Integrated WASH and Food Nutrition Security in Ethiopia SUMMARY 
Ethiopia has made significant progress in reducing child mortality. Still, much work in many areas will have to be done to address structural and social factors that affect children’s health. These actions include water and sanitation, nutrition and the economic and social empowerment of women as children’s primary caregivers. This project wants to reduce morbidity, mortality and malnutrition among children, by improving their Water, Sanitation and Hygiene (WASH) and Food and Nutrition Security (FNS) situations. The project is being implemented by Plan International Ethiopia and it will reach the total population of 357,953 people in two Woredas (districts), namely Bahir Dar Zuria (Amhara) and Dara (SNNPR). The project started in September 2013 and will run till June 2019. It uses Community-Led Total Sanitation (CLTS) and Multiple Use System (MUS) approaches, in combination with nutrition education and support for Village Saving and Loan (VSL) groups. Compared to previous gains, it will probably be more difficult to keep reducing child mortality in Ethiopia. This is because the really marginalised and disadvantaged groups have yet to be reached and continued progress requires efforts on many fronts to address structural and social factors that affect children’s health.

There are three main causes of illness and death among children under five. 
(a)	There is limited knowledge about the importance of improved sanitation and appropriate hygienic practices, particularly in rural areas. Hygienic practices, better access to safe water, and improved sanitation can reduce diarrhoea-related illnesses by up to 45, 32 and 25 per cent respectively (WHO 2004). In Ethiopia, only 21 per cent of people have access to sanitation (UNICEF, 2011). 

(b)	There is limited knowledge about mother, new-born and child health nutrition. In Ethiopia 31 per cent of pregnant women are anaemic, 20 per cent of new-borns are underweight, 51 per cent of infants younger than six months are not exclusively breastfed and 33 per cent of all children are moderately to seriously underweight. The stunted growth rate is 51 per cent (UNICEF).

(c)	Women have a low socio-economic status, which is perpetuated by the limited support they receive from men and society in general. Women play key roles in generating income and food production and preparation, so their status significantly affects the nutritional condition of households, and children in particular. Action is needed to improve women’s status and reinforce the responsibilities of men as caretakers. Plan Ethiopia is using CLTS and MUS approaches, in combination with nutrition education and support for VSL groups. In the context of this project these approaches will be integrated and will therefore reinforce one another.

VSL groups (with 15-20 members, mainly women) are an important starting point for the work to be done in the chosen communities. A VSL skill and entrepreneurship training course (in combination with sanitation marketing) will increase the investment capacity of the community in a healthy environment. 

The CLTS approach raises awareness for sanitation and good hygiene practices in rural communities and stimulates the population to take collective action to improve their situation. A main principle of CLTS is not providing a subsidy or financial reward if a community reaches what’s called ‘100 per cent Open Defecation Free’ (ODF) status. 

The MUS approach makes water available for domestic as well as production purposes. People need water for drinking, cooking, washing their hands, other forms of sanitation and for watering animals, growing food and generating income. 

Nutrition education will improve the diet of women of a fertile age and of small children. It will do so by making women and men aware of what a good diet constitutes and of its importance. 

By using these different approaches in the same project, people will be motivated and able to create a healthier environment for themselves. They will also be able to invest in their own health and thus reduce child mortality. Regarding WASH, Ethiopia’s major policy frameworks are the Water Resource Management Policy, the Hygiene and Sanitation Strategy, and the Universal Access Plan. These aimed for 98 per cent access to safe water and 100 per cent sanitation coverage by 2012. And while the government made significant efforts to increase access to safe water and improve sanitation, progress still trails national targets and Millennium Development Goals. 

The project mirrors priorities identified by the Dutch Ministry of Foreign Affairs (MoFA) and the Netherlands’ Embassy in Ethiopia. More specifically, it relates to the third thematic priority of the MoFA, “Access to safe drinking water and sanitation”. The focus of MoFA and the Embassy is on creating synergies between the two main themes of water and food, which is exactly what this project is focusing on.

All Plan International Ethiopia (PIE) water projects are carried out in a community-managed approach and in line with the relevant government policy. This is all a good fit with an initiative called the Health Sector Development Program (HSDP4), which has made good progress in making health services available in Ethiopia at community level.

