Five Factors That Drive Cooperation, Accountability, and Sustainability for Water Interventions in Healthcare Facilities: Lessons Learned from Honduras and Ghana

Leading and CGSW Learning in WASH Center for Global Safe WASH

Five factors that drive cooperation, accountability, and sustainability for water interventions in healthcare facilities: Lessons learned from Honduras and Ghana

Presented by: Lindsay Denny, MPH, Public Health Program Associate, Emory University

Compiled by: May 2016 Mia Gallegos, MDP, Public Health Program Associate, Emory University Water in Healthcare facilities – A Neglected Crisis

• An estimated 61% of healthcare facilities have access to an improved water source within 500m1 • year-round access to water on premises drops by more than half

Hospital water sources Use of stored water due to intermittent access

1. Cronk R, Bartram J, Boisson S, Montgomery M, Gordon B. 2014. Water, sanitation, hygiene and environmental conditions in 2 health care facilities in low-resource settings. World Health Organization: Geneva. Meeting the Fundamental Need for Safe Water in Healthcare Facilities

• The 2015 Sustainable Development Goals include target to achieve “universal access to safe drinking water in health facilities by 2030.”

• Majority of healthcare facilities will require onsite treatment in order to meet safe drinking water guidelines.

• Need to better understand the sustainability of water treatment systems to improve provision of safe water in healthcare facilities.

3 Sustainability of WASH interventions is a problem

• Failure rates for water systems are still high after decades of intervention.

Broken hand pump outside a hospital in Cambodia. Patients and caregivers access water with a bucket by lifting the cover over the well. • Globally, 1/3 of rural water infrastructure is not functional or has major problems (Akvo, 2015).

4 Hospitals in the developing world are…. … Busy …Crowded … Chaotic … unclean floors and surfaces … poor infrastructure Project Overview

• General Electric Olanchito Foundation (GEF) Gracias donated membrane filters and chlorination La Esperanza systems • 10 Healthcare San Lorenzo Facilities • 4 District Level Government Hospitals in Honduras • 6 District Level Bole Government Hospitals Kintampo in Ghana Kete-Krachi

Mampong

Apam

Axim Project Objective

To evaluate suitability and the sustainability of safe water access in healthcare facilities with water treatment systems donated by the GEF

? ? ? ! ? Methods

Mixed Methods Approach: • 10 Health Care Facilities in 2 countries • Survey data: interviews addressing knowledge, attitudes, and practices related to water provision and use in the hospital. (N=~450) Emory MPH student, Ledor Igboh, thanks a nurse after an interview (Ghana). – In-depth interviews with administration, directors, maintenance, and lab personnel – Surveys with care providers, staff, patients, and visitors – Facility inspections and Observations regarding water/sanitation infrastructure • Lab data: Tested water samples for microbial and chemical indicators of water quality. (N=~900) – Total Coliforms, E. coli, Pseudomonas Emory MPH student, Samantha Lie- Tjauw, evaluates the hospital water aeruginosa, Chlorine Residual, and Turbidity infrastructure (Honduras). Methods

Domain Sustainability Technical On-Site Metric Structure Feasibility Capacity Subdomain •Water Source and •Organization and Sub-domain Availability Communication •Local Access to •Training and Capacity Replacement Parts Strengthening •Current Infrastructure •Maintenance Sub-domain Interview •Water Quality Testing •Repairs Questions Domain Accountability Institutional Sub-domain Water Quality •Monitoring Performance Engagement Data •Oversight by Another Entity •Demand and Awareness •Satisfaction and Perceived Sub-domain •Financial Ownership Value •Finances Observations •Engagement of Hospital Director and Staff •Educational Messaging

0 1 2 3 4

Not sustainable Sustainability Sustainable Cut-Point Sustainability Scores Changes Over Time – Differences at the Hospital Level

Honduran Hospital Sustainability Scores over Ghanaian Hospital Sustainability Scores 3 data 3 data collection periods collection periods

4 4 3.5 3.5 3 3 2.5 2.5 2 2 1.5 1.5 1 1 0.5 0.5 0 0 Gracias La Esperanza Olanchito San Lorenzo Apam Axim Bole Kete Krachi Kintampo Mampong

2012 2013 2015 2013 2014 2015

Sustainability Cut Point

Trend for Change: Positive for Honduras overtime. Varied for Ghanaian Hospitals. Honduras: Hospital Domain Scores during 2012, 2013, & 2015 Data Collection

