Water, sanitation and hygiene in healthcare facilities: an essential investment for health systems

7 min read
FEO CHPS health centre in Bongo district, with midwife Margaret Awovunga. Ghana, December 2019
Image: WaterAid/ Apag Annankra

A new World Health Organization (WHO) / UNICEF report released today is a call to action to new investment in water, sanitation and hygiene (WASH) in healthcare facilities to ensure safe, dignified quality care. George Cobbinah Yorke, Fauzia Aliu and Channa Sam Ol reflect on lessons from Ghana and Cambodia on driving action for WASH in healthcare facilities financing.

The COVID-19 pandemic has forced a global focus on health systems and their capacity to handle shocks. Headlines have been dominated by emergency response measures and the daily challenges faced by health workers, such as shortages of personal protective equipment and intense work demands. The capacity and robustness of health systems around the world have been laid bare – just when they have never been more critical. For many of those health workers, the basic WASH services they need to perform their roles safely are not in place or functioning. This year has shown, more than ever, that we need revolution – we need action to ensure these basics are in place in all healthcare facilities.

New data – a call to action

Today, WHO and UNICEF have launched a report showing progress countries are making one year on from their commitment to ensure healthcare facilities have WASH services through the WHO WASH in Healthcare Facilities Resolution (PDF). Yet the situation in least developed countries (LDCs) remains dire: half of healthcare facilities lack basic water services; one in four lack hand hygiene facilities at points of care; three in five lack basic sanitation services; and seven out of ten lack basic healthcare waste management services.1

More and better funding is needed to improve WASH services and keep them running in the long term. As the report highlights, estimates show that it 'would cost roughly US$1 per capita to enable all 47 LDCs to establish basic water services in health facilities. On average, $0.20 per capita is needed each year to operate and maintain services.'.

Two of the four main recommendations in this new report emphasise the need to consider adequate planning and budgeting for WASH within healthcare facilities:

  1. Implement costed national roadmaps with appropriate financing.
  2. Integrate WASH into regular health sector planning, budgeting and programming, including COVID-19 response and recovery efforts to deliver quality services.

To meet the ambition that all healthcare facilities have at least basic WASH services, the Governments of Ghana and Cambodia are working with WaterAid to investigate the planning and budgeting needed to achieve sustainable WASH services in healthcare facilities.

Michael, a nurse at Wurm Community-based Health and Planning Services, Ghana, washing his hands with soap.
Michael, a nurse at Wurm Community-based Health and Planning Services, Ghana, washing his hands with soap.
Image: WaterAid/ Apagnawen Annankra

Prioritising district-led WASH financing in Ghana

In Ghana we have worked closely with the Government, supporting the development of national WASH in healthcare facilities guidelines, which will be rolled out soon. To ensure this policy change leads to a positive impact on people’s daily lives, WaterAid Ghana has been exploring what financing WASH in healthcare facilities would cost at district level, to understand the financing commitments needed from governments and donors to make the guidelines a reality.

We are working with partners at district and national level to support Government-led efforts to increase financing for WASH in healthcare facilities in the Upper East Region. Mandated by the District Assembly and the District Health Directorates, we have supported the two districts to develop comprehensive, costed WASH in healthcare facilities plans using the Life Cycle Costing Approach. The life cycle cost includes not only the initial, often one-off, cost of installing new infrastructure, but also the short and long-term cost of providing, operating and maintaining these services long into the future.

The districts have integrated the plans into their medium-term development and annual plans, making financial commitments to scale up access to WASH services in all healthcare facilities to address their WASH gaps. The plans are currently being promoted and shared at the district, regional and national level to encourage other districts to take up this approach.

Alongside this district focus, we are also working with other key sector players like Coalition of NGOs on Water and Sanitation (CONIWAS) to track the national budget on an annual basis and use the findings to advocate urgent increases in funding for WASH towards the Sustainable Development Goals.

