Examining factors driving inequities in water, sanitation, hygiene, and waste management services in healthcare facilities in Ghana: An analysis of routine national data

The availability of basic water, sanitation, and hygiene (WASH) services forms the bedrock for infection prevention and control (IPC) practices, patient safety, disease prevention, antimicrobial resistance control, people-centred health services, and motivation and retention of healthcare workers (WHO 2017). The role of WASH in improving the quality of care is therefore critical (WHO 2017; Bouzid et al. 2018). Furthermore, WASH is core to the achievement of health-related Sustainable Development Goals (SDGs) (UN 2016) and is the fundamental element within the context of achieving Universal Healthcare Coverage (Yoder 2017). WASH is critical for reducing healthcare-associated infections, associated maternal and child mortality, and development of antimicrobial resistance (Blencowe et al. 2011; Benova et al. 2014; Graham et al. 2016; Rainey & Weinger 2016; Watson et al. 2019; WHO/UNICEF 2020; Donde et al. 2021). Hence, the lack of WASH services in healthcare facilities (HCFs) poses a significant health risk to patients, staff, and the general population (Rainey & Weinger 2016).

Globally, there are gaps in access to basic WASH services in HCFs (WHO 2020). For instance, the 2023 Global Progress Report on WASH in HCFs shows that 857 million and 780 million people do not have basic water and sanitation services, respectively (WHO & UNICEF 2023). The problem of WASH in HCFs is heightened in Sub-Saharan African countries: i.e., 54% of HCFs in Sub-Saharan African countries have no basic water service, 71% have no basic sanitation services, but there is insufficient data on hand-hygiene services (WHO 2020). This situation in the HCFs threatens IPC practices, health security, maternal and child health, dignity and human rights of careseekers, and health-related SDGs (UNICEF & WHO 2019a, 2019b; WHO & UNICEF 2023).

In Ghana, there is limited data about the status of WASH in HCFs, but a recent study by Ashinyo et al. (2021a, 2021b) in COVID-19 treatment centres revealed critical gaps in the provision of WASH services. Additionally, a situational analysis of WASH by Wateraid in the Upper East region of Ghana showed that about 24% of the facilities surveyed had an interrupted water supply. Only 48% of the HCFs had toilets; there were also gaps in access to hygiene services (WaterAid n.d.). The problem of inadequate WASH services continued to persist in HCFs because of insufficient funding, lack of political commitment, inadequate monitoring of the progress of WASH indicators, poor intersectoral collaboration, limited staff capacity, and competing interests of stakeholders (UN/GLAAS 2014; Buxton et al. 2019; Ashinyo et al. 2021a 2021b).

While studies done by Ashinyo et al. and Wateraid provide valuable insights into WASH in Ghanaian HCFs, their findings do not give a clear national picture of the availability of WASH in HCFs in Ghana, especially the variability of these services across the 16 different regions of Ghana. Additionally, a critical appraisal of the studies done by Ashinyo et al. (2021a,2021b) and WaterAid (n.d.) showed they did not report their findings according to the Joint Monitoring Programme (JMP) WASH service ladders. The JMP on WASH produces WASH indicators that can be compared internationally; their reporting format is critical in monitoring the progress towards the achievement of WASH-related SDGs (UNICEF & WHO 2019b).

Our objectives for this study were to (1) assess the status of WASH in HCFs in Ghana, and (2) examine drivers of basic WASH services in HCFs. This study is crucial as it will help reveal Ghana's progress in attaining WASH-related SDGs. Achieving the WASH-related SDGs is crucial for population health, Universal Health Coverage, and strengthening the health systems in Ghana.

The study was carried out in Ghana using the District Health Information Management System 2 (DHIMS 2) 2021 WASH data. The secondary data utilised in this study were cross-sectional in nature. These data are reported quarterly by HCFs, and are fed into the national WASH database. The data used in this study were for the last quarter of 2021.

The data for WASH in HCFs are collected at the facility level using standardised forms for entry into the DHIMS 2 platform quarterly by trained health information officers. We aggregated the extracted raw data to depict national-level WASH status in HCFs. The data were also segregated by facility type, both hospitals and non-hospitals (Community-based Health Planning and Services (CHPS), Health centres, Maternity homes, Clinics, Polyclinics, and Hospitals), and by the 16 regions of Ghana to depict the status of WASH at different levels of care and by regions.

The outcomes variables for the study were water, sanitation, hygiene, and waste management. The outcome variables were measured according to the JMP service ladders for monitoring of WASH in HCFs (WHO 2020) (Table 1).

The study involved the extraction and analysis of routine WASH-IPC data, which were reported to DHIMS 2 in 2021. The extracted data were cleaned and exported to STATA statistical software for further analysis. The extracted data were analysed using descriptive statistics such as frequencies and percentages for categorical variables. These numerical summaries (frequencies and percentages) were reported for 2021, representing the current state of WASH in HCFs in Ghana.

