By Susan Davis, Executive Director
It is widely acknowledged that the Sustainable Development Goals, in particular access to quality essential health-care services, cannot be achieved without access to basic water, sanitation, and hygiene services. Yet many health care facilities lack basic necessities such as soap, water, and toilets, compromising their ability to provide even the most routine health services. Worse yet, some facilities that have had WASH interventions are challenged to maintain those services at acceptable levels.
Globally, healthcare facilities lack WASH access
A 2018 global assessment of environmental conditions at health care facilities in 78 low- and middle-income countries estimated that 50% lacked piped water, 33% lacked improved sanitation, 39% lacked handwashing soap, and 39% lacked adequate infectious waste disposal (Cronk & Bartram, 2018). Using nationally representative data from six countries, the study found only 2% of healthcare facilities provide all water, sanitation, hygiene, and waste management services. Beyond access to WASH and waste management services, another challenge has been achieving lasting hygienic behavior change at home and at institutions like healthcare facilities and schools. These conditions have implications for disease prevention and maternal-child health care efforts.
Maintaining WASH services at health care facilities continues to be a challenge
Recent case studies reflect the global data and provide insights on new ways forward. Few facilities – even those with previous WASH interventions – meet all water, sanitation, hygiene, cleaning, and waste management criteria. Even having a functional water supply did not mean facilities had sufficient quantity or quality for all needs. In our study, the criteria least often met were having a functioning hand hygiene station with water and soap within 5 meters of latrines, at all points of care, and near waste management areas.
Yet WASH has relatively low priority at healthcare facilities
In our study, a few examples suggested that healthcare facilities maintaining WASH and waste management conditions that meet standards could be less about finance and more about staff priorities. This echoes findings of a review of Ethiopia’s Clean and Safe Health Facilities program, which found that the facilities where the most change had been achieved were those where staff had a “commitment to the issue, energy and enthusiasm and an interest and appreciation of the issue of WASH and IPC [infection prevention and control]” (WHO, 2017).
Recommendations for funding WASH in healthcare facilities
Before designing the intervention: Understand the present context. All grants should build in time to fully understand and define the problem with relevant stakeholders. For example, are WASH-related challenges like lack of soap and water treatment products due to inappropriate budgeting? Lack of finance? Poor supply chain? Then appropriate actors for addressing these root causes (e.g., local/national government finance officials, private sector or government supply chain) should be engaged in program design.
Rather than focusing simply on infrastructure and training at individual facilities, WASH and waste management efforts in healthcare facilities should consider the dynamics of who sets and enforces priorities and how best to work within them.
But don’t forget the past. All grants should build in time and funding before the design to learn about what works over time. Methods could include one or more of the following:
- Review the existing evidence base
- Evaluate past WASH in healthcare interventions in the area, if relevant
- Conduct a pre-mortem exercise
Grants should also include funding to improve WASH and waste management conditions at facilities that already had an intervention (if conditions are found to be sub-standard), whether directly with technical advice of funding, or by supporting local governments.
Consider patient points of view. Grants should include time and funding to interview patients at representative facilities about satisfaction with facility cleanliness and WASH facilities, especially pregnant women and mothers who recently delivered.
Work within existing efforts. Some countries have been working on universal health care and/or improving quality of care. Your funds can go farther and lead to longer lasting results if you work with/expand/treat existing government or global initiatives like Clean Clinics, Healthy Start, WASHFIT, CASH (Ethiopia), Results Based Financing (Kenya).
Remember that clinics are part of the community. When households around the clinic don’t have their own toilets, they might use the ones at the clinic, making it hard to keep them clean. New interventions should include or collaborate with (or advise governments on) community wide sanitation approaches that include institutions as well as households.
Power to the People: Invest in leadership training. Funders should consider ways to support local / regional government in ensuring all healthcare facility directors get leadership training that includes education on the importance of WASH and IPC to healthcare, as well as performance management and contingency planning. For example, Ethiopia has a robust leadership program. Perhaps expanding this using a train-the-trainers method, where one person is trained and receives some incentive to train peers at other facilities, could be an effective way to reach all directors.
Pump up performance. In addition to following the recommendations of recent reviews (de Buck, et al., 2017; WaterAid, 2017), funders should consider replicating or expanding results-based financing programs that have shown success with improving health service delivery, ensuring that WASH and waste management related results / indicators are included.
Ensure staff and patients get hygiene training. Following WHO recommendations, funds should support (directly or through advice) local and regional governments in ensuring all healthcare facility staff, including volunteers and cleaners, get WASH and infection prevention & control (IPC) training and regular refresher training. A train-the-trainers method, where one person is trained and receives some incentive to train colleagues, could be an effective way to reach all staff. Patients should also be educated on how to use WASH facilities and the benefits of doing so.
Super Structures: Fund robust sources and distribution of water. When designing new interventions, donors should recognize the multiple water needs for healthcare facilities, different than households or schools, including drinking water for patients, cleaning of wards, showering for patients, handwashing for staff and patients, and disinfecting instruments. Because water is heavy and facility staff have multiple duties, it is worth the incremental funding to make access as easy as possible, e.g., pumps and pipes to get water to sinks inside treatment rooms and to handwashing stations around the facility (including near latrines and waste management areas). This should also reduce time and effort needed for cleaning.
Finance for the future: Include funds for WASH and waste management life-cycle cost analysis for one or more representative healthcare facilities, if these have not already been conducted for that specific context. Then interventions must be designed in collaboration with those who will pay the operation and maintenance costs for water supply and distribution, water treatment, soap, and managing medical and other wastes, including costs, to ensure these costs are covered by adequate budgetary allocations.