Fivefactorsthatdrivecooperation,accountability,andsustainabilityforwaterinterventionsinhealthcarefacilities:LessonslearnedfromHondurasandGhana

Presentedby:LindsayDenny,MPH,PublicHealthProgramAssociate,EmoryUniversity

Compiledby:MiaGallegos,MDP,PublicHealthProgramAssociate,EmoryUniversity

May2016

CGSWCenter for Global Safe WASH

Leading and Learning in WASH

21.Cronk R,BartramJ,Boisson S,MontgomeryM,GordonB.2014.Water,sanitation,hygieneandenvironmentalconditionsinhealthcarefacilitiesinlow-resourcesettings.WorldHealthOrganization:Geneva.

• Anestimated61%ofhealthcarefacilitieshaveaccesstoanimprovedwatersourcewithin500m1

• year-roundaccesstowateronpremisesdropsbymorethanhalf

Hospitalwatersources Useofstoredwaterduetointermittentaccess

WaterinHealthcarefacilities– ANeglectedCrisis

3

• The2015SustainableDevelopmentGoalsincludetargettoachieve“universalaccesstosafedrinkingwaterinhealthfacilitiesby2030.”

• Majorityofhealthcarefacilitieswillrequireonsitetreatmentinordertomeetsafedrinkingwaterguidelines.

• Needtobetterunderstandthesustainabilityofwatertreatmentsystemstoimproveprovisionofsafewaterinhealthcarefacilities.

MeetingtheFundamentalNeedforSafeWaterinHealthcareFacilities

• Failureratesforwatersystemsarestillhighafterdecadesofintervention.

4

BrokenhandpumpoutsideahospitalinCambodia.Patientsandcaregiversaccesswaterwithabucketbyliftingthecover

overthewell.

• Globally,1/3ofruralwaterinfrastructureisnotfunctionalorhasmajorproblems(Akvo,2015).

SustainabilityofWASHinterventionsisaproblem

Hospitalsinthedevelopingworldare….

…Busy

…Crowded

…Chaotic

…uncleanfloorsandsurfaces

…poorinfrastructure

• GeneralElectricFoundation(GEF)donatedmembranefiltersandchlorinationsystems• 10HealthcareFacilities• 4DistrictLevelGovernmentHospitalsinHonduras

• 6DistrictLevelGovernmentHospitalsinGhana

ProjectOverview

Olanchito

Gracias

LaEsperanza

SanLorenzo

Apam

Axim

Bole

Kete-KrachiKintampo

Mampong

Toevaluatesuitabilityandthesustainabilityofsafewateraccessinhealthcarefacilitieswithwatertreatmentsystemsdonatedby

theGEF

ProjectObjective

?

?!

??

EmoryMPHstudent,SamanthaLie-Tjauw,evaluatesthehospitalwater

infrastructure(Honduras).

EmoryMPHstudent,LedorIgboh,thanksanurseafteraninterview(Ghana).

MixedMethodsApproach:• 10HealthCareFacilitiesin2countries

• Surveydata:interviewsaddressingknowledge,attitudes,andpracticesrelatedtowaterprovisionanduseinthehospital.(N=~450)– In-depthinterviewswithadministration,

directors,maintenance,andlabpersonnel– Surveyswithcareproviders,staff,patients,

andvisitors– FacilityinspectionsandObservations

regardingwater/sanitationinfrastructure

• Labdata:Testedwatersamplesformicrobialandchemicalindicatorsofwaterquality.(N=~900)– TotalColiforms,E.coli,Pseudomonas

aeruginosa,ChlorineResidual,andTurbidity

Methods

Domain

Sub-domain

Sub-domain

Sub-domain

Sub-domain

InterviewQuestions

Water QualityData

Observations

SustainabilityMetricStructure

0 1 2 3 4

Notsustainable SustainableSustainabilityCut-Point

TechnicalFeasibility•WaterSourceandAvailability

•LocalAccesstoReplacementParts

•CurrentInfrastructure•WaterQualityTesting

On-SiteCapacity•OrganizationandCommunication•TrainingandCapacityStrengthening

•Maintenance•Repairs

Accountability•MonitoringPerformance•OversightbyAnotherEntity

•FinancialOwnership•Finances

InstitutionalEngagement•DemandandAwareness•SatisfactionandPerceivedValue

•EngagementofHospitalDirectorandStaff

•EducationalMessaging

Methods

Subdomain

Domain

SustainabilityScoresChangesOverTime– DifferencesattheHospitalLevel

TrendforChange:PositiveforHondurasovertime.VariedforGhanaianHospitals.

