A recently released joint report from WaterAid and the World Bank highlights that Sub-Saharan Africa is losing $8.4 billion annually in GDP and health budgets due to healthcare-acquired infections like sepsis and pneumonia.

Released to coincide with this year’s World Health Day, which was last month, the report indicated that if healthcare-acquired illnesses were cut by half, at least 138,000 lives could be saved each year and a staggering $4.2 billion (sh15trillion) could be saved as a cost to the economy.

In Uganda’s case, the report indicated that healthcare-associated infections, which were conservatively estimated at 422,000 in 2022, with 43,600 excess deaths per year, cost the country $580 million (sh2 trillion), corresponding to about 1.4% of its yearly GDP.

It further put forth that the financial costs of providing healthcare to treat healthcare-associated infections in Uganda were $123 million (sh468 bn), or 7.9% of the country’s total health expenditure.

In the seven African countries where the study was conducted, namely Uganda, Nigeria, Malawi, Ethiopia, Zambia, Mali, and Ghana, an estimated 2.6 million cases of healthcare-associated infections occurred in 2022 (of which at least 50% were believed to be antimicrobial resistant) resulting in 277,160 excess deaths.

In Uganda, half of the 422,000 healthcare-associated infections were anticipated to be antimicrobial resistant.

By all accounts, antimicrobial resistance (AMR) rates vary across drugs and across settings within Uganda, but available estimates suggest that a majority of healthcare-associated infections will be resistant to first-line drugs.

The UNICEF and World Health Organisation 2023 Global Progress report highlighted that Uganda in the past year integrated WASH data into its national antimicrobial resistance plans and had completed WASH baseline assessments.

According to WaterAid and the World Bank, inadequate WASH coverage in sub-Saharan Africa was exacerbating the problem of anti-microbial resistance by increasing the burden of infections, including resistant infections, and its associated overuse of antimicrobials.

Tanzanian water, sanitation, and hygiene (WASH) expert, Michael Mwamba, notes that sub-Saharan Africa has, over the years, made very little progress in improving its water, sanitation, and hygiene coverage rates.

“The WaterAid and World Bank report in a way, reiterates previous findings. If you, for instance, reference, the 2023 "Water, Sanitation, Hygiene, Waste and Electricity Services in Health Care Facilities: Global Progress” report, you will get a sense of what the region is going through.”

Published by the World Health Organisation, which designated providing WASH amenities in healthcare facilities as one of the 13 urgent health challenges for the next decade in 2020, the Water, Sanitation, Hygiene, Waste and Electricity Services in Health Care Facilities: Global Progress” report indicated that only 68% of primary health facilities in Sub Saharan Africa have hand hygiene facilities.

A year earlier in 2022, the UNICEF and the World Health Organisation’s Joint Monitoring Programme (JMP) report, found that only one-third (37%) of the region’s healthcare facilities had handwashing stations with water and soap in their restrooms.

“This inadequate WASH status quo jeopardises the region’s health security. To reduce the overall burden of healthcare-acquired infections, which in most cases are associated with higher healthcare costs, disability, longer hospital stays, poor clinical outcomes, and, in some cases, death, countries in the region have to earnestly prioritize WASH and infection prevention and control (IPC) interventions,” Mwamba adds.

Guy Mbayo, the regional technical officer in charge of WASH for the World Health Organisation, Africa office says the effort required by countries in the region to achieve WASH-related SDGs is enormous.

“Around 2 out of 5 deaths from unsafe WASH are concentrated in sub-Saharan Africa. African countries, like other WHO members, committed at the 2019 World Health Assembly to take important steps that would help achieve the goal of universal access to water, sanitation, waste management, and hygiene services in healthcare facilities by 2030, but little progress has been made thus far.”

Under the SDGs, the global targets are to ensure that at least 50% of all healthcare facilities globally and in each SDG region offer basic WASH services by 2022, 80% by 2025, and 100% by 2030.

Guy Mbayo, the regional technical officer in charge of water, sanitation and hygiene for the WHO Africa ofiice. Courtesy Photo

In countries where WASH services exist, the target is advanced levels of service, with the aim of 100% by 2030.

The JMP report indicated that no country in sub-Saharan Africa had reached 50% coverage by 2021, aside from Rwanda, Ghana and Zimbabwe.

“It is very likely that Sub-Saharan Africa, which failed to meet the now-defunct Millennium Development Goal targets of 62% for improved sanitation facilities and 74% for improved drinking water sources, will also come up short with the SDG’s related to WASH,” states public health researcher, Dorothy Kyarikunda.

She went on to state: “Without meeting the indicators of WASH services in healthcare facilities, sub-Saharan Africa will face long odds in meeting the 2030 SDG targets for universal access to WASH SDG 6.1 and 6.2 and universal health coverage SDG 3.8.”

