Forging Relationships Between Faith-based and Secular Organizations to Address the Global Water Crisis: A Case Study from Liberia

It is imperative to engage in interdisciplinary and multisector partnerships as we seek to develop and deliver effective solutions to address the global water crisis. These partnerships allow us to live out our Christian charge to demand justice for the vulnerable and promote human flourishing. This case study reviews the benefits and challenges of multisector partnerships between faith-based and secular organizations using the example of a multi-year water filter distribution project in Liberia. Benefits of the partnership include shared expertise, investment in students and Liberians, and results-driven research. Challenges include differing sub-goals, logistical challenges, communication difficulties, and different ways of communicating results. Intentional program planning, avoiding preferential treatment, and engagement in process evaluation are all suggestions for mitigating the potentially harmful effects of these


Introduction and Literature Review
In 2008, a Christian young adult group in Washington, DC, asked two questions: 1. What is the greatest need in the world? and 2. Where is the most challenging place in the world? 1 Out of these two questions, along with a commitment by the group to address them, emerged the goal to bring the gospel and clean water to all Liberians by 2020. This article will discuss this effort and the need for strong, multisector partnerships between faith-based and secular organizations to achieve global health goals, and the benefits and challenges of working between sectors.

Where is the most challenging place?
The nation of Liberia was identified as an area of need due to its history and context. The history of Liberia is wrought with conflict, which has served as a major barrier to development. Liberia was colonized by freed American slaves in 1820 and eventually gained independence from the United States in 1847. 2 The freed slaves, titled Americo-Liberians, established a government under which native Liberians were oppressed. As a result, nine major civil conflicts, which impeded development, resulted between 1847 and 1931. Following a short time of peace, civil unrest emerged again beginning with a coup d'etat in 1980 and resulting in multiple civil wars until relative peace was assumed again in 2003. 3 The country experienced further tragedy during the Ebola epidemic that raged in the country between 2014 and early 2016. During this outbreak, over 10,500 Liberians contracted Ebola of which nearly 5,000 Liberians died. 4 This epidemic exposed the inadequacy of the health care delivery system and health workforce capacity in Liberia.
Today, Liberia is known as one of the poorest countries in the world. Of its 4 million inhabitants, 54 percent are impoverished and 45 percent experience food poverty. 5 These needs are even greater in rural areas where 70 percent of rural Liberians are impoverished and 53 percent experience food poverty.

What is the greatest need?
Access to clean drinking water was identified as the greatest need in Liberia as only 70 percent of the country has access to improved sources of drinking water within a 30-minute walk from their residence. 6 Not surprisingly, only 60 percent of rural Liberians, compared to 80 percent of urban Liberians, have access to these sources. Unfortunately, improved sources of drinking water does not mean the water is, or remains, contaminantfree. Many factors can compromise the safety of drinking water, including the source of piped water, water storage practices, and whether households choose to consistently use the improved sources versus unimproved sources of water. 7 Access to and consistent use of clean drinking water is integral to health. Contaminated drinking water can transmit many diseases, such as diarrhea. According to the World Health Organization (WHO), diarrheal disease is the 6 th leading cause of death for children under the age of five in Liberia, accounting for 560 deaths per 100,000 live births. 8 Diarrheal disease is closely associated with malnutrition in children leading to impairments in physical growth, cognition, and immune strength. 9,10,11 Diarrheal disease has been effectively reduced in developing countries through interventions focused on increasing access to improved sources of drinking water, sanitation, and hygiene. 12,13,14 Our Christian call to justice The discussion around our Christian call to justice is often limited to the Pentateuch and the Old Testament prophets. New Testament writings, however, reflect the commitment of Jesus to proclaiming and practicing justice. In the Great Assize in Matthew 24, Jesus calls us to feed the hungry, give drink to the thirsty, be hospitable to the stranger, and visit those who are sick or imprisoned. This passage, along with references to Isaiah in the book of Luke urging the undoing of injustice, demonstrates the importance Jesus places on lifting up those who are downtrodden and promoting justice. 15 The character of God, as revealed in Jesus, emphasizes the value of human life and the promotion of human flourishing. 16 The universal church proclaims the kingship of Christ, and thus, has a prophetic role to preach justice in a broken world and to demonstrate both stewardship and servanthood as modeled for us through Jesus Christ. 17 The apostle Paul in II Corinthians identifies the church as ambassadors of Christ, rooting our identity in Christ's work and teaching. 18 This then serves as a context for promoting justice and engaging in efforts to serve those who are vulnerable. Our efforts to address inequalities should be done in cooperation with others, as Daniel O'Neill aptly reminds us "though the Church is designed to embody the fullness of truth, she does not have a monopoly on the truth." 16 While the church, through faith-based organizations and local faith communities, play an important role in global public health efforts, we are called to work cooperatively with other people of all faiths. 16

