How is it possible that, in 2021, one-quarter of health care facilities lack basic water services? And what kind of human and technological failures have allowed one-third of health care facilities to go without hand hygiene at the point of care? How is it that these basic failings persist — even in the midst of the COVID-19 pandemic — despite catastrophically undermining the quality of care?
The most recognizable problems in health care facilities come down to plumbing: faucets go unrepaired or toilets are not included in construction plans. Water, sanitation, and hygiene are so often low down on the list of health sector priorities. Limited resources drive understaffing within health care facilities, and already overwhelmed medical staff and cleaners frequently lack the awareness, skills, supplies, or incentive to deal with basics.
The COVID-19 pandemic has helped to expose inadequate WASH — especially the lack of hand hygiene facilities — as a major gap for infection prevention and control. Resource-limited countries with strong plans and programs in place for WASH in health care facilities before COVID-19, such as Ethiopia and Laos, have been able to mobilize millions of dollars domestically to strengthen WASH services, with hospitals given priority.
WASH is not only important to prevent infections; it is also a social justice and gender issue and about supporting dignity and compassion.
—Laos has gone further to support climate-smart solutions in primary care facilities, including installing low-cost, environmentally friendly autoclaves for treating health care waste.
However, the pandemic has also imposed high demands on carrying out COVID-19 efforts, such as supplying personal protective equipment, oxygen, diagnostics, and vaccines, which potentially distract precious human resources and attention away from WASH and other core health systems functions.
This has exacerbated an already dire situation where countries, such as Liberia and Mozambique, are reporting little or no domestic budget support for WASH in health care facilities and are requesting support — from the World Health Organization, United Nations agencies, bilateral donors, NGOs, and others — on how to advocate for increased funding.
A range of innovations can be seen in rural health care facilities, such as the provision of water through solar-powered boreholes, toilets with ramps and rails that those with limited mobility can access, and rainwater catchment systems.
However, these are, more often than not, small-scale and short-term successes that rely on project-based implementation. Such innovations cannot be scaled up nationally without good systems of governance and committed leadership.
So, what are the solutions? Below are WHO recommendations:
1. Increasing national assessments and monitoring
With the growth of nationally representative data on health care facilities from 125 to 165 countries over the past two years, the world is taking notice. The World Health Assembly Resolution 72.7 commits countries to establish baselines, develop and implement road maps, and embed WASH into key health programs and budgets.
All WHO regions are ready to step up support for improvements in WASH assessments, training, and the development of national road maps. DHIS-2 is an open-source health information platform that countries are using to better manage WASH in health care facility data and react in real-time.
In addition, countries can report their progress on implementing the WHA resolution, as well as WHO and UNICEF’s eight practical steps, through regional and national fora, with regular updates posted on the global knowledge portal.
Of note, the eight practical steps are evidenced-based national actions to improve WASH in health care facilities for the ultimate goal of better quality care. Furthermore, the infection prevention and control assessment framework — or IPCAF — provides a robust measure to support understanding and improving infection prevention and control — or IPC — practices at the facility level.
National and local examples of systems strengthening and innovation exist. Community scorecards on patient satisfaction in Ghana have proven to be a powerful accountability tool and a means to engage community members on how they can also contribute to solutions, such as beautifying the grounds and building a fence to keep children and animals away from health care waste.
2. Prioritizing provision of WASH to enable higher-quality care in maternity wards
Investments in WASH should focus on where the needs and the potential gains are greatest. Approximately 20% of all global deaths are caused by sepsis — around 11 million deaths each year. Improved WASH and IPC, could prevent more than half of all cases of health care-associated sepsis, which disproportionately affect neonates and pregnant mothers.
Furthermore, WASH is not only important to prevent infections; it is also a social justice and gender issue and about supporting dignity and compassion. A 2019 survey of over 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 health care.
What does this mean in practice? It means that maternity settings should get WASH access first — not last — and no health intervention in a maternity setting should be delivered without concurrent investments in WASH where services are lacking. WASH must come first.
3. Increasing financial support for WASH within health systems strengthening
WASH in health care facilities must be integrated into the regular sector, standard-setting, budgeting, and programming.
Within broader health systems planning, in particular universal health coverage efforts and specific health programs, such as those focused on antimicrobial resistance and maternal and child health, WASH in health care facilities needs to be reported on, integrated into national standards or licensing — as has occurred in the Philippines — budgeted for, and included in pre-service and continual professional development training.
The costs are modest and latest estimates on the cost of achieving universal basic WASH standards in health care facilities in the 46 least developed countries (in a report authored by Michael Chaitkin et. al. currently under peer review) are $6.5 to 9.6 billion over 10 years or only $0.60 per person per year. Conversely, lost productivity from poor-quality health care costs $1.4 to 1.6 trillion each year.
The world is at an inflection point. COVID-19, the climate crisis, and growing conflicts all threaten our very existence and — for the unlucky poor, which number in the billions, life is becoming more and more unbearable. We can and must provide WASH to every health care facility and, in doing so, we will not only save millions of lives, we will reinforce the common thread that connects us all together as human beings.
Visit the WASH Works series for more coverage on water, sanitation, and hygiene — and importantly, how WASH efforts intersect with other development challenges. You can join the conversation using the hashtag #WASHWorks.
About the authors
Bruce Gordon
Bruce Gordon is the unit head of water, sanitation, hygiene, and health at the World Health Organization. He oversees a global portfolio of water and health-related work ranging from the development of norms on drinking-water and wastewater/sanitation to global monitoring of access to WASH and the burden of disease. Prior to joining the water unit at the World Health Organization in 2004, he contributed to the organization’s work on sustainable development with a focus on children’s health and environment. He has an academic background in biochemistry and environmental management.
Maggie Montgomery
Maggie Montgomery has a doctorate in environmental engineering. As an environmental engineer, she has experience in research, public health, and fixing pipes. For the past 10 years, she has been part of the water, sanitation, hygiene, and health team at the World Health Organization, working to improve access to water and sanitation, particularly in health care facilities. In her spare time, she enjoys hiking, getting dirty with her kids, and writing poetry.
Maria Neira
Maria P. Neira has been directing the Department of Environment, Climate Change, and Health at the World Health Organization since September 2005. She has led and advised on policy and management in key areas of environmental health. Before that, she served as under-secretary of health and president at the Spanish Food Safety Agency. From 1993-1998 she was coordinator of the Global Task Force on Cholera Control. Dr. Neira began her career as a medical coordinator working with refugees in El Salvador and Honduras for Médecins Sans Frontières. She then spent several years working in different African countries during armed conflicts.
