Assessment of water, sanitation and hygiene service availability in healthcare facilities in the greater Kampala metropolitan area, Uganda

Water, Sanitation and Hygiene (WASH) in Healthcare facilities (HCFs) encompasses the provision of water, sanitation, health care waste management, hand hygiene and environmental cleanliness services [1]. Provision of WASH services in HCFs is fundamental for the provision of quality healthcare. Good WASH services in HCFs, especially in maternity and primary care settings have the potential to reduce healthcare acquired infections (HAIs), increase trust and uptake of healthcare services, increase efficiency and improve staff morale [1, 2]. In addition, improved WASH supports the core universal healthcare aspects of quality, equity, and dignity for all people [1].

Globally, WASH in HCFs remains a significant public health challenge. Global baseline estimates on WASH in HCFs indicate that 26% of HCFs lack access to an improved water source on the premises, 14% of HCFs have a limited water supply and 12% have no water supply at all [1]. Water service indicators are worse in low resourced countries where 45% of HCFs do not have access to basic water supply [1]. About 16% of HCFs globally also lack hand hygiene facilities at points of care, in addition to lacking soap and water at toilet facilities [1]. In terms of access to sanitation, over 21% of HCFs worldwide depend on unimproved toilets or have no toilets at all while in sub-Saharan Africa only 23% of HCFs have basic sanitation [1].

Inadequate WASH compromises safety and quality of healthcare services, and places a huge preventable risk to both health providers and clients [3]. Mothers and new-borns are at greater risk. Given the profound impact of WASH on patient dissatisfaction and quality of care [3], there is growing attention towards WASH in HCFs. WASH has for instance been recognised as key to the attainment of universal health coverage [1]. Besides, Sustainable Development Goal (SDG) 6 includes a target to achieve universal access to basic WASH for all including households, schools and HCFs, by 2030. However, even with just a decade to the evaluation of the attainment of the SDG 6, there is limited evidence on availability of WASH services in HCFs [1].

There is limited data on WASH in HCFs in urban Uganda, however, a study conducted in south western Uganda indicated critical gaps in the provision of WASH in HCFs in rural facilities [4]. Mulogo, Matte [4] reported that only 38% of the HCFs had toilets with hand washing facilities; with only 24% of the toilets having soap and water [4]. Similarly, Guo, Bowling [2] reported that less than 50% of rural HCFs in Uganda had access to improved water sources on premises, improved sanitation, and consistent access to water and soap for handwashing. Whereas Mulogo, Matte [4] and Guo, Bowling [2] give useful insights into WASH in HCFs in rural settings, their findings do not explicitly give a picture of availability of WASH services in a typically growing urban setting such as the Greater Kampala Metropolitan area (GKMA). Besides, their findings are not comparable to the Joint Monitoring Programme (JMP) WASH service ladders [1]. The JMP is an entity which was formed by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) to produce internationally comparable statistics, and monitor progress towards attainment of SDG targets related to WASH. The JMP classifies water supply, sanitation, hygiene, waste management, and environmental cleanliness as basic, limited and no service [1].

In this study, we established and classified availability of WASH services in HCFs in the GKMA. This setting was chosen because of its representativeness of many growing cities in the Global South [5]. Findings from this study can be used to inform WASH programming and policy. Besides, data generated by this study can be used to track progress towards the attainment of national and international standards for WASH in HCFs.

This study assessed the availability of WASH services in HCFs in an urban setting in Uganda. Though existing literature on WASH in HCFs in low resource settings indicates limited access to improved water sources, this study found out that almost all the HCFs in the GKMA had access to an improved water source, however, access rates remain below the WHO target of 100% coverage by 2030 [13]. The high access to improved water sources in our study could be attributed to deliberate efforts by the government and line ministries to invest in improved access to safe water in urban settings. For Uganda’s case, our findings are not different from those of rural settings as reported by Mulogo, Matte [4]. While almost all HCFs had an improved water source, a significant proportion did not have an alternative water source. Lack of an alternative source may compromise access during times of seasonal scarcity and breakdown of water facilities.

