Getting WASH into Health Care Facilities: An Urgent Global Health Need

Getting WASH into Health Care Facilities: An Urgent Global Health Need

Will the UN’s prioritization of clean water, sanitation and hand washing in health care facilities finally breed action?

The picture is a close-up of the girl’s hands, showing the water droplets cascading of her soapy hands. An adult pours the water from a metal cup.
A girl washes her hands as she commemorates Global Handwashing Day at the Child Protection Center in Kathmandu, Nepal on October 15, 2011. REUTERS/Navesh Chitrakar

Even the possibility that health care facilities would not have water, soap and toilets sounds ludicrous. But the widespread lack of access to Water, Sanitation, and Hygiene, known within global health and development circles as WASH, is a reality that impacts health around the world, complicating infection prevention, challenging efforts to contain pandemics, and contributing to the spread of antibiotic resistance. 

Providing safe water, working sinks and toilets, waste management systems, and the ability to practice good basic hygiene like hand washing is clearly a solvable problem and certainly is not too much to ask. Success hinges not on scientific or technological breakthroughs—but on three reasonable, systemic changes. 

First, WASH systems and health systems can no longer operate independent from one another. From policy and people to institutions and resource allocation—everyone needs to step out of their silos and integrate their efforts locally, nationally and internationally. 

The picture shows a social worker washing the face of a child standing at the sink. He doesn’t look like he’s enjoying it.
Access to clean, running water, like that shown at the Puericultorio Perez Aranibar children's home in Lima, Peru on Mar. 9, 2012, is a basic sanitation asset many health care facilities do not have. REUTERS/Enrique Castro-Mendivil

Second, WASH projects must, from conception, include commitments to ongoing training and maintenance. Broken pumps, pipes and faucets are part of any WASH system. Success has been elusive, in many places, because sustainability has not been part of the plan.

It doesn’t matter how nice a new facility or building looks if health care providers can’t wash their hands

Third, WASH requires a budget. We’ve got to stop building and retrofitting health care facilities with no budget line items for WASH installation, upgrades, or maintenance. It doesn’t matter how nice a new facility or building looks if health care providers can’t wash their hands. WASH investments not only strengthen health systems that are still evolving, they also offer long-term economic impact when productivity is not lost to poor health. That’s a good return on investment. And while costs are neither trivial nor excessive given the benefits, they are expected to decrease when WASH is integrated into health care facility designs, plans and operations, and as health care facilities and community WASH systems are better connected.  

“There are no shortcuts to a healthier world. We need to realize that health is an investment in the future,” wrote World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus last month when he named the 13 most urgent global health challenges in the coming decade. WHO’s list includes getting WASH into healthcare facilities for the very first time. “Countries invest heavily in protecting their people from terrorist attacks, but not against the attack of a virus,” he wrote with prescience, “which could be far more deadly, and far more damaging economically and socially. A pandemic could bring economies and nations to their knees.”

The image is a purple and pink representation of the globular virus.
A computer model of a coronavirus like the one linked to COVID-19, created in February, 2020. NEXU Science Communication via REUTERS

Enter coronavirus. When faced with a novel virus that has no vaccine and is spread person-to-person through coughing, sneezing and fecal contamination—the coronavirus is but the most recent example—other than trying to avoid those who are sick (which is impossible in a health care facility) the single best way to stay healthy is to for everyone to wash their hands and properly dispose of waste. But when soap, water and waste management are absent in health facilities, everyone, from patients to health care professionals to the cleaners, are at daily risk.

In the Democratic Republic of Congo, half of all healthcare facilities have no clean water

Consider the 2014 Ebola outbreak. Ebola not only killed some 11,000 people, it was 103-fold higher in healthcare workers in Sierra Leone than in the general population and 42-fold higher in Guinea health workers. Liberia lost 8 percent of its health workforce, in part because they did not have access to adequate WASH, according to the U.S Centers for Disease Control and Prevention (CDC). As of the publication of this article, according to China’s National Health Commission, at least 1,716 health care providers have contracted coronavirus and at least six have died.