We recoded the availability of basic water, sanitation, hygiene, and waste management services into binary outcome variables. HCFs were considered to have basic access if they met all indicators for the JMP basic service level (as defined in Table 1). Facilities that did not meet all basic access indicators (i.e., limited or no service) were aggregated into a less-than basic access category (WHO 2020). To know the drivers of basic water, sanitation, hygiene, and waste management services, a stepwise removal of non-significant variables, with the significance of removal set at 0.20 was implemented to arrive at the final variables used in the final models. The potential predictor variables were region of the HCF, level of HCF, availability of the WASH-IPC action plan, availability of a WASH-IPC manager, availability of an assistant WASH-IPC manager, and training for the WASH-IPC manager. It is worth noting that the predictor variables considered for this analysis were those available to the researchers as part of the tool used in reporting WASH-IPC data to DHIMS 2. All analyses were considered statistically significant at p values less than 0.05. The results were reported using odds ratios with their respective confidence intervals and p values.

Complete data were available for 1,646 facilities. The majority (17%) of the facilities were from the Central region of Ghana, followed by the Northern region (12%) and the Greater Accra region (10%). Half (50%) of the facilities had WASH-IPC action plans, 67% of the facilities had WASH-IPC managers, but toilets for disabled persons were lacking in the majority (56%) of the facilities. In Ghana, 58% of the HCFs had basic sanitation services, 64% had basic hygiene services, 69% had basic water services, and less than half (44%) had basic waste management services (Table 2).

Access to basic sanitation was more likely in hospitals (OR = 12.40; 95% CI: 6.77, 22.73) and clinics (OR = 2.19; 95% CI: 1.30, 3.71) than in CHPS compounds (Table 3). We observed higher access to basic sanitation services among facilities that have an assistant WASH-IPC manager (OR = 1.90; 95% CI: 1.41, 2.58) compared with facilities that do not have an assistant WASH-IPC manager (Table 3).

Our analysis also showed the presence of a trained assistant WASH-IPC manager (OR = 0.36; 95% CI: 0.21, 0.62) seems to have resulted in an increased likelihood of having basic hygiene services (Table 3).

Facilities located in Bono (OR = 5.33; 95% CI: 1.43, 19.94) and the Greater Region (OR = 3.73; 95% CI: 2.23, 6.25) were more likely to have access to basic waste management services compared with facilities located in the Ahafo region (Table 4). Additional drivers of basic waste management services were a clinic, health centre, and hospital (Table 4).

Facilities located in the Northeast region (OR = 0.13; 95% CI: 0.05,0.31), Savannah region (OR = 0.12; 95% CI: 0.05, 0.29), and the Upper West Region (OR = 0.55; 95% CI: 0.32, 0.96) were disadvantaged in terms of access to basic water services compared with facilities in the Ahafo region (Table 4).

In this study, we evaluated the status of WASH services and drivers of basic WASH services in Ghanaian HCFs. The analysis revealed that only 69% of the HCFs had access to basic water services, meaning water is available from an improved source in 69% of the HCFs (UNICEF & WHO 2019b). This finding is higher than that of the global progress report on WASH in HCFs, 2020 (WHO & UNICEF 2020), as well as in studies conducted in Uganda (Kayiwa et al. 2020) and in six Eastern African countries (Guo et al. 2017). The availability of basic water services in most of the HCFs may be an indication of deliberate investment by the government of Ghana and development partners in the WASH sector, especially as part of the preparedness and response to the COVID-19 pandemic. Even though more than half of the facilities had basic water services, access rates remain lower than the SDG targets of universal access to water services in HCFs.

Basic water coverage was higher than that of basic sanitation coverage where a little over half of the HCFs had access to basic sanitation services. Among the WASH domains, HCFs always perform better in the water domain compared with the sanitation domain (Mulogo et al. 2018; Berihun et al. 2022). The reason for this is unclear, but the perception of the fact that water is very crucial to life may account for this trend, meaning players in the WASH sector may be prioritising water coverage compared with sanitation. The low sanitation coverage found in this study is worrying, as this could have negative repercussions on the quality of healthcare and the likelihood of healthcare-associated infections among healthcare workers, patients, and the surrounding communities. Basic hygiene services were also available in over 60% of the HCFs, meaning more than half of the HCFs had a ‘functional hand-hygiene facility (with water and soap and/or alcohol-based hand rub) at their premises’ (WHO 2020). Our finding is a little bit higher than a study conducted in Uganda, where access to basic hygiene services was 57% (Kayiwa et al. 2020).

More worrying was the finding on basic waste management services, where coverage was unacceptably low (44%), meaning only a few of the facilities had their ‘waste safely segregated into at least three bins, and sharps and infectious waste are treated and disposed of safely’ (WHO 2020). The appalling state of WASH services in the HCFs will have several negative repercussions on the quality of health service delivery, particularly care for mothers and new-borns in Ghana. For instance, some scholars elsewhere have found an association between suboptimal WASH services and the likelihood of maternal mortality (Benova et al. 2014). Indeed, elsewhere in Tanzania, early exit of the facility after delivery was linked to a lack of water for post-delivery bathing (McMahon et al. 2014). Lastly, patient disaffection with health services and women's reluctance to seek maternity care are linked to poor provision of WASH services in HCFs (Bouzid et al. 2018). This growing evidence about the role of WASH services in maternal and child healthcare calls for deliberate actions by the government of Ghana and development partners to work to address gaps in access to WASH services in HCFs.

