and Matthews55,Reference Anand and Roy79 Individually, Ethiopia had the most publications with six,Reference Derso, Tariku, Biks and Wassie 62 ,Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman63,Reference Alemu, Ahmed, Yalew, Birhanu and Zaitchik71,Reference Medhin, Hanlon and Dewey75,Reference Hagos, Hailemariam, WoldeHanna and Lindtjørn77,Reference Alemayehu, Tinsae, Haileslassie, Seid, Gebregziabher and Yebyo80 TanzaniaReference Chirande, Charwe and Mbwana 52 ,Reference Altare, Delbiso, Mutwiri, Kopplow and Guha-Sapir70,Reference Semali, Tengia-Kessy, Mmbaga and Leyna78 and SomaliaReference Kinyoki, Kandala and Manda 66 ,Reference Kinyoki, Berkley, Moloney, Odundo, Kandala and Noor69,Reference Kinyoki, Berkley, Moloney, Kandala and Noor74 had three articles each, while GhanaReference Van de Poel, Hosseinpoor, Jehu-Appiah, Vega and Speybroeck 72 ,Reference Darteh, Acquah and Kumi-Kyereme87 and South AfricaReference Said-Mohamed, Micklesfield, Pettifor and Norris 8 ,Reference Bourne, Pilime and Behr81 had two articles each, and Cameroon,Reference Pongou, Ezzati and Salomon 51 Gambia,Reference Nabwera, Fulford, Moore and Prentice 59 Nigeria,Reference Akombi, Agho, Hall, Merom, Astell-Burt and Renzaho 50 Kenya,Reference Kimani-Murage, Muthuri, Oti, Mutua, van de Vijver and Kyobutungi 58 Sierra Leone,Reference Knoblauch, Hodges and Bah 82 Uganda,Reference Habaasa 56 ZambiaReference Hangoma, Aakvik and Robberstad 84 and ZimbabweReference Prendergast, Rukobo and Chasekwa 64 had one publication each (Fig. 4). An electronic survey of specific policies related to Water-only, Sanitation-only, and WASH and subsequent links to health and/or nutrition in individual SSA countries was also conducted (Table 3). Of the 49 countries surveyed, policies relating to water could not be found for 6 countries (Angola, Djibouti, Central African Republic, Equatorial Guinea, Gabon and Somalia). The authors could not access the specific water policy documents for 12 countries (Angola, Djibouti, Central African Republic, Comoros, Republic of Congo, Equatorial Guinea, Gabon, Gambia, Guinea-Bissau, Mauritius, Seychelles and Somalia). For nine countries (Central African Republic, Republic of Congo, Equatorial Guinea, Mauritius, Somalia, South Sudan, Swaziland, Tanzania and Zambia), no sanitation policy was found. The sanitation policy documents could not be accessed for 10 countries (Central African Republic, Republic of Congo, Equatorial Guinea, Seychelles, Somalia, South Sudan, Swaziland, Tanzania and Zambia). For four countries, there were no other policy documents reviewed that linked WASH and health/nutrition (Angola, Equatorial Guinea, Mauritius and Swaziland). No WASH policies were found.
Fig. 4. Number of publications by country.
Table 3. SSA policies
In terms of the content of the policies, some 16 countries (Burkina Faso, Burundi, Eritrea, Ethiopia, Gambia, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Namibia, Nigeria, Sudan and Zimbabwe) made reference to hygiene in their respective policies. A total of four countries (Burundi, Mauritania, São Tomé and Príncipe, and Uganda) linked water and nutrition in general. A further two countries (Liberia and Zimbabwe) linked water and child health in general, while two countries (Rwanda and South Africa) linked water and nutritional status in children. Some 14 countries (Burundi, Cape Verde, Chad, Comoros, Democratic Republic of the Congo, Djibouti, Gabon, Guinea-Bissau, Kenya, Niger, Rwanda, São Tomé and Príncipe, Senegal, and Togo) linked sanitation and nutrition in general. A total of six countries linked sanitation and child health in general, and three countries (Cameroon, Malawi and Uganda) made reference to the importance of the link between sanitation and nutritional status in children.
