Review Report of the National Open Defecation Free (ODF) and Hand Washing with Soap (HWWS) Strategies

Introduction Diarrhoeal diseases pose significant health risks for the rural population and account for 18% of deaths each year in children under the age of 5. Increasing access to basic sanitation and hand washing with soap at critical times are key interventions to the prevention of future diarrhea and cholera cases. The Government of Malawi with its development partners developed the Open Defecation Free (ODF) Malawi (2011 – 2015) and the National Hand Washing Campaign 2011-2012 Strategies, in line with the MDGs to support attainment of its goal to create a clean, safe and healthy environment. As the initial strategies came to an end (2011-2015), the global community entered the new phase of Sustainable Development Goals (SDGs 2016-2030). As such, Malawi also felt the need to up-date the ODF and the National Hand Washing Campaign strategies to be in line with the national sanitation and hygiene targets and SDG Goal 6.2: by 2030. It is against this background that the National Open Defecation Free Task Force (NOTF) commissioned this consultancy whose TORs were to provide a framework for facilitating the review and development of the new National ODF and Hand Washing with Soap (HWWS) strategies. This report is as a result of field data collection, literature review and stakeholder consultation which are informing the revision of the ODF and HWWS strategies to support Malawi in meeting the SDG targets. Objectives NOTF outlined specific objectives for this review which have been arranged in two stages as follows: Stage 1: • Review of current country strategies with emphasis on original assumptions. • Review the effectiveness of the scope, mechanisms and actions applied in the implementation of the ODF/HWWS Strategies. • Review the extent to which different programmes, approaches and other cross cutting issues (by Government, NGOs and development partners) have contributed to the implementation of the ODF/HWWS strategies. Stage 2 • Examine the extent that the changing assumptions and indicators impact achievement of ODF Malawi and Hand Washing behaviours. • Examine how the strategies link in with other WASH related strategies and approaches • Identify gaps in the ODF Malawi Strategy (2015) and National Hand Washing Campaign and incorporate lessons and practical experiences from field application. Methods The assignment used a number of data collection methods including stakeholder analysis, desk review, field research and stakeholder consultation detailed as follows: Stakeholder analysis: Stakeholder analysis was used to identify project's key people with stake, interest or influence in reducing open defecation and promoting hand washing with soap. Stakeholder analysis was a useful tool for identifying people and organizations and institutions that assisted in providing information regarding ODF and HWWS. The information from identified stakeholders was gathered using Key Informant Interviews (KII) and Focus Group Discussions (FGD) during field research and stakeholder meetings. Desk review: The desk review constituted an important step in the process of reviewing the national ODF and HWWS strategies. It provided the evidence base for the review. Reviewing all documentation (grey, published and peer reviewed information) relating to the issues covered in the existing strategies to develop as complete a picture as possible of the current state of ODF and HWWS both in and outside Malawi. This involved using the following techniques: Internal Desk Research, External Desk Research, Online Desk Research, Government published data and Customer desk research. Field Research: This involved creation and collection of primary data from the field setting. The process involved determining what precise data was necessary and from where this information needed to be obtained. Field research was performed by the consultancy team in person in 6 Districts and with key stakeholders, through KIIs (n=24) and FGDs (n=38). Purposive sampling was used to recruit participants for both the KIIs and FGDs. Stakeholder Workshop was undertaken to get provide feedback and validation of the desk review and field results, as well as receive input from further Districts and stakeholders. The workshop used presentations, world café consultation and direct feedback. Results Key Findings Findings demonstrate that there have been positive results and progress towards meeting strategic targets from 2011-2015. Nevertheless there are still significant barriers and challenges to the achievement of key goals of ODF and HWWS across Malawi. The main gaps identified include: Scope • The ODF strategy focuses only on the rural population, which has limited the focus and success of ODF achievement. • The ODF strategy referred only to households with no requirement for ODF status in public spaces and institutions. • There is no reference or integration of ODF strategy with menstrual hygiene management. • Neither strategy has specific reference or support for vulnerable and marginalized groups. Mechanism • Both the ODF and HWWS strategies do not provide specific definitions of latrines, hand washing facilities, etc. which leads to variation in implementation. • The ODF strategy does not consider the whole sanitation chain (capture to disposal). • ODF strategy implementation was to be overseen by the NOTF which represents the Ministry of Health and the Ministry of Agriculture, Irrigation and Water Development with key development partners and civil society which doesn’t include other ministries. • The current ODF strategy is limited to the use of Community Led Total Sanitation (CLTS) and sanitation marketing and does not take