February 15, 2018

A new study has produced, for the first time, estimates of the environmental conditions in health-care facilities in low- and middle-income countries around the world. Using nationally representative data from six countries, researchers calculated that only two percent of health-care facilities provide all four of water, sanitation, hygiene, and waste management services.

Dr. Jamie Bartram

Dr. Jamie Bartram

Dr. Ryan Cronk

Dr. Ryan Cronk

The study co-authors, both researchers in the Gillings School of Global Public Health at the University of North Carolina in Chapel Hill, are Ryan Cronk, a postdoctoral scholar at The Water Institute at UNC, and Jamie Bartram, PhD, Don and Jennifer Holzworth Distinguished Professor of environmental sciences and engineering and director of The Water Institute.

Their full article, titled “Environmental conditions in health care facilities in low- and middle-income countries: Coverage and inequalities,” was published online by the International Journal of Hygiene and Environmental Health.

Safe environmental conditions and the availability of standard precaution items are important to prevent and treat infection in health-care facilities. Additionally, these basics are necessary for countries to meet the Sustainable Development Goal (SDG) targets for health and water, sanitation and hygiene that have been put forth by the United Nations.

The SDGs were launched in 2015 to replace the MDGs (Millennium Development Goals); health-care facilities are a new addition based on the language the goals use around universal access: “The SDG targets aim to achieve ‘universal access’ by 2030. ‘Universal’ implies all settings, not only households, but also schools, health-care facilities, workplaces and other public spaces.”

Upon considering the SDGs, Cronk and Bartram recognized that no baseline coverage levels had ever been recorded for environmental conditions in health-care facilities. They addressed the lack of data by producing the first global estimates of both environmental conditions and standard precaution item availability in health-care facilities in low- and middle-income countries. Additionally, they explored factors associated with incidents of especially low coverage within these countries.

The researchers compiled data from monitoring reports and peer-reviewed literature and tabulated information specific to 21 indicators of environmental conditions, service levels and inequalities. After reviewing data from 78 low- and middle-income countries, which were representative of 129,557 health-care facilities, they calculated that 50 percent of health-care facilities in these countries lack piped water, 33 percent lack improved toilets and 39 percent lack handwashing soap. Furthermore, 39 percent lack adequate infectious waste disposal, 73 percent lack sterilization equipment and 59 percent lack reliable energy services.

Data analysis also revealed that statistically significant inequalities in coverage exist between facilities based on urban versus rural setting, managing authority, facility type and sub-national administrative unit.

“These results suggest that there is quite a lot of work ahead, but this is a fixable problem that should be embraced by the health sector,” Bartram said. “Fixing these problems can help to end a vicious cycle, wherein low levels of investment in improving environmental conditions and the availability of standard precautions in health-care facilities leads to higher rates of health-care acquired infections, which in turns leads to higher costs for patients and the health sector. Making these investments will result in long-run cost savings as well as help achieve the SDGs.”

By identifying these previously undocumented environmental health challenges, Cronk and Bartram hope to inform SDG stakeholders.

“This is an enormous issue,” said Bartram, “but it comes hand-in-hand with an amazing opportunity to benefit the health and well-being of millions around the globe.”


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Gillings School of Global Public Health contact: David Pesci, director of communications, (919) 962-2600 or dpesci@unc.edu

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