OPINION | HEALTH | WATER

This year’s World Water Day theme “Valuing Water” asks a simple question: what does water mean to you? Life starts and thrives on water, that is uncontested.  

The paradox for Uganda is that in healthcare facilities – where lives are treated and mended - a safe and adequate water supply is the least priority.

The World Health Organisation (WHO) has defined minimum standards of water quality, quantity and access that should be available for clients and health workers - at least five litres per person per visit, of quality that is safe for drinking, full-time supply on site; easy access for sanitation and cleaning the health facility environment; handwashing stations in critical points of care and washrooms for menstrual hygiene management.

Short of these basic standards, healthcare facilities fail on their core purpose and ultimately fail to deliver quality of life for a productive population and socio-economic development. 

Mismatch between promise and practice

The Government of Uganda has the mandate to deliver health services to the people, through its decentralised units – the district local governments. 

Yet, the financial authority remains with the central government which dispenses conditional block grants that are not aligned to make specific allocations to water sanitation and hygiene within the health facility. 

The health sector Budget Framework Paper (BFP) for FY 2018/19 – FY2022/23 which aligns resources to sector efficiency lists up to thirteen priorities, including public health promotion, human resource and staff performance, health management information systems and healthcare financing, to mention some. 

Water supply, sanitation and hygiene services within the health facility do not feature at all.

This kind of planning undermines the promise defined through national standards for health infrastructure, that every health facility must have a functioning source of safe water located on the premises that are adequate to meet all demands for drinking, personal hygiene, medical interventions, cleaning, laundry, and cooking (Service Standards and Service Delivery Standards for the health sector in Uganda, Ministry of Health, 2016).

With no targeted funding for WASH services in healthcare, the same facilities that ought to save lives are, to put it mildly, a den of disease and a death trap.

State of WASH in healthcare facilities

Kabarole’s population of about 330,000 people is served by 42 health facilities: one referral hospital, two health center IVs, 22 health center IIIs, and 17 health center IIs (Kabarole District Development Plan, 2016 – 2020).

An assessment of the state of WASH in healthcare facilities carried out by Kabarole DLG in collaboration with Centers for Disease Control and Prevention [CDC], IRC and Mountains of the Moon University, reveals enormous gaps in water supply, sanitation, hygiene, and environmental conditions of 40 healthcare facilities.

“Many health facilities rely on rainwater harvesting for their water supply; it is not reliable during the dry season. The alternative is to fetch from sources outside and far from the facility. 

Some depend on tank-stored water for the rest of the year, which gets contaminated and unsafe for drinking,” Cecilia Birungi, the Kabarole District Health Inspector says. 

Kansiime Stella Enroled Nurse at Nyakitokole HCII, Karangura SC in Kabarole (L) receives safe drinking water station from IRC WASH Advisor.

Some health facilities had on-site supply but no access inside the patient rooms had broken storage tanks and did not consistently provide treated water for drinking. 

Health workers and cleaning staff reported that the lack of water put their lives at risk of infection and was a hindrance to managing flush toilets and latrines. 

Some facilities could not afford to hire dedicated staff to treat water through boiling, nor to install labelled containers distinguishing drinking from handwashing water.

Handwashing facilities were not enough and were not consistently refilled with clean water and lacked soap. Hygiene supplies especially gloves and alcohol-based hand rub were in short supply, exposing the workers to infection especially at critical patient-care points such as when giving injections and collecting blood samples.

Lessons from Kabarole

Learning and adaptation: The assessment illuminated grey areas in healthcare service delivery which if addressed would propel the district to meet health as well as water and sanitation targets by 2030.

Numerous assessments of healthcare service performance in Uganda are graded on indicators including staffing, presence of qualified healthcare staff, waiting time, and drug supply. 

Water sanitation and hygiene are not considered as core indicators in healthcare service studies. 

Duty bearers, in turn, respond with increased investment in construction, bed capacity, drug supplies and advanced medical technology while ignoring installation and maintenance of basic water sanitation services

COVID-19 has amplified the urgency of water in healthcare, even though the risk of infection that healthcare workers and patients are exposed to due to limited water supply has been longstanding well before the pandemic. 

Hand hygiene through washing hands with soap and running water or sanitising with alcohol-based hand rub have been the main defence to control the spread of the coronavirus. 

Deliberate actions by Kabarole leadership and partners on WASH in healthcare facilities helped the district to respond quickly and efficiently to the COVID-19 crisis.

Beyond the funding mobilized for Personal Protective Equipment (PPE) through the Ministry of Health to the district task force, IRC responded with holistic and sustainable interventions: 

Latrines in 12 health care facilities were renovated to meet the standards of privacy, stances separated by gender, staff and clients, washrooms, handwashing points, cleanable floors and walls and accessibility for people with disabilities.

Collaboration with the Uganda Infectious Diseases Institute (IDI) resulted in locally produce alcohol-based hand sanitizer, supplying 30 health care facilities. 

Hand hygiene adherence increased from 5% in 2018 to 25% in 2020.

“We found it meaningless to provide hand sanitizer and walk away, without solving the consistent problems of water, sanitation, and hygiene once and for all. 

We have now rolled out an intensive project on WASH in healthcare facilities in Kabarole. 

We are carrying out health promotion campaigns, installing washbasins with running water within patient and treatment rooms, constructing sanitation facilities, providing drinking water stations and equipment for environmental hygiene to model at least 5 health care facilities to the standard on prescribed by WHO,” says Jane Nabunnya Mulumba, Country Director IRC Uganda.

Planning and financing

Through a succinct District WASH Masterplan (2018 – 2030), Kabarole is trailblazing on resource mobilization for an ambitious target to deliver 100% coverage of WASH services for all by 2030. 

Specifically, the district is aiming for access to safely managed water services on premises for all Health Centre IIIs; separate toilets for patients, and staff (with gender segregation); patient/toilet ratio of 25 to 1; handwashing facilities with soap and water; improved sanitation facilities with provisions for menstrual hygiene and washrooms for patients; and waste management infrastructure with provision for waste segregation, effective disposal, placenta pits, and incinerators.

For Kabarole, data from the assessment has provided the missing perspective on the link between water and sanitation services to the quality of life and ultimately to the holistic socio-economic transformation of its population.

Our call to action

The efficiency of a healthcare system rests on the WASH services therein. The essence of the healthcare facility is to save lives; people must not get ill from infections that could be easily avoided by a clean environment and safe water in the very spaces where they seek healthcare. 

Sub-standard WASH services will drive the clients further away from seeking services at the health facility.

On the journey to achieve sustainable development goals by 2030, the goal of health will be better and faster achieved if clean water and sanitation are prioritized.

Investment, both public and private should be deliberately directed to ensuring that clean and safe water supply, sanitation and hygiene are a must-have in every healthcare facility in Uganda. 

“The climb towards socio-economic transformation for Uganda is steeper and less tenable if the access and quality of Water Sanitation and Hygiene (WASH) services in healthcare is perpetually ignored. Human health and WASH are two sides of the same coin. 

They are so inextricably connected that an attempt to separate them or to address one exclusive of the other is to fail at both,” says Jane Nabunnya Mulumba, Country Director IRC Uganda.