“When you preach water and you drink wine” Exploring the implementation, use and management of WASH in healthcare facilities: A Case Study from Kenya

Abstract

Health care facilities (HCFs) are lifesaving resources for the sick in communities however, the inadequacy of basic necessities such as water, sanitation, hygiene, waste management and environmental cleaning (WASH) often affect the quality of care they dispense. Adequate WASH services in HCFs are critical for infection prevention and control. Yet the WHO/UNICEF joint monitoring program for water supply, sanitation and hygiene report indicates that only 51% and 23% of HCF in sub-Saharan Africa (SSA) have basic access to water and sanitation, respectively. These facilities are burdened during emergencies as seen in the case of the COVID-19 pandemic. Global commitments to improving access to WASH in HCF surged in 2015. The sustainable development goals (SDGs) 6-ensure access to water and sanitation for all and 3-ensure healthy lives and promote wellbeing for all at all ages further highlight the need for WASH in HCFs. However, socially and institutionally driven challenges are major hindrances to improved service provision in SSA. This thesis employs a political ecology of health (PEH) and the Sendai Framework for disaster risk reduction to explore the social, economic and ecological processes hindering access to and the contributions of safe WASH to resilient HCFs and communities, using Kisumu, Kenya as a case study. The research has three broad objectives. First, document the policy context for WASH in HCFs in Kenya. Second, to investigate the psychosocial impacts experienced and coping strategies employed by patients, caregivers and healthcare workers due to inadequate WASH in HCFs. Third, to explore the impacts of the COVID-19 pandemic on WASH services in HCFs and community residents who access the HCFs. The research was conducted in partnership with Community Health Support (COHESU), a Kenyan Non-Governmental Organisation supporting sustainable health activities in communities in the Lake Victoria region. Data were collected in two phases. From May to September 2019, 17 relevant policy documents were gathered in the first phase. Concurrently, interviews were conducted with health care providers regarding access to WASH and the role of WASH in responding to emergencies like disease outbreaks, building resilient HCFs and emergency preparedness. In-depth interviews in one informal settlement and three rural dispensaries with key informants (KIs) (n=13), healthcare workers (n=16), as well as community members (n=39). While those data were being analyzed, a global pandemic was declared on March 11, 2020. To capture stakeholder reflections during this natural experiment, follow-up virtual interviews were undertaken with a subset of key informants. Results allow us to engage with the hypothetical and the real to assess recommendations for moving forward. The second phase involved follow-up interviews with KIs (n=15) were conducted between August and September 2020 regarding the impact of COVID-19 and the role of WASH services in emergency preparedness in health systems and communities. Findings from the first phase of this research indicate none of the national documents mentioned all the components of WASH in healthcare facilities. WASH in HCFs in Kenya remains fragile. Power and politics influence institutional challenges such as corruption, inadequate financing, prioritization as well as weak stakeholder collaborations that shape the integration of WASH in HCFs. Ecological factors (floods, disease outbreaks) compromised WASH infrastructure and the resilience of HCFs. 44 percent of participants were of the perspective that HCFs were not building resilience for emergencies and would not be able to recover should a serious disease outbreak occur due to inadequate access to WASH services. Also, 38% of participants however felt the HCFs were prepared for any emergency because of the health referral system but this view was dependent on available resources within the health system. Findings from the second phase indicate institutional challenges observed during the first phase were amplified during the COVID-19 pandemic. All participants indicated that the health system was ill-prepared for the pandemic and leaders were overly reliant on donors for support. Health workers were psychosocially burdened and subsequently embarked on strikes in protest. These situations influenced citizens' perceptions of the COVID-19 pandemic as a hoax and caused a surge in some health measures such as maternal mortality rates. This research offers theoretical, methodological, policy and practice contributions, Employing PEH in this research is important for understanding and expanding knowledge on multiscale (global, national, county) analysis of how access to WASH in HCF is embedded within social networks that are produced, and reproduced, over time. This research contributes to the calls for qualitative research, to identify approaches most effective in reducing infection by providing insights into enablers and barriers of quality healthcare services in SSA by using multiple qualitative methods. Moving forward, we recommend the need for authentic partnerships among multiple stakeholders to develop context-driven sustainable solutions to WASH and emergency preparedness. We emphasize the need to legislate these solutions to ensure continuity. Community members should continue to engage their development leaders to demand basic human rights such as water. To achieve SDG 6, prioritization of WASH is required at all levels.