Investing in equity and quality in Cambodia

Cambodia’s health system has made progress by making sure health centres and hospitals provide basic health services without putting users in financial hardship for seeking them. The National Health Strategic
Plan 3 2016–2020 builds on these successes and outlines a comprehensive plan for improving the quality of healthcare in Cambodian public healthcare facilities. WaterAid, along with WHO and UNICEF, worked with the Ministry of Health to ensure WASH is recognised within this definition of quality, with targets set for water and sanitation in all healthcare facilities.

To support the delivery of improving quality of care through financing and supporting continuous quality improvement at all public healthcare facilities, a joint Government–donor pooled funding project, the Health Equity and Quality Improvement Program (H-EQIP), has been implemented. WASH in healthcare facilities is embedded within the national quality monitoring mechanism, which is linked to service delivery grants, which are designed to financially support facilities directly to improve quality, including WASH.

Improvements are financially incentivised because higher quality scores are rewarded with performance-based financing schemes. In a project with Johns Hopkins University, we explored what improvements were being prioritised and what gaps remained. Both types of grants are contributing to changes in basic WASH infrastructure such as installing bathing and hand hygiene stations, purchasing cleaning supplies and hiring cleaners.

However, the budget available remains inadequate to meet newly endorsed National Guidelines on WASH in Healthcare Facilities, the development of which we provided technical input for. This is in part due to insufficient financing available for major upgrades to older facilities, limited maintenance systems and financial barriers to implementing major construction projects such as accessible latrine upgrades or bathrooms at maternity wards2 and connecting to year-round water supply. In addition, we are ensuring the upgrades have clear technical designs and processes, to make sure all infrastructure is accessible and usable for all healthcare facility users, including pregnant women and people with limited mobility.

While important steps have been made under the National Health Strategic Plan 3, additional financing will be required to ensure all healthcare facilities in Cambodia reach basic WASH service levels, and that these service levels are sustained. This will be essential to realise the Royal Government of Cambodia’s commitment to achieve health for all.

Time for action

A healthcare facility without water, sanitation and hygiene is not a healthcare facility.

- Dr Maria Neira, Director of Public Health and Environmental and Social Determinants of Health, World Health Organization

As we look to 2021 and consider efforts to build back better after the COVID-19 pandemic, urgent action is needed to usher in a strategic shift in investment in essential WASH services in healthcare facilities, towards the achievement of Universal Health Coverage.

To rebuild a more sustainable and inclusive future after COVID-19, investing in WASH in healthcare facilities is the clear and necessary next step forward. A lack of WASH compromises infection prevention and safe care for patients and health workers, and undermines dignified and inclusive care. This must change.

The new WHO and UNICEF report highlights the stark reality of the global status of WASH in healthcare facilities. But it also shines a light on examples of country progress and national leadership – strengthening health systems through WASH.

Seizing the momentum

We cannot keep jumping from one epidemic to the next while ignoring the obvious: WASH in healthcare facilities is a prerequisite for safe, quality healthcare, whether for routine or emergency services. Governments, development partners and multilateral organisations need to urgently increase financial support for sustainable WASH services in healthcare facilities. As shown in these examples from Ghana and Cambodia, progress is possible with adequate financing, planning and accountability, and political leadership. The time to act is now.

George Cobbinah Yorke is Head of Policy, Advocacy and Campaigns at WaterAid Ghana, Fauzia Aliu is Rooted Advocacy Policy Officer at WaterAid Ghana, and Channa Sam Ol is WASH and Health Program Manager at WaterAid Cambodia.

1 And there is insufficient data to make an estimate for environmental cleaning in healthcare facilities, the fifth service area for monitoring WASH in healthcare facilities in the Sustainable Development Goals.

2 WASH in Health Care Facilities, AASH FIT evaluation in Cambodia: draft technical report conducted by Johns Hopkins University, WaterAid and Ministry of Health 2020.