Evaluating the Effectiveness of Safe Drinking Water in Severe Acute Malnutrition Treatment

A study to investigate whether adding safe drinking water in SAM treatment reduces treatment time, increases recovery rates, and improves cost-effectiveness in CMAM programs.

More than half of child deaths under five can be attributed to malnutrition, often stemming from preventable and treatable diseases. Community Management of Acute Malnutrition (CMAM) is an effective approach to treating uncomplicated cases of Severe Acute Malnutrition (SAM) – with treatment provided at home. Ready to Use Therapeutic Foods (RUTF), a nutritious paste, is one factor leading to the success of CMAM, however, given its high cost, efficacy is crucial. Children receiving this treatment also need access to safe drinking water, since diarrheal diseases from contaminated water reduces the effectiveness of RUTF and prolongs the duration of treatment. Providing safe drinking water could ultimately decrease the amount of RUTF needed, and lower treatments costs all together.


Based on this logic, the Evaluating the Effectiveness of Safe Drinking in Water Severe Acute Malnutrition Treatment project launched a study to investigate whether adding safe drinking water in SAM treatment reduces treatment time, increases recovery rates, and improves cost-effectiveness in CMAM programs. The research team hypothesized that adding safe drinking water to SAM treatment will reduce exposure to pathogens causing diarrheal disease, thereby resulting in shorter recovery periods for children with SAM.

The study was conducted in Sindh Province, Dadu District, Pakistan, using a randomized controlled trial study design. The trial included four study arms; each intervention arm was given and trained to use one of three kinds of water treatment options in the household:

  1. Control group: SAM treatment + jerry can;
  2. SAM treatment + jerry can + Aquatabs;
  3. SAM treatment + jerry can + Proctor & Gamble Purifier of Water; and
  4. SAM treatment + jerry can + Ceramic candle water filter.

Results from this study demonstrated that providing water treatment products significantly increased the recovery rates of SAM children in outpatient programs, as all arms with a water treatment device had higher recovery rates than the control group. Children in the Aquatab arm had a significantly lower prevalence of diarrhea than the control group during the study period, yet the other two intervention arms did not vary significantly from the control group for this outcome.

The cost-effectiveness analysis shows that Aquatabs were the least expensive treatment per child recovered, and this method was in fact cheaper per child recovered than the control group receiving SAM treatment alone. Ultimately, incorporating safe drinking water was not seen to reduce prevalence of diarrhea, as originally hypothesized, indicating the need for additional research to better understand the role of safe drinking water and diarrhea in SAM recovery.


These findings suggest that water treatment products can be an effective method for improving nutritional treatment outcomes in CMAM programming. Additional research to understand the pathway between water treatment devices and improved nutrition outcomes in CMAM programs remains critical, but Action Against Hunger will start to explore the policy implications (in Pakistan and beyond) of these findings, and in particular, how relevant nutrition policies can best reflect the emerging evidence and experience in incorporating water treatment as part of nutrition interventions.

Project Information

Thematic Area: Protection Research Water Sanitation and Hygiene
Intervention Area: Pakistan
Implementation Period: October 2015 – June 2017
Results Expected: Publication of results expected in Summer 2018
Partners: Action Against Hunger (NY and Pakistan – operational and research partner), Health Department, Government of Sindh, and Johns Hopkins University – Bloomberg School of Public Health (research partner)
Donors: R2HC/ELHRA with funding from Wellcome Trust and DFID, ECHO (funding the nutrition program in Sindh), Proctor & Gamble (additional funding)


Ellyn Yakowenko, Associate Director of Research – Action Against Hunger USA
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