Water and health experts consult one another all too rarely. This despite the fact that waterborne diseases contracted from unsafe drinking water kill 2.6 million human beings each year! These diseases are well known: cholera, diarrhea, typhoid fever, hepatitis A, bilharzia, polio, etc.
Unsafe drinking water is a major cause of mortality and, as such, it is a humanitarian emergency—particularly in the poorest countries where populations are beset by conflicts and natural disasters.
Water and health constitute two of the main priorities of the UN’s 2030 Agenda for Sustainable Development and its 17 Goals (SDGs). Goal 6 seeks to achieve universal access to drinking water and sanitation in 10 years.
Although progress has been made, the official figures show we still have a long way to go (see pp. 6-7 of our Barometer). As it stands, 29% of the global population lacks access to drinking water and 55% to sanitation.
Likewise, 1.4 billion people lack access to sanitary facilities equipped with water and soap, and 3 billion are still unable to wash their hands at home. Moreover, 80% of the world’s wastewater is released into the environment untreated.
Nearly 1 in 4 health centres worldwide lacks access to drinking water. 1 in 10 lacks access to sanitation services. And the situation is far worse in the 47 least-developed countries, where 1 in 2 health centres lacks drinking water and 3 in 5 lack sanitation. As of 2019, a mere 30% of schools worldwide were equipped to provide pupils with safe drinking water.
We need to act now: unsafe drinking water doesn’t just kill ; it also stifles development.
And we need to act on two fronts simultaneously: 1 – delivering humanitarian and development assistance to vulnerable populations, and 2 – lobbying institutions to ensure that policies get enacted and critical resources mobilized.
We need to pick up the pace and seek out new tools if we are to achieve universal access to drinking water, sanitation and hygiene, as per the unanimous commitment made by 195 states at the UN in 2015.
By Antoine Peigney, chairman of Solidarités International and Alain Boinet, founder of Solidarités International
From a professional point of view, he is since July 2017 the Director of the Health Department of Expertise France, the French agency for international technical expertise.
From 1998 to 2016, he headed the international operations of the French Red Cross. During this period, Antoine Peigney engaged teams in nearly eighty countries in crisis response, development aid and cooperation. Prior to that, he carried out several field missions from 1990 to 1995, mainly in the Horn of Africa and the former Yugoslavia, but also in Romania, Lebanon, Mauritania, Angola and Haiti, and was responsible for programmes in Africa at the headquarters of the NGO EquiLibre from 1995 to 1997. In this capacity, he supervised missions in Mali, Niger, Madagascar, Burundi, Uganda and Morocco.
Antoine Peigney is an auditor of the “Institut des hautes études de la Défense Nationale” from the 2013/2014 session, and graduated in 1991 from the Institut Bioforce-Développement in Lyon.
Today, 2.2 billion people – or 29% of the world’s population – lack access to safely managed domestic water supply services; 4.2 billion people – or 55% of the world’s population – lack safely managed sanitation services; 3 billion people – or 40% of the world’s population – still lack basic home-based handwashing facilities1. These figures have serious consequences, with some 525,000 children dying every year from diarrhoea2. Yet 58% of diarrhoea cases in middle- and low-income countries are attributable to inadequate access to water, hygiene and sanitation services3.
However, Sustainable Development Goal (SDO) n°6 aims to ensure that everyone has access to clean water services by 2030. In order to achieve this goal, many organisations – NGOs, International Organisations, governments etc. – are mobilised in the field to achieve this goal. The actions of these institutions are coordinated at the national level by governments, or by “national WASH clusters4” or “WASH humanitarian coordination group”. Their aim is to coordinate the international response and distribute the different actors geographically. The latter, in turn, provide data – mostly quantitative – on the activities carried out. Qualitative evaluations of projects also take place, but often once the programme has ended. This is often too late to allow managers to take corrective action.
It is from this observation that the Global WASH Cluster’s Quality Assurance & Accountability Initiative (QAAI) was born in 2018. Its main objective is to strengthen the qualitative monitoring of activities in order to improve the quality of humanitarian responses and the sector’s accountability towards the people affected. This initiative is implemented by Solidarités International, in partnership with Oxfam, Tufts University and UNICEF.