Multisector partnerships
Lofty population health goals often miss their mark, as demonstrated by the incomplete implementation of the United States Healthy People 2010 goals and the World Health Organization's Millennium Development Goals. This lack of success can be attributed to fragmentation across sectors, lack of collaboration, and no entity taking primary ownership of the goal. 19 With the introduction of the United Nations Sustainable Development Goals (SDG) in 2016, the need for multisector partnerships was outlined in the seventeenth goal, noting that partnerships are vital to successfully achieving the other goals. 20 The creation of partnerships across sectors to promote global health is fundamental. 21 Effective multisector partnerships are integral for comprehensive and sustainable public health efforts. 22 The advantage of collaboration has been attributed to the concept of synergy, "the power to combine the perspectives, resources, and skills of a group of people and organizations." 23 Synergy within partnerships can generate more creative, comprehensive, practical, and transformative thinking. 23 Multisector partnerships have demonstrated success in several global health efforts including increased health care utilization in Odisha, India, and reduction of under-5 mortality by 69 percent in Ethiopia. 24,25 However, partnerships can also hinder these efforts. Poor performance in population health goals has been attributed to poor partnership quality which can result from lack of strong cooperation, lack of individual responsibility by partnering organizations, and an imbalance or misuse of power. 19,26 Faith-based organizations have a record of success in global health efforts. Several studies have explored the importance and successful efforts of faith-based organizations in partnership with the public and private sectors. 27,28,29 However, collaborative efforts between faith-based and secular organizations can be hindered by differing goals and challenges in sacrificing aspects of autonomy. 30 In order to ensure continued effectiveness and synergy, multi-sectoral partnerships need to engage in a process of continuous improvement, considering the work as a learning process rather than an organizational structure. 31 This case study of water filter distribution in Liberia has brought together a Christian non-governmental organization (NGO), a Christian liberal arts college, and a private, for-profit organization. While the process of filter distribution seems relatively straightforward, the implementation and evaluation of the effectiveness is quite complex and requires a variety of expertise. As the project developed, a core team composed of three sectors emerged as leaders. The Last Well, a faith-based NGO, established in 2008 to address the needs addressed in this project, coordinates the implementation of the project and oversees filter distribution and data collection. Sawyer International, a US-based company, donates the filter systems, trains and equips partners on how to use their point-of-use filters in the field, and trains and equips partners on the GIS data collection. Calvin College, a Christian liberal arts college, cleans and analyzes data and reports on filter use and the effects of filter distribution on health and wellbeing in Liberia. This partnership benefits from collective expertise and is driven by a common goal to address the global water crisis in an efficient and cost-effective manner.
The case study utilizes results from an internal mid-project process evaluation conducted among the key project leaders to assess the partnership. The evaluation seeks to understand the benefits and challenges of such partnerships as identified through the core leadership team.

Method
The primary purpose of the process evaluation is to determine the strengths and challenges of the partnership in order to make mid-project modifications to further strengthen the work of the project going forward. Secondarily, the process evaluation will inform future multi-sectoral partnerships.

Participant characteristics
In order to evaluate the partnership process, six core leaders emerged from the three different organizations. The leaders included the field operations coordinator at the Last Well, the international director from Sawyer, Inc., and faculty members from the geography, mathematics and statistics, and public health departments at Calvin College, including the authors of this publication.