More than a quarter of the HCFs in the study area reported experiencing intermittent water supply, and often suffered severe water shortage. These results are similar to those of a study conducted in Rwanda which indicated seasonal water shortages in HCFs [14]. Besides seasonal shortages, intermittent water supply in HCFs in Uganda could also be related to failure of HCFs to pay water bills. In addition, the national utility which is mandated to supply water in the urban areas often fails to meet the water demand [15, 16]. This poses a serious challenge in urban settings where the population and the number of clients seeking care from HCFs are large. Therefore, intermittent water supplies could provide an environment for opportunistic infections especially among immunocompromised patients such as the new-borns and mothers.

In a tenth of the HCFs, 50% of the water samples met the recommended WHO microbial water quality standards of 0 CFU per 100 mL. Water samples that did not meet the WHO microbial water quality standards were mainly from HCFs whose main water source was not piped. Unlike other water sources, piped water in the GKMA is treated with chlorine, a highly efficient disinfectant which reduces the risk of faecal contamination. Therefore, the presence of E.coli in drinking water in a tenth of the HCFs suggests faecal pollution and presents a serious potential hazard in those HCFs [17]. Our finding is similar to a previous study by Huttinger, Dreibelbis [14] in which over 25% of water samples in selected rural HCFs in Rwanda did not meet the WHO standards of microbial water quality. The low microbial quality of water in urban HCFs in the GKMA could be attributed to contamination resulting from pipe leakages, lack of clean storage reservoirs such as water tanks and poor environmental sanitation surrounding the water sources [18].

Our study indicates that almost all HCFs in the study area had a sanitation facility, which was either jointly used by staff and patients or separated for either categories. Although stances for both patients and staff could be on the same latrine block, it is a common practice for the stances used by healthcare staff to be kept under lock and key for purposes of maintaining them clean. The fact that most HCFs had adequate sanitation facilities enables provision of quality healthcare [1]. Our findings corroborate those of a study in Jordan where all HCFs had sufficient toilets [19]. Despite availability of sanitation facilities in most of the HCFs in our study, about 71.7% of these facilities were not gender sensitive. The low gender sensitivity in toilet design may affect proper usability of these facilities due to issues of privacy and comfort. Huttinger, Dreibelbis [14] in their study also highlighted lack of gender sensitive sanitation facilities in HCFs. Unhygienic conditions of visible flies, unpleasant smells and visibly unclean toilets were common. The unpleasant smells that characterise sanitation facilities in the GKMA could be related to inadequate funding for WASH services, and consequently poor cleaning routines. This study also brings to light a lack of menstrual hygiene facilities in HCFs. Though rarely studied, a lack of menstrual hygiene facilities could result into patient dissatisfaction with health care services [1]. Therefore, provision of these menstrual hygiene facilities would improve usability of sanitary facilities. From our study, we reveal that a significant proportion of sanitation facilities in healthcare settings lack adequate lighting, most especially at night. This is likely to affect usability of the facilities and may result into indiscriminate excreta disposal. Adequate lighting in sanitation facilities should be ensured since lighting increases feelings of security and safety for users and encourages their optimal use [20, 21]. It is worth noting that 68.3% of the sanitation facilities in the surveyed HCFs did not have flies. This could be attributed to the fact that a significant proportion of HCFs had improved sanitation facilities.