into consideration the use of other participatory approaches such as Participatory Hygiene and Sanitation Transformation (PHAST) and mechanisms to achieve ODF. • Although there is the inclusion of 2 levels of ODF status in the strategy (i.e. 1- appraising a community towards the attainment of the ODF status; 2- sustenance of ODF status after attaining the ODF status), there is little reference to the effective use of the sanitation ladder to achieve continued improvement and sustainability. • HWWS strategy uses health facilities and schools as key locations for good practice and development of agents of change, but in many cases these were identified as having the poorest standards. • The use of Health Surveillance Assistants (HSAs) in the drive for ODF was reported as inconsistent across partners. • CLTS was seen as a ‘project’ by HSAs, and once partners were gone the implementation also stopped. • HSAs were used to receiving allowances to undertake this work and therefore stopped their CLTS/ODF activities when they became routine activities. • Data was inconsistently reported and in some cases validity is called into question. • In the implementation of both strategies there has been a focus on infrastructure with little concentration on behavior change communication for sustained change. Key recommendations Scope • The scope of the strategies should include proper definitions of a latrine (including menstrual hygiene management) and hand washing facilities, and should consider the whole sanitation chain. • Areas must ensure ODF and HWWS in all households and public areas and institutions before they can be declared ODF. • New strategies must tackle both urban and rural populations. • Support for vulnerable and marginalized populations must be more effectively integrated. • Integration of menstrual hygiene management • Criteria and mechanisms for being declared ODF should be reviewed. Mechanism • NOTF should be more multidisciplinary in its membership with the inclusion of representatives from nutrition, disabilities and other appropriate government departments to ensure integration of services. • Effective sanitation marketing and financing models need to be more fully integrated into CLTS triggering programmes. • Movement towards a requirement for standard systems to be constructed should be considered which would improve quality of latrines and create business for masons and entrepreneurs. • Training of masons should be linked to technical training colleges and schools. • ODF must be incorporated into the routine activities of HSAs without the requirement of allowances. • Funding must be ring-fenced for ODF activities from the District budget. • Stakeholders reported the need for integration in community structures for effective implementation, and the valuable role of Natural Leaders. They suggested a continued use of traditional and natural leaders to support the implementation, achievement and sustainability of ODF status. It was also suggested that natural leaders and their roles in community sanitation and hygiene achievement should be recognized. • Vulnerable and marginalized groups should be engaged from the offset of the CLTS programme and be involved in the training, implementation and verification processes to ensure appropriate systems are in place to support them. • By laws should continue to be encouraged but must be enforced consistently for all community members and be facilitative rather than punitive, taking into consideration human rights. • Large ODF celebrations attended by the Minister and dignitaries should only take place when the District has achieved ODF status. • School WASH standards need to be completed and circulated to ensure improvement at facilities. These standards must include a range of low cost HWF suitable for school settings. • The concept of using schools and children as agents is still a welcome one but needs better integration and structure • Health facilities must be supported to ensure that they are modeling improved sanitation and HWWS to promote good behaviour. • HWWS promotion needs to be integrated into all relevant clinics, e.g. antenatal, growth monitoring, immunisations, OPD, etc. • Behaviour change messaging needs to be developed based on sound principles and with an understanding of the audience and behavioural factors which are being targeted. • The need for, and promotion of HWWS requires effective public private partnerships and these require to be engaged on a more regular and formal basis. • Strengthen CLTS and HWWS monitoring systems: There is need for more detailed monitoring and evaluation of progress and effectiveness. • Improved integration of behavior change communication to support sustained improvements in ODF and HWWS throughout Malawi. Cross cutting recommendation for future strategy development It is clear from the feedback from all stakeholders and desk review, that future strategies must address concerns regarding integration of sanitation and hygiene programmes to ensure sustained change across Malawi and achievement of the SDGs by 2030. With this in mind, it is the overall recommendation of this review that the current ODF and HWWS strategies should be integrated into a more general ‘hygiene and sanitation’ strategy. This would support not only the integration of HWWS and ODF programmes, but also the inclusion of key issues raised in stakeholder meetings such as menstrual hygiene management and solid waste management (including faecal sludge management). This would be an all encompassing strategy which targets rural and urban populations, domestic houses, commercial premises and institutions across the country. Only then can Malawi truly meet the target of Universal Sanitation and Hygiene for All

