BELFAST, Northern Ireland — Hand-washing is the first line of defense against COVID-19 and many other diseases. Yet 1 in 4 health care centers around the world has no hand-washing facilities, and in the lowest-income countries, almost half have no clean water.
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A lack of facilities means over 2 billion people are forced to seek care in a place where there is no clean water and 1.5 billion people visit health care facilities with no sanitation services at all.
Advocates say that needs to be understood in order to help low- and middle-income countries control the virus.
“The vital role of good hygiene in preventing hospitals [from] becoming breeding grounds for disease is being woefully overlooked as part of the global response to COVID-19,” said Tim Wainwright, chief executive of WaterAid.
In a statement for WaterAid, Rhoda Phandama, a nurse and midwife in Malawi, added that the Katimbira Health Centre in Nkhotakota, where she works, doesn’t have enough soap.
“We need to have enough supplies so that we are protected and that the clients who come here with issues like injuries and other diseases do not end up catching coronavirus,” she said.
Aside from hand-washing, soap and water are needed to clean floors, operate some medical devices, and deliver babies, said Lindsay Denny, health advisor at Global Water 2020, an initiative focused on water access and security. Over 1 million deaths annually are associated with unclean births.
“We’ve heard stories of people using swamp water because it’s the only water available and that causes infection in the lungs of newborns,” Denny added. “And can you imagine being told ‘oh there’s an outbreak but you can’t wash your hands?’ If anyone needs to have access it’s nurses and doctors,” she said.
As well as patients, the lack of hygiene puts health care workers themselves at risk.
“We know of midwives who don’t go to the toilet on a 12-hour shift because the toilets are on the other side of the freeway from the health center or because it’s not safe,” Denny said, which can lead to infections.
At last year’s World Health Assembly — the annual governance forum for the World Health Organization — ministers of health signed a water, sanitation, and hygiene in health care facilities resolution. The agreement committed to developing national roadmaps, setting targets, increasing investments, and strengthening systems around the issue. In 2018, United Nations Secretary-General António Guterres also made a global call to action for achieving WASH in all health care facilities.
But in many places, this is yet to happen.
Ahead of this year’s World Health Assembly — which is taking place online due to the pandemic, on May 18 — WaterAid issued a call for change.
“As leaders meet virtually at the World Health Assembly we want to see rapid commitments that will mean that no nurse, midwife, or doctor has to work without somewhere to wash their hands,” Wainwright said.
In the Democratic Republic of the Congo, health care workers in rural areas often have to travel long distances to collect water from the nearest well or river, which means less time providing care, according to Amuda Baba Dieu-Merci, a former community health worker and director of the Panafrican Institute of Community Health.
Dieu-Merci blamed an absence of water companies focused on rural areas and the costs being higher than many facilities can afford.
For Denny, the siloed approach to global health and WASH is the main culprit. “When you have a breakdown of water in your health care facility you don’t necessarily have the expertise there to solve these problems. Similarly, the people working in the health system have a health perspective and they may not see water as important to the work they’re doing,” she said.
Zoe Pacciani, country director for Engineers Without Borders USA in Uganda and advisor to Freshwater Project International — an organization that provides WASH to villages, schools, and health centers — said many rural health centers were built years ago when building hand-washing facilities outside of the operating rooms wasn’t thought of.
Of the facilities that once had a water supply, many have deteriorated due to a lack of operation and maintenance, Pacciani explained, “rehabilitation on its own is not enough.” Mechanisms to enable district governments to maintain new water systems and local operators to perform routine operations and minor maintenance are needed alongside more funding, she said.
Just 3% of Uganda’s national budget is allocated to water and environment, and that figure drops to 1.5% in Malawi. Pacciani hopes the pandemic will highlight the need to prioritize water supply and hand-washing facilities in health centers.
“It’s shining a light that we’ve ignored this issue for so long. It’s been such a neglected crisis,” Denny agreed. “The outbreak will help countries and major organizations reprioritize and think about how we really focus on what the key elements of a health care facility are.”
In the meantime, Dieu-Merci hopes NGOs will step in, especially in places like DRC where conflict and displacement remain higher priorities for the government.
WaterAid constructs water tanks, towers, and toilets for health centers in several countries including Malawi, Ghana, Zambia, and Mali, while also working to put plans in place for their maintenance. In partnership with Engineers Without Borders, Freshwater Project International is also upgrading and replacing pumps, tanks, sinks, and taps in health care facilities in Malawi.
But this is not something that the WASH sector can solve alone, Denny said. “It’s about coming together, prioritizing, and budgeting. If we don’t have the money for it, it’s never going to be something that’s prioritized,” she said.
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