Hand hygiene remains a significant challenge in HCFs. This study revealed that only 58% of the HCFs had at least one functional hand hygiene facility with both water and soap in patient care areas. This low proportion of functional hand hygiene facilities indicates potential for elevated risk of for transmission of HAIs at points of care across HCFs. Our findings differ from a study conducted by Mulogo, Matte [4] that revealed that only 24% of the HCFs in south-western Uganda had water and soap present at the hand washing stations. The disparity in these findings could be related to the fact that our study was conducted in an urban area with considerably more WASH investments as compared to Mulogo’s study which was conducted in predominantly rural HCFs. Lack of functional hand hygiene facilities in HCFs is likely to compromise infection prevention and control efforts for highly infectious diseases such as Ebola and COVID-19. Furthermore, less than half of the HCFs had a functional hand hygiene facility with water and soap within 5 m of the toilet block, similar to a study by Guo, Bowling [2] which showed that only a small proportion of HCFs in Uganda have water and soap available for hand washing near the toilets. The low proportion of hygiene facilities with water and soap may be attributed to limited funds to put up and sustain functioning hand hygiene facilities that meet the basic requirements at the HCF. This indicates a need for more financial investments but also improve attitudes among both health care in charges and administrators.

It was noted in this study that most HCFs segregated waste safely into separate bins, contrary to what has been reported in previous studies about the absence of proper waste segregation practices at the point of generation in HCFs [22‐24]. More than half of the HCFs did not treat infectious waste and sharps most of the time. These findings concur with those of an Ethiopian study, where there was no pre-treatment of infectious wastes by the HCFs [25]. This implies that health workers, waste handlers and the public could be at risk of infections from the waste. Nonetheless, majority the HCFs had protected areas for the storage of HCW awaiting disposal. Protected waste storage areas can minimize risks of potential injuries and infection, particularly among the public and stray animals venturing to the waste sites are deterred.

In comparison with the JMP indicators, this study revealed that majority of the HCFs had a limited WASH service. This indicates gaps in WASH in HCFs and the need for more investments for attainment of optimal WASH services. Limited investment in WASH in HCFs could partly explain this. To put this into context, any improvements in WASH in HCFs in Uganda are dependent on the availability of the already meagre primary healthcare funds [26]. Therefore, with limited funds and regular financial needs, HCFs may have to make a trade-off between financing WASH services and sustaining other HCF operations such as paying non-wage staff and paying off other utility bills such as electricity.

From this study, there is some evidence that the provision of WASH services differs across the ownership and level of HCFs. More PNFP HCFs had better WASH services compared to the public HCFs. It has been assumed that private HCFs at the same level as public HCFs generally have better service standards [4]. Unlike public HCFs where services are free, PNFP HCFs in the study area provide healthcare services at a cost. Therefore, the funds generated from the provision of these healthcare services may be used to increase the budget for WASH. In addition, PNFP HCFs are interested in attracting more clientele so they may have more deliberate efforts to improve WASH so as to attract more clients and ensure patient satisfaction.

A higher proportion of hospitals in the study area had an overall basic WASH service based on JMP service ladders compared to the lower level HCFs. This could be attributed to the fact that hospitals in Uganda are given more primary healthcare funds to support improvements in WASH, given that hospitals have relatively large population catchments and offer a wider range of MNCH services. In addition, hospitals are often accorded more attention due to a higher patient load and a higher risk of transmission of hospital acquired infections compared to the lower level HCFs. The higher patient load in hospitals could also trigger more investments in WASH services due to the fear of transmission of HAIs, thus a higher proportion having an overall basic WASH supply [27].

Overall, majority of the HCFs had access to improved water sources and sanitation facilities but few had functional hand hygiene facilities. However, based on the JMP service ladders, majority of the HCFs had a limited WASH service. The WASH service significantly differed across the different levels and ownership of HCF. Our findings demonstrate structure and performance limitations in provision of WASH services in HCFs, and indicate the need for deliberate and strategic investments in healthcare WASH services, especially in terms of finances, infrastructure and policies. The present study also reveals that environmental cleanliness and treatment of infectious waste can be achieved in the absence of infrastructure improvements, if there is better oversight and personnel to do it. Improvements in WASH conditions will not only minimize the risk of transmission of hospital acquired infections but also may cut on associated costs. We therefore suggest improvements in WASH conditions in HCFs to improve healthcare seeking among patients.