Assessing the Sustainability of Decentralized Water Treatment Systems in Six Ghanaian Hospitals between 2013 and 2014 Open Access

Swearing, Erin Ashley (2015)

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Background: There has been insufficient attention given to water access and quality in health care facilities in low-income countries. The lack of safe water in health care settings can compromise the quality of care and lead to health care-associated infections. Decentralized water treatment technology is a potential solution for facilities that rely on intermittent or unimproved water sources. In 2005, the General Electric Foundation donated decentralized water treatment systems to six hospitals in Ghana. A baseline sustainability assessment was conducted in 2013 and a follow-up assessment was performed in 2014 to identify factors contributing to gaps in sustainability of the water system.

Objective: To compare baseline data collected in 2013 to follow-up data collected in 2014 in six Ghanaian hospitals and identify areas for improvement in sustainability of decentralized water treatment systems through the assessment of internal factors within each study hospital.

Methods: A mixed-methods approach was utilized. Water samples were tested for total coliforms, Escherichia coli, Pseudomonas aeruginosa, and residual chlorine. KAP surveys and in-depth interviews assessing hospital practices and perceptions of water quality were administered to hospital staff and patients. A sustainability metric was used to systematically measure four domains of sustainability: Accountability, Technical Feasibility, On-site Capacity, and Institutional Engagement and Support. Baseline data collected in 2013 was compared to follow-up data collected in 2014.

Results: Four of the six study hospitals experienced an increase in the overall sustainability score from 2013 to 2014, and the scores for three hospitals met the sustainability cutoff. Among hospitals that met the cutoff in 2014, scores in the On-site Capacity domain increased the most between 2013 and 2014. From 2013 to 2014, the percentage of tap samples without detectable organisms in study hospitals decreased from 55.0% to 42.3% for total coliforms, increased from 58.3% to 69.2% for E. coli, and decreased from 54.4% to 36.8% for P. aeruginosa. There was a statically significant increase (p-value: 0.0385) in the percentage of staff that drank water from hospital taps between 2013 and 2014.

Conclusion: There is a need to better engage stakeholders to provide oversight and technical support for improved water in health care facilities. Facilities with strong internal communication and financial management were more likely to sustainably operate and maintain on-site water treatment systems.

Table of Contents

Introduction and Background. 1

General Electric Foundation. 1

GEF History in Ghana and 2013 Baseline Study. 2

Study Sites. 3

Problem Statement. 4

Purpose. 4

Research Objectives. 4

Research Questions. 4

Significance. 5

Literature Review. 6

Global Water Access. 6

The Drinking Water Ladder. 6

The Diarrheal Disease Burden. 6

Guidelines for Drinking Water Quality. 7

Water Quality and Usage in Health Care Settings. 7

WASH and Health-Care Associated Infections in Low-Income Countries. 8

HCAI: Pseudomonas aeruginosa. 9

Source Water Quality and Availability in Ghana. 10

Decentralized Water Treatment. 11

Sustainability. 12

Significance. 14

Methods. 16

Research Design. 16

Research Tools. 16

Knowledge, Attitudes, and Practice Surveys. 16

In-depth Interviews. 16

Water Use Survey. 17

Water Sampling. 17

Water Quality Testing. 18

Site Observations. 19

Sustainability Metric. 19

Analysis. 20

Results. 24

Sustainability Measurements. 24

Water Quality. 33

Perceptions and Practices. 45

Discussion. 48

Sustainability. 48

Water Quality. 53

Perceptions and Practices. 56

Strengths and Weaknesses of the Sustainability Tool. 57

Strengths of the Study. 58

Limitations. 58

Areas of Consideration for Future Studies. 59

Recommendations. 60

Recommendations for the National Government of Ghana to Improve the Provision of Safe Water in Health Care Facilities. 60

Recommendations for Study Hospitals to Improve Provision of Safe Water. 60

Conclusions. 62

References. 63

Additional Figures. 67

Appendices. 87

Appendix A. 2014 Sustainability Tool. 87

Appendix B. 2014 Sustainability Metric. 145

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