The impact of climate change on water, sanitation, and hygiene (WASH) has driven an increased focus on climate-resilient WASH development. Evidence suggests that adaptation in the WASH sector is underway, but the progress is limited in certain domains and the participation of the public health community may be lacking. Using the Lake Victoria Basin (LVB) as a climate vulnerability setting for this analysis, this study aimed to identify factors that impede full engagement of the health sector in climate-resilient WASH development. In-depth semi-structured interviews were conducted with 13 WASH sector stakeholders across lakeside urban centers in Kenya, Uganda, and Tanzania. Several barriers to health sector engagement were identified including factors related to donor-driven financing and priority setting, a relative neglect of climate vulnerabilities associated with sanitation and hygiene, ministerial siloes, and broader systems of adaptation governance which compromise health sector leadership in climate adaptation. These results suggest room for expansion of interdisciplinary collaborations and deepened involvement of the health sector in WASH-related climate adaptation, which starts with addressing these and other barriers to full health sector engagement.

  • As climate change threatens WASH systems globally, there is an increasing need to mainstream climate adaptation into WASH sector development.

  • A failure to adapt WASH services to climate-related hazards could have important adverse consequences with regard to human health.

  • More interdisciplinary collaboration, among other measures, is needed to enhance the involvement of the health sector in WASH-related climate adaptation.

The impacts of climate change on water, sanitation, and hygiene (WASH) have become an increasing cause for concern, particularly as they threaten to undermine decades of WASH progress in climate-vulnerable settings worldwide. Not only do extreme weather events cause damage to essential water and sanitation infrastructure, but flooding and drought compromise water quality and access, driving water insecurity and undermining the capacity of individuals to uphold safe hygiene and sanitation practices (UNICEF n.d.). It is in this context that the notion of climate-resilient WASH planning, also understood as climate adaptation in the WASH sector, has gained salience.

In 2017, UNICEF, in collaboration with the Global Water Partnership, released an updated version of their ‘Strategic Framework for WASH Climate-Resilient Development’, together with a series of technical briefs and learning modules to support implementation actors in conducting strategic risk assessments, appraising and prioritizing options, and delivering locally tailored, climate-resilient WASH solutions (Global Water Partnership and UNICEF 2017). In 2019, the UN-Water Expert Group on Water and Climate Change followed this initiative with an added call for the ‘integration of climate-resilient water resource management in health, sanitation, and development planning’ (UN Water 2019). More recently, at the COP26 summit held in Glasgow in November 2021, the notion of climate-resilient WASH planning attracted further attention, with a series of related talks led by the Stockholm International Water Institute as part of a dedicated Water Pavilion (Jun 2021).

However, despite the increased attention drawn to this area, much of the dialogue has reflected a disproportionate focus on water, including broader issues of water resource use and integrated watershed management, amongst others (Fox et al. 2019; Gordon & Hueso 2021; Kohlitz & Iyer 2021). Consequently, stakeholders from the agriculture, energy, infrastructure, and environment sectors have taken a leading role in the planning and piloting of solutions to climate-driven impacts on the WASH sector, with the health sector less engaged. This has occurred despite the myriad health-specific implications of water insecurity and reduced sanitation access under projected climate scenarios (Kohlitz et al. 2017). To better understand the barriers to engaging the health sector in climate-resilient WASH development, WASH sector stakeholders across the Lake Victoria Basin (LVB), a hydrological zone spanning five countries in East Africa that have been highly impacted by climate change in recent years, were consulted on their experiences and observations while working in this intersectoral space.

