Dirty hospitals do not promote patient safety; clean water, decent sanitation and good hygiene do

6 min read
Image: WaterAid/ Dennis Lupenga

Ahead of the 5th Global Ministerial Summit on Patient Safety, Annie Msosa urges health leaders to protect patients everywhere by highlighting investment in water, sanitation and hygiene (WASH) in healthcare facilities as a fundamental and priority action. There is no excuse, she says, for not solving this scandalous problem.

February, 2023. In one part of the world, a robot helps a surgeon perform heart surgery. In another, a midwife looks after four women going through labour as more than fifty others wait for her for their antenatal checkups. She has no soap or water to wash her hands between these examinations.

In one part of the world, a woman can give birth in a bathtub full of water. In another, a woman who has just given birth faces a difficult choice: she can either wipe herself with a cloth or bathe herself and her newborn with unsafe water.

And yet, one thing remains universal. When people walk into a healthcare facility anywhere in the world what they hope to receive is quality and dignified care. After all, what is a healthcare facility supposed to provide if not this? What is it supposed to be if not a place where experts in health, trained to follow due processes and good hygiene standards, deliver – and, more importantly, are able to deliver – safe care?

So then why is it that where I come from, Malawi, one often feels great apprehension when one has to visit a public hospital? This is not an unfounded fear. Data show one in ten hospital patients in low- and middle-income countries acquire a hospital infection while receiving treatment. It is scandalous, I know. And, for the people forced to use these services, it is scary.

Filomena Fabiaõ washing used medical utensils in the maternity ward at the health centre in Mecanhelas, Niassa Province, Mozambique. Jul 28, 2022. Image: WaterAid/ Etinosa Yvonne

Dirty hospitals undermine the work of healthcare workers

Healthcare workers often find themselves in complex, high-stress and high-risk environments, where they must think on their feet to save lives. We know that human error cannot be eliminated. This is why health systems must take reasonable steps to create a conducive environment in which healthcare workers can care for patients as safely as possible, especially when it comes to known problems that have known solutions.

Handwashing has been acknowledged as essential to public health since 1846. That’s 170 years ago!

And yet, half of the world’s healthcare facilities (PDF) run without a place for health workers and patients to wash their hands.

Imagine you are a nurse, doctor, cleaner or midwife working in such an environment. Despite your best intentions, your expertise and the ethical vows you took to do no harm, you are unable to guarantee your patients safe care. Instead, you are forced to work in an environment where harm happens by design – but you can’t turn away patients! And so, as patients look to you for help, you do your best, knowing it may not be enough to protect them from inadvertent harm.

Imagine learning that, after you have performed complicated surgical or childbirth procedures on a patient, they still died because you did not have the basic tools to properly sterilise medical equipment or even to keep your hands clean. 

It is unacceptable that healthcare workers continue to be placed in such compromising – not to mention distressing – situations. Undoubtedly it must affect their motivation, their relationships with their patients and their mental health. Hospitals that do not have clean water, decent sanitation and good hygiene are not safe for anyone – neither those who seek medical help, nor those who work tirelessly to provide it.

A key step is to improve the environment in which healthcare workers are expected to care for patients. By giving healthcare workers the basic tools and infrastructure they need to maintain good hygiene standards, and by promoting practices and behaviours that prevent the spread of infections, the risk of harm can be reduced.

Nyaganga Juma Samuel, 37, nurse and midwife, holding a newborn baby whom she helped mother Susan Magoma (left), 32, deliver the night before at Nyamalimbe Dispensary, Geita District, Tanzania. June, 2019. Image: WaterAid/ James Kiyimba

If our health systems are so advanced, why are we failing to implement the basics?

Universal coverage will not help patients while hospitals are dirty

What good is medical advancement if what kills a patient is a completely avoidable hospital infection? And what good will universal health coverage do by merely increasing people’s access to dirty hospitals, thereby increasing the number of people such health systems can harm?

You must wonder (and I do too) why such a grave yet completely avoidable patient safety mistake is still allowed to perpetuate in healthcare facilities. And I can tell you this:

It is not because the problem of lack of WASH in healthcare facilities is not known well enough.

Infections associated with unclean birth environments cause 26% of newborn deaths and 11% of maternal mortality (PDF) each year, accounting for more than 1 million deaths annually in total.

Around 11 million people (PDF) each year die because of sepsis – that’s 20% of all global deaths.

Only 15% of healthcare facilities meet minimum standards for infection prevention and control.

It is not because the benefits of having adequate WASH services and behaviours are not well understood

Good hand and environmental hygiene in healthcare facilities could more than halve the risk of death caused by infections by drug-resistant pathogens and reduce the associated long-term complications and health burden by at least 40%.

Improved WASH and infection prevention and control measures could halve the number of healthcare-associated sepsis cases (PDF), averting up to 1.4 million maternal and neonatal deaths each year.

Every dollar invested in improving hand hygiene in healthcare settings could save US$16.50 in healthcare expenditure resulting from the effects of poor hand hygiene.

It is not because people seeking healthcare are not asking for change

A survey of more than 1 million women and girls in 114 countries found that, after respectful care, WASH was the second most important demand for quality reproductive and maternal healthcare.

A survey of midwives (PDF) found that "Midwives around the world desire to work in an environment where they have access to basic needs that should be afforded to any health provider: space, equipment, clean water, and medicines to treat the women in their care."

It is not because the solutions do not exist

The world already has affordable technologies and packages for promoting WASH in healthcare facilities.

And it is certainly not because it is too costly or resource intensive to eliminate the problem

It would only take US$9.6 billion (an average of just $0.65 per person per year) to by 2030 reach every healthcare facility in least-developed countries with the WASH they need to keep patients safe. That is $600 million in external and $355 million in domestic financing annually. Compare that cost with the $3.2 trillion annual spending on global heath projects that have little or no impact on good health outcomes!

Simply put, there is not a single excuse why this completely avoidable patient safety mistake continues to happen – and at this scale. It persists because health leaders choose to ignore it.

This is why I am asking health leaders attending the 5th Global Ministerial Summit on Patient Safety to:

  1. Unequivocally highlight the value of investment in improving WASH in healthcare facilities. This is a fundamental and priority action to achieve patient safety in low- and middle-income countries.
  2. Urge countries to keep their promises by accelerating implementation of the World health Assembly WASH in healthcare facilities resolution (PDF).

Dirty hospitals do not promote patient safety. Clean water, decent sanitation and good hygiene do.

Learn about our work to improve WASH in healthcare facilities

Annie Msosa is WaterAid's Advocacy Advisor for Health. Follow our advocacy at the Patient Safety Summit on Twitter.

Top image: Mary Khobiri, nurse and midwife, holding the newborn baby of Dolophy Kinilosi, who stands next to her, at Mangamba Health Centre, Machinga, Malawi. April, 2019.