Forcibly displaced populations are repeatedly exposed to public health risks and threats when they leave behind their social networks, livelihoods, service providers, and infrastructures. Displaced people often see their health weakened during their displacement journey because they lack food and adequate nutrition, safe water and sanitation services, and often do not have the resources to maintain basic hygiene.
There may be public health risk factors unique to a displaced population that make forced migrants specifically vulnerable compared with the host population. These additional risk factors are linked to a lack of access to health records, unknown immunisation histories, and limited knowledge of, and access to, health-care services. These public health risks are exacerbated by other challenges facing displaced people, including lack of the right to work, limited freedom of movement, lack of documentation, and poor access to financial services, housing, land, and property rights.
All these risk factors create vulnerabilities which often result in increased morbidities and mortality, caused by infectious diseases (for example, respiratory infections, diarrhoeal diseases, typhoid, measles and hepatitis) and vector-borne diseases (such as malaria, dengue, zika and leishmaniasis). Lack of access to safely managed water, sanitation and hygiene (WASH) services accounts for approximately 829,000 preventable deaths per year worldwide, 297,000 of which are of children under five years old. Unsafe drinking water, inadequate availability of water for hygiene, and lack of access to sanitation together contribute to about 88% of deaths from diarrhoeal diseases, with diarrhoea being the second leading cause of death and a leading cause of malnutrition in children under five.
The protracted nature of many displacement situations demands a change in how traditional emergency public health is delivered, with a strong need for prioritisation of sustainable solutions, including those that strengthen local and national systems. These solutions require a synergy of various components – such as the provision of WASH services – that contribute to sustained health outcomes.
Challenges for the WASH sector
Over the last decade, the humanitarian community’s public health responses to displacement emergencies have struggled to provide life-saving relief at the same time as addressing the underlying causes of infectious disease. The WASH sector has often failed to assume a critical and proactive role in contributing to improved health outcomes and instead has frequently assumed a reactive role as coordinator of service provision.
The reasons for these shortcomings are many, including: growing complexity and duration of displacement situations; considerable gaps in the coordination between sectors of assistance; inadequate funding for public health response; and a plethora of humanitarian agencies responding to crises, resulting in competition for funding. These agencies have a range of mandates, which sometimes overlap and can pose considerable challenges to coordination and collaboration. In addition, there are instances where the collective areas of expertise of these organisations do not match the needs on the ground. Finally, these factors are compounded by the lack of clear frameworks that promote collaboration, which can undermine individual actors’ considerable efforts.
Environmental degradation and climate change are key challenges to reducing the spread of infectious diseases. The WASH sector needs to develop an in-depth understanding of the relationship between public health and the environment – including aspects such as water resource management and water safety, air and soil pollution control, vector control, treatment and disposal of chemical weapons, hazardous waste management, and human waste treatment and management.
Another key challenge is the lack of funding. In the past decade, WASH has been chronically underfunded, lagging considerably behind other sectors. For example, Yemen faces one of the most complex humanitarian emergencies in modern times, with simultaneous cholera and COVID-19 outbreaks which require WASH services as a key part of the response. Despite this obvious need, resources for WASH in Yemen are dramatically declining: in 2020, funding for WASH was only 1.2% of the overall funding allocated to the response. The link between investments in basic WASH services and impacts on environmental and public health outcomes has been clearly demonstrated, yet WASH remains underfunded.
In addition to funding shortfalls, humanitarian organisations face the growing complexity of emergencies hampering their ability to deliver. For example, between 2017 and 2020 in the Democratic Republic of Congo more than five million people were forcibly displaced in an unstable environment with the threat of armed conflict coupled with numerous public health risks, including outbreaks of yellow fever, measles, plague, cholera, Ebola and, most recently, COVID-19. These dangers add to pre-existing burdens facing the population such as high acute malnutrition rates and high morbidity due to malaria. Ensuring the safety and well-being of displaced people within this complex environment is highly challenging, made worse by direct attacks against humanitarian actors, which have seen some agencies withdraw staff and cease operations.
Unlike the health sector, the humanitarian WASH sector is not yet equipped with coherent or effective systems to measure or evaluate the causal effects, outcomes or impacts of its activities. Agencies and coordinating bodies lack the resources to develop and scale up a robust monitoring system. This, in turn, makes it difficult to advocate effectively for increased WASH expenditure in a competitive funding environment.
Creating a roadmap
A process to integrate WASH, health and nutrition interventions into an effective and comprehensive public health response during humanitarian crises began in late 2017. This process was designed to address all relevant areas, from health-care facilities to social behaviour change programmes. It culminated with the launch of a dedicated five-year initiative called ‘Integration and Coordination of WASH into Public Health Issues’ within the WASH Roadmap 2020–2025, which will incorporate the global, regional and national contributions of WASH actors.