Change between Baseline Honduran Hospital Domain Scores Overtime (2012) and Endline (2015)

4.0 Accountability +1.97 3.5 Technical 3.0 +1.13 Feasibility 2.5 On-Site 2.0 +1.13 Capacity 1.5 1.0 Institutional +0.79 0.5 Engagement

0.0 Accountability Technical Feasability On-Site Insitutional Engagement Overall Change: +1.24

2012 2013 2015

Yearly Hospital Domain Scores 2012 2013 2015 Accountability 1.2 2.6 3.2 Technical Feasibility 2.0 2.4 3.2 On-Site 2.5 2.5 3.6 Institutional Engagement 2.2 2.5 3.0 Overall Sustainability Score 2.0 2.5 3.3 All domain scores showed a positive change between baseline and endline. The domain of Accountability showed the most change over time. Ghana: Hospital Domain Scores during 2013, 2014, & 2015 Data Collection

Change between Baseline Ghanaian Hospital Domain Scores Over time (2013) and Endline (2015)

4.0 Accountability +0.22 3.5 Technical 3.0 - 0.07 Feasibility 2.5 2.0 On-Site +0.15 1.5 Capacity 1.0 Institutional 0.5 +0.33 0.0 Engagement Accountability Technical Feasibility On-Site Capacity Institutional Engagement

2013 2014 2015 Overall Change +0.16

Yearly Hospital Domain Scores 2013 2014 2015 Accountability 1.5 1.7 1.8 Technical Feasibility 1.6 1.7 1.5 On-Site 1.9 2.1 2.1 Institutional Engagement 2.3 2.5 2.6 Overall Sustainability Score 1.8 2.0 2.0 Three out of four domain scores showed a positive change between baseline and endline. The domain of Institutional Engagement showed the most change over time. Changes in domain scores over time were not as significant as the score changes for Honduran hospitals. Organizational Management Factors effect WASH conditions and practices and consequentially effects care.

Limited resources

Leads to increased health risk Differences between Honduras and Ghana Hospital Sites

Technical On-Site Capacity Feasibility • Organization and Communication • Water Source and Availability • Training and Capacity Strengthening • Local Access to Replacement Parts • Maintenance • Current Infrastructure • Repairs • Water Quality Testing

Accountability Institutional • Monitoring Engagement Performance • Demand and Awareness • Oversight by Another • Satisfaction and Entity Perceived Value • Financial Ownership • Engagement of Hospital • Finances Director and Staff • Educational Messaging Lessons Learned: Domains that changed the most

Domains that improved the most, contributing to enabling ? environments for sustained safe water provision. Honduran hospitals experienced the most change over time and these score changes highlight factors for success but also show the main differences between projects in Honduras and Ghana.

The Top Five Most Dramatic Score Changes from 10 Study Hospitals Over Time Impact from study Domain Subdomain Broad Question Score Change Interventions? Is the hospital able to pay reoccurring costs for the Accountability Finances system and does it maintain a record of their finances +2.3 No regarding the water system? Does the hospital rely on external funding for its water Accountability Sources of Funding +2.0 No system? Is there a reliable water source that provides the Water Source and Technical Feasibility quantity and availability of water needed to meet +1.8 Yes Availability demand? Training and Capacity Is there sufficient trained personnel to manage, Onsite Capacity +1.5 Yes Strengthening maintain, and operate the water system? Are daily, weekly, and monthly maintenance procedures followed? (1.3) Onsite Capacity Maintenance +1.5 Yes Is there limited downtime in the operation of the water system? (1.8) Lessons Learned

Can water treatment systems improve sustained safe water provision in Healthcare facilities?

Donations of wells and on- BUT, our data suggests that… site treatment systems can • Ultra membrane filtration appear to be an attractive systems are niche humanitarian action to donations… promote WASH in HCF. • …that require careful assessment of the hospital and country before installation.

? Leading and CGSW Learning in WASH Center for Global Safe WASH Thank you to: Research Team: Technical Support: Katharine Robb, Samantha Lie- Kwame Akorsa of New Holyfield Tjauw, Erin Swearing, Ledor Sira-Idee Engineering, Jim Stunkel and Tim Igboh, Yuke “Andrew” Wang, Lindsay Reynolds of Assist International Denny Staff and Patients of: Study PI: Apam, Axim, Bole, Kete Krachi, Dr. Christine L Moe Kintampo, and Mampong District Our Funders: Hospitals General Electric Foundation Grant Manager: Asha Varghese Questions