In this resource we will provide a brief introduction to the basics of WASH system strengthening. We will begin by exploring some key definitions and rationale, before outlining some frameworks and touching on monitoring progress.

The majority of content is drawn from the basics module in IRC’s WASH Systems Academy learning platform (which is free to access) and their report on Understanding the WASH system and its building blocks, partners report and experiences as well as our webinar on WASH & health system strengthening to create sustainable public initiatives, where our partners presented experiences from the field.

For a more in-depth exploration of WASH system strengthening activities conducted in the field throughout the pandemic, including reflections on key challenges and lessons, see our learning brief.

System strengthening refers to the “process of analysis, implementation, adaptation and learning used to address the barriers to achievement of inclusive, sustainable, universal access to WASH services and behaviours, recognising that this access is the result of interactions between multiple actors and factors in a complex, dynamic system” (WaterAid). Strong WASH systems are needed to ensure WASH gains last and deliver benefits to everyone in society. System strengthening is a global, multi-sectoral movement which has been widely embraced by the WASH sector in a bid to address several persistent challenges, namely: inadequate scalability, accountability, learning and adaption, social exclusion and sustainability. WASH Agenda for Change and their members have been key in driving the movement forward.

The system strengthening movement has caused a transition from the traditional hardware-focused, reductionist WASH approach to a more holistic, human-centred / behaviour-centred approach which considers behavioural practices. Central to system strengthening is the concept of systems thinking, which entails “seeing and understanding systems as wholes, paying attention to the complex and dynamic interactions and interdependencies of its parts” (IRC). Systems thinking has been adapted by many other sectors, including the health sector which is more advanced, and challenges biases and assumptions through considering the combined effect of intersecting factors.

WASH system refers to “all the social, technical, institutional, environmental and financial factors, actors, motivations and interactions that influence WASH service delivery in a given context” (IRC). As the system strengthening movement has gathered momentum, many frameworks have arisen. One of the most common approaches to conceptualising WASH systems is the building block framework, introduced via the WHO’s Health Systems Framework in 2007. The building block approach breaks the system down into several key components, or ‘blocks’ and illustrates the interlinked relationship between the different components. Critically, building block frameworks acknowledge that WASH systems interact with and are impacted by other systems (e.g., healthcare and education) and wider political economic dimensions.

The building block framework is highly adaptable and has been used by many key WASH organisations, including UNICEF, WSUP and Sanitation and Water for All. For the purpose of this resource, we are going to focus on frameworks from the IRC and WaterAid, displayed below.

Note that although both frameworks use the building block approach, the number of blocks differ and the actors involved are incorporated into WaterAid’s framework, but not the IRCs.

The overall aim of WASH system strengthening is to achieve a WASH system which is safe, equitable, inclusive, sustainable, co-created, adaptable, robust and resilient to climate change.

Access to sustainable and safe WASH services and behaviours are undeniably important to human health, wellbeing and livelihoods. WASH is critical in preventing infections in healthcare settings and curbing the spread of enteric and respiratory infections.

Inadequate WASH can also cause ill health – for instance, eating food without washing hands with soap may result in ingestion of contaminants causing diarrhoea and drinking unsafe water can transmit infections such as cholera, typhoid, or neglected tropical diseases. Moreover, WASH is inextricably linked to virtually all sustainable development goals (SDGs), including ending poverty and achieving gender equality and education. Hence, it is widely acknowledged that achieving SDG 6 (clean water and sanitation) will have positive secondary impacts on several other SDGs.

Despite its evident importance, the WASH sector is in serious need of reform and lags behind other sectors in many respects. Globally, WASH systems remain unreliable and inadequate, and are characterized by insufficient financing, planning and infrastructure, among other factors. There is also a lack of data and evidence-based practice within the sector, impeding efforts to develop context-specific WASH systems.