Sampling procedure and measures
The core leadership team were invited via email to participate in the process evaluation in July and August of 2018. Each of the six members answered five, open-ended evaluative questions: 1) What do you perceive to be your organization's role in the project? 2) What do you perceive to be your organization's goals in this project? 3) What does your organization hope to see as results from this project? 4) What do you perceive to be the advantages/benefits of completing this project with multiple sectors/organizations? Please be specific. 5) What have been the challenges of completing this project with multiple sectors/organizations? Please be specific. The answers to the open-ended questions were combined and categorized by themes. These themes were presented in the results as benefits and challenges of engaging in this partnership.

Benefits of the approach
The goal of bringing water to all Liberians by 2020 requires a broad swath of expertise and community trust. Engaging in these collaborative partnerships was described as vital for solving global, regional, and local challenges. This multisector partnership has allowed each partner to contribute meaningfully and within their scope of knowledge. For instance, The Last Well understands the cultural context and has a strong relational presence in Liberia, while Sawyer International provides state-of-the-art water filters and develops and maintains the GIS-based data collection software. Calvin College provides expertise in analyzing and communicating results of large-scale, data-driven projects.
By partnering, each organization focuses on areas of expertise which also can contribute to better outcomes.
The approach also allows each organization to further develop sustainable efforts by investing in both local community members and student researchers. Partnering organizations have more time to invest in others as their time is only focused on their areas of expertise. This investment is primarily seen in the development of a public health workforce as local Liberians are called upon to distribute filters and collect data, and students are involved in the data analysis and communication of results.
Unlike many other public health partnerships, this partnership engages the corporate sector. This sector is largely results driven, pushing other partners to complete the work in a timely fashion. Furthermore, this sector introduces a business and marketing model into public health practice, emphasizing the potential for the project to be replicated and advertising the work to a variety of audiences. By utilizing academia in the research, the data are analyzed, and statistically significant results are identified and communicated.

Challenges of the approach
Working in a global, multi-sector partnership also presents challenges including differing subgoals, logistical challenges, communication difficulties, and different ways of communicating results. In this case study, partners discovered each organization had other priorities in addition to the main goal of creating access to clean water in Liberia and, ultimately, to more people worldwide. For example, as a business, Sawyer International wants to see other NGOs use their product to provide clean water to other areas of the world, even if it means foregoing some profit in selling their product at a discounted rate. The Last Well aims to preach the gospel throughout all of Liberia. Calvin College researchers seek to publish and provide a way for students to gain research experience and to quantify effectiveness of filter distribution in a variety of ways. While the existence of different sub-goals presents advantages in the scope of work being done, it unfortunately causes differential prioritization by each partner.
Logistical challenges also have affected the timeliness and quality of the partnership. The data collection method relies on local lay people in Liberia, which builds local capacity but requires long-term training, monitoring, and evaluation. The collected data often requires additional cleaning before it is ready for analysis, resulting in longer lagtimes between data collection and dissemination of results. The process of getting the filters from manufacturing through customs in Liberia has been a challenge and, additionally, the geography and climate of Liberia slow distribution and data collection as many villages are very inaccessible, particularly during the rainy season.
Communication can also be a challenge as the partners are stationed in different parts of the world, resulting in most decisions being made via phone or e-mail. Even in times of limitless access to phone or e-mail, these mediums can contribute to confusion. Different ways of expressing ideas or different priorities due to differing professional backgrounds also can hinder communication. For instance, those on the academic end often become too absorbed in minor dataset issues while those on the corporate or NGO end often rely on anecdotal stories or observations. Furthermore, it is a challenge to communicate with those who are collecting data as they are often undereducated due to war and poor educational systems in Liberia.
Finally, different backgrounds and goals often require different final products, ways of communicating information, and various response times. For example, while academic publications often are overly detailed and rigorous, marketing materials need to convey the story concisely and effectively to a lay person. For organizations like Sawyer International, timeliness is critical as they need to demonstrate results to make the case that this approach is a viable solution and can be adopted by other NGOs and aid organizations. This quick turnaround time is relatively foreign in the academic setting and requires increased nimbleness and responsiveness to data requests.

