During the last session of the 2018 UNC Water and Health Conference a rich group of epidemiologists, program managers and practitioners opined on the future of WASH as Bruce Gordon (World Health Organization) bounced around the room, passing a lapel mic to the next eager hand and jotting notes on a folded sheet of paper. Gordon had asked the group to reflect on what we are confident that we do, and do not know, about the health impacts of WASH.
As one participant after another implored the group to consider the multitude of ways that enteric pathogens make their way into children’s mouths — from their own shit to those of their ruminant companions — a familiar image loomed overhead.
The f-diagram adaptation from WHO’s new guidelines for sanitation and health projected on the screen during the session belied the intricacy of the discussion in the room. “Stunting is a highly complex outcome” Guy Howard (DFID) told the group. The room nodded in agreement. The graphic on the screen remained unchanged.
Throughout this year’s conference, allusions to the confounding and systemic-nature of WASH hid everywhere in plain sight. Service environments have many interconnected elements speakers told us. People don’t want to change their behavior and none of our regression models tell us why. We can’t measure everything, so we do what we can, others intoned. We need to recognize, USAID’s Ryan Mahoney told one session, that “we are always intervening in a system”.
Earlier in the closing session, Rick Johnston of the JMP shared a simple yet compelling image from a recent publication from SaniPath researchers illustrating the striking non-linear nature of fecal loads on health outcomes. This relationship has a tipping point, above which modest reductions in exposure will likely have no effect on enteric disease burden. And yet, Rick noted, we keep believing that modest improvements will lead to modest outcomes. Major initiatives like WASH Benefits and SHINE have shown us that’s just simply not true. Then again, this didn’t seem to be news to anyone in the room.
One thing from this year’s UNC Water and Health conference is clear; the sector is talking in systems, a lot. What is not clear, is what we are going to do about it. By their nature, complex systems are difficult to understand, intervene in and monitor. They are highly dynamic and context-specific. They require the participation of diverse groups of actors who each see the problem from unique and often contradicting perspectives. Even for this group of esteemed sector thought leaders, opinions on best practices collide. We all seem to agree in theory that among all the chaos there must be some leverage points, but there doesn’t appear to be any consensus on what they are or how to find them.
Whatever we choose to call it, transformative WASH, whole systems thinking, or just plain WASH, we need to acknowledge that the tools we are currently using only begin to approach understanding the deep complexity of service delivery. Despite the overwhelming evidence that the world does not operate in simple, linear, cause-and-effect relationships, we continue to use methods built on this logic(think of logframes, theories of change, SFDs, stakeholder maps etc..). While there are encouraging signs that the sector is starting to move towards creating more tools for embracing complexity (thanks in no small part to the innovative work and systems advocacy by IRC WASH and others), there is also reason to be concerned that that ‘systems thinking for WASH’ could be on its way to the buzzword graveyard if we fail to put actions behind our words. The answer to how we do that will hopefully be addressed when WASH systems advocates meet in March 2019 for IRC’s All Systems Go Symposium.