The key ingredients to Universal Health Coverage in Ghana: water, sanitation and hygiene

6 min read
Community nurse, Francisca Edwin, with her baby using the new hand washing station at the Bandunu healthcare facility.
Image: WaterAid/Chaka Uzondu

As Ministers of Health represented on this year’s WHO Executive Board meet to agree on the priorities for this year’s World Health Assembly in Geneva, Chaka Uzondu, Policy Manager for WaterAid Ghana, calls for urgent action to improve WASH in Healthcare Facilities.

This week in Geneva, a select group of Member State representatives are meeting to lay the groundwork for this year’s World Health Assembly. They will discuss a wide range of urgent global health priorities, foremost of which is how to fulfil the promise of Universal Health Coverage (UHC) – health for all – by 2030. UHC is based on a belief that everyone should have access to people centered care that is of appropriate quality and comprehensive in nature, and that accessing quality health care – if and when necessary – should not create impoverishment.

There is real commitment to UHC in Ghana...

The global health sector is driving forward universal health coverage. Last year the Government of Ghana announced its commitment to that vision. At the 71st World Health Assembly in May 2018, Honourable Kwaku Agyeman-Manu, the Minister of Health, was “awarded for his role in helping to address antimicrobial resistance (AMR): a threat to global health and the achievement of universal health coverage”. Importantly, the Honourable Minister also, on behalf of Ghana, signed the Universal Health Coverage Global Compact.

Ghana’s commitment to achieving UHC is welcome news to the thousands of people in Ghana who worry when their child gets sick because they know they can’t afford quality care. Making UHC a reality will require that Ghana ensures that we have the tools to protect children everywhere from disease and ill health. This is central to the human right to health and ensuring that everyone’s right to health is protected and realised requires that our leaders increase investments in health and act decisively.

The 2019 budget recently released by Ghana’s Ministry of Finance provides hope. The allocation for the health sector was GHS 6,037,506,718 (US$1,202,230,000). This is 8.2% of Ghana’s Gross Domestic Product, representing a 1.1% increase on the 2018 budget. This is significant; however a promise remains unfulfilled. In 2001, in Abuja, Nigeria, African countries committed to spending 15% of their GDP on the health sector. This has never been fulfilled by any government in Ghana. Still, everyone, especially the health sector, welcomes the increase – it is an important increase in budgetary allocation. Of course, allocation is not to be confused with disbursement and value for money in expenditure. We will certainly need the latter two, if we are to transform the healthcare system.

...but the foundations for UHC must not be forgotten

Improving health infrastructure is key to improving the health care system and achieving UHC. The Ministry of Health has been explicit about its commitment to improving health infrastructure. The provision of water, sanitation, and hygiene (WASH) services must be included in this improvement of health infrastructure. The magnitude of this challenge – the lack of adequate WASH services in Healthcare facilities – is a known, unknown. We all know that many health care facilities do not have access to safe WASH services. But what remains unknown is exactly how many facilities do not have access, on a district level, regional or national level.

WaterAid Ghana have been supporting the Ghana Health Service to assess this gap by working with the Navrongo Health Research Centre. Here are a few findings that will hopefully keep the Minister of Health awake at night:

  • Of all the health care facilities where women go to give birth in two districts, only 31% of healthcare facilities had pipe borne water in the maternity wards.
  • Of all the health care facilities where women go to give birth in two districts, only 14 of 29 of them had toilets available for outpatients and only three of the facilities had separate toilets for females and males.
  • Of all the health care facilities where women go to give birth in two districts, only 14% of them have handwashing facilities near the toilet.
  • Of all the health care facilities where women go to give birth in two districts, only six of the 29 health care facilities have functioning incinerators to manage medical waste.

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The data above only looks at WASH in Healthcare facilities in two districts. There needs to be a great deal more work done to generate similar data for the entire country. This will certainly be key to planning and budgeting for WASH in all Healthcare facilities across the nation. However, even if the reality across the rest of the country is 100% better than what the Navrongo Health Research Centre research found in these two districts, there is still a huge gap in access to WASH in healthcare facilities.

The infrastructure gap is not only a facility and/or water gap. In fact, there is a massive sanitation and hygiene gap. Around the country many healthcare facilities provide toilets for staff, but those for patients are conspicuously missing and/or abysmally unhygienic. Therefore, achieving UHC must mean realizing that systematic investment in the provision of not only water, but also sanitation services and hygiene facilities and behaviour change communication is of critical importance.

Investing in human capital is as important as infrastructure

At the WHO Executive Board meeting this week in Geneva, Member State representatives will discuss UHC, but they will also discuss Patient Safety and a proposal for a World Health Assembly formal resolution on WASH in Healthcare Facilities put forward by the Governments of Eswatini, Tanzania and Zambia. This proposal is crucial for reminding all governments everywhere that achieving UHC is only possible if health systems are strong in promotive and preventative health, the bedrock of public health and safety. The provision of WASH in all healthcare facilities is fundamental to those strong health systems.

While it is vital to address the WASH infrastructure gap, it is perhaps even more critical that we address the human capital gap. Human capital refers to the capabilities, capacities, skills and health possessed by a population and/or individual. Are the majority of healthcare workers familiar with antimicrobial resistance (AMR) and have the majority of them been trained in infection prevention and control? If so, are their behaviours in accordance with their knowledge? If not, then this too may speak to a human capital gap. The point is this – it is of fundamental importance that the onward move to UHC also include greater funding, for instance, for training healthcare workers in water, sanitation, and hygiene and Infection Prevention and Control (WASH IPC), essential newborn care, and antimicrobial stewardship.

This is the time for action – in Ghana and across the world

In short, the Government of Ghana must invest much more in human capital to go along with investments in infrastructure, including WASH. And if we are going to realise Universal Health Coverage and the dream of health for all, then there needs to be prioritization of WASH in healthcare facilities. WaterAid urges all governments to take action on this issue as a fundamental component of their UHC plans. And we urge the WHO Executive Board members to give WASH its rightful place at the heart of the World Health Assembly agenda.


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