WASH as a Critical Component of Primary Health Care and Health Security

More than three decades have passed since the Declaration of Alma-Ata proclaimed primary health care (PHC), along with water, sanitation, and hygiene (WASH), to be basic inputs for public health. More recently, the UN Sustainable Development Goals (SDGs) highlighted universal health coverage and access to safely managed water and sanitation services as key pillars of human security. The outbreaks of Ebola virus in West Africa and in the Democratic Republic of Congo reinforced the important role WASH services play in protecting clinical staff from infection and preventing community transmission of the virus. Yet, neither PHC nor WASH has received the attention and investments needed to safeguard health, prevent infections in households, schools, and health care settings, and promote health security. Indeed, the first draft of the World Health Organization (WHO) formal resolution declaring the Covid-19 outbreak to be a worldwide pandemic failed to mention WASH at all.

PHC facilities and community health workers, especially those serving the poorest, are at the forefront of disease surveillance and management in many countries. However, such facilities struggle to provide adequate care, not just because they face shortages of trained care providers but also because they lack basic infrastructure improvements, including WASH services, that are critical to infection control. Globally an estimated 25 percent of health care facilities have no basic water services, with one-third having insufficient supplies for handwashing with soap at the point of care, both of which are critical to preventing postpartum infections and improving maternal and child health outcomes. With an estimated 15 percent of patients globally acquiring an infection during a hospital stay, an adequate supply of WASH can help address overreliance on the preventive use of antibiotics and mitigate the spread of antimicrobial resistant pathogens to the broader community as well.

According to recent estimates, at least half of the world’s nearly 8 billion people still lack full coverage of essential health services. The 2019 WHO and United Nations Children’s Emergency Fund (UNICEF) Joint Monitoring Program for Water Supply, Sanitation and Hygiene report noted that approximately 1.3 billion people still lacked access to even basic sanitation in 2017, and 785 million still had access to very limited or no water service at all. The global hygiene situation is also alarming, with an estimated 40 percent of people unable to wash their hands with soap and water.

In the midst of a global pandemic, it is difficult to overstate the importance of strengthening systems that deliver primary care and water and sanitation services. A revised version of the WHO pandemic resolution issued on May 18 mentions water and sanitation once, calling on member states to “Take measures to support access to safe water, sanitation and hygiene, and infection prevention and control, ensuring that adequate attention is placed on the promotion of personal hygienic measures in all settings, including humanitarian settings and particularly in health facilities.” But there is much more at risk if the global community fails to strengthen WASH services at the PHC level.

In the short term, populations in countries with the worst access to WASH services, which tracks closely with low access to health services generally, may find the delivery of Covid-19 vaccines delayed. Even in the most optimistic scenario, vaccination rates in the lowest income countries relying on access to Covid-19 vaccines through the COVAX Advanced Market Commitment (AMC) are likely to remain low well into 2022 and possibly into 2023. This means that the basic precautions of masking, social distancing, and handwashing to prevent the spread of coronavirus will remain the first line of defense against the new and more transmissible variants of the virus already spreading from Brazil and South Africa.

And Covid-19 is just one among many acute health threats that populations without regular access to affordable and safe WASH face. Over the course of 2020, as the Covid-19 pandemic gained traction, measles outbreaks were reported in several countries, and at least 40 countries postponed measles vaccinations due to the pandemic, raising the specter of even more outbreaks in coming years. Cholera, controlled through the provision of safe water and sanitation, is periodically reported in both lower- and middle-income countries but is deadliest in communities already weakened by conflict, weak health systems, and malnutrition. Bangladesh, home to hundreds of thousands of refugees, and Yemen, the site of a brutal civil conflict, experienced the worst cholera outbreaks in 2020, but there have been recent outbreaks during the Covid-19 crisis in East Africa as well.

Before the pandemic, there had been some positive momentum on global attention to WASH and PHC. In 2017, the World Bank and WHO’s Service Coverage Index, which measures access to a list of 16 essential health services and tracks progress toward meeting SDG 3.8 regarding universal health coverage, included WASH among the list of services assessed. And the Global Task Force on Cholera Control identified improving access to basic WASH services as a critical goal in its 2030 Global Road Map. Following the UN secretary-general’s 2018 call for greater leadership and accountability to provide WASH services in all health care facilities, the WHO and UNICEF issued the first WASH in Health Care Facilities report and developed a set of targets for realizing universal access to WASH in clinical settings globally.    

The economic disruptions occasioned by the pandemic may now challenge this forward movement. Even in countries where reported cases of Covid-19 infections are low, the pandemic has taken a huge economic toll. According to World Bank estimates, nearly 150 million additional people will be pushed into extreme poverty by the end of 2021 as a consequence of Covid-19. While many countries will recover and rebound, in at least ten countries, the impact is likely to linger for a decade or longer. With a few exceptions, the worst economic impacts are likely to be felt in Southern Asia and sub-Saharan Africa, where an additional 32 million and 26 million people, respectively, are likely to fall below the poverty line. Women have been disproportionately burdened by loss of income, increased childcare responsibility, and the stress of providing for their families during lockdowns. At the same time, women have faced increased risk of being infected with Covid-19 because of their responsibilities as frontline health workers and because, as more frequent users of health care facilities, they may have a greater chance of being exposed to the virus when visiting clinical settings that lack basic WASH services.