The photo shows a crowd of people around a metal water pipe with no water flowing.
Congolese refugees displaced by fighting gather around dry water taps on July 17, 2013. In the Democratic Republic of Congo today, half of all healthcare facilities have no clean water. REUTERS/James Akena

In early 2018, WHO published its annual top ten list of prioritized diseases that pose the greatest public health risks. That same summer, the world experienced the unprecedented and simultaneous outbreak of six of those ten diseases, including the current Ebola outbreak in the Democratic Republic of Congo, where half of all healthcare facilities have no clean water, 59 percent have no sanitation facilities, and 38 percent don’t have soap and water or hand sanitizer at points of care. 

20 percent

Some 20 percent of deaths worldwide are due to sepsis—or “blood poisoning” as it is commonly known

We know this data because in 2019, WHO/UNICEF issued the first-ever global assessment detailing conditions in hundreds of thousands of healthcare facilities in low- and middle- income countries: 1 in 4 health facilities lacks basic water services; 1 in 5 lacks any sanitation; and 2 in 5 lack hand hygiene facilities at points of care. That 17 million women in Least Developed Countries give birth in facilities without WASH every year is unacceptable, denies them dignity, and gravely endangers their lives and the lives of their newborns. The venerable Lancet Commission on Quality Healthcare found that poor quality health facilities kill more people than HIV/AIDS, malaria and Tuberculosis combined.

The picture shows two girls, one pumping, the other washing, and both laughing.
A hand pump provides access to water in the village of Lal Bux Lund in Pakistan's Sindh province on July 8, 2011, but 1 in 4 health facilities around the world lack basic water services. REUTERS/Akhtar Soomro

This issue is not just “over there”. A recently-released Lancet study cites sepsis as being far worse than previously known—double previous estimates—and responsible for at least 20 percent of deaths worldwide. Sepsis, or “blood poisoning” as it is commonly known, is the body’s overreaction to an infection and causes organ failure. More than 40 percent of sepsis victims are children under five and not surprisingly, 85 percent of those cases are in low- or middle-income countries. 

However, sepsis also kills some 258,000 people in the United States every year and costs nearly $24 billion to treat, making it the most costly condition in the U.S. hospital system. A fundamental way to curtail sepsis is to prevent hospital-acquired infections through improved WASH practice, and that must include all practitioners, everywhere, consistently washing their hands. 

Photo shows a plate with small round dots of various size—the colonies of bacteria.
Colonies of E. coli photographed at the U.S. Centers for Disease Control and Prevention after U.S. health officials reported the first case of a patient with an infection resistant to all antibiotics. CDC via REUTERS

But it is WHO’s warning [PDF] about antibiotic resistance that should stop each of us in our tracks: “Without urgent action, the world is headed for a ‘post-antibiotic era’ in which common infections and minor injuries which have been treatable for decades can once again kill, and the benefits of advanced medical treatments such as chemotherapy and major surgery will be lost.”

Public health is ultimately a political choice

WHO Director-General Tedros Adhanom Ghebreyesus

Antibiotic resistance is widespread across twenty-two countries, but no country is immune. According to the CDC, the United States experiences an estimated 2.8 million cases of drug resistance each year resulting in some 35,000 deaths and spends $2 billion annually to combat resistance. But such efforts are undermined when globally, the overuse of antibiotics substitutes for infection prevention and control that includes, you guessed it, WASH. As WHO Director-General Tedros noted in his recent announcement, WHO’s new global health priority list was developed by experts from around the world and “reflects a deep concern that leaders are failing to invest enough resources in core health priorities and systems. “Public health is ultimately a political choice,” he wrote.  

Coming on the heels of UN Secretary-General Antonio Guterres’s 2018 Call to Action to get WASH in health care facilities and WHO Member States’ unanimous adoption of a Resolution [PDF] to this effect in 2019, WHO’s new prioritization of WASH in health care facilities is well-timed as coronavirus breeds fear into the hearts of millions of people. 

Let’s hope prioritization breeds resolute action. 

The photo shows Director-General Tedros talking and guesturing with his hands.
Tedros Adhanom, director general of the World Health Organization, speaks about COVID-19 at the Diaoyutai State Guesthouse in Beijing, China on January 28, 2020. REUTERS/Naohiko Hatta

Ambassador (ret) John Simon is Managing Partner of Total Impact Capital, and former U.S. Ambassador to the African Union.

Susan K. Barnett is a former award-winning investigative journalist with ABC News and NBC News networks, and founder of Cause Communications. An active advocate for access to critical safe water, sanitation, and global water security, she led communications for Global Water 2020, a three-year advocacy and acceleration initiative.



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