Regarding CLTS, PIE works closely with key stakeholders like the Ethiopian government and UNICEF in a Hygiene and Sanitation Taskforce and a Health and Sanitation Technical Working Group. The end beneficiaries are the 357,953 people living in the districts of Bahir Dar Zuria (191,141) and Dara (166,812). While CLTS and nutrition education components will cover all beneficiaries, the VSL component targets 60 per cent of households. Some 24,000 people will have access to clean water within 500 metres of their homes. Furthermore, about 20 households (100 people) will benefit from a nutrients recycling pilot. The activities in this project can be broken down into five clusters and these are described below. 
1.	VSL groups
1.1.	The formation of VSL groups 
The VSL concept will be introduced, in which interested people will form VSL groups in each community, or Kebele. During the first phase about 32 groups will be formed, each with 15-20 members, of which at least 60 per cent will be women. The number of groups will increase during the project (see 1.4).
1.2.	Training and supporting VSL groups
During the first year the VSL groups will receive intensive support and training so they can function independently. During the next phase additional training will be given on topics like financial skills, business planning, agriculture, technical skills, health, nutrition and social issues like gender.
1.3.	The formation of VSL networks
VSL networks will form a strong organisation capable of making development plans, starting up and supporting new VSL groups, and lobbying and advocating for its members. The project will support these networks by providing training and advice to network members.
1.4.	Helping VSL networks to form new VSL groups
The success of the VSL system will attract new members. New groups will be supported and trained in VSL methodology by existing network members. The project will underscore this process and, for the first 32 groups, will also help provide the necessary equipment.
2.	Water 
2.1.	The design and configuration of MUS
A feasibility study will identify existing and potential water sources, as well as the needs for drinking water, hand-washing facilities, hygiene and sanitation, small-scale irrigation and for other productive uses of water. The MUS approach will be designed around this, and could include springs, hand-dug wells, minor stream diversions, rainwater-collection installations and the rehabilitation of schemes. 
2.2.	The construction of school and health-post water supplies 
To strengthen the hygiene-education component, health posts and schools will be provided with water and sanitation facilities. 
2.3.	Training households and communities on safe water use, hygiene awareness and behavioural change
This training will be given in combination with the CLTS health and nutrition training (result 3 and 4). A condition of ODF verification is safe water handling in the household.
2.4.	Water, Sanitation and Hygiene Committees (WASHCO) at a community level 
A WASHCO will be formed for every water scheme. Its members will be the main users of the scheme and at least half of them will be women. Their main task will be operating and maintaining the water scheme. 
2.5.	Capacity building at Woreda level
Capacity building activities at Woreda level will be carried out in collaboration with partner, SNV. Where necessary, Plan will also give additional technical training, e.g. train Woreda-level water officers in technical aspects like water quality, and provide the essential equipment. 
2.6.	Helping to make WASHCOs legal bodies
The process of making WASHCOs legal bodies is on-going. PIE will continue to support this process. 
3.	Sanitation 
3.1.	Training community facilitators
First of all, Woreda healthcare trainers will be trained and these will then train the community facilitators, who are people already working as health extension workers at community level.
3.2.	Using the CLTS approach to trigger communities to wash their hands
The trained community facilitators will organise several activities to increase awareness about sanitation and hygiene in the various kebeles. These kebels will make community action plans.
3.3.	The construction of school latrines (ventilated and improved latrines)
The project will help construct school latrines. Parent-Teacher Associations will encourage parents to help build these latrines and to do the necessary maintenance. 
3.4.	Post-triggering
To ensure that communities can be certified as ODF, once the latrines are constructed they will be closely monitored by village sanitation committees. 
3.5.	Verification/certification by the “District Sanitation Committee”
Communities claiming to be ODF will be verified and certified by the District Sanitation Committee. 
3.6.	Celebrating a community attaining ODF status
A highlight of the CLTS programme will be a ceremony during which the community will show government representatives and neighbouring communities that they have constructed latrines and that their environment is now clean. 
3.7.	 Follow up and monitoring
After communities have officially become ODF, monitoring and follow-up is still necessary to ensure they don’t revert back to their old habits.
3.8.	Sanitation marketing
People will be trained to produce or market sanitation facilities. In every ODF community a group will be formed to market sanitation materials that improve the quality of latrines and the sustainability of sanitation and hygiene facilities. Some start-up assistance/capital will be given to the groups to help them produce these sanitatio (F) People will be encouraged to create a healthier environment for themselves and invest in their own health with local materials/capacity, but without external funding. Once WASHCOs become legal bodies, for example, they will be able to open bank accounts for money collected from water sales, which they will then be able to use for operation and maintenance.
(I) The capacity of national, district and local governments will be enhanced and interventions will be harmonised with other actors. For example, once communities have officially been declared ODF, they will still need monitoring and follow-up to ensure they don’t revert to their old habits. At first, Plan staff will do this, but healthcare workers and other government employees will gradually take over.
(E) A focus of the project is empowering people to invest in a healthy environment, such as by helping VSL networks at Kebele level to make business plans that take local economic and agricultural opportunities into account. Special assistance will be given to ‘green’ and ‘healthy’ business plans, such as producing wood-saving stoves and sanitation facilities.
(T) The project will also use locally available materials and capacity. Water systems and latrines, for example, will be constructed in such a way that the local communities can easily manage them. 
(S) The project will focus on everybody in a community and on collective action. People will help other people who are more vulnerable than themselves (less abled, widows, the old, etc.), with women and children being the main end beneficiaries.