To stop the spread of SARS-CoV-2, the virus that causes Covid-19, many governments have taken steps to impose restrictions on movements, closing businesses and offices when infections have spiked. The impacts of “lockdowns” have been felt by both business and public service providers, especially in urban areas. While health care personnel have been overwhelmed by demand for services, basic utility providers have suffered because some governments have suspended the practice of disconnecting services if clients cannot pay. The government of Ghana, for example, initially suspended disconnections for non-payment of water bills, and has extended the free provision of up to five cubic meters of water daily until March 2021. While this undoubtedly eased the burden temporarily for some households and businesses, it also led to precipitous declines in revenues for service providers, who at the same time are facing higher costs associated with social distancing practices and provisioning staff with personal protective equipment.  

There is evidence that tighter budgets are already leading to deferred maintenance of infrastructure, threatening current investments and delaying much needed investments to expand WASH services, especially among smaller providers who tend to serve peri-urban or rural populations. A recent survey on the impact of Covid-19 on WASH access in six sub- Saharan African countries found that approximately one-third of respondents reported facing difficulties in accessing water because of the pandemic. More worrying is the fact that even though water access was made free in some countries, about 3.7 percent of respondents reported falling below the “basic” service level and having to resort to using unsafe water sources.

In 2017, more than 80 percent of countries which shared WASH funding data with the United Nations reported having insufficient funds to meet their national WASH targets. While official development assistance (ODA) for WASH activities rose slightly from 2017 to 2018, reaching $9.4 billion, it was still a fraction of the $114 billion a year needed to finance new infrastructure for meeting the SDGs for safely managed water and sanitation services. In 2020, 20 developing countries and territories showed a funding gap of 61 percent between identified needs to achieve national WASH targets and available funding.

International donors and multilateral financial institutions have promised and released hundreds of billions of dollars to governments for debt service relief and to cope with the fiscal shocks imposed by the pandemic. While donor commitments for health-related programs are not insignificant, the bulk of funds are earmarked for vaccine production and distribution ($8.5 billion). Strengthening health systems, especially primary care services, has not been a priority, and projects focused on health systems have received approximately 6 percent of the total commitments ($560 million). Water and sanitation, where they are mentioned, are low on the list of priorities. According to the Devex Funding the Response to Covid-19 Dashboard, a mere 0.03 percent of bilateral and multi-region funding has been allocated to strengthening existing WASH programs or implementing new ones.

There are several steps policymakers focused on service delivery can take to better integrate WASH and PHC as components of health security during and beyond the Covid-19 pandemic.

First, PHC providers and centers, especially those serving the most disadvantaged and hardest to reach populations, must be prioritized in national budgets. This is key not only to preventing unnecessary, additional mortality and morbidity among women and children, but also to protecting populations in future outbreaks. As public budgets will undoubtedly shrink in many countries because of pandemic disruptions, it will be even more critical to prioritize those PHC facilities which currently lack even basic WASH facilities and ensure they are provisioned with the services they need to control infections and prevent the transmission of antibiotic-resistant microbes.

Second, water and sanitation service providers should be incentivized to expand and maintain infrastructure in PHC settings. Health budgets siloed by disease often leave no room for fundamental health inputs such as safe WASH, as such services are seen as the responsibility of environmental or public works agencies and outside the mandate of the health sector. Integrating WASH and health planning and budgeting can lead to more sustainable investments at the facility level and better outcomes for health systems in the aggregate. 

Third, governments and donors must do everything possible to protect the recent and hard-won behavioral improvements in handwashing. A Covid-19 knowledge, attitude, and practice survey in 67 countries, led by a collaboration between the Massachusetts Institute of Technology (MIT), Johns Hopkins University, the WHO Global Outbreak Alert and Response Network (GOARN), and Facebook, found that between 70 percent and 90 percent of respondents in Tanzania, Kenya, and Uganda practiced handwashing as a precaution against Covid-19, a behavior more consistently practiced than even mask wearing or social distancing. Supporting this behavior with key investments in WASH is key to reducing all infectious disease related mortality and improving the prospects for improved hygiene practices in the long term. 

And finally, discussions about health systems strengthening and global health security, including at the 74th World Health Assembly, to be held May 24–June 1, and through the Global Health Security Agenda’s Action Package on Antimicrobial Resistance should include WASH as critical elements of promoting PHC and advancing infection control and prevention.  

Meeting in Astana to commemorate the 40th anniversary of the Declaration of Alma-Ata on PHC, 2,000 global health experts and policymakers recommitted to the goal of health for all, placing special emphasis on expanding population access to affordable and high-quality health care as a means of promoting peace, security, and economic development. During the Covid-19 pandemic—and beyond—ensuring the provision of WASH services within PHC settings can help speed progress toward that goal.

Tanvi Nagpal is director of the International Development Program at the Johns Hopkins University School of Advanced International Studies (SAIS). Katherine E. Bliss is senior fellow with the CSIS Global Health Policy Center.

Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

© 2021 by the Center for Strategic and International Studies. All rights reserved.

Katherine E. Bliss
Senior Fellow and Director, Immunizations and Health Systems Resilience, Global Health Policy Center

Tanvi Nagpal

Director of International Development Program, Johns Hopkins University School of Advanced International Studies (SAIS)