In June 2017, Médecins Sans Frontières published a report highlighting the main limitations of the humanitarian WASH sector, covering technical competency within the sector, operational capacity to respond rapidly, and the culture of complacency. The report challenged the sector to remove WASH ‘silos’ within humanitarian responses, to look beyond the emergency phase, and to make clearer the links between WASH and health outcomes. The report found that sub-optimal emergency responses in public health crises (such as the cholera outbreaks in Haiti, Somalia and Nigeria, and the Ebola crisis in West Africa and DRC) cast doubt on the humanitarian WASH sector’s competence and ability to deliver a timely, efficient and adequate humanitarian WASH response to a public health emergency. For example, when one of the worst cholera outbreaks on record was occurring in Yemen, very few WASH actors were able to intervene during the acute emergency phase (partly because of lack of access but also because of lack of operational, logistical capacities), despite a growth in the number of actors worldwide.
In October 2017, the Inter-Agency WASH Group (IAWG) – an informal group, formed in the 1990s, of the largest WASH organisations – and the Global WASH Cluster (GWC) invited the major WASH stakeholders and agencies for a two-day workshop to identify challenges and opportunities for the sector. The recommendations emerging from this workshop informally shaped the foundation of the WASH Roadmap. A comprehensive analysis was then commissioned by the GWC and presented to partners in 2019. Linked to the GWC annual meeting, UNICEF, the IAWG and the GWC organised a meeting with the emergency directors of the 15 largest international agencies involved in the WASH sector in order to formally launch the WASH Roadmap process.
Endorsement and rollout
By early 2020, the WASH Roadmap document had been completed. It includes three functional pillars – capacity, coordination and finance – and three operational axes. The first of these axes is the need (and capacity) of the WASH sector to deliver an effective humanitarian response that addresses the life-saving needs of affected populations at scale and with impact – also referred to as ‘survival WASH’. One of the WASH Roadmap’s main objectives is to ensure that by 2025 humanitarian WASH responses are systematically embedded and integrated into public health operational frameworks and programming, and driven by public health outcomes.
Seventeen strategic initiatives, each headed by one or more lead agencies, will deliver the WASH Roadmap, sharing the implementation work across agencies. In January 2021, all 15 Emergency Directors officially endorsed the WASH Roadmap, confirming their commitment to contribute and support the implementation plan. A number of initiatives have been prioritised for rollout, including ‘Initiative 3.3: Integration and coordination of WASH into public health issues’. This five-year initiative on public health within the WASH Roadmap aims to identify existing gaps and further analyse the challenges for effective coordination among these sectors. Building on this analysis and lessons learned through other relevant programmes (for example, national coordination mechanisms), the leading agencies for this initiative will develop inter-sectoral guidance, tools and standard operating procedures for creating an enabling environment for a well-coordinated approach to public health emergency responses. The final phases of the plan will look at a list of pathways and opportunities to roll out the tools, pilot them in relevant platforms, and coordinate with local authorities. At the same time, a body of evidence will be built to sustain advocacy and secure funding.
Specific areas that will be explored under this initiative include how to:
- document the systematic use of data relating to epidemiology and the environment, to improve targeting within emergency WASH responses
- create a protocol for the systematic design and documentation of humanitarian WASH responses based on health outcomes, including the impact on lives saved and the reduction of the burden of disease
- expand the sector’s capacity to tackle environmental health risks and impact
- strengthen the community management of WASH infrastructures linked to health-care facilities and nutrition-focused centres to ensure that they adhere to minimum WASH standards, expand use of services, and improve WASH provision overall
- strengthen engagement and participation with the UN health cluster system
- leverage and strengthen partnerships that support and advance cross-cutting approaches
- create linkages with advocacy efforts and bring interventions to scale.
Although there have been significant efforts made by some key agencies to ensure the systematic inclusion of WASH interventions within public health response strategies, there remains considerable work to be done. Successful implementation of the activities emerging from this initiative will require an inclusive approach with active engagement from field practitioners, academics, government authorities, donors, displaced persons and affected communities. By promoting an integrated public health response, the humanitarian community can reduce public health risks and adverse environmental consequences for millions of forcibly displaced people across the world.
Claudio Deola firstname.lastname@example.org
Senior Humanitarian WASH Advisor, Save the Children
Syed Yasir Ahmad Khan syahmad@InternationalMedicalCorps.org.uk
Global WASH Adviser, International Medical Corps
Antonio Torres email@example.com
Global WASH Coordinator, International Organization for Migration
Emmett Kearney firstname.lastname@example.org
Senior WASH Officer, UNHCR
Ryan Schweitzer email@example.com
Former WASH Officer, UNHCR
 UNHCR (2014) Global Strategy for Public Health 2014–2018 www.unhcr.org/uk/protection/health/530f12d26/global-strategy-public-health-unhcr-strategy-2014-2018-public-health-hiv.html
 WHO (2019) ‘Drinking-water’ www.who.int/news-room/fact-sheets/detail/drinking-water
 WHO (2017) ‘Diarrhoeal disease’ www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease
 Inter-Agency WASH Group (2017) ‘Where now for the Water, Sanitation and Hygiene sector’s response in emergencies?’