Nexus between WASH, undernutrition and governance
In terms of nutritional status, 44 articles considered stunting,Reference Black, Victora and Walker 7 ,Reference Said-Mohamed, Micklesfield, Pettifor and Norris8,Reference Cumming and Cairncross11,Reference Brown, Cumming and Bartram22,Reference Bhutta, Das and Rizvi35,Reference de Onis and Branca48–Reference Hoffman, Cacciola, Barrios and Simon54,Reference Habaasa56–Reference Nabwera, Fulford, Moore and Prentice59,Reference Derso, Tariku, Biks and Wassie62–Reference Medhin, Hanlon and Dewey75,Reference Hagos, Hailemariam, WoldeHanna and Lindtjørn77–Reference Syed, Ali and Duggan89 17 articles underweight,Reference Black, Victora and Walker 7 ,Reference Bhutta, Das and Rizvi35,Reference Guerrant, Oriá, Moore, Oriá and Lima49,Reference Pongou, Ezzati and Salomon51,Reference Griffiths, Madise, Whitworth and Matthews55,Reference Habaasa56,Reference Kimani-Murage, Muthuri, Oti, Mutua, van de Vijver and Kyobutungi58,Reference Nabwera, Fulford, Moore and Prentice59,Reference Kinyoki, Kandala and Manda66–Reference Crane, Jones and Berkley68,Reference Medhin, Hanlon and Dewey75,Reference Anand and Roy79,Reference Alemayehu, Tinsae, Haileslassie, Seid, Gebregziabher and Yebyo80,Reference Balk, Storeygard, Levy, Gaskell, Sharma and Flor83,Reference Stevens, Finucane and Paciorek86,Reference Salam, Das and Bhutta88 and 16 articles wasting.Reference Black, Victora and Walker 7 ,Reference Bhutta, Das and Rizvi35,Reference Hoffman, Cacciola, Barrios and Simon54,Reference Habaasa56,Reference Kimani-Murage, Muthuri, Oti, Mutua, van de Vijver and Kyobutungi58,Reference Nabwera, Fulford, Moore and Prentice59,Reference Derso, Tariku, Biks and Wassie62,Reference Crane, Jones and Berkley68,Reference Kinyoki, Berkley, Moloney, Odundo, Kandala and Noor69,Reference Kinyoki, Berkley, Moloney, Kandala and Noor74–Reference Fernandez, Himes and de Onis76,Reference Anand and Roy79,Reference Alemayehu, Tinsae, Haileslassie, Seid, Gebregziabher and Yebyo80,Reference Knoblauch, Hodges and Bah82,Reference Salam, Das and Bhutta88 A total of eight articles were concerned with water aloneReference Chirande, Charwe and Mbwana 52 ,Reference Yarnoff, Allaire and Detzel57,Reference Keusch, Rosenberg and Denno60,Reference Kinyoki, Kandala and Manda66,Reference Kinyoki, Berkley, Moloney, Odundo, Kandala and Noor69,Reference Kinyoki, Berkley, Moloney, Kandala and Noor74,Reference Fernandez, Himes and de Onis76,Reference Semali, Tengia-Kessy, Mmbaga and Leyna78 while four articles dealt solely with sanitation.Reference Hoffman, Cacciola, Barrios and Simon 54 ,Reference Habaasa56,Reference Derso, Tariku, Biks and Wassie62,Reference Medhin, Hanlon and Dewey75 A combination of water and sanitation was reported in 21 articlesReference Black, Victora and Walker 7 ,Reference Said-Mohamed, Micklesfield, Pettifor and Norris8,Reference Guerrant, Oriá, Moore, Oriá and Lima49–Reference Pongou, Ezzati and Salomon51,Reference Danaei, Andrews and Sudfeld53,Reference Griffiths, Madise, Whitworth and Matthews55,Reference Kimani-Murage, Muthuri, Oti, Mutua, van de Vijver and Kyobutungi58,Reference Van de Poel, Hosseinpoor, Speybroeck, Van Ourti and Vega67,Reference Altare, Delbiso, Mutwiri, Kopplow and Guha-Sapir70–Reference Hathi, Haque, Pant, Coffey and Spears73,Reference Hagos, Hailemariam, WoldeHanna and Lindtjørn77,Reference Anand and Roy79,Reference Alemayehu, Tinsae, Haileslassie, Seid, Gebregziabher and Yebyo80,Reference Knoblauch, Hodges and Bah82–Reference Hangoma, Aakvik and Robberstad84,Reference Stevens, Finucane and Paciorek86,Reference Darteh, Acquah and Kumi-Kyereme87 and 13 articles reported on WASH.Reference Cumming and Cairncross 11 ,Reference Bhutta, Das and Rizvi35,Reference de Onis and Branca48,Reference Nabwera, Fulford, Moore and Prentice59,Reference Brown, Cairncross and