A Methodological Crisis in the WASH Sector: Crunching Numbers and Throwing Them over the Wall

Abstract

Some pre-digital ‘Common Sense’ is urgently needed to salvage the WASH sector. A spate of recent Randomized Control Trials (RCTs) have shown negligible effect of improved water, safe sanitation and non-risk hygiene behaviour on health outcomes, prompting a methodological crisis amongst practitioners. Three different behaviour change methodologies, Community Led Total Sanitation (CLTS) routinely used to trigger improved sanitation, Social Marketing to promote hand washing, and the Community Health Club (CHC) approach to improve hygiene behaviour, have all shown through RCTs to have little impact on health, with much debate as to the reasons for such failure. When RCTs question the validity of such interventions, lives may be affected as funding is hard to justify. In one case at least, common sense prevailed, when Rwandan Ministry of Health, instead of aborting the Community Based Environmental Health Promotion Programme (CBEHPP) on the recommendation of the cRCT, chose instead to enhance it by including a substantial nutrition component with the rationale this would be essential if stunting as well as diarrhoea was to be controlled. There is increasing recognition that to achieve sustained health impact much more time is needed in WASH programmers than is normally available to inventions evaluated through most RCTs.