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WaterAid submission to the International Development Committee’s inquiry into FCDO’s approach to sexual and reproductive health
1.1. WaterAid is an international not-for-profit organisation working to make clean water, decent toilets, and good hygiene normal for everyone, everywhere within a generation. We are committed to advance gender equality in water, sanitation, and hygiene (WASH) in the long-term through changes in norms and systems, including working with the sexual reproductive health and rights (SRHR) sector.
1.2. Our evidence includes a submission from a representative of the Christian Health Association of Malawi, whose members make up 30% of Malawi’s healthcare facilities and run 11 of Malawi’s 15 healthcare training institutions.
2.1. WASH is not only essential for health and safety during the reproductive cycle, but also plays a critical role in maintaining sexual health and preventing and treating infections and injuries. It is fundamental to ending preventable deaths of mothers and babies.
2.2. WASH is not just an issue of service delivery, but one of health, rights, and dignity. If WASH and SRHR interventions are better integrated, increased health and women’s rights outcomes can be achieved.
2.3. The government has made alarming cuts to the WASH sector, which will hamper the realisation of their ambitions on SRHR. FCDO should adopt a ‘WASH in all policies’ approach to maximise the impact of their strategy on Women and Girls, including by integrating and resourcing WASH interventions within SRHR programmes.
2.4. FCDO should include WASH in healthcare facilities minimum standards in all SHRH programming, service delivery policies and guidelines and advocate for national governments to do this too at national and subnational levels.
3.1. Every minute a new-born dies from infection caused by lack of safe water and an unclean environment. Lives that could have been saved by the simple act of being washed in clean water and cared for in a clean environment by people who had washed their hands[i].
3.2. Having WASH facilities readily available in healthcare settings dramatically improves reproductive, maternal, adolescent and child health. Practising straightforward hygiene during antenatal care, labour and birth reduces the risk of healthcare-acquired infections, sepsis and death for infants and mothers. Yet, women are still giving birth in environments that do not have clean water, soap and sanitation and are attended to by carers who cannot observe basic hygiene practices.
3.3. Half of the world’s healthcare facilities do not have basic hand hygiene services – rising to two thirds across the 46 least developed countries (LDCs). That means in 2021, 3.85 billion people used healthcare facilities without basic hand hygiene services, 1.7 billion used facilities that lacked basic water services, and 780 million used facilities with no sanitation services[ii].
3.4. The tragic consequences highlight shocking global inequality. For example, babies born in hospitals in low- and middle-income countries (LMICs) are up to 20 times more likely to develop neonatal sepsis than are hospital-born babies in high-income countries like the UK.[iii] This is even more tragic when you consider that more than half of all cases of healthcare-associated sepsis are thought to be preventable through basic WASH services and appropriate infection, prevention and control (IPC) measures[iv].
3.5. A recent study in LMICs that found very high levels of sepsis-causing bacteria resistant to antibiotics in mothers and, even more so, in their newborn babies. The study found that that frequent handwashing by mothers reduced the risk of carrying resistance genes (compared to occasional handwashing) and underscores the importance of access to safe water, sanitation, and especially good hygiene to reduce neonatal sepsis and mortality rates in LMICs.[v]
4.1. Lack of WASH in healthcare facilities contributes to significant patient dissatisfaction and stops women from seeking maternity care[vi], which contributes to poor health outcomes for mothers and babies. Improving WASH in healthcare facilities should be prioritised as a means of tackling healthcare-acquired infections, but also to improve patient satisfaction and encourage timely seeking of care.
4.2. When the White Ribbon Alliance asked women from 114 countries about their top demands for maternal healthcare, they received 1.2 million responses with a clear message: after respectful and dignified care, women’s second highest priority was WASH. Women want safe, dignified care — and that includes having health facilities with running water, private toilets, and clean beds and sheets.[vii]
4.3. Women comprise 70% of the world's healthcare workers[viii], making the lack of WASH in healthcare facilities an issue of women’s right to health and safety. It places healthcare providers at increased risk of healthcare-associated infections, undermining their safety, motivation and ability to do their job well in a clean and safe environment. This can contribute to the challenge of retaining staff, particularly in rural areas. Ensuring all healthcare facilities have access to these most basic of services would not only improve workplace safety but would also address the specific needs of women, such as menstrual hygiene management.