Ensink61,Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman63–Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65,Reference Crane, Jones and Berkley68,Reference Bourne, Pilime and Behr81,Reference Motarjemi, Käferstein, Moy and Quevedo85,Reference Salam, Das and Bhutta88,Reference Syed, Ali and Duggan89 Twenty-one articles considered water source,Reference Cumming and Cairncross 11 ,Reference Bhutta, Das and Rizvi35,Reference de Onis and Branca48,Reference Akombi, Agho, Hall, Merom, Astell-Burt and Renzaho50,Reference Chirande, Charwe and Mbwana52,Reference Nabwera, Fulford, Moore and Prentice59–Reference Brown, Cairncross and Ensink61,Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65–Reference Altare, Delbiso, Mutwiri, Kopplow and Guha-Sapir70,Reference Kinyoki, Berkley, Moloney, Kandala and Noor74,Reference Anand and Roy79–Reference Bourne, Pilime and Behr81,Reference Balk, Storeygard, Levy, Gaskell, Sharma and Flor83,Reference Hangoma, Aakvik and Robberstad84,Reference Darteh, Acquah and Kumi-Kyereme87 11 were concerned with access to water,Reference Black, Victora and Walker 7 ,Reference Said-Mohamed, Micklesfield, Pettifor and Norris8,Reference Yarnoff, Allaire and Detzel57,Reference Kimani-Murage, Muthuri, Oti, Mutua, van de Vijver and Kyobutungi58,Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman63,Reference Van de Poel, Hosseinpoor, Jehu-Appiah, Vega and Speybroeck72,Reference Fernandez, Himes and de Onis76–Reference Semali, Tengia-Kessy, Mmbaga and Leyna78,Reference Knoblauch, Hodges and Bah82,Reference Syed, Ali and Duggan89 19 with type of infrastructure as defined by the JMPReference Cumming and Cairncross 11 ,Reference Bhutta, Das and Rizvi35,Reference Akombi, Agho, Hall, Merom, Astell-Burt and Renzaho50,Reference Pongou, Ezzati and Salomon51,Reference Danaei, Andrews and Sudfeld53,Reference Griffiths, Madise, Whitworth and Matthews55,Reference Brown, Cairncross and Ensink61,Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman63,Reference Prendergast, Rukobo and Chasekwa64,Reference Altare, Delbiso, Mutwiri, Kopplow and Guha-Sapir70,Reference Hathi, Haque, Pant, Coffey and Spears73,Reference Anand and Roy79,Reference Alemayehu, Tinsae, Haileslassie, Seid, Gebregziabher and Yebyo80,Reference Hangoma, Aakvik and Robberstad84,Reference Stevens, Finucane and Paciorek86 and 2 with water treatment.Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus 65 ,Reference Alemu, Ahmed, Yalew, Birhanu and Zaitchik71 Twenty-one articles dealt with access to sanitation,Reference Black, Victora and Walker 7 ,Reference Said-Mohamed, Micklesfield, Pettifor and Norris8,Reference de Onis and Branca48,Reference Hoffman, Cacciola, Barrios and Simon54,Reference Habaasa56,Reference Kimani-Murage, Muthuri, Oti, Mutua, van de Vijver and Kyobutungi58,Reference Nabwera, Fulford, Moore and Prentice59,Reference Brown, Cairncross and Ensink61,Reference Derso, Tariku, Biks and Wassie62,Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65,Reference Van de Poel, Hosseinpoor, Speybroeck, Van Ourti and Vega67,Reference Crane, Jones and Berkley68,Reference Altare, Delbiso, Mutwiri, Kopplow and Guha-Sapir70,Reference Van de Poel, Hosseinpoor, Jehu-Appiah, Vega and Speybroeck72,Reference Hathi, Haque, Pant, Coffey and Spears73,Reference Hagos, Hailemariam, WoldeHanna and Lindtjørn77,Reference Bourne, Pilime and Behr81–Reference Balk, Storeygard, Levy, Gaskell, Sharma and Flor83,Reference Salam, Das and Bhutta88,Reference Syed, Ali and Duggan89 and 22 with type of sanitation.Reference Said-Mohamed, Micklesfield, Pettifor and Norris 8 ,Reference Cumming and Cairncross11,Reference Bhutta, Das and Rizvi35,Reference Guerrant, Oriá, Moore, Oriá and Lima49–Reference Pongou, Ezzati and Salomon51,Reference Danaei, Andrews and Sudfeld53,Reference Griffiths, Madise, Whitworth and Matthews55,Reference Brown, Cairncross and