This is illustrated by the fact that globally, 2.1 billion people lack access to safe water and 4.5 billion have no access to safe water and sanitation. Moreover, 24% and 73% of health facilities globally have limited or no access to water and hygiene services, respectively. Even where populations do have access to WASH, 40% of WASH facilities are not functioning as intended (e.g., unsafe or broken) highlighting the sustainability issues faced by the sector. These WASH gaps are disproportionately high in low resource settings, particularly in rural areas, where 8 in 10 people have no access to drinking water. These existing gaps are also being exacerbated by climate change, population growth, economic inflation, conflict, and urban migration. Importantly, without strengthening the system, improving WASH access, and sustaining them over time will be a continuous challenge.

Aside from contributing to poor health outcomes and generational poverty, insufficient WASH leads to inadequate hand hygiene, which causes some half a million preventable deaths annually. Access to safe WASH service and behaviours is key in increasing preventive behaviours, such as hand hygiene, which more critical than ever, as we continue efforts to tackle the COVID-19 crisis and re-emerging infectious diseases, such as Ebola.

According to the recent UN-Water Global Analysis and Assessment of Sanitation and Drinking Water (GLASS) report, 75% and 55% of countries are not on track to reach the SDG sanitation and drinking water targets, respectively. According to this study, US$12.2–US$15.3 billion will be needed over the next 10 years to achieve universal hand hygiene in the 46 least developed countries (who have made the least progress). Overall, it is estimated that US$114 billion per year is required between now and 2030 to achieve SDG 6 and it is widely accepted that the goal will be unachievable without WASH system strengthening.

There are numerous roadmaps which can be followed when conducting WASH system strengthening. For building block frameworks, there is a focus on examining all blocks to ascertain where the strengths and weaknesses lie, so that we can identify the block (s) with the greatest potential for improvement. However, it is crucial that we don’t lose sight of the larger picture, as all blocks must be functional across all levels to achieve a strong WASH system.

The FCDO outlines several key considerations when strengthening WASH systems 1) the process is not linear – WASH systems are complex, unpredictable adaptive systems and require an iterative approach 2) system strengthening is not a one off – it requires long-term commitment and continuous adjustments 3) there is no silver bullet – each context is different 4) WASH system strengthening is a political issue and must be treated as such 5) multi-sector and multi-stakeholder engagement is key.

All members of Agenda for Change (including WaterAid and the IRC) subscribe to a universal roadmap for strengthening WASH systems, composed of five key steps 1) Introduction and visioning – concept introduced to stakeholders and vision and goals of stakeholders captured 2) Institutional strengthening – assessment followed by strengthening activities 3) Assessment – assets, water resources, service levels and providers and costs and finance 4) Planning – data analysis and validation and strategy creation. Typically entails a building block assessment to identify gaps and challenges and 5) Implementation and monitoring – periodic review and reflection on lessons learned and accountability. As the diagram below illustrates, there is a feedback loop from the implementation and monitoring stage to the assessment phase.

Each Agenda for Change member has adopted a variation of the roadmap above; see below for an infographic outlining the IRC’s roadmap, along with an informative video.

Whilst we are very good at designing theoretical frameworks on paper, implementing them takes considerable time, expertise and money and there are numerous challenges being faced, which are explored in this systematic review. These include the fact that there are too many novel frameworks with a lack of generalizability between frameworks and that the majority of frameworks require a medium to high level of analytical capacity. There is also a lack of research in urban settings and there is an unequal geographical distribution, with Uganda, Ghana and India accounting for the majority of studies. Finally, few frameworks explicitly explore the interrelation of factors, even though systems thinking is central.

For more information, see these helpful toolkits from WaterAid which relate to the introduction and visioning stage and the assessment stage, or this report from Agenda for Change which outlines all of the stages. You can also find various resources related to WaterAid’s five-year WASH system strengthening programme, SusWASH via the following blog. This section briefly outlined the key theoretical steps involved in WASH system strengthening – for case studies of frameworks being implemented in the field, see our learning brief.