This article will return to the Global WASH Cluster and QAAI. It will describe the tools developed by the project to implement an effective and continuous quality assurance and accountability system and it will look at the start of the project’s roll-out in Southern Sudan.
The origins of the Global WASH Cluster
Clusters are born as a result of the 2005 Humanitarian Reform agenda 2005. This reform aims to improve the predictability of aid, the accountability of organisations, the coordination between different humanitarian actors and to strengthen partnerships during emergency humanitarian responses. It advocates the establishment of “clusters” which could be activated during crises and which would enable humanitarian action to better coordinate.
This desire to improve aid was reiterated following the earthquake in Haiti and the floods in Pakistan in 2010. The Inter-Agency Standing Committee (IASC) publishes a transformative agenda to strengthen the effectiveness of multilateral humanitarian aid.
Once again, the humanitarian community, through this document, reiterates its desire to transform aid in order to strengthen its accountability, coordination and leadership5. The Global WASH Cluster (GWC) was born out of this movement in 2006 and now has 77 members.
Why implement a Quality Assurance and Accountability System?
Humanitarian crises are complex and dynamic. Partners need to be able to rely on reliable information, gathered in real time, in order to (i) meet their commitments in terms of quality and accountability towards beneficiaries and (ii) improve and adapt their practices in line with the changing context in which they operate.
National Clusters mostly focus on monitoring the activities of partners or evaluating the coverage of the response rather than understanding whether it is safe, inclusive, participatory and effective. In other words, National Clusters tend to answer the questions “who does what, where and when” rather than asking whether the response is relevant and meets the needs of beneficiaries.
The risk is then to evaluate the humanitarian response and manage it in such a way as to maximise the number of beneficiaries or water, hygiene and sanitation (WASH) services, without understanding whether real progress is being made towards achieving quality or accountability objectives. For example, the number of latrines built in an area is monitored but not their actual use by different groups in the community.
Quality Assurance and Accountability Systems (QAAS) are one way of addressing this situation, strengthening accountability to beneficiaries, and ensuring that quality standards are met by partners on a sustainable basis.
What is quality and accountability and why is it essential?
The quality of a humanitarian response is judged by two elements: the results achieved and the process by which these results are achieved. Deviations in quality are measured against standards and are mainly due to the way in which humanitarian aid is designed and/or implemented. They are reflected either directly in programme results or in the way people affected by the crisis perceive the aid provided.
Quality can be objectively defined and measured. However, humanitarian responses are subject to external constraints. A realistic approach is therefore needed to optimise the quality of programmes, rather than trying to achieve too high standards.
Partners in the sector, in this case WASH, must therefore commit to a process of continuous improvement of their programmes while taking into account the constraints associated with the context. A Quality Assurance and Accountability System (QAAS) is a coordinated approach that allows decisions to be made based on concrete facts. The aim is to ensure that the quality and accountability standards, decided by WASH partners for their interventions, are respected and discussed with a view to continuous improvement.
This system provides a means to monitor the WASH response against a framework of reference listing quality and accountability standards for humanitarian WASH interventions. These standards are established by consensus among partners and adapted to the context. They are regularly reviewed.
The QAAI project, how does it work?
The Quality Assurance and Accountability initiative has developed two main tools to support WASH humanitarian coordination groups in the implementation of a continuous and collective Quality Assurance and Accountability System.
The first is a note explaining the quality assurance process which provides a framework for monitoring and analysis to improve programmes. The second is the Modular Analysis Framework which defines basic standards, indicators and monitoring approaches to be used according to WASH’s areas of intervention which are priorities in the given context.
The quality assurance process is defined in 5 steps: define, measure, analyse, improve and learn.
It is adapted from the “Define-Measure-Analysis-Improve-Control “6 method used in the industrial sector.
The approach combines a continuous process of monitoring, analysis and improvement with a periodic review of lessons learned. Monitoring focuses on the collection of relevant, feasible and results-oriented measures.
It gives priority to understanding the “reality on the ground”, through the perspectives of people affected by the crisis.
This first step allows national WASH Clusters to define key quality and accountability indicators that are adapted to the context and identified priorities. These will be integrated into the modular analysis framework – which we present below – for the monitoring and qualitative evaluation of ongoing programmes. The exercise of defining key indicators allows us to focus only on those indicators that are relevant to improving effectiveness.