Ensink61,Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman63–Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65,Reference Crane, Jones and Berkley68,Reference Medhin, Hanlon and Dewey75,Reference Anand and Roy79,Reference Alemayehu, Tinsae, Haileslassie, Seid, Gebregziabher and Yebyo80,Reference Knoblauch, Hodges and Bah82,Reference Hangoma, Aakvik and Robberstad84–Reference Darteh, Acquah and Kumi-Kyereme87,Reference Syed, Ali and Duggan89 A total of six articles were non-specific in so far as they considered multiple forms of hygiene or hygiene as an integrated concept,Reference de Onis and Branca 48 ,Reference Nabwera, Fulford, Moore and Prentice59,Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman63,Reference Prendergast, Rukobo and Chasekwa64,Reference Crane, Jones and Berkley68,Reference Syed, Ali and Duggan89 while three considered food hygiene,Reference Brown, Cairncross and Ensink 61 ,Reference Bourne, Pilime and Behr81,Reference Motarjemi, Käferstein, Moy and Quevedo85 two domestic hygieneReference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus 65 ,Reference Bourne, Pilime and Behr81 and five hand washing.Reference Cumming and Cairncross 11 ,Reference Bhutta, Das and Rizvi35,Reference Brown, Cairncross and Ensink61,Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65,Reference Salam, Das and Bhutta88
Fourteen articles made explicit reference to the sentiment that the results of the research conducted had policy implications,Reference Said-Mohamed, Micklesfield, Pettifor and Norris 8 ,Reference de Onis and Branca48,Reference Habaasa56,Reference Yarnoff, Allaire and Detzel57,Reference Kinyoki, Kandala and Manda66,Reference Van de Poel, Hosseinpoor, Speybroeck, Van Ourti and Vega67,Reference Alemu, Ahmed, Yalew, Birhanu and Zaitchik71,Reference Hathi, Haque, Pant, Coffey and Spears73,Reference Fernandez, Himes and de Onis76,Reference Alemayehu, Tinsae, Haileslassie, Seid, Gebregziabher and Yebyo80,Reference Bourne, Pilime and Behr81,Reference Balk, Storeygard, Levy, Gaskell, Sharma and Flor83,Reference Stevens, Finucane and Paciorek86,Reference Salam, Das and Bhutta88 while a total of 15 articles advocated for the importance of their results for the planning and development of interventions.Reference Guerrant, Oriá, Moore, Oriá and Lima 49 ,Reference Pongou, Ezzati and Salomon51,Reference Chirande, Charwe and Mbwana52,Reference Hoffman, Cacciola, Barrios and Simon54,Reference Nabwera, Fulford, Moore and Prentice59,Reference Derso, Tariku, Biks and Wassie62,Reference Prendergast, Rukobo and Chasekwa64,Reference Crane, Jones and Berkley68–Reference Altare, Delbiso, Mutwiri, Kopplow and Guha-Sapir70,Reference Medhin, Hanlon and Dewey75,Reference Hagos, Hailemariam, WoldeHanna and Lindtjørn77–Reference Anand and Roy79,Reference Knoblauch, Hodges and Bah82 A total of 17 of the articles included noted the importance of their results for both policy and intervention planning.Reference Black, Victora and Walker 7 ,Reference Cumming and Cairncross11,Reference Bhutta, Das and Rizvi35,Reference Akombi, Agho, Hall, Merom, Astell-Burt and Renzaho50,Reference Danaei, Andrews and Sudfeld53,Reference Griffiths, Madise, Whitworth and Matthews55,Reference Kimani-Murage, Muthuri, Oti, Mutua, van de Vijver and Kyobutungi58,Reference Keusch, Rosenberg and Denno60,Reference Brown, Cairncross and Ensink61,Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman63,Reference Ngure, Reid, Humphrey, Mbuya, Pelto and Stoltzfus65,Reference Van de Poel, Hosseinpoor, Jehu-Appiah, Vega and Speybroeck72,Reference Kinyoki, Berkley, Moloney, Kandala and Noor74,Reference Hangoma, Aakvik and Robberstad84,Reference Motarjemi, Käferstein, Moy and Quevedo85,Reference Darteh, Acquah and Kumi-Kyereme87,Reference Syed, Ali and Duggan89 None of the articles unfortunately elaborated on neither precise policies nor specific intervention mechanisms but rather remained non-descript in their reports.
