WASH in PHCs — How Fulfilling Evidence Gaps Contributes to Improved Policy and Practice

By Oguntola Ibukun & Dara Ajala-Damisa (Lead Writers)

5 percent of the facilities visited in the FCT and 65 percent of the facilities visited in Niger State do not have access to pipe-borne water.

Nigeria is among the countries where about 17% of health care facilities had no access to a water source as at 2019. A 2019 joint WHO/UNICEF report showed that worldwide, 896 million people use health care facilities with no water supply and 1.5 billion people use facilities with no sanitation services — these indices are daunting.

Water, Sanitation and Hygiene are three core issues that according to UNICEF are so interdependent that almost one-tenth of the global disease burden could be prevented by improving water supply, managing water resources and enhancing sanitation and hygiene facilities. Lack of access to WASH is a major contributing factor to various deadly infectious diseases like cholera and diarrhoea. A study has shown that inadequate WASH services is directly related to the high burden of diarrheal diseases in Nigeria and other low- and middle-income countries.

The often-overlooked link between WASH & infection prevention and control in health facilities
WASH services are required for virtually every activity in a primary health centre (PHC). Uninterrupted access to safe, quality and equitable WASH services is fundamental to preventing and controlling infections in health care facilities and ensuring the delivery of quality healthcare services — a requirement for achieving universal health coverage. Thus, suboptimal access to water and sanitation services in healthcare facilities in Nigeria poses a threat to quality healthcare delivery, especially at the PHC level where most of the population in rural communities should access health care services.

United Nations Secretary-General António Guterres captured the important link between WASH in health facilities and prevention of disease when he stated, “Water, sanitation and hygiene services in health facilities are the most basic requirements of infection prevention and control, and of quality care. They are fundamental to respecting the dignity and human rights of every person who seeks health care and of health workers themselves.

Image credit: Nigeria Health Watch

Fulfilling the evidence gap
There is significant documentation of WASH capacity in health facilities, however, in the push to strengthen WASH capacity at the PHC level, it is critical to review disaggregated PHC specific data to understand the challenges and inform policy interventions. A lack of PHC-specific data would mean a lack of evidence to guide policy action to strengthen WASH capacity at the primary health care level. To generate this vital data and bridge this critical evidence gap, Nigeria Health Watch carried out assessments of WASH in PHCs in 2019, as an informed enquiry into the availability and functionality of WASH services and Infection, Prevention and Control (IPC) processes in PHCs in the FCT (Federal Capital Territory), Niger State and Kaduna State.

One hundred and four (104) PHCs were selected by randomly choosing two PHCs from each LGA (one rural and one urban) across the three senatorial zones in the three states with 50 PHCs assessed in Niger, 12 PHCs in the FCT, and 42 PHCs in Kaduna State. The process was jointly carried out by the State Primary Healthcare Development Agency and the Nigeria Health Watch research team.

These assessments aim to provide an overview of the state of WASH services in PHCs in the states. Sustainable Development Goal 6 emphasises ensuring availability and sustainable management of WASH for all by 2030. This calls for greater attention to WASH services beyond the household. In addition, SDG 3 aims to ‘ensure healthy lives and promote well-being for all at all ages and includes a specific target (3.9) to reduce the burden of disease from unsafe water, unsafe sanitation, and lack of hygiene. Access to safe WASH services is a key contributing factor to protecting the health, security, and economic potential of individuals and communities around the world.

Identifying that a key task for researchers and advocates has been to translate evidence from myriad research to action for improved water, sanitation, and hygiene in primary health centres where the risk of cross-infection is particularly high if stringent measures are not taken, the strategy employed for the WASH in PHCs assessments was to engage policymakers in states assessed right from inception to understand evidence gaps from the policy angle. Through sustained advocacy engagements to health officials in these states, the research team also helped these officials elevate the need for evidence-based policy action for improved WASH in PHCs.

Following policymaker engagement, the research team assessed the PHCs against the Technical guide for Water, Sanitation and Hygiene (WASH) in PHC Centres in Nigeria. Focused group discussions and in-depth interviews were carried out with different cadres of health workers at selected PHCs , and the assessments provided policymakers with a clearer picture of the state of WASH in the PHCs in hard-to-reach communities, as well as the unique challenges each facility faces.

Image credit: Nigeria Health Watch

The findings from the assessment point to critical gaps in service provision in the PHCs. For example, 5% of the facilities visited in the FCT and 65% of the facilities visited in Niger State do not have access to pipe-borne water. Additionally, of the facilities visited that have pipe-borne water, 58% in the FCT and 55% in Niger State experience frequent interruptions in their water supply. Therefore, a pregnant woman attending antenatal in any of these facilities may have to wait till she gets home if she needs to use the toilet.

WASH is about equity and justice. Often times, the people that need it the most are those that can’t provide it for themselves. They need the assistance of all relevant stakeholders to provide it for them”, Dr. Tochi Okwor, AMR & IPC Programme Coordinator at the Nigeria Centre for Disease Control emphasised.

Image credit: Nigeria Health Watch

Evidence generated from the assessments was used for advocacy during town hall and stakeholder meetings, in order to create a sense of ownership for policymakers and relevant stakeholders and to garner their support. The stakeholders also included community leaders, male youth leaders, female community members, facility managers and staff.

Need to translate evidence into action
The data generated provides decision makers and project implementers with additional insights in the focus states, helping them understand the current gaps in WASH provision in PHCs under their authority. To get a more detailed picture of the gaps in WASH provision in other states, would require replicating the assessments in PHCs in other states.

In addition, continuous engagement with relevant stakeholders is required to ensure that the assessments result in positive action. Ultimately, it is important that PHCs are fully-functional, well equipped and deliver quality services and adhere to recommended hygiene and sanitation standards.

Image credit: Nigeria Health Watch

The challenges of inadequate WASH facilities in PHCs exposes those working in the facilities and their patients to threats of infectious diseases. Nigeria is currently responding to the COVID-19 outbreak, and one of the constant advisories from the government and experts is that people should wash their hands frequently with soap and running water. With over 20% of our health facilities lacking access to water and sanitation services, and only 31.4% with access to basic handwashing facilities, the incredible importance of WASH in preventing the spread of infectious diseases has become more urgent. All stakeholders must act now.

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Nigeria Health Watch

We use informed advocacy and communication to influence health policy and seek better health and access to healthcare in Nigeria. nigeriahealthwatch.com