Transforming health systems with water, sanitation and hygiene
To ensure every woman can give birth in a healthcare centre with clean water, decent toilets and good hygiene facilities, governments, donors, researchers and NGOs need to work together and step up efforts. Alison Macintyre, Health Advisor at WaterAid, introduces our new report, which showcases examples from our work on improving water, sanitation and hygiene in healthcare and strengthening health systems.
Encouraging women to give birth in a hospital or clinic offering basic healthcare has been a global health priority for decades. Great achievements have been made, with three quarters of women now delivering with a skilled birth attendant, resulting in a 44% reduction in maternal mortality since 1990.
It seems then anachronistic that, in March of this year, the UN Secretary General called for urgent action to improve water, sanitation and hygiene (WASH) in healthcare facilities. Surely a healthcare centre without adequate WASH facilities is not one that can provide care to women, or, in fact, anyone? One would assume that the first steps taken decades ago to improve maternal health would have been underpinned by the provision and practice of WASH. Sadly, that was not the case. In sub-Saharan Africa, a study of seven countries showed that almost a quarter of facilities did not meet basic requirements for supporting safe deliveries, including the provision of water. As Margaret Chan, former Director-General of the WHO stated at the World Health Assembly six years ago:
"What good does it do to offer free maternal care and have a high proportion of babies delivered in health facilities if the quality of care is sub-standard or even dangerous?"
The harm is clear
As few as 2% of healthcare facilities in low- and middle- income countries provide all four basic water, sanitation, hygiene and waste management services as defined by the WHO/UNICEF Joint Monitoring Program for Sustainable Development Goal (SDG) 6.
Although there is little research into the health impacts of inadequate WASH in healthcare facilities, it is likely that it increases the risk of healthcare-associated infections, the spread of antimicrobial resistance, and the risk of mothers and newborns dying from sepsis. As seen during the recent Ebola and cholera outbreaks, poor WASH can reduce the effectiveness of preventing and responding to health emergencies.
Since the first WHO and UNICEF global status report in 2015 – showing that 38% of healthcare facilities do not have a water supply, 19% do not have safe sanitation and 35% do not have basic hygiene infrastructure such as a sink and soap – global WASH and health communities have made progress in addressing the problem:
There are now globally agreed indicators to track WASH in healthcare facilities under the SDGs, enabling countries to set targets and monitor progress.
Several major health strategies and WHO guidelines – such as the Global Action Plan for Antimicrobial Resistance, WHO’s Standards for Improving Quality of Maternal and Newborn Care, and WHO’s Core Components of Infection, Prevention and Control – all recognise WASH as core to achieving their goals.
Less talk, more action
However, guidelines are not sufficient. Governments and international institutions must adopt, implement and reinforce them. This requires strong health systems, leadership and accountability.
Underlying the alarming WASH conditions in many healthcare facilities is a systematic neglect of WASH within health systems and global financing. The WASH problem must be tackled across all elements of the health system, to support strong governance, robust accountability and monitoring, quality service provision, sustainable financing, a well-trained and adequate workforce, and the provision of the right technologies and commodities.
It must also be supported by sufficient domestic and international financing. Only through a well-funded, system-wide approach will WASH be improved to a level that can support quality healthcare and the achievement of universal health coverage.
Transforming health systems
Over the past four years, WaterAid has worked in partnership, primarily with ministries of health and health actors such as WHO and UNICEF, to drive country-level action. Our report ‘Transforming health systems: the vital role of water, sanitation and hygiene’ highlights practical snapshots from our work, showing how a systems strengthening approach has driven WASH improvements and thereby the quality of care in several countries. Examples come from diverse contexts in Malawi, India, Nicaragua, Mali, Myanmar, Cambodia, Tanzania, and Uganda.
The snapshots draw out several key lessons:
Leadership at national level is essential so that WASH is integrated into health strategies, policies, guidelines and monitoring systems.
Coordination is essential and should be led by ministries of health to bring together and align multisector stakeholders to maximise impact.
Understanding what works through robust research on how WASH improvements are made ensures that interventions are evidence-based and sustainably drive behaviour change.
Building a strong health workforce with the right mix of skills for clinical and non-clinical health needs, such as WASH, is crucial.
The report also showcases examples of working effectively with communities to drive citizen-led accountability and action – a critical but often-neglected element of ensuring quality care. As Aruna B, an auxiliary nurse midwife in India said:
"People hush me up. I speak my mind and they dislike it. But unless I speak up, how else will the crisis here get solved?"
During a WHO and UNICEF-led meeting in May, global health and health experts agreed that the UN Secretary General’s Call to Action demands escalated activity on WASH in healthcare facilities. Efforts should focus on driving change at the country level, supported by global-level advocacy, financing and technical support.
Delegates acknowledged that improving the quality of healthcare through strengthening health systems is the way to improve WASH in healthcare facilities, and that examples, such as those we highlight in our report, are crucial to shaping effective global action.
Reaching everyone with healthcare
If we are to achieve universal health coverage, ensuring every woman receives good-quality and safe care during childbirth, every health facility must have basic WASH services. To reach this goal, we call for urgent, country-led and globally supported action at scale.
We call on Governments to:
commit to, invest in and implement plans to improve WASH in healthcare facilities to meet global minimum standards and address the needs of all.
We call on the global health and WASH communities to:
coordinate and align efforts at global and country level
focus research on capturing what works to drive long-term and sustainable services and practices
target efforts across the health system.
Finally, we call for greater investment and commitment from international development partners and national financing, to ensure plans are supported by the resources required to improve WASH.
Only then, as highlighted by Dr Maria Neira, Director Public Health and the Environment at WHO, will we achieve WASH that "…will contribute enormously to reduce mortality, to increase the health of the people and to make sure that our health care facilities are equipped with what should be a basic human right."