Discussion
In the literature that was included in this review, only 46 articles were included and indicate a relatively limited body of knowledge on the nexus between governance, WASH and nutritional status in children in the sub-Saharan African context. Publications on this topic have however been increasing, suggesting that this is an emerging and growing field of interest. In conducting this systematic review, there were no scientific studies or evidence specifically focused on linking the governance of WASH and nutritional status in children. All included publications did note some policy implications based on study results; however, the precise manner in which this could or should be operationalised was rarely elaborated on.
In terms of the coverage of the literature for each of the individual WASH components, among the observational studies, more articles reported water as a significant risk factor than sanitation. Interestingly, among the reviews, more articles reported sanitation as a significant risk factor than water, with hygiene being the least represented component in both the observational studies as well as reviews. While some studies are concerned with water or sanitation separately, water and sanitation were reported most, followed by WASH. Water source was reported most often, followed by type of water infrastructure, access to water and finally water treatment. Access to sanitation was most reported followed by type of sanitation infrastructure. With regard to hygiene, being the least represented component, hand washing was reported most, followed by food and domestic hygiene, respectively.
In terms of geographic coverage, parts of the Horn, East Africa, along with Southern Africa and pockets of West Africa were represented. Governments are also making progress by having water and sanitation policies in place with reference to the importance of WASH have for the health and nutritional status of children. However, for many countries, much work needs to be done in the political sphere to bring new knowledge and evidence to the fore in order to keep policy mechanisms in tune with the requirements of the population. It is important to note that there are no specific health or nutrition outcomes that policies are evaluated against, especially not when it comes to children, and that each component of the WASH triad also have their own unique intricacies.
The link between WASH and nutrition is not one that should come as a surprise. WASH has long been part of the UNICEF conceptual framework, which provides a lens through which maternal and child undernutrition can be examined. This is achieved through providing a scalar model that incorporates immediate causes such as disease and dietary intake, underlying causes including household environment, food security and health services, as well as basic causes, referring to socio-economic and political context. 31
Advocating for multi- and inter-sectoral approaches are therefore not new. 31 ,Reference Bhutta, Das and Rizvi35,Reference Walt and Gilson47,Reference Bhutta, Ahmed and Black90,Reference Black, Allen and Bhutta91 Fundamental to these kinds of grand challenges is the integration of various actors and the effective governance of resources and services as a precondition for the effectiveness and sustainability of WASH programmes and services.Reference Jiménez, Kjellén and Le Deunff 29 Overwhelmingly, it seems that governments are committed, at least in principle and in policy, to linking WASH to health and/or nutritional outcomes (Table 3).
