Overcoming barriers to wash in Health Care Facilities to meet sdgs



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Overcoming barriers to WASH in Health Care Facilities to meet SDGs

An assessment of Water, Sanitation, and Hygiene (WASH) in Health Care Facilities (HCF) in six district hospitals in Ghana shows the need to modify the operation and maintenance of hospital-based water filtration systems and WASH infrastructure.

“[The] majority of healthcare facilities will require onsite treatment in order to meet safe drinking water guidelines,” observes Habib Yakubu, Senior Public Health Program Associate of the Center for Global Safe Water, Sanitation, and Hygiene (CGSW) of Rollins School of Public Health at Emory University, U.S.A.

This will also have long term implications including the attainment of the Sustainable Development Goals, which include a target to achieve “universal access to safe drinking water in health facilities by 2030” as captured in Goal 6.


This was a key issue raised at the fifty-third edition of the National Level Learning Alliance Platform (NLLAP 53) which was held on Thursday 10th December, 2015 at the Erata Hotel in Accra. This edition was themed: “Water, Sanitation, and Hygiene in Health Care Facilities in Ghana: The Present Conditions and Programs to Meet the Sustainable Development Goal.” This edition hosted the Center for Global Safe Water, Sanitation, and Hygiene (CGSW) of Rollins School of Public Health at Emory University, U.S.A with the support of the General Electric Foundation and in collaboration with WaterAid Ghana and the Resource Centre Network (RCN). This communiqué is meant to share key highlights of NLLAP 53.

The CGSW discussed WASH in Healthcare facilities around the world and the new WASH in Healthcare Facilities tools that they developed. They shared results and discussed WASH conditions in Healthcare facilities; shared programmes and plans of WaterAid Ghana in respect to WASH and Health.


WASH Conditions and Water Treatment Systems in Six Hospitals in Ghana

Consistent supply of safe water in healthcare facilities is required for a variety of medical, hygiene, and drinking purposes. The World Health Organisation (WHO) has made universal access to drinking water, sanitation, and hygiene in healthcare facilities a sustainable development goal; however, most HCFs in low-resource countries struggle to meet this basic requirement.

Against this backdrop, the CGSW conducted a multi-year, multi-country study to assess water access, use, and quality in 10 HCFs in Ghana and Honduras and identify key factors that determine sustainable operation and maintenance of on-site water treatment systems (WTS) and provision of safe water.

Presenting an aspect of the study on The WASH Crisis in Healthcare Facilities in Low-Income Countries: The Challenges and Sustainable Development Goal” Yakubu said “Water use in healthcare facilities is complex with multiple uses of different quality for multiple populations with different needs”

In another presentation titled: “The Sustainability of Water Treatment Systems in Healthcare Facilities in Ghana and the Water Infrastructure and Water Quality Which Contribute to Sustainability,” Marisa Gallegos, MDP, Public Health Program Associate at CGSW, presented the results from the six district hospitals that were surveyed. The hospitals are Axim, Bole, Kete Krachi, Kintampo, Mampong and Apam.

With photographs, she illustrated that hospitals around the world are busy, crowded, and chaotic places which can have unclean floors and surfaces, as well as poor WASH infrastructure. The concern is that poor WASH infrastructure could lead to increased risk for hospital acquired infection and spread of disease within healthcare facilities.

“While hospitals in Ghana have access to an improved water source, hospitals which were surveyed did not have consistent water flowing from the taps 100% of the time.” The shortages were attributable to seasonal changes and frequent power outages of varying durations. Water shortages were also due to water infrastructure issues, like patient taps which were often non-existent, non-functional, or locked.

When the team investigated further, they found that the staff of health care facilities had better access to hand washing facilities and soap than patients. For example: 86% of staff taps functioned while only 29% of patient taps functioned. Of the 29% functional patient taps only 50% had soap. This research shows the need for patient hand washing facilities in order to increase patient hygiene practices and decrease the potential for hospital-acquired infections.

With regards to quality, the CGSW staff tested water samples for Total Coliforms, Escherichia coli (E.coli), Pseudomonas aeruginosa, turbidity, and free as well as total chlorine.

The team observed positive change in water quality overtime as the percentage of samples that met WHO microbial standards1 improved. Gallegos reported that the addition of appropriate levels of chlorine is necessary to achieve high quality and safe water. The adherence to chlorine application protocols varied by hospital but overall chlorine levels were below WHO standards2 in most hospitals. Hospitals that were studied often could not add chlorine to their water because chlorine was expensive or difficult to acquire.

Water quality results also varied by hospital. Only one hospital was able to achieve consistent access to water, which met WHO guidelines.

More specifically, the team documented that:


  • Raw water (unfiltered water) was more contaminated than the filtered water and the tap water at the hospital. However, there was a rise in total coliforms in the water storage containers. (Veronica Buckets).

  • Raw water was more contaminated with E. coli than the filtered water and recontamination with faecal bacteria was occasional.

  • Pseudomonas aeruginosa was present in raw and filtered water but not in large amounts. Noticeable concentrations of Pseudomonas aeruginosa were found in tap water and water storage containers (water from Veronica Buckets).

  • Water stored in Veronica Buckets within hospital wards are highly contaminated with Pseudomonas aeruginosa.

The Veronica Bucket Conundrum

The CGSW found contamination in Veronica buckets at six hospital sites in Ghana. At first buckets were used at all six hospital sites and were rarely cleaned. Overall water quality at the point of use was better in hospitals which did not use veronica buckets.

In 2015 a Veronica Bucket cleaning protocol and management system was implemented. After implementation the presence of Total Coliforms, E. coli, and Pseudomonas aeruginosa were not found in 94% of samples collected from Veronica Buckets.

This success indicates that clean and safe water from Veronica Buckets is possible if veronica buckets are cleaned and if hospital management makes staff accountable for cleaning water storage containers.



The Way Forward

After half a day of deliberations, participants agreed that taking the following steps will help address bottlenecks pertaining to HCFs:


  • Consistent access to water should be seriously considered a first priority in order to achieve basic hygiene and sanitation within healthcare facilities.


  • Hospitals that suffer from water scarcity and have veronica buckets for water provision could consider implementing veronica bucket cleaning protocols and adding chlorine to the veronica buckets in order to improve water quality.

  • Hospital level management systems should be established for guarantee availability, maintenance, and functionality of taps as well as soap provision to sustain a safe hospital environment.

  • More research should be done to contribute to the evidence-base for promoting safe water in healthcare facilities as a priority within the global water sector.



1 WHO Guideline for Total Coliform and E. coli for drinking water is <1 MPN/100 mL

2 CDC Safe Water System Guidelines for free chlorine residual is 0.20-2.00 ppm



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