‘When you preach water and you drink wine’: WASH in healthcare facilities in Kenya

Access to basic water, sanitation and hygiene, waste management and environment cleaning (WASH) in healthcare facilities (HCFs) is critical for infection prevention and control. The WHO/UNICEF 2019 global baseline report on WASH in HCFs indicates that 51 and 23% of those in sub-Saharan Africa have basic access to water and sanitation, respectively. Guided by the political ecology of health theory, this research engaged with 13 key informants, 16 healthcare workers and 31 community members on their experiences on the implementation, use and management of WASH in HCFs. Interviews were conducted in one informal settlement and three rural dispensaries in Kisumu, Kenya from May to September 2019. Findings indicate improvement in water access, yet water quality and other WASH service components remain a challenge even in newly constructed maternity facilities, thus impacting local health promotion efforts. Institutional challenges such as limited financial resources and ecological factors like climate variability and disease outbreaks compromised WASH infrastructure and HCF resilience. To achieve Sustainable Development Goal 3, good health and well-being, as well as Sustainable Development Goal 6, clean water and sanitation, the prioritisation of WASH in HCFs is required at all levels, from the local to the global.


GRAPHICAL ABSTRACT INTRODUCTION
Healthcare facilities (HCFs) require safe water, sanitation, hygiene, environmental cleaning and waste management (WASH) to provide quality services to promote, restore, maintain and improve health. The lack of access to WASH in HCFs contributes to increasing infection rates (Allegranzi et al. ), while the inconsistent supply of water limits essential activities like handwashing and cleaning. As a result, some HCFs only minimally fulfil their role of supporting patients (Essendi et al. ). For example, lack of safe WASH infrastructure has been shown to impact women's safety, privacy and comfort accessing HCFs (Steinmann et al. ). Research links neonatal sepsis and maternal mortality to poor hygiene resulting from a lack of safe WASH (Blencowe et al. ). In developing countries, 4-56% of all healthcare-associated infections caused death during neonatal periods; 75% of these cases occurred in South East Asia and sub-Saharan Africa (SSA) (WHO ). In SSA, only 51% of HCFs have basic access to water, and only 23% have basic access to sanitation (WHO & UNICEF ). The situation of WASH in HCFs is more precarious in rural areas, where 15% of rural HCFs had no access to water services compared to 5% of urban HCFs (WHO & UNICEF ). In addition, the quality of WASH services provided remains a challenge; Guo & Bartram () found Escherichia coli in sampled water from HCFs in 14 low-and middle-income countries (LMICs).
Major global events such as climate change and disease outbreaks (e.g., Ebola and COVID-19) compound WASH service challenges. For example, water scarcity is expected in drought-prone areas (Paterson et al. ). Furthermore, recent Ebola outbreaks in SSA resulted in compromised health service delivery due to disease spread and mortality of many, including healthcare workers (Shoman et al. ). These recurring events require HCFs to be adequately equipped to sustain WASH services provision, even during adverse events. From 1990 to 2014, 18% of reported global disasters were from SSA (IMF ). This region experienced 39% of epidemics, 37% of floods and 8% of droughts globally. Building health facility resilience (i.e., the capacity to absorb the shock of an emergency and at the same time continue to provide regular health services, without jeopardising full functioning of other sectors) is critical to achieving Sustainable Development Goal 3 (health and well-being for all) and Sustainable Development Goal 6 (water and sanitation for all). Guidelines such as the Sendai Framework for Disaster Reduction aim at reducing disaster risk, loss of lives and livelihoods (United Nations ). Its fourth target seeks specifically to 'Substantially reduce disaster damage to critical infrastructure and disruption of basic services, among them health and educational facilities, including through developing their resilience by 2030' (United Nations ). Achieving this target means ensuring the effectiveness and efficiency of all the components of an HCF, including WASH. This paper explores the contribution of safe WASH to resilient HCFs, using Kisumu, Kenya as a case study. We undertook in-depth interviews with key informants (KIs) (n ¼ 13), healthcare workers (n ¼ 16) as well as community members (n ¼ 39) in order to explore the social, ecological and institutional challenges hindering access to safe WASH in HCFs. Following this introduction, we frame the paper within the political ecology of health (PEH) theory and then describe the research design and methods used.
Results stemming from a comprehensive thematic analysis of the interview data are followed by a discussion and conclusion that includes recommendations for research, policy and practice.

FRAMING ACCESS TO WASH IN LMICS
We are guided in this investigation by PEH, which provides an effective merger between political ecology and population health (King ). Using PEH, we can start to understand how health patterns are produced through circumstances of living and arrangements of power and politics (King ).
Power and politics influence decisions made at the macro scale (national governments and global agencies) as well as the mesoscale (county-level managers) subsequently affecting the quality of health service delivered at the community level. PEH also allows us to explore power struggles at the micro-level, where grassroots actors influence policies, regulations, guidelines and practices. In many parts of the world, marginalised groups have been able to resist oppression from structural processes, thus exhibiting their own power (Bryant & Bailey ). For instance, communities with attachments to and responsibility for local hospitals, through identity, politics and activism, have successfully opposed the state and other actors when these hospitals were threatened with cuts or closure (Andrews et al. ). In the context of WASH, PEH has been used to explore how institutional and individual power influenced access to water in Kenya (Bisung et al. ). In the context of HCFs, PEH can be used to explore structural factors that influence access to WASH and the agency of facility workers and managers in managing WASH in HCFs.