Strong Government leadership and functioning relationships are vital, as they are a central component in virtually all of the WASH building blocks, including financing, institutional arrangements & capacity and policy, strategy & planning. Hence, we must build close relationships and understanding, particularly with national, provincial, state, and local government. It is important to establish a close working relationship with national and local government and other relevant institutions and organisations working in the sector, as well as in the selected target area, before initiating WASH system strengthening work. Prior to initiating activities, ensure that you take the time to build or refresh Government’s understanding of the WASH system, systems strengthening and the building blocks of a WASH system. Next, agree on the purpose of the WASH system strengthening and work and emphasise how the work can support Government to build a strong WASH system and advance progress towards universal, safe, and sustainable inclusive WASH.

Monitoring refers to the “continuous assessment that aims at providing all stakeholders with early detailed information on the progress or delay of the ongoing assessed activities” (UNDP). As highlighted earlier, system strengthening is not a one-off process; it requires an iterative approach with continuous adjustments. Monitoring mechanisms allow us to identify and address problem building blocks as they arise, accelerating progress and ensuring adaptability and sustainability of WASH systems. There numerous rationales for monitoring system strengthening progress, summarised below.

Despite the evident importance of monitoring system strengthening progress, there is a knowledge gap, with a recent systematic review reporting that just 7% of studies on WASH system strengthening reported on programmatic outcomes.

There are numerous approaches to conducting WASH system strengthening and the exact mechanism will vary depending on your context. Generally speaking, it is most efficient if you develop a government-led system which is integrated into existing monitoring evaluation mechanisms. Doing so will likely lessen the load when conducting training and capacity strengthening. The process is closely interlinked with the IRC building blocks of 1) learning and adaption 2) finance 3) infrastructure 4) strategic planning and 5) regulation and accountability. Therefore, design and implementation of the monitoring framework is complex and often requires multi-sectoral and multi-level collaboration.

According to the IRC, there are four key components which are central to effective system strengthening monitoring: 1) clear institutional arrangements 2) integration of monitoring into national institutions and or ongoing mechanisms 3) effective information systems and 4) effective monitoring frameworks.

Monitoring processes usually focus on a few building blocks, though as highlighted earlier, it is important not to lose sight of the whole system. Progress can be assessed using quantitative, qualitative, or mixed-method data. When choosing indicators, there is a trade-off between complexity, cost-effectiveness, and usability. Potential outcomes of measure include accessibility, availability, and quality. Regardless of what you choose to measure, you must ensure that indicators are harmonised to allow comparison and that disaggregated data is collected to enhance equity.

Data on behaviour practices should always be collected; this aligns with the movement away from focusing on hardware, as highlighted earlier on. In addition to ensuring that infrastructure is present, we must ascertain whether it is actually being accessed, so that any barriers can be addressed. For instance, women and girls might not be accessing toilets at night in camps, because the lighting is inadequate and they are fearful of gender-based violence.

Indicators can be set nationally, or internationally; the most commonly used international WASH indicators come from the Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP). JMP use indicators for WASH service level relating to drinking-water, sanitation and hygiene and have produced a “ladder” for each type of service which serves as benchmark for comparison.
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Monitoring might also include repetition of the building block assessments conducted in the assessment stage. These assessments are typically conducted through discussions with stakeholders and asking a set of self-assessment questions for each block, from which a score of strength is assigned. For instance, WaterAid conducted annual participatory building block assessments throughout their SusWASH project and the IRC conducted more regular assessments during a WASH systems strengthening programme in Honduras.

In reality, the IRC stipulates that best practice is to use mixed-methods indicators and incorporate a combination of building block assessments, WASH service level assessments and political economy analyses to track progress targets relating to 1) service levels 2) WASH practices 3) sustainability 4) implementation of software and hardware 5) financing 6) water source and quality. Crucially, there should be periodic reflection and documentation of lessons learned, to feed into evidence-base practice.