Written Evidence Submitted by WaterAid to International Development Select Committee

 

 

Role of water, sanitation and hygiene in COVID-19 response and resilience to future health crises

 

  1. Millions of people, in their homes and communities, as well as millions of frontline health workers do not have the basics of clean water and soap – the first line of defence against COVID-19. Three-quarters of households in Sub-Saharan Africa don’t have soap and water, and in least-developed countries nearly half of health centres lack basic water services. Millions of people are unable to follow the number one public health advice – to wash their hands and maintain high standards of hygiene. These are basic human rights that should be normal for everyone – and they are the tools that we, in wealthy countries, are using to keep ourselves safe. As acknowledged by the Secretary of State for International Development, it is only by strengthening health systems everywhere that people around the world – including in the UK and it’s NHS will be protected.

 

  1. Despite being the number one public health advice issued to individuals and an urgent priority recommendation for action from WHO to all Ministries of Health,[1] urgent investment in hygiene and the safe water systems needed to deliver hygiene, is not being prioritised by governments and donors. So far, hardly any financing announcements made by big donors and wealthy countries even mention hygiene support to developing countries. The overwhelming majority of financing commitments have focused on funding the search for a vaccine against COVID-19. While this is a vital part of ending this pandemic, it will come far too late for the poorest or marginalised people who need a massive increase in their access to water, soap and sanitation. This would prevent and protect against a catastrophic spread of the disease in countries with weak health services, already undermined by the lack of the basics. Even if a vaccine is available, WASH will remain a critical first line of defence. Also, coverage with any vaccine in low income countries and with marginalised groups will be challenging – and it is critical to ensure its roll out is underpinned by access to WASH.

 

Why hygiene, water and sanitation are vital for preventing and responding to health crises

 

  1. A lack of water, sanitation and hygiene (WASH) in homes, communities, health care facilities, public places, workplaces and schools, has devastating impacts on health and wellbeing. Poor WASH conditions and lack of hygiene practices contribute to the spread of infections and make it very difficult to control outbreaks such as COVID-19, which spreads because properly protected water sources, toilets and good hygiene habits are absent or inadequate. Lack of WASH additionally becomes a barrier to effective education, the ability to maintain livelihoods and live dignified lives.

 

  1. WASH is one of the most cost-effective strategies for increasing pandemic preparedness, particularly in low income countries and in resource constrained contexts. It is especially crucial in the absence of a vaccine for COVID-19 and where health systems are weak. Handwashing is one of the most effective disease prevention methods available. It has been shown to reduce cases of pneumonia by 50%, acute respiratory infection by 16-23%, and an up to 48% reduction in risk of endemic diarrhoea.[2] Where WASH and waste management practices are consistently applied they can serve as barriers to human-to-human transmission of the COVID-19 virus. 

 

  1. According to the WHO, investing in core public health infrastructure, including WASH systems is a 'no-regrets' policy. Frequent handwashing with soap and water is one of the key components of controlling the spread of infectious diseases, including COVID-19. Safely managed WASH services are also key to any 'recovery' phase of a disease outbreak in order to mitigate secondary impacts on community livelihoods and wellbeing. However, analysis indicates access to water and handwashing facilities and handwashing services, practices and infrastructure are lagging.In 2017, 22% (1.6 billion people) had handwashing facilities that lacked water or soap at the time of the survey, and 18% (1.4 billion people) had no handwashing facility at all.[3] This creates risks of illness and disease transmission as well as challenges to delivering safe, quality healthcare for many communities in low and middle-income countries: 

 

 

 

The importance of WASH in health care facilities 

 

 

  1. WASH services and hygiene practices within health care facilities are fundamental to the provision of safety, quality and dignity in healthcare for patients and health workers alike. Without WASH in health care facilities, frontline staff cannot deliver high quality, safe healthcare, putting the lives of patients in danger. This is especially true for those with underlying health conditions, or those with low immunity due to age or disability status. Additionally affected are those who cannot avoid healthcare facilities even in times of pandemics and are then further compromised by the lack of safe WASH such as new mothers and newborn babies. Yet these basics are frequently lacking: 

 

 

 

Poor WASH exacerbates the impact of COVID-19 on the most marginalised or poorly served populations in developing countries

 

 

  1. The poorest and most marginalised people in the world will be the worst hit by pandemics such as COVID-19, and they are being further excluded or discriminated against in the response. For example, those living in informal settlements cannot follow ‘social distancing’ and lack the basic sanitation to keep their environments clean. It is impossible to stay at home isolating if you do not have a toilet at home. The poorest who work in insecure jobs for meagre daily wages cannot ‘work from home’ and can’t afford the bills to keep their water flowing. The public health advice being given by governments is often impossible to follow for people with disabilities, unable to use inaccessible facilities or excluded from services because of stigma. The quality of life and working conditions for the world’s sanitation workers, vital ‘key workers’ crucial to ensuring public health, are being ignored. 
  2. Around the world, women already carry the burden for the majority of care-taking and health-giving work – burdens exacerbated in the current crisis.   A lack of access to water impacts on women and girls’ ability to manage menstruation during a lockdown.  Violence against women is also more prevalent during crises, and COVID-19 is no exception.  Having to travel distances to get water or access sanitation puts women and girls at great risk to violence, especially as violence against healthcare facilities and workers increases during health crises.[11]

 

Some key facts:

 

     Because of gender divisions of labour, it’s women and girls who will have to collect this extra water, perform more labour and do more caring for people who become sick.

