'Doing the maths': Financing WASH in health care facilities in Ghana

9 April 2019
WaterAid/ Eliza Powell

As new official data reveals the crisis in provision of water, sanitation and hygiene (WASH) in health care facilities around the world, WaterAid Ghana’s Policy Manager Chaka Uzondu ‘does the maths’ about the urgent need for a step-change in financing to address this.

Financing water, sanitation and hygiene in health care facilities (WASH in HCFs) is essential for achieving the Sustainable Development Goal (SDG) of universal health coverage for everyone everywhere by 2030. Yet many health care facilities globally do not have access to the essential WASH services to ensure patient safety and to prevent and control the spread of infections. New data just published by the WHO and UNICEF – the first globally representative data on this issue – reveals the scale of the challenge: an estimated 45% of health care facilities in least-developed countries, and one in four globally, do not have a basic water service.

Health care challenges in Ghana

The challenge of inadequate WASH in HCFs is also a reality for Ghana, where the report estimated that nearly 30% of health care facilities lacked a basic water service. Ghana was among the many countries who were unable to provide sufficient data to meet the new SDG definition of ‘basic sanitation service’, which says that sanitation is improved and usable, with a toilet dedicated for staff, a sex-separated toilet with menstrual hygiene facilities, and at least one toilet accessible for people with limited mobility. So while the data shows that 83% of health care facilities in Ghana have ‘improved sanitation’, much more work is needed to ensure it meets the new minimum standard for the SDGs. It is also concerning that only half of health care facilities in Ghana are estimated to have a basic waste management service.

These challenges are consistent with the findings of a recent WaterAid Ghana situational analysis of two districts, which revealed that only 31% of health care facilities had pipe borne water in the maternity wards, only 3 out of 29 HCFs had separate toilets for women and men, and only 6 HCFs had functioning incinerators to manage medical waste. As the issue gains traction globally, the question on many minds is what would financing WASH in HCFs cost, and therefore what new commitments are needed from governments and donors?

Doing the maths

WaterAid Ghana is currently collaborating with two districts to develop long term strategic plans for WASH in HCFs. Central to this process is establishing what it would cost to ensure full access to WASH services in all health care facilities in the respective districts. One of the key factors to consider when developing this long term plan is population growth. The current population of Bongo District is 103,060. It has a growth rate of 2.6%, which is higher than the national growth rate of 1.5. By 2040 Bongo is expected to have a population of 176,679: an increase in population of approximately 73,000 people.

District-wide context of WASH in healthcare facilities

Today the Bongo population is served by 49 health care facilities. One is a district hospital. The district has six health centers and 32 community health posts (CHPS). The key difference between these are the level of services they provide, whether they provide inpatient care or not and the size of the population they serve. Seventeen of the CHPS do not currently have structures. In other words, a community health nurse could literally be providing outreach services under a majestic baobab tree, a community built structure using local material, or a formal structure built by the district. And of those health care facilities that do have structures, most of them do not have full WASH services. Excluding the hospital, only a few HCFs currently have full WASH services, i.e. WASH and waste management that would meet the SDG minimum standards. WaterAid Ghana is currently working in five HCFs to provide WASH and waste management services.

Shower used as a storage room, Ghana.WaterAid/Chaka Uzondu
Shower used as a storage room in a health care facility, Ghana.

By 2040, it is expected that the District will need at least 64 health care facilities to address the health care needs of its population. The Bongo district authorities expect to build 15 more CHPS within the next few years. This is informed by a new policy from the Ministry of Health, which requires that each electoral area should have at least one CHPS. The objective is to make primary health care as accessible as possible.

What would it cost?

We have established that Bongo district has 17 health care facilities without physical structures as they were initially designed to be community outreach posts. Given this, let’s make two assumptions. First, that the number of facilities needed, 64, are adequate to serve the population in 2040. Second that only 32 health care facilities will need to be upgraded. What will this cost the district?

In the five health care facilities where WaterAid Ghana is currently improving WASH services, the approximate cost per facility is 356,000 Ghana Cedis (US$71,200). Therefore, the cost of WASH investment as part of upgrading 32 facilities is approximately GH₵ 11,392,000.00 (US$ 2,278,400). This does not include the cost of building a facility, which according to the district assembly, is approximately GH₵ 400,000. The cost of building 32 CHPS with the full WASH complement is therefore approximately GH₵ 25,326,000.00 ($5,065,200.00).

It is worth noting that this is just the initial cost of construction and does not consider the life cycle cost of these facilities and services. It does not consider the cost of goods and services. Critically, it does not include the cost of staff. However, this analysis, focusing on only 32 facilities, gives us some insight into the magnitude of the challenge of financing WASH in HCFs in one district.

Scaling up

Part of the challenge is that, as the new JMP data illustrates, there is not sufficient data currently available about the status of WASH in HCFs across the country. But we can make some projections to gain some perspective. Ghana currently has 256 local government administrations. Assume that each of them has approximately 20 HCFs that will need complete WASH investments. (From WaterAid Ghana’s situational analysis of HCFs in two districts, at least 60% of them did not have full WASH services). If we assume further that the cost of construction will not change much, then we can use the local government and WaterAid Ghana cost for our estimates. This means that approximately 5,120 HCFs across Ghana will need WASH investments. Assuming the physical structures exist and only the inclusion of WASH services is required, then the cost is approximately, GH₵1,822,720,000.00 (US$364,544,000.00). If the physical construction of new facilities is necessary (quite likely since there has been a recent expansion in the number of local government administrations from 217 to 256), then the cost of constructing these new HCFs with the full WASH complement is GH₵ 3,870,720,000.00 ($744,144,000.00).

So for Ghana, WASH in health care facilities is at least a three billion, eight hundred and seventy million, seven hundred and twenty thousand Ghana Cedis challenge. This is a big number, but it’s worth putting it into perspective. The annual budget for the Ministry of Health in 2019 is GH₵ 6,037,506,718.00, including GH₵ 845.7 million for capital expenditure. Yet, we should not get too excited about the possibilities just yet. Current financing for the health sector remains inadequate. The capital expenditure allocation for 2019 is only about 46% of what is required to provide WASH services for at least 20 health care facilities in each district across the country.

Financing promises must be kept, in Ghana and around the world

In 2001, the African Union countries including Ghana met and pledged to set a target of allocating at least 15% of their annual budget to improve the health sector. Sadly hardly any governments have yet kept this promise. Fulfilling the Abuja Declaration remains as critical as ever if Ghana (and other African countries) are to be able to finance WASH in all health care facilities and universal health coverage.

Financing WASH in all health care facilities is an opportunity to enable the realisation of a Ghana beyond aid, characterized by Universal Health Coverage and quality care. With the appropriate prioritisation, the Government of Ghana can realize its commitments to the people of Ghana.


In May a delegation from WaterAid will be at the World Health Assembly in Geneva, encouraging leaders to support a resolution on WASH in health care facilities. Bookmark our 'World Health Assembly' page and keep up to date with what we've got planned.