This phase is to be carried out continuously. It consists of collecting data to inform the key quality indicators set out in step 1 and to disaggregate them by gender, age, disability, location, etc. as required. The data will enable stakeholders to have an overall picture of quality, in the form of a Quality Snapshot.
This phase takes place in parallel with step 2 – data collection. It enables us to identify the points where quality needs to be strengthened and to list the actions to be implemented to remedy this. These proposals will take the form of an action plan.
The programme improvement phase is also carried out continuously and in parallel with steps 2-collection and 3-analysis. During this stage, programmes can be readjusted to better meet the needs of the population. The communities targeted by the programmes are included in the reflection process and their feedback on the quality of the programmes is discussed and taken into account.
This last phase allows us to take a step back from the initial hypotheses and strategic orientations defined in the Humanitarian Needs Overview. It aims to reflect on the long term humanitarian response in the country.
The table below summarises the steps to follow.
The Modular Analysis Framework is a flexible tool for targeting priorities.
The Modular Analysis Framework is composed of different modules that provide guidance on standards and indicators, according to sub-areas that each cluster can prioritise according to the local context and constraints.
It is a flexible tool to be used to collect the information strictly necessary to improve the programmatic and technical quality and accountability of the response at the sector level.
So far, three modules have been developed: “Public Health Risks”, “EHA Service Delivery” and “People Centred Programming”.
Each module is composed of the following 5 elements:
Standards: a reminder of international reference standards.
Key Quality Indicators: to assess whether the quality objective is achieved.
References: elements which enable the key quality indicators to be contextualised (locality, security context, etc.).
Monitoring approaches: indicate the way in which data is collected.
Data collection: examples of questions to be included in questionnaires, interviews, etc.
We share here, in part, the “Public Health Risks” module in order to report concretely on the work of the initiative.
MODULE ON PUBLIC HEALTH RISKS
Water, hygiene and sanitation (WASH) programmes generally address public health risks related to fecal-oral disease transmission. Diagram F illustrates the different routes of fecal-oral transmission, as well as the barriers that are effective in preventing transmission. It is often difficult to use health data to monitor the effectiveness of WASH programmes because of the availability of data and the many factors that can confound results. Monitoring the presence of key barriers can be used as a proxy for estimating the level of risk to public health from WASH-related diseases.
In this example, four components have been identified as potentially posing a public health risk. These are the ones that will need to be addressed to prevent fecal-oral disease transmission. They are presented in the table below.
Each component is associated with an international standard, which is then broken down into key quality indicators adapted to the context.
The Key Quality Indicators (KQIs) proposed in this module provide an overview of the relative risks of oral faecal transmission in different settings, places and population groups. Although they cannot be used to define an absolute risk, their use can help in understanding and prioritizing where corrective measures are needed to improve the effectiveness of responses.
For example, for the water quantity component, the standard, derived from the Sphere 2018 handbook, is as follows:
Water Supply Standard 2.1 : Access and quantity of water. People have equitable and affordable access to a sufficient quantity of safe water to meet their domestic and drinking needs.
The proposed key quality indicator for this component is: “% of the affected population using sufficient water for drinking, cooking, household and personal hygiene”. “Sufficient water quantity” is to be defined by the national WASH Cluster in consultation with the groups concerned or by reference to national standards.
Three kinds of monitoring approaches are proposed by the QAAI teams. For water quantity, this can be (i) rapid: key informant interviews, observation, (ii) in-depth: survey of water users, (iii) triangulation: water pumping/delivery records, mapping of water points, qualitative information from focus group discussions or participatory approaches. These approaches can be used by Cluster partners.
Analysis questions are then proposed. In order to assess the quantity of water available, the teams can analyse the data collected from the proposed questions:
Is there enough water available at household level to enable all affected people to drink, cook and wash and to keep their environment clean?
Who faces particular difficulties in accessing water of sufficient quality?
Who might need different amounts of water?
How much water is used on a daily basis?
Does water use change due to seasonality or functionality (due to changes in demand or supply)?
It is up to each national WASH cluster to adapt this modular analytical framework to its own terrain and priorities.
