WASH & Health

Health⁷⁰ is an immediate factor influencing both dietary intake and the uptake of micro-nutrients. Many women reported to suffer from diseases (i.e. respiratory diseases, malaria and diarrhoea). In 2015, diarrhoeal diseases accounted for roughly 530,000 deaths worldwide (UNICEF, 2015). The high prevalence of malaria (especially in Togo) is particularly threatening for the target group. Pregnant women face the risk of maternal anaemia, and infants born to mothers with malaria are more likely to have low birth weight (UNICEF, 2004).

“Food and nutrition security includes a sanitary, adequate health services and care […] to ensure a healthy and active life” (FAO et al., 2017). The access and availability of basic WASH & health infrastructures plays an important role in preventing micronutrient deficiencies, stunting and nutrition-related deaths (Gain, 2018). Half of the cases of child undernutrition is due to repeated diarrhoea and intestinal infections caused by poor sanitation and hygiene or a lack of safe water (WHO, 2019). It is estimated that the use of clean water and soap can prevent nearly half of all cases of childhood diarrhoea. This, in turn, can stem the loss of nutrients and reduce stunting in children under the age of five by up to 15 % (Gain, 2018). Problematically, many villages in Maritime and in Eastern Province do not have access to basic WASH & health facilities.

70 Improved health of women is associated with an increase in perceived female authority over several farm and household decisions, suggesting that physical and mental capabilities are a crucial component of bargaining power (Anderson et al., 2017).

In Zambia, basic patient care is free of charge for pregnant mothers, whereas in Togo, pregnant mothers have to bear the costs of all medical treatments. The target group’s access to clean drinking water is limited in both countries, and individuals (including infants, pregnant women and lactating women) occasionally drink water from contaminated sources.

Figure 13 shows the interrelation of the proposed activities meant to improve the health-status of the target group.

Figure 13: Measures to improve the health -status of the target group

Source: Own illustration.

As for the access to and use of latrines, the situation in Zambia and in Togo differs significantly. While in rural Zambia, around 33 % of the population uses sanitation facilities, less than 3 % of the population in rural Togo has access to latrines (UNICEF, 2011) and open defecation is common. Local organisations have years of experience and knowledge in the WASH & health sector (such as SNV in Zambia’s Eastern Province, where “shaming” is used as a method to improve household hygiene, and the Eco-San latrines promoted by the Red Cross in Togo’s Maritime).

In both regions, some health workers and caregivers have difficulties to identify stunting. This deficit can be attributed to a lack of materials (i.e. growth charts)

and a lack of knowledge. Men are the main decision-makers regarding the resources that go into the monitoring of child growth (e.g., health expenditures, transport). However, most men are unaware of the signs of stunted growth and its long-term consequences for the infant and the family, and their financial contribution is low.

The ambivalent influence of secondary care givers (grandmothers, siblings, fathers) on dietary intake and health needs to be addressed. Positive aspects (e.g.

knowledge transfer through grandmothers) need to be accentuated, in line with the inclusion of negative side effects, as less time allocated to infants by mothers.

During pregnancy and after giving birth, women consult multiple actors (public health workers but also traditional and religious authorities) on care and advice. A study from Nigeria (2016) found multiple ways in which pregnant women seek care and conclude for a strong involvement of communal structures (Akeju et al., 2016).

The way young mothers feed new-borns has long-lasting effects on child development.⁷¹ Insufficient breastfeeding is presumed to be related to child mortality (Black et al. 2008). Unfortunately, some mothers in both regions appear to lack knowledge about appropriate diets during pregnancy and adequate care of infants.

In this context, the high percentage of early pregnancies needs to be highlighted and addressed. Following a report on Eastern Province, 35.4 % of 15–19 y/o girls already have children (GZR, 2014). In Togo’s Maritime (without Lomé), the number is 16.4 % (RT, 2014). Early pregnancies can have a negative impact on the health of mothers and children as both compete for nutrients (Imbuto Foundation, 2018) and this can increase the prevalence of low birth weights, preterm births and maternal anaemia (Yu et al., 2016). The fact that young mothers try to hide their pregnancy and eat less increases the risk of stunting. Accordingly, Win and her co-authors argue that “attention should be paid to improving maternal nutrition status, and especially pre-conceptual nutritional status” (Win et al., 2013). Another issue is the time- interval between pregnancies. If the interval is too small, the foetus competes with the (breastfed) infant child for their mother’s nutrients.

Family planning methods (number and timing of pregnancies) can reduce pressure on food security (Smith and Smith, 2015) and has a positive impact on infant and young child feeding practices. Child spacing helps women’s bodies to recuperate

71 The WHO recommends that mothers breastfeed their children for six months (WHO, 2018).

and replenish essential nutrients and leads to higher birth weight for their children (Naik and Smith, 2015).

Addressing WASH & health-related issues in interventions is essential to reduce stunting. Interventions need to continue to focus on local WASH & Health conditions, especially of vulnerable groups, and involve key decision makers.