         An estimated 70% of the global health and social care workforce are women.

         Frontline workers face increased pressure and exposure to the virus, often with little personal protective equipment. This is in the context of 55% of healthcare facilities in in least developed countries lacking basic water supplies.[12]  

 

 

Enhancing DFID and UK Government response

 

 

  1. Whilst we welcome DFID’s announcements related to hygiene through support to Unilever and IFRC, and support to Gavi, WaterAid calls for a much greater scale and urgency of prioritisation of hygiene, water and sanitation services to meet the scale of the need in low income countries.  The UN has published a Framework for the immediate socio-economic response to COVID-19. The framework calls for responses to help build “a more sustainable, gender-equal, and carbon-neutral path—better than the ‘old normal’.” The framework includes WASH as an area of focus, specifically noting the “UN’s response in the field of social protection and basic services will support governments to adapt, extend and scale-up services including water and sanitation”.[13] However, while this mention of WASH in the UN’s framework is welcome, it is clearly not being translated into urgent action by governments and donor agencies. Additionally, former UK PM Gordon Brown has released a new piece calling for more urgent and ambitious international action on COVID response and specifically mentioned WASH as a key issue for the world’s most vulnerable. The UK should use its position on the board of the World Bank to leverage more support for these measures, and to assume a position of global leadership.

 

  1. Even before the coronavirus pandemic, the financing of hygiene, water and sanitation services in poorer countries was already in crisis. Less than 15% of countries had the financing needed to implement their national hygiene, water and sanitation plans, and some countries were reporting funding gaps of more than 60% between need and money available. The WHO has issued guidance on preventing the spread of the pandemic which recommends the use of handwashing as the first line of defence in the strongest possible terms.[14] And yet, millions do not have access to this fundamental right. Now more than ever, donors need to urgently step up financial support for these basic services. 

 

WaterAid’s recommendations for UK Government leadership in COVID-19 response

 

  1. We are urging DFID to further scale up investment in WASH in its COVID response, and for the UK Government to be a global champion for the vital need for new financial commitments to hygiene, water and sanitation as a first line of defence against COVID.  Building on the ‘pledging marathon’ for COVID-19 vaccines and diagnostics launched on 4th May that Prime Minister Johnson co-hosted, we believe a similar level of ambition and new financing is needed for hygiene, water and sanitation in relation to COVID. This could be a pledging conference designed to secure commitments to a multilateral funding mechanism such as the World Bank, or a coordinated increase in bilateral financing with other major donors. Commitments that places vital hygiene, water and sanitation systems at the centre of worldwide resilience to health and climate crises.

 

  1. Additionally, as the host nation of the Gavi replenishment on 4th June and its largest contributor, the UK is in a key position to champion the need for vaccines and good hygiene to go hand-in-hand at the centre of the global COVID response. Large-scale hygiene promotion needs to be a key part of the roll-out in vulnerable communities of any coronavirus vaccine when it materialises, and integrating hygiene promotion with the continuing rollout of routine immunisations is an approach that can deliver multiple benefits as outlined by the London School of Hygiene and Tropical Medicine (LSHTM). For example, in Nepal WaterAid has supported the Ministry of Health to pioneer this approach and they are already adapting this to include COVID-19 specific behaviour change messaging.[15]

 

  1. As part of this increased investment in WASH in the context of COVID-19, we are asking DFID to embed and ringfence WASH in its funding via multilaterals, and other channels, including Country Office budgets and the RRF. For the RRF we urge DFID to consider expanding the range of recipients of funding of the Rapid Response Facility (RRF), to include relevant specialist NGO’s that bring WASH expertise. As it stands, many NGOs or Community Based Organisations are unable to access the level of funding required to meet the scale of need in some of the most vulnerable communities, for whom hygiene and access to clean water are a priority. As was seen with the Ebola outbreak, local community and civil society action was pivotal in addressing preventative measures at the scale necessary, but this was largely unfunded. NGOs are often the best channel through which to provide resources and funding on the ground.

