Safe water, improved sanitation, waste management, and electricity are prerequisites for infection prevention in health care facilities. However, the dire state of water, sanitation, and hygiene (WASH) in health care facilities globally, both rural and urban, is a neglected problem — and never more critical than now as COVID-19 tears its way around the world.
Swachchhata, which means cleanliness in Nepali, is a $4.9 million, five-year USAID WASH project (2016–2021) in rural Nepal. In light of COVID-19, the importance of cleanliness is clear. Nepal is a USAID priority country for water, and this project’s goal is to get sustainable WASH into health care facilities where there is little to none.
I had the opportunity to travel with SNV USA, now known as DevWorks International and the prime implementing partner for Swachchhata, into the rugged middle mountains of Nepal to see the activity’s innovative improvements and community engagement firsthand. As it would turn out, this trip took place at the exact time COVID-19 was silently brewing next door in China.
In Nepal, USAID is funding groundbreaking work to improve the foundation of safe health care, at a cost of just $11 per person. USAID is building and renovating small-scale drinking water, sanitation and waste management systems, as well as solar-powered electrical systems in 80 health care facilities in Provinces 5 and 6. Now, 57 health posts have fully functioning water supply systems, separate female latrine facilities that are accessible to people with disabilities, and solar electrification. Now with COVID-19, a number of local committees are installing 500-liter drums and handwashing stations at the entrances of their health posts for patients to wash hands with soap and water before entering. Swachchhata has also provided critical infection prevention and control (IPC) commodities for 140 facilities, and trained health care workers on IPC in 147 facilities. When the project is completed, 147 health care facilities and the nearly 430,000 people they serve are going to have far more effective IPC, and dramatically improved safe, dignified, and sustainable health care now and for years to come.
Not only is this USAID activity creatively solving urgent infrastructure challenges in 147 health care facilities, Swachchhata is also providing essential technical assistance and training to community-based health care facility management committees. Nepal’s national government mandates these local oversight committees to create a sense of local pride, ownership, and financial buy-in. It’s an innovative approach to the Achilles heel of WASH the world-over: sustainability.
Around the globe, WASH suffers from a lack of funding, coordination, preventive maintenance and repairs, and training. The result is a global graveyard of busted pipes, pumps, wells, faucets, sinks, toilets, and more that plague health facilities by the hundreds of thousands across low- and middle-income countries (Joint Monitoring Programme 2019). It is in these dilapidated facilities that women give birth, emergencies are treated, and diseases need to be prevented and contained, including COVID-19.
In Nepal, though, these community management committees are comprised of local people — businessmen, elected leaders, health workers, health volunteers, and others — who, while dedicated and passionate, are by no means experts in how to meet the special needs of running a health care facility. Swachchhata is working with each committee to create long-term capacity and training in finance, funding needs, record keeping, supply chain, self-assessment, preventive maintenance, repair capabilities, and IPC, so they’ll have the resources and know-how they need to support safe — and sustainable — health care.
USAID is also working with health facility staff on effective hygiene inside facilities, and how to influence hygiene behavior in patients’ homes. Effective hygiene also includes training cleaners, who often go unseen and unacknowledged. Which brings me to an unexpected, heated discussion I witnessed.
I found myself standing between a cleaner and the ward chairman who also chairs the facility management committee (akin to a town mayor). Though I don’t speak Nepali, this cleaner made it abundantly (and loudly) clear that she wanted specific changes to the facility so that she can clean to the best of her ability. In a rural society that maintains strict social hierarchy, and men dominate, she was not to be deterred. I’d put my money on her getting what she wants, and the patients and staff will be better for it.
For far too long, getting WASH into health care facilities has been neglected around the world. Swachchhata was in place well before the COVID-19 pandemic and WASH is vital to global health security and safety. We must continue to increase prioritization of WASH in global health. Getting sustainable water and sanitation into health care facilities requires cross-sector coordination. Swatchchhata’s innovative approach of combining specialized WASH design and construction with the provision of equipment, training, and local-level sustainability and governance interventions illustrates the potential, power, and impact of USAID WASH programming.
This article appears in Global Waters, Vol. 11, Issue 3; for past issues of the magazine, visit Global Waters’ homepage on Globalwaters.org.