Dr. Md. Aurangzeb
Imagine a mother, in the throes of labour, choosing to risk a birth at home rather than seek the presumed safety of a clinic. Her reason? Not cost, nor distance, but the visceral fear of the facility itself – the stench of overflowing latrines, the sight of blood-stained floors, the absence of soap and clean water. This is not a scene from a distant past, but a present-day reality in far too many healthcare facilities (HCFs) globally, undermining decades of public health progress. The neglect of Water, Sanitation, Hygiene (WASH), and environmental conditions within the very institutions meant to heal constitutes a profound betrayal of public health principles and a critical failure in our pursuit of health equity and universal coverage.
The evidence linking poor WASH in HCFs to devastating health outcomes is unequivocal and mounting. These are not mere inconveniences; they are vectors for infection, engines of AntiMicrobial Resistance (AMR), and direct contributors to preventable morbidity and mortality. Studies consistently show that inadequate sanitation and hygiene in HCFs are major drivers of Healthcare-Associated Infections (HAIs), turning places of healing into sites of danger. Critically, this failure has a disproportionate impact on the most vulnerable. As highlighted in reviews of maternal and child health, poor WASH conditions are a significant cause of patient dissatisfaction and a powerful deterrent, particularly for women seeking essential institutional delivery and newborn care. When mothers fear infection more than the perils of unattended birth, our health systems have failed a fundamental test. The consequence is stark: limited access to improved WASH directly undermines the quality of care (QoC) and sabotages hard-won gains in maternal and child survival.
The global picture, as reported by the WHO/UNICEF Joint Monitoring Programme, remains alarming. Despite being fundamental to safe care, only around half of healthcare facilities globally provide basic water services, and even fewer have basic sanitation and hygiene services at the point of care. This gap represents a catastrophic blind spot in health systems strengthening. Bangladesh, like many nations, recognizes this crisis and its National Strategy for WASH in Healthcare Facilities and Framework for Action 2019-2023 represents a crucial step forward. Its objective – to standardize Infection Prevention and Control (IPC) and usher in quality healthcare – is laudable and urgently needed. Its multi-pronged approach, focusing on building a robust national evidence base, harmonizing monitoring, developing specific standards and operation/maintenance frameworks, upgrading infrastructure with equity in mind, improving medical waste management, building IPC capacity, engaging communities, and establishing sustainable coordination and financing, provides a comprehensive roadmap. This strategy correctly identifies that fixing WASH in HCFs is not merely a construction project but requires embedding standards, building capacity, ensuring accountability, and securing long-term resources within the health system.
However, a national strategy, however well-designed, is only the beginning. The true challenge lies in its resourced implementation and the political will to prioritize what has been historically sidelined. The public health imperative is undeniable. WASH is the bedrock upon which effective healthcare is built. It is the first line of defence against the spread of pathogens within facilities. Without it, even the most advanced medical interventions are compromised.
The global picture, as reported by the WHO/UNICEF Joint
Monitoring Programme, remains alarming. Despite being
fundamental to safe care, only around half of healthcare
facilities globally provide basic water services, and even fewer
have basic sanitation and hygiene services at the point of care
Hand hygiene, reliant on accessible water and soap, is arguably the single most effective measure to prevent transmission. Safe sanitation prevents the contamination of the healthcare environment with human waste, a major source of pathogens. Reliable water is essential for sterilizing equipment, cleaning surfaces, and performing basic clinical procedures. Poor WASH fuels the AMR crisis by creating environments where infections spread easily, driving unnecessary antibiotic use and ultimately breeding resistant superbugs – a global threat demanding urgent, multifaceted action, of which WASH in HCFs is a critical pillar.
Furthermore, the impact extends beyond infectious diseases. Bangladesh, facing a significant double burden of disease with Non-Communicable Diseases (NCDs) like heart disease and diabetes now causing the majority of deaths, still relies heavily on functional HCFs for screening, management, and treatment. Patients undergoing surgery, chemotherapy, or dialysis are exceptionally vulnerable to infections. Poor WASH conditions jeopardize these life-saving interventions, adding unnecessary risk and potentially fatal complications to already challenging treatments. It erodes trust in the health system, discouraging people from seeking care for any condition until it becomes critical, further straining resources and worsening outcomes.
Addressing this crisis demands more than isolated projects; it requires systemic integration. WASH standards must be mandated, monitored, and enforced with the same rigor as clinical standards. Investment in WASH infrastructure and its ongoing operation and maintenance must be recognized not as a discretionary add-on, but as core, non-negotiable healthcare expenditure. Training for all healthcare workers – doctors, nurses, cleaners, technicians – must consistently emphasize and empower IPC practices grounded in functional WASH. Communities have a right to demand and expect clean, safe facilities and should be engaged as advocates and monitors. Crucially, financing mechanisms must move beyond donor dependence towards sustainable domestic allocation, recognizing WASH in HCFs as fundamental to efficient and effective healthcare delivery and a prerequisite for achieving Universal Health Coverage (UHC). As Bangladesh's strategy acknowledges, documenting successes and failures is vital for learning and scaling effective approaches nationally and contributing to the global evidence base.
The neglect of WASH in healthcare facilities is a public health emergency hiding in plain sight. It undermines every other health investment, fuels AMR, discourages health-seeking behaviour, and costs lives – particularly those of mothers and newborns. Bangladesh’s strategic framework offers a path.
Now, the world, and nations like Bangladesh leading the charge, must summon the political courage and financial commitment to translate strategy into reality. We must build and maintain healthcare facilities where the environment itself actively promotes healing, not harbours harm. Until every clinic and hospital worldwide can guarantee this most basic foundation of safety and dignity, our declarations about quality healthcare and universal coverage ring hollow. The health of millions, and the integrity of our health systems, depend on us finally washing our hands of this deadly neglect.
Dr. Md. Aurangzeb is a distinguished public health expert with two decades of experience. Renowned as an academic leader, author and media commentator, he champions critical issues including WASH, health education, policy reform, and humanitarian interventions. Contact: dr.aaru@gmail.com.