00.51

1.52

2.53

3.54

Gracias LaEsperanza Olanchito SanLorenzo

HonduranHospitalSustainabilityScoresover3datacollectionperiods

2012 2013 2015

00.51

1.52

2.53

3.54

Apam Axim Bole KeteKrachi Kintampo Mampong

GhanaianHospitalSustainabilityScores3datacollectionperiods

2013 2014 2015

SustainabilityCutPoint

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Accountability TechnicalFeasability On-Site InsitutionalEngagement

HonduranHospitalDomainScoresOvertime

2012 2013 2015

YearlyHospitalDomainScores2012 2013 2015

Accountability 1.2 2.6 3.2TechnicalFeasibility 2.0 2.4 3.2

On-Site 2.5 2.5 3.6InstitutionalEngagement 2.2 2.5 3.0

OverallSustainability Score 2.0 2.5 3.3

ChangebetweenBaseline(2012)andEndline(2015)

Accountability +1.97

TechnicalFeasibility +1.13

On-SiteCapacity +1.13

InstitutionalEngagement +0.79

OverallChange: +1.24

Alldomainscoresshowedapositivechangebetweenbaselineandendline.ThedomainofAccountabilityshowedthemostchangeovertime.

Honduras:HospitalDomainScoresduring2012,2013,&2015DataCollection

Ghana:HospitalDomainScoresduring2013,2014,&2015DataCollection

YearlyHospitalDomainScores2013 2014 2015

Accountability 1.5 1.7 1.8TechnicalFeasibility 1.6 1.7 1.5

On-Site 1.9 2.1 2.1InstitutionalEngagement 2.3 2.5 2.6

OverallSustainability Score 1.8 2.0 2.0

ChangebetweenBaseline(2013)andEndline(2015)

Accountability +0.22

TechnicalFeasibility - 0.07

On-SiteCapacity +0.15

InstitutionalEngagement +0.33

OverallChange +0.16

Threeoutoffourdomainscoresshowedapositivechangebetweenbaselineandendline.ThedomainofInstitutionalEngagementshowedthemostchangeovertime.Changesindomainscores

overtimewerenotassignificantasthescorechangesforHonduranhospitals.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Accountability TechnicalFeasibility On-SiteCapacity InstitutionalEngagement

GhanaianHospitalDomainScoresOvertime

2013 2014 2015

FactorseffectWASHconditionsandpractices

andconsequentiallyeffectscare.

Leadstoincreasedhealthrisk

Limitedresources

OrganizationalManagement

TechnicalFeasibility• WaterSourceandAvailability

• LocalAccesstoReplacementParts

• CurrentInfrastructure• WaterQualityTesting

On-SiteCapacity• OrganizationandCommunication

• TrainingandCapacityStrengthening

• Maintenance• Repairs

Accountability• MonitoringPerformance

• OversightbyAnotherEntity

• FinancialOwnership• Finances

InstitutionalEngagement• DemandandAwareness• SatisfactionandPerceivedValue

• EngagementofHospitalDirectorandStaff

• EducationalMessaging

DifferencesbetweenHondurasandGhanaHospitalSites

?

LessonsLearned:Domainsthatchangedthemost

TheTopFiveMostDramaticScoreChangesfrom10StudyHospitalsOverTime

Domain Subdomain BroadQuestion ScoreChangeImpact fromstudyInterventions?

Accountability FinancesIsthehospitalabletopayreoccurringcostsforthe

systemanddoesitmaintainarecordoftheirfinancesregardingthewatersystem?

+2.3 No

Accountability SourcesofFunding Doesthehospitalrelyonexternalfundingforitswatersystem? +2.0 No

TechnicalFeasibility WaterSourceandAvailability

Isthereareliablewatersourcethatprovidesthequantityandavailabilityofwaterneededtomeet

demand?+1.8 Yes

OnsiteCapacity TrainingandCapacityStrengthening

Istheresufficienttrainedpersonneltomanage,maintain,andoperatethewatersystem? +1.5 Yes

OnsiteCapacity Maintenance

Aredaily,weekly,andmonthlymaintenanceproceduresfollowed?(1.3) +1.5 Yes

Istherelimiteddowntimeintheoperationofthewatersystem?(1.8)

HonduranhospitalsexperiencedthemostchangeovertimeandthesescorechangeshighlightfactorsforsuccessbutalsoshowthemaindifferencesbetweenprojectsinHondurasandGhana.

Domainsthatimprovedthemost,contributingtoenablingenvironmentsforsustainedsafewaterprovision.?

LessonsLearned

?

Canwatertreatmentsystemsimprovesustained safewaterprovisioninHealthcarefacilities?

Donationsofwellsandon-sitetreatmentsystemscanappeartobeanattractivehumanitarianactiontopromoteWASHinHCF.

BUT,ourdatasuggeststhat…• Ultramembranefiltrationsystemsarenichedonations…

• …thatrequirecarefulassessmentofthehospitalandcountrybeforeinstallation.

ResearchTeam:KatharineRobb,SamanthaLie-Tjauw,ErinSwearing,LedorSira-IdeeIgboh,Yuke“Andrew”Wang,LindsayDenny

StudyPI:Dr.ChristineLMoe

OurFunders:GeneralElectricFoundationGrantManager:AshaVarghese

TechnicalSupport:KwameAkorsa ofNewHolyfieldEngineering,JimStunkelandTimReynoldsofAssistInternational

StaffandPatientsof:Apam,Axim,Bole,Kete Krachi,Kintampo,andMampongDistrictHospitals

Thankyouto:

CGSWCenter for Global Safe WASH

Leading and Learning in WASH

Questions