The Greater Accra and Ashanti regions have been consistently ranked as the regions with the highest coverage of basic WASH services, to the neglect of the other regions, especially the recently created regions by the government of Ghana. These two regions might have been overprioritised for basic WASH services because they are the most developed and populous regions in Ghana and were also the two notable epicentres of the COVID-19 outbreak in Ghana that saw more investment. While this is encouraging in these two regions, we call on the government of Ghana and development partners to work to address the inequalities in regional access to basic WASH services in HCFs. More attention is needed in the recently created regions and those regions from Northern Ghana. This is crucial to attaining universal access to WASH services in Ghanaian HCFs.

We fitted a logistic model to determine the association between potential drivers of access to basic WASH services in the HCFs. The model revealed the geographical location of the HCF, level of service delivery of the HCF, and the availability of assistant WASH-IPC manager and a trained assistant WASH-IPC manager, which were significant drivers of basic WASH services. We observed higher access to basic WASH services among facilities that have a trained assistant WASH-IPC manager compared with facilities that do not have a trained assistant WASH-IPC. This is consistent with published literature from 14 low- and middle-income countries where the presence of WASH-IPC focal persons resulted in better WASH services (Kmentt et al. 2021). This finding reinforced the need for facilities to appoint WASH-IPC managers to facilitate WASH services at all levels of care as part of governance arrangements for WASH systems. Perhaps the WASH-IPC managers may highlight gaps in WASH services in their facilities and establish the appropriate quality improvement interventions in the HCFs for improvement. This may be the possible explanation for why there is an association between the presence of a WASH-IPC manager and the likelihood of having basic WASH services. While the presence of WASH-IPC structures such as a WASH-IPC action plan, a trained WASH-IPC manager, and an assistant WASH-IPC manager was beneficial to the availability of WASH services, these structures were notably lacking in CHPS, health centres, and, more importantly, where women go for childbirth (maternity homes). Indeed, the logistic regression revealed that lower facilities were disadvantaged in terms of access to basic WASH services. Therefore, WASH sector interventions by players should prioritise the lower-level HCFs to bridge the inequity gaps.

This paper is very crucial for WASH in HCFs. It is the largest-ever WASH status report in Ghanaian HCFs. Additionally, this paper has revealed potential drivers of WASH services in Ghanaian HCFs, which is worthy of note for WASH sector players in Ghana and beyond. The main limitation is that we utilised routine health service data. Hence, we could not independently verify the reported data. However, we do not doubt the competencies of the healthcare workers to report data that will truly depict the status of WASH in HCFs. Furthermore, we utilised secondary data in the analysis, hence, we could not amend or add variables we deemed necessary.

WASH form the bedrock for recommended IPC practices, healthcare worker safety, patient safety, people-centred services, and the overall quality of healthcare. Ghana has made significant progress in attaining universal access to basic WASH services in HCFs, but this progress is not without deficiencies. These deficiencies pose an immediate health risk to healthcare workers, patients, their families, and the surrounding communities. Overall, more than half of the HCFs in Ghana have basic WASH services, but less than half have basic waste management services. The potential drivers of basic WASH services in Ghanaian facilities are geographic location of the HCF, level of service delivery of the HCF, and the availability of an assistant WASH-IPC manager and a trained assistant WASH-IPC manager. There are inequalities in access to basic WASH services regionally and at different facility levels. The analysis also revealed significant gaps in WASH-IPC structures in Ghanaian HCFs with WASH-IPC structures notably lacking in CHPS compounds, health centres, and, more importantly, where women go for childbirth (maternity homes).

The findings of this study have implications for WASH sector policies and programming in Ghana: (1) urgent WASH actions are required at the national, regional, and HCFs levels to help improve WASH conditions in HCFs. This is crucial in scaling up WASH coverage in Ghanaian HCFs, thereby minimising the risk of healthcare-associated infections and their associated costs, (2) urgent intentional policy actions are needed to prioritise investments in WASH-deprived HCFs and regions in Ghana, (3) there is a need for training and capacity building of personnel on WASH in HCFs coupled with the allocation of sufficient resources to WASH activities to enable the healthcare workers to operate and maintain WASH facilities, and (4) this study further recommends that the building of new HCFs should fully incorporate WASH services. This recommendation is crucial in the building of WASH impoverished facilities like CHPS, health centres, and maternity homes in Ghana.

We thank the World Health Organisation Country Office, Ghana, for the financial and technical support in implementing this project. The authors would like to thank WASH-IPC managers in the various HCFs for the continuous efforts in collecting and inputting the WASH data into DHIMS 2.

The study is an analysis of secondary data. Additionally, the study did not include any patient-level data; hence, no ethics approval or patient consent was required.

Data cannot be made publicly available; readers should contact the corresponding author for details.

The authors declare there is no conflict.