WaSH in rural health facilities in sub-Saharan Africa: a six-country cross-sectional study Amy Guo Georgia Kayser, Jamie Bartram, Michael Bowling The Water Institute at UNC October 10, 2016

Background Healthcare as a human right Basic WaSH is vital to provision of adequate healthcare: Water: adequate supply of clean water Sanitation: for both patients and staff, preferably on premises Hygiene: handwashing, safe disposal of medical waste, etc. WHO/UNICEF have recognized HCF as a high-impact site for WaSH improvements Sustainable Development Goals include improvements to WaSH in HCFs

Current activity Little research on status of WaSH in healthcare facilities Current research: Little monitoring dedicated to WaSH in HCF exists Poor S, H infrastructure in HCF affects health-seeking behavior (Steinmann et al. 2015) Poor S associated with adverse pregnancy outcomes (Padhi et al. 2015) Gaps: Few harmonized cross-sectional studies Water quality data

Methods Timeframe Countries Methods June 2014 to January 2015 Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia Methods Random selection of health facilities in rural areas Interview: Health professionals in each health facility Questions on water (water source and service, quality, quantity, continuity, and reliability); sanitation (type, quantity, and quality); hand hygiene (types of materials, continuity) Water quality testing E. coli enumeration in Uganda and Mozambique

Methods (cont.) Sample sizes and sampling frame Country NGO sample NGO frame Non-NGO sample Non-NGO frame Total sample Total frame Ethiopia 281 520 253 418 534 938 Kenya 74 52 126 Mozambique 99 101 198 202 Rwanda 49 68 25 41 109 Uganda 63 71 119 172 182 243 Zambia 141 204 TOTAL 629 897 689 925 1318 1822 Results from paper questionnaires double-entered Weighted analysis in SAS 9.4 (SAS Institute Inc., Cary, NC) Health posts/health centers the most common in all of the countries. Response rate >86.9% in all countries.

Results: Access to water Over 74% used an improved water source Boreholes (E, U, Z) Rainwater (K) Piped water into the yard (R, M) 62% (E) to 84% (Z) had continuous service Water quality E. coli presence in water samples from rural health facilities in Uganda and Mozambique.   Uganda (n=144) Mozambique (n=172) Low risk (<1 MPN) 84.7% 70.4% Intermediate risk (1-10 MPN) 7.3% 10.7% High risk (10-100 MPN) 8.0% 18.9% Very high risk (>100 MPN) 0.0% TOTAL 100.0%

Results: Access to water (cont.) Distance to water source? Rwanda, Uganda, Zambia Ethiopia, Kenya, Mozambique Improved piped source on premises 7% (U) to 57% (R) Pictured to right: Water tank and maternity ward at Mmambo health facility, Malawi. Photo taken by Camille Morgan (2013).

Results: Access to water (cont.)

Results: Availability of sanitation Over 66% had access to improved sanitation Pit latrine with slab (E, K, R, M) Ventilated improved pit latrine (U, Z) Over 88% reported that sanitation was functional Quality of service: indicates problems with privacy, cleanliness, and regular repair in over 22% of HCF in each country

Results: Hand hygiene Basic hygiene service

Results: Hand hygiene (cont.)

Results: combined access to WaSH* Country Improved water, improved sanitation, AND soap and water always Ethiopia 5% Kenya 10% Mozambique Rwanda 8% Uganda Zambia 19% *Does not include analysis based on on-plot or functionality of sanitation

Discussion Basic WaSH provision has not been achieved in HCF: <19% combined Opportunities for intervention Piped water: on premises, high quality Training: for safe water handling Sanitation: maintain existing facilities Hygiene: hand hygiene essential etc. Future iterations (and improvements) in research Policy implications

Acknowledgements Special thanks to World Vision: esp. Jordan Smoke UNC: team members Georgia Kayser, J. Michael Bowling, Camille Morgan, and Ronna Chan, under PI Pete Kolsky; Jamie Bartram, Ryan Cronk Odum Institute: for technical support In-country research teams

For further questions, please contact me at aguo@live.unc.edu. Thank you / Q&A For further questions, please contact me at aguo@live.unc.edu. Pictured to left: World Vision field officer by a water point at health facility in Chingale, Malawi. Photo taken by Camille Morgan (2013).