A total of 13 in-depth, semi-structured, individual interviews were conducted with both civil society and public sector stakeholders involved in climate adaptation and WASH planning in the LVB, with all representatives based in lakeside urban centers across Kenya, Uganda, and Tanzania. Additional details on interviewed subjects are provided in Table 1. Interviews were conducted both in-person and virtually and were recorded and manually transcribed afterward. The transcripts were inductively coded, employing principles of constant comparison between new and old data, using Dedoose qualitative data analysis software. A thematic content analysis was conducted to identify overarching themes on major barriers to regional health sector engagement in climate-resilient WASH development. Ethics approval for this project was obtained from both the University of Alberta Research Ethics Board (REB-1) and the Maseno University Ethics Review Committee.

Table 1

Characteristics of the interviewed stakeholders

Institution name (country)Institution sectorNo. of participants (sex)
AMPATH (Kenya) Public–private partnership 1 (F) 
FreeKenya Foundation (Kenya) Civil society (local NGO) 1 (F) 
Safe Water and Aids Project (Kenya) Civil society (local NGO) 2 (1M, 1F) 
Siaya County CDC Office (Kenya) Public sector 1 (M) 
Kombewa County Referral Hospital Infection Prevention and Control Dep. (Kenya) Public sector 1 (F) 
Water Mission (Uganda) Civil society (international NGO) 1 (F) 
Uganda Ministry of Water and Environment (Uganda) Public sector 1 (F) 
Uganda Water and Sanitation Network (Uganda) Public sector 1 (F) 
Tanzania Institute of Rural Development Planning (Tanzania) Public sector 1 (F) 
Tanzania Water and Sanitation Network (Tanzania) Civil society (national NGO) 1 (M) 
Lake Victoria Basin Commission Climate Adaptation Department (Kenya, Uganda, Tanzania, Rwanda, Burundi) Civil society (regional NGO) 2 (M) 
Institution name (country)Institution sectorNo. of participants (sex)
AMPATH (Kenya) Public–private partnership 1 (F) 
FreeKenya Foundation (Kenya) Civil society (local NGO) 1 (F) 
Safe Water and Aids Project (Kenya) Civil society (local NGO) 2 (1M, 1F) 
Siaya County CDC Office (Kenya) Public sector 1 (M) 
Kombewa County Referral Hospital Infection Prevention and Control Dep. (Kenya) Public sector 1 (F) 
Water Mission (Uganda) Civil society (international NGO) 1 (F) 
Uganda Ministry of Water and Environment (Uganda) Public sector 1 (F) 
Uganda Water and Sanitation Network (Uganda) Public sector 1 (F) 
Tanzania Institute of Rural Development Planning (Tanzania) Public sector 1 (F) 
Tanzania Water and Sanitation Network (Tanzania) Civil society (national NGO) 1 (M) 
Lake Victoria Basin Commission Climate Adaptation Department (Kenya, Uganda, Tanzania, Rwanda, Burundi) Civil society (regional NGO) 2 (M) 

Several interconnected barriers to health sector involvement in climate adaptation in the WASH sector were identified in this study.

The first was the role of donors in driving the strategic direction of adaptation financing. When asked about common donor-supported climate adaptation projects in the WASH sector, study participants overwhelmingly reported upon water projects involving nature-based solutions (e.g., agroforestry, tree planting, wetland restoration, river catchment regeneration, etc.) or water infrastructure development. Few exclusively sanitation- or hygiene-related projects were reported as donor-funded ‘climate adaptation’ projects.

Other comments from interview participants shed light on why a donor preference for water-oriented and ecosystem-based adaptation projects may preclude the full involvement of health actors in WASH and adaptation planning and implementation. Several explicitly noted that only sanitation and hygiene, among the three WASH pillars, are considered to fall under the exclusive auspices of the health sector at both national and district planning levels. As such, ‘WASH’ projects which focus primarily on the ‘water’ component of WASH tend to give stakeholders in the fields of environment, energy, and agriculture, amongst others, a more central role, even if the involvement of community health workers or other health-related staff are solicited for social and behavior change communication around domestic water use. Even for projects exclusively focused on clean water supply, it was only when the supply was targeted for use by healthcare facilities that health stakeholders, as opposed to utility companies, engineers, and hydrogeologists, would play a central role in project planning and oversight.

