1. 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

2. 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

3. 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

4. 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

5. 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.

6. 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 ( MPN)
8.0%
18.9%
Very high risk (>100 MPN)
0.0%
TOTAL
100.0%

7. 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).

8. Results: Access to water (cont.)

9. 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

10. Results: Hand hygiene
Basic hygiene service

11. Results: Hand hygiene (cont.)

12. 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

13. 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

14. 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

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