 

  1. In its role on the board of the World Bank we believe the UK is well-positioned to ensure the Bank’s transformative funding supports investment in access to clean water and hygiene as part of this crisis response. The World Bank have yet to prioritise and invest new financing in water and hygiene as crucial interventions in combatting COVID-19. Water and sanitation utilities are critical to ensuring the continuation of services but are facing huge financial and other technical challenges.  The World Bank holds many loan and grant relationships with many of these and could easily provide debt relief and more importantly new grant financing that keeps these services switched on.

 

  1. Finally, we call on the UK government to increase invest in long-term strengthening of water, sanitation and hygiene systems in order to support communities to build long-term resilience to crises. COVID-19 is one crisis amongst many facing the most vulnerable communitiesStrong water, sanitation and hygiene systems underpin stronger health systems and therefore healthier, productive and more resilient populations.  

 

 


[1] WHO, Interim recommendations on obligatory hand hygiene against transmission of COVID-19, 1st April 2020. Available at: https://www.who.int/who-documents-detail/interim-recommendations-on-obligatory-hand-hygiene-against-transmission-of-covid-19

[2] WaterAid, How to ensure everyone can wash their hands with soap and water, to protect lives from covid19, March 2020. Available at: https://washmatters.wateraid.org/blog/how-to-ensure-everyone-can-wash-hands-to-protect-lives-from-covid19

[3] Unicef and WHO, “Progress on household drinking water, sanitation and hygiene I 2000-2017”, p. 36. Available at: https://www.unicef.org/media/55276/file/Progress%20on%20drinking%20water,%20sanitation%20and%20hygiene%202019%20.pdf

[4] WHO and UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (2019) WASH in health care facilities: Global Baseline Report 2019. Available at: https://washdata.org/sites/default/files/documents/reports/2019-04/JMP-2019-wash-in-hcf.pdf

[5] WHO and UNICEF JMP (2019) Progress on household drinking water, sanitation and hygiene 2000-2017. Special focus on inequalities. Available at: https://www.washdata.org/sites/default/files/documents/reports/2019-07/jmp-2019-wash-households.pdf

[6] Freeman, M. et al (2014) Systematic review: Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Published in Tropical Medicine and International Health Journal, 28 May 2014. Available at: https://doi.org/10.1111/tmi.12339

[7] WHO and UNICEF JMP (2018) Drinking water, sanitation and hygiene in schools: Global baseline report 2018. Available at: https://washdata.org/sites/default/files/documents/reports/2018-11/JMP%20WASH%20in%20Schools%20WEB%20final.pdf

[8] WHO and UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (2019) WASH in health care facilities: Global Baseline Report 2019. Available at: https://washdata.org/sites/default/files/documents/reports/2019-04/JMP-2019-wash-in-hcf.pdf

[9] WHO and UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (2019) WASH in health care facilities: Global Baseline Report 2019. Available at: https://washdata.org/sites/default/files/documents/reports/2019-04/JMP-2019-wash-in-hcf.pdf

[10] WaterAid, Putting equality, inclusion and rights at the centre of a COVID 19 water, sanitation and hygiene response, April 2020. Available at: https://washmatters.wateraid.org/blog/putting-equality-inclusion-and-rights-at-centre-of-covid-19-water-sanitation-and-hygiene-response
and Unicef, Mitigating the impacts of COVID-19 on menstrual health hygiene, April 2020. Available at: https://www.unicef.org/media/68371/file/Mitigating-the-impacts-of-COVID-19-on-menstrual-health-and-hygiene-Brief.pdf

and C. Wenham, J. Smith and R. Morgan, COVID-19: the gendered impacts of the outbreak, The Lancet, (vol. 395, issue 10227), 6th March 2020. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30526-2/fulltext

 

[11] WaterAid, Putting equality, inclusion and rights at the centre of a COVID 19, water, sanitation and hygiene response, April 2020. Available at: https://washmatters.wateraid.org/blog/putting-equality-inclusion-and-rights-at-centre-of-covid-19-water-sanitation-and-hygiene-response

[12] For more information, and to see case study in Nepal, see: https://washmatters.wateraid.org/blog/putting-equality-inclusion-and-rights-at-centre-of-covid-19-water-sanitation-and-hygiene-response

[13] “Shared responsibility, global solidarity and urgent action for people in need”. Available at: https://www.un.org/sites/un2.un.org/files/un_framework_report_on_covid-19.pdf

[14] WHO, Interim recommendations on obligatory hand hygiene against transmission of COVID-19, 1st April 2020. Available at: https://www.who.int/who-documents-detail/interim-recommendations-on-obligatory-hand-hygiene-against-transmission-of-covid-19

[15] SHARE, LSHTM & WaterAid, Integrating immunisation and water, sanitation and hygiene: a holistic approach to health, April 2020. Available at: https://washmatters.wateraid.org/sites/g/files/jkxoof256/files/integrating-immunisation-and-water-sanitation-and-hygiene-a-holistic-approach-to-health-policy-brief.pdf