The issue of responsibility, including budgeting and strategy planning, across WASH development domains came up frequently in discussions on the ministerial division of labor within government. Many interview participants spoke about the relative mutual isolation of different departments all loosely involved in WASH, including Ministries of Education, Health, Agriculture, Environment, Infrastructure, Social Development, etc. This isolation was reported to take the form of both separate strategy development and planning and separate (sector-specific) budgeting. While interview participants spoke of joint forums where representatives from various ministries would meet to discuss their shared investments in WASH, these forums were reported to be few and far between, with the majority of WASH planning happening in isolated department spaces.

As stated by one interviewee, not only does a lack of cross-sectoral dialogue limit collaborative WASH planning, but it also means that each sector tends to focus on the specific area of WASH related to their mandate, whether it be WASH in schools (Ministry of Education), WASH in healthcare facilities (Ministry of Health), gender-inclusive WASH (Ministry of Social Development), etc. This makes integrated planning more complicated when joint forums are held, as each department has become habituated to a culture of more vertical programming. In the case of early warning systems for extreme weather events, for example, one interview participant highlighted the lack of integration between meteorological forecasting systems and epidemiological data tracking for waterborne disease surveillance – another reflection of the sector-driven approach to WASH planning to emerge from the findings of this study.

This study presents novel findings on some of the interrelated barriers contributing to the relative marginalization of the health sector from policy and practice in building climate resiliency in the WASH sector, specifically in the LVB region. The small number of participants and limited geographic scope limit the conclusions that can be drawn. Nevertheless, they do offer useful insights into what is needed to move towards more interdisciplinary collaboration addressing the intersection between climate change and WASH.

The finding that donors tend to set the strategic direction of adaptation financing is not new and is consistent with the structure of the international adaptation finance system. Adaptation finance is generally the business of multilateral entities such as the UN Development Programme and the World Bank (Duus-Otterström 2015). Major funds such as the Least Developed Country Fund, the Special Climate Change Fund, and the Adaptation Fund, are administered by bodies that operate largely independently of recipient country governments and have been accused of failing to provide in-country stakeholders sufficient control over funding priorities (Duus-Otterström 2015). As such, international actors have a large influence over the climate adaptation agenda and may direct investments toward preferred target areas. Given the rise in prominence of ecosystem-based adaptation on the global adaptation finance agenda, it is not surprising that many adaptation-related WASH sector initiatives would fall under this category (German Agency for International Cooperation 2018). Such findings have also been reported in other settings, such as Bangladesh, where the main water-related adaptation tasks were found to include the management of watercourses, protection of riverbanks, and amelioration of waterlogging (Rahman et al. 2020). Tree planting schemes have also proliferated as climate adaptation initiatives worldwide, owing to their mitigation co-benefits and the carbon credit investment opportunities they have come to represent (Chia et al. 2016). It is important to note, however, that none of the participants interviewed in this study represented donors or private sector entities themselves. As such, further research could explore the perspectives of these actors in more depth, with the view of soliciting an understanding of how they may be incentivized to invest more heavily in certain underfunded areas.