An initiative, rooted in the field
The work of the Quality Assurance and Accountability Initiative team does not stop there. Once these tools have been developed, the teams support the national clusters in adapting the proposed procedures and implementing their own quality assurance and accountability system. The objective is first of all to take stock of the existing quality approach within the national EHA clusters (see general questions for Southern Sudan*), while adapting the approach to the priorities of the field teams and local issues.
The first field missions took place in 4 countries: Bangladesh (Cox’s Bazaar), Myanmar, South Sudan and Colombia. Six other countries are also part of the pilot countries: Afghanistan, Central African Republic, Haiti, Mali, Ecuador and Venezuela. Due to the Covid-19 pandemic, the majority of implementations are being done remotely. In this last section, we will detail the implementation of the initiative in Southern Sudan, where the IAQ teams were able to visit.
The launch of QAAI in Southern Sudan
The Quality Assurance and Accountability Initiative team met with members of the WASH cluster in Southern Sudan. The objectives of the 10-day visit were as follows:
To improve the understanding of the WASH humanitarian response in Southern Sudan.
Raise awareness of the Global WASH Cluster’s QAAI initiative among the national WASH coordination.
Agree on a definition of quality and identify the monitoring protocol appropriate to the context.
Develop an action plan for quality monitoring.
Data was first collected on the general context of Southern Sudan. This country presents a complex humanitarian situation, marked by a large number of internally displaced people with increased needs. The level of water, hygiene and sanitation services is relatively low. Some WASH infrastructures have been targeted by armed actors during the different conflicts. The country is facing cholera, malaria and hepatitis E epidemics. Waterborne diseases are present in the country and are linked to malnutrition issues. Gender-based violence is closely linked to access to WASH services. In general, the humanitarian response is under-funded. More specific information on the functioning of the humanitarian response has also been compiled.
The QAAI teams are asking themselves the following questions* in order to answer the above objectives.
How is quality defined in humanitarian responses? What documents are used to disseminate this definition? How is this definition jointly developed by partners?
How do we ensure that the collective reports of WASH partners reflect the reality on the ground? (and as experienced by the people concerned)?
How do we ensure that the reports trigger corrective action on the ground?
Concretely, during the visits, all existing quality and accountability indicators are identified and analysed. Some proposed by the QAAI are already integrated by the national clusters. In this case, the teams think about how to improve data monitoring. Others are to be added in the cluster approach, in order to comply with the quality framework proposed by the QAAI.
At present, several indicators have already been integrated into the monitoring and analysis of the WASH Cluster:
Consultation of affected communities before the start of activities.
The implementation of a complaints/feedback mechanism.
The taking into account of consultations and complaints/feedback to adapt the activities implemented.
From these observations, an action plan was developed by the national WASH Cluster teams and the QAAI project team. This document plans the integration of the Quality Assurance and Accountability initiative into the WASH Cluster’s project monitoring processes.
This first step in the initiative’s process enables actions to be refocused on affected populations. Ultimately, these actions will enable the WASH South Sudan Cluster to develop the Quality Snapshot as proposed by the initiative and described above.
More generally, the QAAI project is part of a strong desire on the part of humanitarian organisations to improve the quality, sustainability and accountability of their actions. The initiative responds to this by supporting the setting up of continuous quality assurance and accountability systems in national WASH Clusters. It is the continuous aspect which makes the QAAI proposal specific and strong, as it will enable projects to be improved in real time and to be as close as possible to the needs expressed by the target population. This project within the Global Wash Cluster puts the people affected and the response to their needs at the heart of its action.
Who is Lise Lacan?
Lise Lacan is a chemical and environmental engineer. She has worked for more than 10 years in major NGOs and UN agencies as a Water, Hygiene and Sanitation specialist in Africa, the Middle East and Central Asia responding to emergencies in different contexts, including armed conflicts, natural disasters or epidemics. She now works at Solidarités International as coordinator of the Quality Assurance and Accountability Initiative of the Global WASH Cluster, of which the NGO is a member.
After a degree in Anthropology at Paris Nanterre, Madeleine went on to complete a Master’s degree in Human Rights and Humanitarian Action at Sciences Po Paris. Interested in humanitarian and public health issues, she now works with Alain Boinet for the publishing of the Défis Humanitaires website.