“The region will also face long odds in terms of finances- the estimates are that three times the current investment – at least US$114 billion per year is needed in developing countries to meet the WASH-related SDG targets by 2030.”

WaterAid and the World Bank underscore in their report that despite growing recognition of the importance of WASH in healthcare facilities, financing from both donors and international financial institutions (IFIs) for WASH in healthcare facilities remains inadequate, and it is under prioritised in major health initiatives such as those on maternal health and health systems, strengthening/Universal Health Care, and global health initiatives, resulting in missed opportunities to foster mutual benefits.

Infant & maternal mortality and poor WASH amenities

Mwamba says the absence of proper WASH amenities in healthcare facilities is directly linked to infant and maternal mortality.

“Many maternal deaths are caused by infections such in the first 6 weeks following childbirth, and many of these such as maternal and neonatal sepsis are due to unsanitary practices and poor infection control during labour and delivery.”

Ostensibly, sub-Saharan Africa continues to be the region with the highest under-five mortality rate in the world-71 deaths per 1,000 live births.

In 2022, 1 in 14 children in the region died before reaching their fifth birthday -15 times higher than the risk for children born in high-income countries and more than 20 years behind the world average, which achieved a 1 in 14 rate by 2001.

In terms of maternal mortality, Sub-Saharan Africa accounted for 70% of global maternal fatalities in 2020, according to the latest WHO factsheet on maternal mortality.

It is estimated that 390 women in the region will die in childbirth for every 100,000 live births by 2030.

That is more than five times above the 2030 SDG target of fewer than 70 maternal deaths per 100,000 live births.

In Uganda, recent health ministry statistics, have shown that over 23,000 Ugandans, including 19,700 children under the age of five, die each year from diarrhoea, with roughly 90% of the deaths being directly related to inadequate water, poor sanitation, and unsanitary practices. This ostensibly costs the country sh539 bn, annually.

It was noted in the WaterAid and World Bank report that the lack of essential WASH services in healthcare facilities poses significant health risks for patients, particularly women and children, and healthcare workers.

The two organisations observed that, given that women make up 70% of the global health workers and the majority of patients in low and middle-income countries, a lack of WASH in healthcare facilities disproportionately affects women, such as 31-year-old Jennifer Khaitsa, a mother of five from Bunapondi village in Buweswa parish in Manafwa district, who experienced serious pregnancy complications in her fourth pregnancy in 2021 after being exposed to contaminated water.

Proposed interventions for bringing about change

WaterAid and the World Bank, state that governments, UN Member States, international financial institutions and the G7 and G20 Presidencies should collaborate to ensure that every healthcare facility in the region has clean water, sanitation, and hygiene services (WASH), as they are the first line of defence against antimicrobial resistance for both people living in this reality and the global economy.

A man washes his hands in an African rural area. Courtesy Photo

They noted that governments of low and middle-income countries must prioritise the development and implementation of national and district plans on water, sanitation, and hygiene services in healthcare facilities, with dedicated budget lines, to coordinate stakeholders and mobilise funding; and should prioritise this as an area for partnership with multilateral development banks and other sources of finance.

In a statement quoted on WaterAid's website, Sol Oyuela, WaterAid's Executive Director of Global Policy and Campaigns, stated, “We need to see high-income countries and development banks prioritise finance and delivery of water, sanitation, and hygiene in clinics and hospitals in all major global health decision-making, as well as low-and middle-income countries earmarking finance for this in all domestic health budgets.

“If action is not taken imminently, the most vulnerable communities will continue to pick up the tab with their lives now – with the rest of the world soon to follow”.

Additionally, WaterAid and the World Bank pointed out that Uganda can achieve significant reductions in healthcare-acquired infections through targeted interventions as well as improved general training and healthcare practices.

At the release of the Water, Sanitation, Hygiene, Waste, and Electricity Services in Health Care Facilities: 2023 Global Progress report, Dr Maria Neira, Director of the World Health Organisation's Department of Environment, Climate Change, and Health, stated that WASH services in health care facilities could not be secured without increasing investments in basic measures such as safe water, clean toilets, and safely managed health care waste.

Elicad Elly Nyabeeya, the Technical Advisor - Water Resources and Climate Change at the Africa Water Facility, an initiative of the African Ministers Council on Water, agreed: "Governments need to prioritise and increase investment financing to the WASH sector to meet ever-increasing water demand due to population growth and urbanisation, while sustaining ecosystems, minimising water scarcity, and the impacts of climate change."

Mbayo holds that if the WASH status quo is to improve, governments in the region owe it to their citizens to strengthen their health infrastructure, WASH service monitoring systems, capacity building of their health workforce to deliver and maintain WASH, and community engagements, as they committed at the 72nd World Health Assembly.

At the continental level, it is envisaged that the sustained efforts of the African Union’s Specialised Committee on Water and Sanitation or AMCOW will accelerate the achievement of water and sanitation goals on the continent.