In 2015, the World Health Organization (WHO) in partnership with United Nations Children's Fund (UNICEF) stressed the importance of having adequate water, sanitation, and hygiene (WASH) in healthcare facilities. This is due to the fact that inadequate WASH in a healthcare facility leads to a dramatic increase in adverse health outcomes. On top of the increase in healthcare-associated infections (HCAI), the lack of WASH facilities could also increase patient dissatisfaction and aversion to seeking medical care. This is especially true for women seeking care at maternity services. This just goes to show that water is vital for the operation of any healthcare facility. Water is the main component of most WASH facilities. Without water, performing tasks related to sanitation and hygiene is immensely difficult or even impossible. We could therefore conclude that the provision of adequate, safe and quality water to healthcare facilities is one way of realizing a fairer and healthier world.
WASH - What is it and why is it Important?
To be able to provide quality care, healthcare facilities must provide safe and accessible water to each patient. Aside from that, healthcare facilities must also provide sanitation, healthcare waste management, environmental cleaning infrastructure, appropriate waste disposal systems, and hygiene services across all parts of a facility including hand hygiene facilities at points of care and at toilets. All of that put together constitutes WASH. Water always comes first. It is not possible to provide all other aspects of WASH without access to water.
Provision of WASH facilities supports core universal health care aspects of quality, equity, and dignity for all people. It can also significantly improve health within a community. Therefore, it is important that healthcare facilities and the surrounding community are given access to infrastructure that supports WASH facilities.
Benefits of having reliable WASH facilities
The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) emphasized the importance of WASH because it has several benefits which include:
Primary Care and Childbirth is Safer
Not all Healthcare-Associated Infections are caused by the lack of WASH services. Still, a lack of access to WASH facilities in healthcare institutions can place many patients at risk of acquiring infections.
The lack of WASH facilities in healthcare institutions is well studied. One review showed that approximately 30% of delivery rooms in low-income countries don’t have adequate access to water. This means that in these delivery facilities, mothers have to bring their own water so that they can wash themselves and their newborn baby. Moreover, it also means that both the mother and the baby are more prone to infections due to the general lack of water.
It has been established that the lack of WASH facilities can place patients at risk of acquiring infections. A study conducted by the London School of Hygiene and Tropical Medicine (LSHTM) demonstrated the opposite. That a significant reduction in healthcare-associated infections was observed when WASH interventions were introduced to the healthcare facilities that lacked them. All in all, access to WASH services improves primary care and makes childbirth safer.
An effective weapon against Cholera
Despite advances in medicine, disease as preventable as cholera still affects 47 countries and causes 95,000 deaths per year worldwide. One of the reasons why this disease still persists today has to do with the lack of or inadequate WASH facilities. That is why the provision of WASH facilities is one of the most effective ways of curbing cholera cases. This is especially effective in areas considered as cholera hotspots. To make WASH services even more effective, they are installed in healthcare facilities that are in close proximity to or in hotspot areas.
Combating Antimicrobial Resistance (AMR)
When a healthcare facility has adequate WASH facilities, the healthcare workers are able to follow hand hygiene protocols with ease. When healthcare workers are able to observe hand hygiene, the spread of diseases from patient to patient, also known as nosocomial infections, can be prevented. In countries where WASH facilities are inadequate, hospitals try to prevent nosocomial infections through the prophylactic use of antibiotics. This isn’t a good strategy in the long run, as using broad-spectrum antibiotics as prophylaxis can lead to the appearance of antimicrobial-resistant bacteria.
Aside from that, without WASH facilities, hospital wastes wouldn’t be disposed of properly which could lead to the spread of AMR in the environment and in communities.
The Magnitude of the Problem - the Lack of WASH in healthcare facilities
All over the world, there is a significant lack of WASH in healthcare facilities, especially in low- to middle-income countries. A recent survey revealed that 50% of hospitals in low- to middle-income countries don’t have access to piped water, 33% of their hospitals lack improved sanitation, 39% lack soap for handwashing, and 39% lack adequate infectious waste disposal. As discussed earlier, this is a serious problem that can put the lives of patients at risk.
Why is there a persistent lack of WASH in healthcare facilities?
We’ve established that WASH is essential for the operation of a healthcare facility. However, why is there a persistent lack of it worldwide, especially in low- to middle-income countries? There are several reasons why this is so:
Lack of or inadequate standards
A significant number of countries have inadequate standards for WASH in their healthcare facilities. In most hospitals where standards do exist, implementation is hampered by the lack of funding and or interest by the administration. According to a survey conducted by the World Health Organization in 2017, up to 80% of the 78 countries that participated in their survey reported that they implemented WASH policies in their hospitals. Yet, upon closer inspection, only 25% of these countries actually prepared funding for the implementation of the WASH policies.
Lack of or inadequate monitoring regarding the implementation of WASH
Most countries don’t possess a reliable national health monitoring system that can collect data regarding the implementation of WASH policies. Whenever data is available, most of the time it comes from externally-conducted facility assessments. This means that hospitals rarely assess their WASH facilities. Without the assessments, it is difficult to pinpoint what needs to be done in order to improve healthcare facilities’ WASH policies.
Budgeting for specific diseases
Majority of countries would spend their national health budget for eliminating specific diseases. This entails the acquisition of vaccines, medicines, equipment, and other medical items that are necessary for the diagnosis and treatment of the chosen disease. While this is a good strategy, most of these countries may end up becoming fixated with eliminating specific diseases that preventive methods, such as the implementation of WASH policies, would get overlooked. When the implementation of WASH policies is overlooked, funding wouldn’t be allocated for it leading to inadequate WASH facilities.