When it comes to dealing with the nexus between governance, WASH and nutritional status in children in SSA, scalability and sustainability depend on good governance and technical factors such as infrastructure and improved knowledge, and the availability of financial resources. However, while actors and stakeholders at various levels in the policy and governance arena advocate for multi- and inter-sectoral approaches, most nutritional status indicators show disappointing results. In 2013, for example, global estimates put the number of stunted children in LMIC at 161 million.Reference de Onis and Branca 48 African prevalence’s have stagnated since 1990 at about 40% and current trends suggest little improvement with business as usual.Reference de Onis, Blössner and Borghi 1 Countries in SSA continue to make headway in terms of increased access to WASH services, financial resources however remain a critical issue. 92 Current levels of WASH financing are not sufficient to fund the achievement of SDG 6, estimated to cost an approximate $122 Billion between 2016 and 2030.Reference Markle and Donnenfeld 18 ,92 Important gaps in financing still exist with SSA countries, on average, committing 0.52% GDP to WASH expenditure. When excluding South Africa, this figure drops to a mere 0.27% GDP. Aid commitments for WASH to SSA have also declined from US$ 3.8 billion to US$ 1.7 billion from 2012 to 2015. 92
Governance issues therefore include limited managerial capacity, poor financial resource administration, corruption and weak institutions, which all limit the capacity of the national sector to deliver sustainable results at scale. 93 No blueprints for WASH governance exist and no easy answers can be found on what constitutes the best governance model. Every country has its own set of governance systems, stakeholder dynamics and institutional structures, and therefore faces different problems and priorities.Reference Jiménez, Kjellén and Le Deunff 29 The primary responsibility for service delivery of water and sanitation, as both a basic service and a human right, lies with the State; however, even if the State holds ultimate responsibility, a number of stakeholders take part in the implementation. The Commission on Global Governance defines governance as follows: ‘the sum of many ways individuals and institutions, public and private, manage their common affairs. It is a continuing process through which conflicting and or diverse interests may be accommodated and cooperative action may be taken. It includes formal […] as well as informal arrangements that people and institutions have agreed to or perceive to be in their interest’.Reference Karns 94 Importantly is the distinction that governance is not exclusively government, as it includes non-governmental (NGO), inter-governmental organisations (IGOs), as well as civil society.Reference Karns 94 With 2025 WHO Nutrition Targets 25 and 2030 SDG 28 deadlines looming, concerted efforts to actively facilitate the necessary inter-sectoral approaches require efforts from all stakeholders to engage so that interventions are not logistically and/or financially prohibitive.
One possible model is that of the South African context where a minister in The Presidency is appointed, overseeing the Department of Planning, Monitoring and Evaluation in order to coordinate planning, monitoring and evaluation of government programmes aimed at improving service delivery, outcomes and impact on society. The main objective of which is to rally around a common set of objectives and priorities to drive development and crosscutting issues. 95 Furthermore, it gathers people from different departments to discuss inter-sectoral issues. Multi- and inter-sectoral approaches require a significant degree of political will, and while gaps across SSA persist in terms of addressing specific sociocultural and political contexts, on a positive note, for the most part across SSA, there are policies concerned with water and sanitation, which furthermore make explicit reference to health and/or nutrition as seen in Table 3.
Moreover, studies linking governance, WASH and nutritional status are increasing, providing a more nuanced perspective on associations on the various components of WASH (Fig. 3). However, much grey literature was not included in this systematic review, most likely due to the peer-reviewed format of scientific publications, thus limiting the body of knowledge included in this review. The authors searched grey literature databases including, the Grey Literature Report in Public Health, 40 African Index Medicus, 41 the WHO Virtual Health Sciences Library, 42 as well as conference proceedings and websites and furthermore reviewed reference lists and where appropriate contacted experts and authors and found that the grey literature concerned with WASH, nutritional status and governance was predominantly located within the IGO and development sector and associated agencies. Examples of this includes the UN through the WHO, 3 ,39 UN Water, 92 UNICEF, 3 ,Reference Jiménez, Kjellén and Le Deunff29,31,93 NGOs such as Save the ChildrenReference Moise 96 and foreign development cooperation agencies such as United States Agency for International Development (USAID). 3
Grey literature also tended to be narrowly focused on a particular WASH component (either water, or sanitation or hygiene – in particular hand washing) and particular disease context, for instance, tuberculosis, HIV or helminth infections, and while acknowledging the role that nutrition plays, rarely made an explicit link between WASH, nutritional status and governance. WASH is in itself a composite concept comprising individual components each with its own body of research and associated complexities. Part of the complexity for WASH as a consolidated concept and topic for research as well as for service delivery seems to be agreeing upon a common nomenclature and standardised definition of what is being discussed. In this regard, the UN JMP 43 ,97 and the WHO and UN Water 39 ,98 have made significant progress in establishing a set of indicators, classifications and units of analysis.
In addition, the bulk of discussions concerned with the nexus between WASH, governance and nutritional status in this systematic review is situated in observational studies and reviews (Fig. 2), thus highlighting the need for more in-depth knowledge on the topic in the various SSA contexts. Surprisingly, no trials were found to form part of the literature under review. This may, in part, be due to the specificity of the search terms. Involvement of various stakeholders and implications for implementation, scalability and policy may not have been reported, specifically in a scientific forum. Furthermore, trials are expensive and while not methodologically required to report on the various interactions with stakeholders are perhaps not explicitly focused on the links to governance structures and civil society as oppose to exploring the biological pathways and determinants.