The finding that sanitation is given less attention in climate adaptation investment planning is also consistent with other research. Several authors have noted that sanitation actors have been slow to integrate climate concerns into thinking and programming, and that climate-related WASH discussions remain predominantly water-focused (Gordon & Hueso 2021; Kohlitz & Iyer 2021). Similarly, the limited progress that has been noted in the sanitation sector has been largely technological (e.g., innovative toilet designs, advancement of wastewater treatment, and fecal sludge management technologies) – as opposed to institutional or legislative (e.g., expanding government funding and investment in public sanitation, monitoring of environmental contamination in and around human waste sites) (Kohlitz & Iyer 2021). Taken together, it is conceivable that the role of the health sector would be marginal in this space, considering that the one pillar they play a lead role in championing is underfunded (with some exceptions in infrastructurally advanced metropoles) and when funding is allocated for it, it is disproportionately targeted at sanitation infrastructure and engineering. The reasons for this general underinvestment in sanitation deserve further exploration but may be driven by a perception that sanitation systems are generally less directly vulnerable to the impacts of climate change than global water systems – something which, despite supportive evidence, does not negate well-documented sanitation risks associated with extreme weather events (Howard & Bartram 2010). Considering the role that vulnerability assessments play in adaptation planning and financing, however, more compelling and tangible evidence on climate-water linkages may be sufficient to result in this disproportionate investment scenario (Biagini et al. 2014). More direct climate-water linkages may also be more conducive to meeting quantitative targets for water, as opposed to sanitation-oriented adaptation projects, making them more attractive to investors.

The culture of vertical siloing between ministries observed in this study raises concerns about multisectoral planning for the many domains of climate adaptation (e.g., WASH, food security, and livelihood promotion) that transcend traditional sectoral boundaries. The published literature suggests, however, that not only do more frequent and effective forums for inter-ministry planning and dialogue on climate adaptation need to be created but that more ministries need to be engaged from the outset, including, most notably, the health ministry. In a review of climate change adaptation planning in Bangladesh, departments related to public health were found to have negligible involvement in the management and use of the adaptation fund under the Annual Development Program (Rahman et al. 2020). Interestingly, the Water Development Board leads this fund but was reported to engage primarily with the Local Engineering Department, as well as with several agencies related to food, agriculture, forestry, rural development, and disaster risk management (Rahman et al. 2020). This is another indication of the limited direct participation of health stakeholders in the water sector, despite their critical role in WASH promotion. In several countries, including Malawi, Tanzania, and Uganda, climate change working groups and steering committees are typically governed under the Ministry of Environment, Natural Resource Management, or Economic Planning and Development, amongst others, but seldom assigned supervision by the Ministry of Health (Pardoe et al. 2020). Simultaneously, health programs, particularly those driven by major donors in low- and middle-income countries (LMICs), tend to be more vertical and disease-focused, reducing the scope for addressing cross-cutting issues such as those which lie at the intersection of climate change and health. These factors likely also contribute to the general marginalization of the health sector from climate-resilient WASH planning, since their role in climate adaptation is limited. The findings of both this study and others (Nhamo & Muchuru 2019), therefore, support existing calls for more integration of climate adaptation and public health. Such integration is not only needed from a climate adaptation perspective but could also be valuable in pushing the health sector toward adopting a more horizontal approach to its programming, shifting away from an exclusive focus on disease-centric, vertical initiatives. Horizontal approaches can prove highly cost-effective while reaping large-scale benefits at the population health level, for they address the underlying (and inherently overlapping) determinants of multiple diseases, such as poor sanitation in relation to a host of waterborne diseases which continue to cause high morbidity and mortality in LMICs.

As climate change threatens WASH systems globally, there is an increasing need to mainstream climate adaptation into WASH sector development. While progress in this domain has undoubtedly occurred, there appear to be shortcomings in the scope and multisectoral collaborations which drive it. This study has presented new evidence derived from consultation with WASH sector stakeholders in the LVB on how the involvement of the health sector, specifically, has been limited in climate-resilient WASH development, and on how factors such as donor-driven financing and priority setting, a relative neglect of sanitation and hygiene, ministerial siloes, and broader systems of adaptation governance, contribute toward this state of affairs. When combined with findings from the literature, these results suggest that climate adaptation is still legislated and operationalized in a sector-specific manner and that there is a need for greater intersectoral collaboration, so that health and other sectors may play a larger role. In the context of climate-resilient WASH, a failure to adapt WASH services to climate-related hazards could have important adverse consequences with regard to human health. The health sector, therefore, has an important role to play. Facilitating more involvement on the part of the health sector starts with addressing the barriers to its full inclusion.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.

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