Discussion
The development of a common framework for global health, as articulated in the SDGs, necessitate the forging of new collaborations. 30 Neither faithbased organizations nor governmental agencies are equipped to solely reach global public health goals, and must rely on the expertise and experience of each other along with other players in civil society. 29,32 Inclusion of multiple disciplines among multiple sectors provides a holistic approach to addressing community health. 33 Continued commitment from "multiple agents of change working across sectors over time across ecological levels" is needed to continue to improve population health outcomes. 19 These partnerships promote access to new resources and skills, capacity-building, have extensive reach globally, and often can reach the most vulnerable populations. 32,34 Faith-based partnerships have a large presence and potential in public and global health. 29 For instance, in this case study, inclusive partnerships can implement and assess large-scale public health projects, such as bringing clean water to an entire nation. More efficient and streamlined service delivery is possible by streamlining processes and maximizing the skillset of each partner.
Several of the challenges we faced in our partnership are inevitable due to the nature of multisector partnerships and interdisciplinary work. However, the negative effects of these challenges can be mitigated by taking an intentional approach to planning and communication throughout the process. Prior to work beginning, it is imperative that a comprehensive plan for action and the partnership structure be clearly articulated. Previous work has highlighted the need for defining governance and management processes along with detailed timelines and work plans. 19,35 Additionally, common goals, as well as individual partner subgoals and priorities, should be laid out prior to the commencement of the project. In partnerships, it is a delicate balance to allow each partner to contribute to the project while also seeking to further their own goals-whether those be evangelical, marketing, or publication goals in our case. The potential contributions of each partner should be identified along with their values, commitments and motivations. 27 These conversations are necessary for building trust, a key element in multisector partnerships between faith-based and secular organizations. 33,35 Communication is a challenge in global health partnerships and poses additional difficulties when the work is interdisciplinary and multisector. These challenges call for increased attention to ensuring understanding and using care in communicating ideas and messages. 21,27 Rather than expressing frustration at the differing ways of communication, each perspective should be valued. Engaging multiple ways of looking at a problem and discussing solutions provide a richer, more complex narrative of the success and failures of a project. Giving voice to all partners, rather than relying heavily on one voice can lead to stronger collaborations. Relationshipbuilding is critical for partnership synergy. 23 Emphasis on building trust, fostering respect, addressing conflict, and acknowledging and addressing power differentials in the partnership leads to better communication and effectiveness. 23 The emphasis on the importance of partnerships in the SDGs necessitates process evaluations to better understand the nature of these partnerships and identify common ways to work more effectively. The establishment of evaluation systems to measure the effectiveness of multi-sector partnerships is integral to determine if these arrangements are merely a fad or if they, in fact, truly enhance global health efforts. 30,36 Using process evaluations throughout project implementation allows participants to build on strengths and address challenges moving forward.
This case study has limitations, namely that it covers only one multi-sectoral partnership and thus the generalizability may be limited. Furthermore, there may be bias as the authors are members of the project team. However, the case study provides lessons learned for future endeavors and encourages the exploration of partnerships between faith-based and secular organizations as we seek to be agents of renewal in God's kingdom.

Conclusion
Multi-sectoral partnerships can provide increased means to optimize the use of each partner's gifts, combine resources to more efficiently address global health needs, and use the partnership to invest in others.
It is imperative to articulate communication needs, desired outcomes and expectations, and program plans throughout the process to promote thriving. As we follow Christ's model of a life of servanthood and His call to justice, we must engage in these effective strategies to address the needs of those who are most vulnerable. We have a sacred charge to do justice, love mercy, and to walk humbly with our God. In considering the global water crisis and other major global health challenges, we must seek opportunities to work alongside those who are best equipped and to identify strategies to promote flourishing in those partnerships to best fulfill our calling here on earth.