Earlier this week, the World Health Organization (WHO) and UNICEF issued a dire warning about the state of water, sanitation, and hygiene (WASH) services in health facilities. Almost two billion people worldwide rely on healthcare delivery in settings where those services are substandard – or lacking altogether.
The global progress report on WASH services in healthcare settings collected data from 165 countries covering 760,000 healthcare facilities. The findings are disturbing. “Worldwide, one in four health care facilities has no water services, one in three does not have access to hand hygiene where care is provided, one in ten has no sanitation services, and one in three does not segregate waste safely,” the WHO summarises in a press release.
This translates to a staggering number of people affected. Approximately 1.8 billion people work in or rely upon for care healthcare facilities lacking in basic water services. For 800 million, they rely on healthcare settings without even a toilet.
The COVID-19 pandemic, the report notes, only underscores the importance of adequate WASH facilities in healthcare settings. Poor sanitation amplifies the risk of contracting COVID-19 – so much so that WHO Director-General Dr Tedros Adhanom Ghebreyesus notes starkly that “working in a healthcare facility without water, sanitation and hygiene is akin to sending nurses and doctors to work without personal protective equipment [PPE]. Water supply, sanitation and hygiene in health care facilities are fundamental to stopping COVID-19. But there are still major gaps to overcome.”
India, to its credit, has made strides in addressing its sanitation issues in recent years. Most notably, its Swachh Bharat Abhiyan initiative has made real strides in tackling the issue of open defecation. However, as with many nations, its performance on scaling up WASH services in healthcare facilities lacks because it is not seen as a priority. As UNICEF notes, this carries real and dire consequences. One particular manifestation of this is neonatal and maternal mortality.
“Inadequate…[WASH] services in India’s health facilities, contributes to the high neonatal mortality rate, which is currently 24 deaths per 1000 live births,” UNICEF India states. “This is primarily due to weak infection prevention and control in health facilities.
“Hospitals with poor WASH facilities are also found to have higher rates of maternal mortality. Due to the lack of access to water and sanitation, women are further discouraged from institutional delivery or they delay health-seeking advice. In India, only 19.2 percent of labour rooms and 3.2 percent of post-natal care wards have functional toilets. Sepsis, which is mostly spread in health facilities, contributes to 16.4 percent of the overall neonatal mortality and eleven percent of maternal deaths.”
The WHO / UNICEF report quotes the testimonials of Indian healthcare workers on the front line. “There is no toilet in the health centre, it was an emergency, so I went behind the bushes,” said one community health nurse. “A student from a nearby school, where I give health education, saw me squatting and called me a hypocrite.”
One nurse said “many have fainted after wearing PPE for a long time. We are dehydrated and not drinking enough water. Nurses are being diagnosed with urinary tract infections – it starts leaking and you want to talk about dignity!” That nurse contracted COVID-19.
UNICEF India outlines the “key challenges” as “[including] a lack of WASH-trained human resources, a lack of adequate planning and financing for implementation of WASH in health care facilities and insufficient monitoring and evaluation. Inadequate WASH in health care facilities has an economic burden because of the increased healthcare / medical costs and decreased wages due to missing work to take care of sick family members.” Indeed, at the global level, WASH services act as a “best buy” according to the WHO. They produce a fifty percent return on investment.
Health Issues India has reported previously of sanitation issues in India’s hospital settings, fuelling high rates of hospital-acquired infections and consequent mortality. Poor handling of biomedical waste has been a long-standing issue – one which has not abated during the pandemic.
As reported by Health Issues India last year, recent years saw “reports [emerge in India] of widespread shortages of adequate WASH facilities: absence of toilets or improper maintenance, lack of availability of clean water, and an absence of data. In delivery rooms…there is a similar gap in Indian facilities to those in four East African nations, where fewer than thirty percent of delivery rooms had access to water.”
India has made encouraging progress, which has been rightly commended. However, there is still further to go. Acknowledging WASH as a “best buy” and a public health good (as well as a moral imperative) must be the key takeaway from this report – and implementing its recommendations ought to be a public health priority, especially during the pandemic.
The four key recommendations are as follows: “implement costed national roadmaps with appropriate financing; monitor and regularly review progress in improving WASH services, practices and the enabling environment; develop capacities of health workforce to sustain WASH services and promote and practice good hygiene; [and] integrate WASH into regular health sector planning, budgeting, and programming, including COVID-19 response and recovery efforts to deliver quality services.” Such efforts are not only cost-effective; they will save lives and bolster our response to the COVID-19 pandemic and other diseases which can run rampant even further in the absence of WASH services.
“Sending healthcare workers and people in need of treatment to facilities without clean water, safe toilets, or even soap puts their lives at risk,” commented UNICEF Executive Director Henrietta Fore. “This was certainly true before the COVID-19 pandemic, but this year has made these disparities impossible to ignore. As we reimagine and shape a post-COVID world, making sure we are sending children and mothers to places of care equipped with adequate water, sanitation and hygiene services is not merely something we can and should do. It is an absolute must.”
“Fundamentals first: Universal water, sanitation, and hygiene services in health care facilities for safe, quality care” – the Global progress report on WASH in health care facilities – can be accessed here.