4.4. A further study by the White Ribbon Alliance in 2021 surveyed 56,105 midwives in 101 countries to hear directly about their needs and wants. 33% of midwives around the world desire to work in an environment where they have access to basic needs that should be afforded to any health provider: space, equipment, clean water, and medicines to treat the women in their care. This is their second highest demand - second only to calls for more human resources[ix].
5.1. Addressing menstrual health (MH) enables women and adolescent girls to better deal with menstruation and acts as a starting point for discussions around SRHR. MH is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in relation to the menstrual cycle. Despite being a critical pathway for gender equality and female empowerment, MH is a largely overlooked aspect of development.
5.2. Achieving MH implies that women, girls, and all other people who experience a menstrual cycle, throughout their life-course, are able to access accurate, timely, age-appropriate information about the menstrual cycle, menstruation, and changes experienced throughout the life-course, as well as related self-care and hygiene practices. [x]
5.3. WASH services and non-inclusive infrastructure, such as a lack of female-friendly public toilets, hamper the fulfilment of SRHR, including the right to health, the right to autonomy and bodily integrity, the right to privacy, the right to equality and non-discrimination, and the right to be free from sexual violence[xi].
5.4. Poor access to gender-sensitive WASH facilities limit the ability for women and girls to manage their periods safely, privately, hygienically, and without stigma. When women and girls can better deal with their menstrual needs, they can go to school for longer, participate in the workforce more effectively and contribute to their communities in more productive ways.
5.5. Normalising discussions among women, men and young people on reproduction, menstruation, hygiene and SRH can contribute to raising the profile of MH as an important issue for women and girls, and contribute to shifting cultural norms, gender attitudes and addressing taboos.
6.1. The focus of FCDO’s new global Women and Girls strategy, as well as the integrated approach to WASH as set out in FCDO’s Ending Preventable Deaths approach papers are welcome steps in the right direction, but the drastic cuts to FCDO WASH funding raises alarming concerns about whether their ambitions on women’s and girls’ rights can be met – including those on sexual and reproductive health and rights.
6.2. The UK Government has previously stated that when funding to women and girls would be restored it would include addressing period poverty and shame[xii]. Yet, while the importance of WASH is briefly referenced in FCDOs Women and Girls strategy, it fails to place enough emphasis on these basics which are transformational to the life chances of women and girls and it mentions menstruation just once.
7.1. At the UN Water Conference in March 2023, FCDO Minister Lord Goldsmith announced a new UK initiative titled ‘WASH systems for Health’, with a budget of £18.5 million. This funding will help provide safe, reliable, and affordable water supply sanitation and hygiene services that help prevent disease, protect people’s health and safeguard the environment from pollution in five countries. It is a key part of the UK government’s commitment to help end the preventable deaths of mothers, young children and infants.
7.2. We need to see many more initiatives like this to build FCDOs WASH programming. Since 2018, the UK aid budget for WASH has been cut by two-thirds, falling from £206.5 million, to approx. £70 million in 2021. For comparison, in 2021, Education received £364,454,107, and Health received £548,027,515.[xiii]
7.3. These cuts pre-date the subsequent development aid cuts and it is important to recognise that WASH as a proportion of the UK ODA budget was already significantly underfunded and resourced compared to its stated level of strategic importance for UK development – despite that fact that polling by YouGov for WaterAid indicates that 53% of the British public list WASH as one of their top three most important ways of spending UK official development assistance[xiv].
8.1. The estimated cost of achieving universal access to WASH in existing healthcare facilities in the world’s 46 LDCs is around $9.6 billion[xv] – an average of just $0.65 per person per year. A recent analysis commissioned by WaterAid found that $960 million annually up to 2030 of additional funding is required. Given Governments have the ultimate responsibility to uphold the health and dignity of their citizens and play a critical role in delivering public services, they must be considered the primary source for mobilising funds for WASH in healthcare facilities. LDCs could reasonably be expected to fund $355 million of this annually from internal sources.
8.2. That would leave $601 million of catalytic funding annually up to 2030 required from external financing. Based on the relative economic power of the most credible grouping of donor countries, G7 countries have by far the largest share of annual funding required at $470 million, or 78% of total funding needed.[xvi]
8.3. At $34.5 million annually the UK’s fair share is 6% of the total annual funding needed – which is just 0.3% of its overseas aid budget.[xvii] This is a key call to action in the recent joint WASH and Antibiotics APPGs’ report, Prevention First: why clean water and hygiene are the best medicine against the spread of drug resistant infections.[xviii]
9.1. Building upon recent £18.5 million WASH for Health funding announcement and:
9.1.1. scaling up financial investment for WASH in a comprehensive approach to improve health outcomes for women and girls, including SRHR, and monitor these investments.
