“What Gets Measured, Gets Done: Identifying Integrated Indicators that Count”

By Bijan D. Manavizadeh

Imagine a two-year old child is sitting on a three-legged stool. If one or two legs are stronger than the other, the stool would not be stable and the child would be at risk of harm. Yet, if the stool has been properly constructed, with resources to ensure all three legs are strong and secure, then the stool would be durable and the child would be at a reduced risk of harm. The same principle is applicable to key factors of growth and development in early childhood—such as water, sanitation, and hygiene (WASH), nutrition, and early childhood development (ECD).

This metaphor was the crux of the Clean, Fed & Nurtured (CF&N) side session at the George Washington University Global Health Mini-University on March 4. Presentations by CF&N members Merri Weinger (USAID), Monica Woldt (FANTA III), and Julia Rosenbaum (USAID WASHplus) outlined the “why” and the “how” of developing and measuring indicators for integrated global health programs to better promote essential multi-sector collaboration of WASH, nutrition, and ECD.

In the first part of the session, the speakers shared evidence supporting the link between the three sectors of WASH, nutrition, and ECD and promoted cross-sectoral collaboration. In the second part, they addressed integral questions, such as:  Which indicators need to be defined? How do we evaluate them? What kind of research is needed to develop more appropriate indicators for successful integration?

As a program officer for the Global Public-Private Partnership for Handwashing, I know the implications that WASH interventions can have on health and development, but I did not know the full extent to which poor WASH practices can inhibit nutrition and ECD. This what I learned and what needs to be done.

What we do know? The first 1,000 days of life—from conception to age two—is the most critical period of cognitive and motor function development in a person’s life. Evidence shows that WASH interventions can prevent diarrhea, which if left untreated can lead to undernutrition and poor physical and cognitive growth. Frequent bouts of diarrhea tend to lead to a reduced appetite and poor absorption of nutrients from the food children do consume. This leads to a vicious cycle. Undernourished children are more susceptible to contracting parasites, viruses, and bacteria that lead to diarrhea. This cycle of diarrhea and undernutrition leads to stunting, which can have lifelong implications as it prevents children from reaching their full potential, both physically and mentally. In the long term, this can lead to negative outcomes in school, in professional settings, and in society.


Why cross-sectoral collaboration? Growing evidence indicates that through integration we can harness synergies. Multifaceted problems need multifaceted solutions. Integration provides the opportunity for streamlining messages and greater efficiency in program delivery. However, there are challenges. Funding, staff motivation and workload, coordination among agencies and organizations are some of the many hurdles that must be overcome. Another hurdle is the lack of common indicators, which inhibit the measurement of program effectiveness.

Why focus on integrated indicators? Properly defined indicators for integration mean that we can learn which interventions worked and which failed to meet expectations. Each of the three sectors represented in CF&N have their own indicators with varying degrees of strength. Indicators that correspond with integrated programs will allow us to better know if our hypothesis—that integrating WASH, nutrition, and ECD will have a greater impact—is correct. We know that indicators developed and utilized must be SMART: specific, measurable, achievable, reliable, and time bound. But, we also know that there is more work to be done. The evidence base for three-way integration is growing, and the development of indicators is a crucial step as we move forward.

How do we move forward? During the second segment of the session at the Mini-University, the audience engaged in a discussion of what is needed to move forward by sharing ideas on ways to identify and develop indicators for integration, as well as methods for overcoming gaps and challenges of delivering integrated interventions.

Increased advocacy with donors is needed, integration must be incorporated at the service delivery level to not overburden families, and a broader range of partners, stakeholders, and implementers must be brought into the conversation. Simply put, more dialogue and a greater emphasis on developing frameworks with indicators that function along a continuum are both needed.

Robust, comprehensive, measurable, and integrated indicators will generate more evidence that will allow us to better hone our work. Ultimately, as the WASH, nutrition, and ECD sectors further collaborate and forge stronger bonds, a broad set of health, nutrition, and child development indicators will be essential to demonstrating impact. Certainly, the challenge is great, but we believe that through our joint efforts we can make a greater impact than we could alone.