A 2013 Cochrane Review on the effect of WASH interventions on nutritional status in children highlighted the low number of studies and low methodological quality of studies conducted in the past.Reference Dangour, Watson and Cumming 24 As such, the production of high-quality data beyond observational associations is a relatively recent development. Despite recent trial results indicating a marginal effect of WASH interventions on linear child growth,Reference Pickering, Djebbari, Lopez, Coulibaly and Alzua 21 ,Reference Null, Stewart and Pickering23,Reference Dangour, Watson and Cumming24 further exploration of the data from these and forthcoming trialsReference Humphrey, Jones and Manges 20 ,Reference Brown, Cumming and Bartram22 will provide a more nuanced perspective on what does and does not work. Broader questions emerge from these results such as, while the microbial quality of drinking water available may be improved, the quantity of water long argued to be a key driver in water-related health gains remains an important consideration.Reference Cumming and Curtis 99 ,Reference Biswas100 Population density and proximity to sanitation facilities are significant drivers in improving environmental conditions around children while delivering community-wide interventions are important for showing an effect of sanitation on linear growth.Reference Pickering, Djebbari, Lopez, Coulibaly and Alzua 21 Other pathways such as nutrition, animal waste and complementary foods as pathways for enteric infection cannot be overlooked. These results show how little we know about the transmission of enteric pathogens, the causes of symptomatic infections and the significance of asymptomatic infections, while at a policy level business as usual in the WASH sector will not be enough to significantly improve child growth.Reference Cumming and Curtis 99
Conclusion
This systematic review sought to examine the literature linking governance, WASH and childhood nutritional status, in sub-Saharan African settings. The authors found that policy makers would benefit from integrating this emerging evidence-based information into their respective policies in order to better articulate and address the intricacies of WASH in various contexts. Utilising consistent and established terminology when referring to the challenges and recommendations for service provision would allow for a more targeted discussion around which particular aspects of the WASH components require further consideration. The importance of early-life exposures and associations with disease risk in adulthood provides further impetus for tackling WASH from a governance perspective. Neither observational studies nor intervention studies included components exploring the role of governance of WASH in their design nor described if and how actors in the field of WASH were incorporated into the research process. Integrating the role of governance through the involvement of civil society, communities, IGOs, government as well as development agencies would be a recommendation for future studies on the topic. The scientific and research community could further contribute by considering the manner in which study findings could or should be operationalised and gain real-world application. Incorporating WASH components in line with consistent and established terminology and definitions will make study design as well as the results that emanate from such studies more pertinent and reproducible. At the same time, more trials are also needed to determine and to evaluate more effective WASH interventions to halt the vicious cycle of exposure to poor WASH conditions in early childhood, repeated infections, inflammation and disease risk in adulthood.
Undernutrition has a complex set of political, social and economic causes, none of which are amenable to easy solutions. Important knowledge gaps still remain concerning critical aspects of child undernutrition, including environmental risks in the neonatal and infant periods, especially in sub-Saharan contexts. Vast differences inevitably occur between communities, between urban and rural, between socio-economic and political landscapes, and between regional and global contexts. The complexity of this is further compounded with the realisation that access to water and sanitation is problematised through an increasingly resource and climate-constrained context. Water resources are found in a variety of geographic settings that transcend geopolitical boundaries. Given the complex spatial context and transboundary nature within which water is situated, a number of dichotomies emerge when attempting to analyse national, regional and even continental or global WASH strategies and initiatives.
Acknowledgements
The support of the DST-NRF Centre of Excellence in Human Development, DST-NRF Centre of Excellence in Food Security and SA MRC/Wits Developmental Pathways for Health Research Unit towards this research is hereby acknowledged. Opinions expressed and conclusions arrived at are those of the authors and not necessarily to be attributed to the CoE in Human Development, CoE in Food Security or the SAMRC/Wits Developmental Pathways for Health Research Unit.
Financial Support
This study was made possible through the support of the SAMRC/Wits Developmental Pathways for Health Research Unit, DST-NRF Centre of Excellence in Food Security (Grant Number: 160502), DST-NRF Centre of Excellence in Human Development (Grant Number: ACC2017007).
Conflicts of Interest
None.
Ethical standards
This study has been assessed by the Human Research Ethics Committee (Medical) at the University of the Witwatersrand and is covered under Clearance Certificates M170872 and W-CJ-170816-8.