9.1.2. making specific funding available to catalyse progress on WASH in healthcare facilities, for which the UK’s fair share of funding is $34.5 million annually.
9.2. Taking the lead on international advocacy to ensure all healthcare settings have adequate access to WASH by advocating additional financing for WASH in healthcare facilities by all countries.
9.3. Adopting a ‘WASH in all policies’ approach to maximise the impact of their strategies on Women and Girls and Ending Preventable Deaths by integrating and resourcing WASH interventions within those programmes.
9.4. Including WASH in healthcare facilities minimum standards in all SHRH programming, service delivery policies and guidelines and advocate for national governments to do this too at national and subnational levels.
10.1. I am a nurse and midwife by profession. I have a lot of first-hand experience working in healthcare facilities and I am currently a training manager at Christian Health Association of Malawi (CHAM). Our members make up 30% of Malawi’s healthcare facilities and run 11 of Malawi’s 15 healthcare training institutions. Through our training institutions we train up to 80% of mid-level health care workers in the country most of whom graduate to work in the rural health facilities. 10.2. Imagine a situation where there is no running water in a facility and healthcare workers and patients, or their guardians must travel some distance to fetch water. We have so many situations like these where there is no running water available either due to broken water systems, unavailability of water pumps and water tanks, no hand hygiene facilities and health care workers must be cautious on how they use the available water. This means that healthcare workers must ration water supplies and the care provided is suboptimal at different levels. 10.3. Midwives move from taking care of one expecting mother to another without washing their hands; and sometimes they must stop working to go and fetch water, sometimes from shared water sources with communities like a well, streams, rivers or a lake. This water is not always clean but must be used for cleaning surfaces, cleaning and decontaminating instruments used for wound dressing, cervical cancer screening or deliveries in the labour, washing bed linen, cleaning the floor and surfaces, handwashing, and to take medicine with. 10.4. Most of the health care facilities have waiting homes where expecting mothers who live far from the health facility will stay as they are nearing their expected date of delivery. Usually expecting mothers come alone to these waiting homes and guardians join them later when they are nearing delivery. In cases where there is no running water, these mothers must go and fetch their own water for use. Having proper WASH facilities in the waiting homes will make the homes more attractive to mothers increasing the number of safe deliveries and improving maternal outcomes. 10.5. The lack of adequate water results in poor infection prevention and control measures at the health facilities including poor decontamination of instruments. In cases where a labouring woman comes in at an advanced stage, and the woman cannot be referred to the district hospital, the midwives have no choice but to use the available delivery instruments increasing the risk of neonatal infections and poor maternal and neonatal outcomes. 10.6. In cases where the instruments used for cervical cancer screening or insertion of long-term contraceptive methods are not decontaminated women and girls seeking these services are sent back and asked to return at a later date. Most of whom do not return because either they got pregnant along the way, or they changed their mind. I remember sending back a woman who came in for insertion of an Intra-uterine device (IUD) for contraception who came back later while pregnant with a 6th child which she had not planned for because her husband was not responsible and was not providing for the family. She had wanted the IUD because she did not want any hormonal contraceptives when they were offered to her and had promised to come back later. The husband left her for another woman when he learned about the pregnancy. 10.7. All these situations leave you helpless, frustrated and demotivated knowing pretty well that the care you are providing is suboptimal and you are continuously putting yourself and those you are caring for at risk of hospital acquired infections. 10.8. This is particularly an issue for women and girls. Every two seconds, a woman gives birth in a healthcare centre without clean water, decent toilets and good hygiene globally. That’s 16.6 million women a year, putting them and their unborn babies at risk of deadly infections. More than one million deaths each year are associated with unclean births. 10.9. What’s more, us women comprise 70% of the world's health care workers, and 90% of the world's nurses, making the lack of WASH in healthcare facilities an issue of women’s right to health and safety. Because we are the ones bearing this risk and this burden everyday. We can’t continue working in such environments anymore putting ourselves and our patients at risk and putting us at odds with the oath that we took. We need immediate and urgent action from all of you to improve access to WASH in healthcare facilities in Malawi. 10.10. The Ministry of Health in Malawi has recently developed a WASH in healthcare facilities Roadmap[xix] to provide direction for the health sector to strengthen WASH interventions implemented in healthcare facilities. I ask that the UK Government works with the Malawi government to finance scaling up national access to WASH in healthcare facilities and implementation of the Roadmap, for which Malawi needs to mobilize financing in excess of US$9m. |
For further information about this submission, including questions to Pacharo Matchere, please contact Rhian Lewis, Senior Advocacy Advisor, at rhianlewis@wateraid.org.