 Find a list of proposed CF&N indicators here. To view the presentation for “What Gets Measured, Gets Done,” please click here.

Taking Action and Marching for Improved WASH and Nutrition this Month

Originally published on the Global Public-Private Partnership for Handwashing’s Website

The beginning of March here in Washington, DC is oftentimes accompanied by signs of an impending springtime. Slowly the days get a little bit longer and the cold winter winds begin to subside. For many, as trees and plants begin to bloom, springtime brings to mind new life. The first few days of spring are tenuous, and the same is true for the first months of a baby’s life. It is, thus, fitting that March kicks off two advocacy campaigns—Water Action Month and #March4Nutrition—that address significant issues of child survival.

Image from MCSPglobal

While to the casual observer, these two campaigns might seem very different, they in fact are incredibly intertwined. Water, sanitation, and hygiene (WASH) interventions are critical allies in the fight against undernutrition, particularly in the first 1,000 days of life. This is because undernutrition is not only caused by a lack of food, but also the body’s inability to absorb nutrients from food.

Undernutrition and diarrhea form a vicious cycle, where children with diarrhea both eat less and are less able to absorb essential nutrients. Likewise, undernourished children are more susceptible to diarrheal diseases. WASH interventions can significantly reduce the risk of diarrheal disease; handwashing with soap alone can do so by up to 50%.  As such, improved access to WASH can help interrupt this cycle.

Undernutrition is the underlying cause of 45% of child deaths each year, but its impact is also much broader with lasting consequences for growth and development.1 Undernutrition manifests itself through reduced growth rate—or stunting—in early childhood. And, while the physical effects of stunting (reduced stature) are most visible, the negative repercussions that stunting can have on the cognitive development of children are lasting. Ultimately, undernutrition can have life-long consequences.

This is why we must continue to explore collaboration across the WASH and nutrition sectors. Evidence continues to emerge indicating that WASH and nutrition integration makes good sense. In Ethiopia, for instance, one study found that WASH interventions reduced the prevalence of stunting by 12 percent.2

Given the positive synergies between sectors, we are working to drive forward thinking around integration. To this end, we are proud to partner with colleagues from both the nutrition and early childhood development sectors in the Clean, Fed & Nurtured community of practice. This month we will celebrate Water Action Month and #March4Nutrition by sharing information and resources around WASH and nutrition integration with weekly facts on Twitter and blog updates with links to some of our favorite WASH and nutrition publications.

An estimated 860,000 deaths per year due to undernutrition can be prevented through WASH. So, please join us this month. Follow #WaterActionMonth and #March4Nutrition online and learn more about these key public health interventions.


  1. Black R et al. 2013. Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries. The Lancet. 382 (9890): 427–451.
  2. Fenn, B., et al. (2012). An evaluation of an operations research project to reduce childhood stunting in a food-insecure area in Ethiopia. Public Health Nutrition.17, 1-9.

Upcoming Event: Clean, Fed & Nurtured Global Health Mini-University Session

What Gets Measured Gets Done: Identifying Integrated Indicators that Count

11:00-12:00 • March 4, 2016
Marvin Center Room 308, George Washington University
Washington, DC

Join the Clean, Fed & Nurtured Community of Practice on Friday, March 4 at the Global Health Mini-University to learn about the “why” and the “how” of developing and using indicators for integrated global health programs.

This session will outline the importance of measurable indicators for integrated programming, explore challenges to effective cross-sector collaboration, specifically between those working on water, sanitation, and hygiene, nutrition, and early childhood development, and allow the opportunity for participants to contribute to the development of inter-sectoral indicators.

Attendance at the Mini-University is free, but you do have to register online. Don’t miss this great opportunity to join the Clean, Fed Nurtured Community of Practice as we work together to promote early childhood growth and development. Register today!