Improving water, sanitation and hygiene in health-care facilities, Liberia.

Introduction Water, sanitation and hygiene in health-care facilities are preconditions for providing health care of good quality. Despite this knowledge, a 2015 report revealed that 38% of the 66101 health-care facilities assessed in low- and middle-income countries had no source of water. (1) In Liberia, a low-income country in western Africa, only 45% of 701 surveyed health-care facilities had an improved water source in 2015, and only 27% of health-care facilities had proper disposal for infectious waste (Ministry of Health, Government of Liberia, unpublished data, 11 October 2016). The 2013-2016 Ebola virus disease outbreak in the country emphasized the importance of cleanliness, sanitation and regular hand washing. During the outbreak, the majority of patients were fearful of seeking care within health-care facilities due to risk of contracting the virus. The poor compliance with infection prevention and control measures and poor water and sanitation infrastructures and hygiene practices within the facilities further contributed to the fear. Between August and December 2014, outpatient visits were 61% lower and antenatal care visits 40% lower than the same timeframe in 2013. (2) The shortage of personal protective equipment and soap and lack of compliance with basic infection prevention and control measures--such as limited screening of patients, poor isolation facilities and training of health-care workers--contributed to 372 health workers acquiring Ebola virus disease, of whom 184 died. Here we describe the efforts made to improve the quality of health services in Liberia, focusing on the development and implementation of a package to improve water and sanitation infrastructures and hygiene practices during and after the epidemic. Local setting A survey of 701 of the 727 health-care facilities in Liberia showed that the majority of them are public (62%), followed by private for-profit (31%) and private not-for-profit facilities (7%). Most of the facilities are clinics (88%), while health centres account for 7% and hospitals 5% (Ministry of Health, Government of Liberia, unpublished data, 11 October 2016). During the epidemic, the Liberian health ministry introduced an infection prevention and control focal person into each of the 15 county's health management team. In some resource-constrained counties, the focal person also serves as the environmental health officer working on water, sanitation and hygiene. The focal person oversees the delivery of routine infection prevention and control measures and water, sanitation and hygiene health-care interventions at health-care facilities, in collaboration with the facility-based infection prevention and control focal person. The focal person is also responsible for county outbreak preparedness and response efforts related to water, sanitation and hygiene and infection prevention and control. Approach To inform the development of a package of interventions to improve and monitor water, sanitation and hygiene, the health ministry, with support from the World Health Organization (WHO), first conducted a situational assessment in 63 health-care facilities. The assessment revealed challenges in water treatment, testing of water quality and health-care waste management, including segregation, handling, treatment and final disposal of waste, a lack of ash and placenta pits and lack of protective fencing in waste management areas. In addition, environmental management was shown to be poor. (3) Subsequently, the health ministry held several multistakeholder meetings to develop the national water, sanitation and hygiene and environmental health package. The package is described in detail elsewhere. (4) Briefly, it is divided into so-called hardware and software components. Hardware components are aimed at improving overall water, sanitation and hygiene infrastructure in health-care facilities, such as construction and maintenance of water points, toilets, hand-washing equipment, burial pits for autoclaved waste and placenta pits for the disposal of placentas and other body tissues. …