RESULTS
Interviews were conducted with KIs from both government and NGOs (n ¼ 13), a range of healthcare workers (n ¼ 16) as well as patients and those who care for them while in the HCFs (n ¼ 39) (Table 1). Results are presented around four key thematic areas that emerged from the qualitative analysis of the interviews. We explored the experience and perceptions of WASH in HCFs, the challenges associated with lack of WASH in HCFs, emergency preparedness and potential policy directions.

Situation of WASH in HCF
Interviews began by exploring participants' perceptions of WASH in HCFs (Table 2). Improved access was a major theme strongly highlighted by healthcare workers and facility users. As of December 2018, Kisumu Water and Sewerage Company (KIWASCO), responsible for the county piped water system, had connected water to all four communities in this research. Each facility had benefited from this investment with at least a standpipe.
However, water challenges persisted and healthcare workers and KIs were concerned about poor water quality as well as availability: 'There is improvement in the facility, first this water from KIWASCO even though it is not clean as such.' (C 4 ) Poor water quality was attributed to the interference of water lines by road contractors: 'There are a lot of road contractors, they interfere with the lines, so when they interfere with the lines you can find 'As much as the facility will want to connect, they have no resources, they don't access any money and most of the money if they get any goes into expenses like drugs, and paying of casual workers, so water is almost number 10 on their hierarchy in terms of needs, because they have more casual workers to be paid' (K 3 ) Funding constraints of course lead to inadequate staffing, with only one person per facility responsible for all cleaning responsibilities: 'One thing I can say this building is not small and I'm just alone and sometimes I'm sick there is no one to take charge that one is a challenge. Another thing also about the stipend I'm getting in the facility, it will take three to four months before I get the stipend so that one also is a challenge because I am a mother with a family so if it takes three to four months, it is a challenge to me.' (C 4 ) At the county level, inadequate staffing meant that monitoring and evaluation by county officials were often limited: 'There is lack of adequate monitoring and evaluation because when these facilities are done there should be proper monitoring and inspections before they are handed over so we can have so many projects in a county and you will find that the personnel who are supposed to do the monitoring are very few, they are not able to reach all these facilities.' (K 11 ) Systemic corruption also played a major role in inadequate WASH in healthcare facilities: 'The last opinion is corruption, people may do an incomplete project and even be paid because there are corrupt people who may intend not to follow the correct procedure, they may not follow the correct designs or they do the designs and do things halfway or haphazardly.'

(K 11 )
Prioritisation at the national and county levels is essential to ensure the allocation of funds for WASH in HCFs. At these levels, curative measures received much attention compared to preventive even with the universal health coverage (UHC). From the study, the managers of the facilities who are also the nurses-in-charge played very key roles in prioritising WASH in HCFs: 'For the government of the day, I doubt if it is a priority, because if it is a priority, then I think it could have been the first thing to be installed when this construction was being done, it was just brought by the management who saw the need for this. In fact, it was through their efforts that they managed to install water in this facility though the funds that came from the government but it was their decision to use the funds to install water in this facility but nobody from the Ministry came to sensitise them.' (CV 1 ) At the community level, some participants perceived that the national and county levels prioritise curative, because patients prioritise curative as opposed to preventive and IPC in HCFs: 'When a patient comes to the hospital, the first thing they want is drugs as opposed to the nurses washing their hands before handling them.' (K 3 ) In addition, KIs and some workers attributed the lack of WASH in HCF to the coordination and consultation process ( Table 2) All participants were asked whether or not HCFs could be resilient to such disasters. In response, 44% said no, 38% said yes and 19% were unsure (

Policy direction
We further engaged respondents in the discussion of potential policy directions to ensure resilient access to safe WASH in HCFs (

).
Finally, yearly floods from torrential rains and frequent disease outbreaks such as cholera affected the resilience of these HCFs. Soil typeblack cotton soiland floods led to the collapse of some latrines. Also, the high water table from floods pushed up medical waste in disposal pits. This is a significant health hazard especially for children who play in the area. Even though some participants felt that the facilities are prepared for any emergency because of the strong referral system, their abilities to respond and recover from emergencies were clearly linked to available WASH services that were not adequately planned for.
While these are important findings relevant to the population health of Kenya and beyond, this research is not without its limitations. The cross-sectional nature of the data collection process limits the contextual framing of the results and their determinants. Understanding the need for, challenges to, and resilience of WASH in HCFs in Kenya (and beyond) requires further research over time.
Despite this, we were able to triangulate the voices of healthcare workers, government agents, as well as patients and caregivers in order to paint a rather comprehensive picture of the experience, perceptions and challenges.