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[i] United Nations Department of Economic and Social Affairs (2015). United Nations Populations Division, 2015.
[ii] Progress on WASH in health care facilities 2000–2021: special focus on WASH and infection prevention and control (IPC). Geneva: World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), 2022. Available at: https://www.who.int/publications/i/item/9789240058699.
[iii] Zaidi, Anita K M et al. “Hospital-acquired neonatal infections in developing countries.” Lancet vol. 365,9465 (2005). Available at: https://pubmed.ncbi.nlm.nih.gov/15794973/.
[iv] Progress on WASH in health care facilities 2000–2021: special focus on WASH and infection prevention and control (IPC). Geneva: World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), 2022. Available at: https://www.who.int/publications/i/item/9789240058699.
[v] Carvalho, M.J., Sands, K., Thomson, K. et al. Antibiotic resistance genes in the gut microbiota of mothers and linked neonates with or without sepsis from low- and middle-income countries. Nat Microbiol 7, 1337–1347 (2022). Available at: https://doi.org/10.1038/s41564-022-01184-y.
[vi] 1. Bouzid M, Cumming O, Hunter P (2018). What is the impact of water sanitation and hygiene in healthcare facilities on care seeking behaviour and patient satisfaction? A systemic review of the evidence from low-income and middle income countries. BMJ Global Health. vol 3, no 3. Available at: https://gh.bmj.com/content/3/3/e000648.
[vii] What women want report, 2022, White Ribbon Alliance. Available at https://whiteribbonalliance.org/resources/what-women-won-report/.
[viii] WHO (2019). Gender equity in the health workforce: Analysis of 104 Countries. Available at: https://apps.who.int/iris/bitstream/handle/10665/311314/WHO-HIS-HWF-Gender-WP1-2019.1-eng.pdf?ua=1.
[ix] Midwives’ Voices, Midwives’ Demands Global Report, White Ribbon Alliance, 2021. Available at https://whiteribbonalliance.org/resources/midwives-demands-global-report/.
[x] Hennegan, J., Winkler, I.T., Bobel, C., Keiser, D., Hampton, J., Larsson, G., Chandra-Mouli, V., Plesons, M., & Mahon, T. (2021) Menstrual Health: A Definition for Policy, Practice, and Research. Sexual and Reproductive Health Matters. Available at: https://doi.org/10.1080/26410397.2021.1911618.
[xi] International Planned Parenthood Federation (2003). IPPF Charter Guidelines on Sexual and Reproductive Health and Rights. Available at: https://www.ippf.org/sites/default/files/ippf_charter_on_sexual_and_reproductive_rights_guidlines.pdf.
[xii] Letter from then FCDO Minster, Vicky Ford, to Chairs to APPGs on WASH and Antibiotics.
[xiii] The UK’s changing approach to water, sanitation and hygiene, ICAI, 2022. Available at: https://icai.independent.gov.uk/new-information-note-the-uks-changing-approach-to-water-sanitation-and-hygiene/
[xiv] All figures, unless otherwise stated, are from YouGov Plc. Total sample size was 1,781 adults. Fieldwork was undertaken between 11th – 12th August 2022. The survey was carried out online. The figures have been weighted and are representative of all GB adults (aged 18+).
[xv] Chaitkin M, et al (2022). Estimating the cost of achieving basic water, sanitation, hygiene, and waste management services in public health-care facilities in the 46 UN designated least-developed countries: A modelling study. Lancet Global Health. vol 10, issue 6. Available at: www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00099-7/fulltext.
[xvi] WaterAid research and analysis, 2021.
[xvii] WaterAid research and analysis, 2023.
[xviii] Joint WASH and Antibiotics APPG report (2023) Prevention First: why clean water and hygiene are the best medicine against the spread of drug resistant infections. Available at: https://appg-on-antibiotics.com/assets/APPG_report_FINAL_updated.pdf.
[xix] Malawi WASH in healthcare facilities Road Map available at https://www.washinhcf.org/wp-content/uploads/2022/05/WASH-IN-HCF-ROAD-MAP_Malawi_Apr22.pdf