Sometimes facility administrators, healthcare providers, and even patients may consider the problem of inadequate WASH to be insurmountable, especially when they are fully aware that there are no funds dedicated to solving the problem. Due to this, they may become desensitized and apathetic to the problem. Aside from that, the majority of these healthcare facilities demand so much from their healthcare providers that they become overburdened. This, on top of the fact that these healthcare providers are under incentivized and do not have proper training, exacerbates the problem of inadequate WASH.
Inferior WASH infrastructure
WASH facilities are built upon the municipal water and sanitation services in an area. If the municipal water and sanitation services are lacking, then installing WASH facilities would be impossible unless the municipal water and sanitation services are overhauled. This could be a heavy financial burden to a healthcare facility not unless the government would cover for the improvement of the municipal water and sanitation services. On the side of the government, if the financial burden of improving the municipal water and sanitation services would be placed upon the health budget, it may take a huge chunk off of the health budget. The best approach would be to take a collaborative approach between those who are responsible for the country’s health and those who are responsible for the country’s infrastructure development. This way, the burden of improving and maintaining the municipal water and sanitation services can be taken off of the health sector. Thus, freeing them to focus more on improving the public’s health.
Assessing WASH Facilities
The Center for Disease Control (CDC) is a reputable third party institution that is more than qualified to assess the WASH facilities of a given healthcare facility. Their evaluation tool includes an interview with the healthcare facility director and a walk-through of the facility. Their assessment tool would cover a broad range of topics including water supply, drinking water, sanitation, hygiene, waste management, cleanliness, and services, staff, and management.
For the water supply, CDC’s WASH evaluation tool would evaluate the availability of the water, quality of the water at the source, and the location of the water source.
When it comes to evaluating the healthcare facilities’ drinking water, the presence of functional drinking water stations, and the quality of the drinking water itself would all be evaluated.
Evaluation of the healthcare facilities’ sanitation includes the inspection of toilets, assessing their accessibility, and evaluating the presence of menstrual hygiene management materials.
For Hygiene, a healthcare facility is expected to provide functional handwashing stations in each clinical room and near each toilet. They are also expected to provide hand hygiene materials like soap, alcohol-based hand sanitizer, hand-drying materials, and gloves.
With regards to Waste Management, a healthcare facility must have proper waste disposal and storage systems. On top of this, they must have multiple functional waste disposal bins in each clinical room such that segregation of waste is possible.
Cleanliness is also evaluated. Healthcare facilities are expected to have the proper cleaning protocols in place, as well as trained cleaning staff. The healthcare facility must have minimal solid waste or visible dirt on their work surfaces and floors. Furthermore, feces or other solid waste must be transferred away from the healthcare facility grounds.
An evaluation of the Services, Staff, and Management is also conducted. Which services are provided, including number of monthly patient visits, admissions, deliveries, and staff, all of these are also evaluated.
Steps to improving WASH in healthcare facilities
Conduct situation analysis and assessment
Before anyone can improve anything, a thorough analysis of what needs improvement must be done. With regards to WASH in healthcare facilities, an examination of the policies of WASH, governance structures, and funding streams are what’s included in the analysis. With the conclusion of the analysis, a basis for which action and resource mobilization to prioritize can be arrived upon.
Set targets and define roadmap
After an analysis of what needs to be improved has been conducted, a roadmap towards the goal of improving a healthcare facility's WASH is next in line. The road map must clearly define the strategies needed to achieve the goal, the goal itself, areas of intervention, the responsibility of each person involved, and most importantly, the budget needed to realize the goal and sustain it over a defined period.
Establish national standards and accountability mechanisms
A national standard must be imposed and this should reflect the reality of the nation’s situation. This is due to the fact that no two countries are the same. Each countries’ national standards regarding WASH policies should have design, costing, implementation, and operation guidelines that take their present situation into account. Besides that, accountability mechanisms must be put into action so that the majority or even all of the healthcare facilities would be able to meet the national standards.
Improve and maintain infrastructure
With the establishment of a national standard, action must be taken to meet the established standards. This includes following policies, gathering resources, and coming up with strategies to keep the infrastructure and services operational over a defined period of time.
Monitor and review data
It's not enough to take action towards improving WASH facilities, data must be collected throughout the process. The data collected could then be used to monitor the efficacy of the steps taken. Aside from that, the data could also reveal what needs improvement.
Develop health workforce
Up-to-date information regarding WASH, and infection prevention and control practices must be given to all health workers including doctors, nurses, midwives, cleanears, etc. Incoming health workers must be given proper training so that they would be able to observe WASH policies. At the same time, health workers that are currently employed must be kept up-to-date with changes in the policies. Essentially, the healthcare workers must be kept competent with regards to following WASH policies.
Beyond the confines of a healthcare facility, administrators must reach out to their prospective customers, the community itself, for feedback on their health services with an emphasis on how the implementation of WASH policies have affected it. These feedback are valuable and should be taken into account when it comes to the decision making process regarding how the healthcare facility would move forward with their WASH policies.
Conduct operational research and share learning
A healthcare facility should not limit themselves with internal review and research for the purpose of improving their WASH policies. They should reach out to third party institutions that could provide valuable insights on what strategies the healthcare facility could implement to make the WASH policies even better.
With regards to healthcare, water is a resource that every healthcare facility should have access to. Sanitation and hygiene are difficult or impossible to carry out without water. Unfortunately, we are faced with the reality that a huge percentage of hospitals in low- to middle-income countries don’t even have access to water. One has to wonder why a severe lack of access to water exists. The problem all boils down to lack of funding, infrastructure, and interest in improving WASH facilities. Although the world is still years away from building a fairer and healthier world. We can’t simply disregard what has been achieved with regards to SDG6; the sustainable development goal that aims to provide access to clean water and sanitation for all.