Acute health risks to community hand-pumped groundwater supplies following cyclone Idai flooding

This longitudinal flood-relief study assessed the impact of the March 2019 Cyclone Idai flood event on E. coli contamination of hand-pumped boreholes in Mulanje District, Malawi. It established the microbiological water-quality safety of 279 community supplies over three phases, each comprising water-quality survey, rehabilitation and treatment verification monitoring. Phase 1 contamination three months after Idai was moderate, but likely underestimated. Increased contamination in Phase 2 at 9 months and even greater in Phase 3, a year after Idai was surprising and concerning, with 40% of supplies then registering E. coli contamination and 20% of supplies deemed 'unsafe'. Without donor support for follow-up interventions, this would have been missed by a typical single-phase flood-relief activity. Contamination rebound at boreholes successfully treated months earlier signifies a systemic problem from persistent sources intensified by groundwater levels likely at a decade high. Problem extent in normal, or drier years is unknown due to absence of routine monitoring of water point E. coli in Malawi. Statistical analysis was not conclusive, but was indicative of damaged borehole infrastructure and increased near-borehole pit-latrine numbers being influential. Spatial analysis including groundwater flow-field definition (an overlooked sector opportunity) revealed 'hit-and-miss' contamination of safe and unsafe boreholes in proximity. Hydrogeological control was shown by increased contamination near flood-affected area and in more recent recharge groundwater otherwise of good quality. Pit latrines are presented as credible e-coli sources in a conceptual model accounting for heterogeneous borehole contamination, wet season influence and rebound behavior. Critical to establish are groundwater level - flow direction, hand-pump plume draw, multiple footprint latrine sources - 'skinny' plumes, borehole short-circuiting and fast natural pathway (e.g. fracture flow) and other source influences. Concerted WASH (Water, Sanitation and Hygiene) sector investment in research and policy driving national water point based E. coli monitoring programs are advocated. [Abstract copyright: Copyright © 2021. Published by Elsevier B.V.

Survival of Infants Born to HIV-Positive Mothers, by Feeding Modality, in Rakai, Uganda

Data comparing survival of formula-fed to breast-fed infants in programmatic settings are limited. We compared mortality and HIV-free of breast and formula-fed infants born to HIV-positive mothers in a program in rural, Rakai District Uganda.One hundred eighty two infants born to HIV-positive mothers were followed at one, six and twelve months postpartum. Mothers were given infant-feeding counseling and allowed to make informed choices as to whether to formula-feed or breast-feed. Eligible mothers and infants received antiretroviral therapy (ART) if indicated. Mothers and their newborns received prophylaxis for prevention of mother-to-child HIV transmission (pMTCT) if they were not receiving ART. Infant HIV infection was detected by PCR (Roche Amplicor 1.5) during the follow-up visits. Kaplan Meier time-to-event methods were used to compare mortality and HIV-free survival. The adjusted hazard ratio (Adjusted HR) of infant HIV-free survival was estimated by Cox regression. Seventy-five infants (41%) were formula-fed while 107 (59%) were breast-fed. Exclusive breast-feeding was practiced by only 25% of breast-feeding women at one month postpartum. The cumulative 12-month probability of infant mortality was 18% (95% CI = 11%–29%) among the formula-fed compared to 3% (95% CI = 1%–9%) among the breast-fed infants (unadjusted hazard ratio (HR)  = 6.1(95% CI = 1.7–21.4, P-value<0.01). There were no statistically significant differentials in HIV-free survival by feeding choice (86% in the formula-fed compared to 96% in breast-fed group (Adjusted RH = 2.8[95%CI = 0.67–11.7, P-value = 0.16]Formula-feeding was associated with a higher risk of infant mortality than breastfeeding in this rural population. Our findings suggest that formula-feeding should be discouraged in similar African settings

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to &lt;90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], &gt;300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of &lt;15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P&lt;0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P&lt;0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Social Inclusion or Social Engineering? The Politics and Reality of Widening Access to Medicine in the UK

Although driven by policy and investment, the available data suggests that, to date, UK efforts to minimise the barriers into professions such as medicine have had mixed success. We explore the myriad social, individual and structural reasons why the resources invested in widening access (WA) activities have not significantly increased the representation of applicants from lower socio-economic groups within medical schools. We discuss the different discourses of widening access/increasing diversity in the UK context – notably those of ‘social mobility’ and ‘increasing diversity to improve workforce efficiency’ – and how these are interpreted and enacted “on the ground”. This includes examining the synergies and tensions between widening access and maintaining quality, and the gap between political directives and policy enactment within medical schools. We discuss if the different discourses of widening access can be reconciled, and if so, whether this can be done in a way to support widening access

Conceptualising metabolic disorder in Southern Africa: Biology, history and global health

This paper traces the history of the concept of metabolic disorder in global health and its application to the collection of health metrics relating to the ‘epidemic’ of non-communicable diseases in Southern Africa, with a focus on Malawi. Although the contemporary science of metabolism points to complexity and contingency, the application of a simplified version of ‘metabolic disorder’ or ‘metabolic syndrome’ as the supposed central driver of non-communicable disease in low- and middle-income countries runs the risk of obscuring the ways in which local circumstances and histories interact with global forces to produce epidemiological change. The paper discusses health data collection and its interpretation in Malawi to demonstrate how the use of this concept has led to a narrowing of the category of non-communicable disease and a neglect of the role of infectious disease in producing chronic conditions. Finally, the paper points to alternative approaches which might yield a better understanding of pressing health problems