Assessing insecurities of water, sanitation, hygiene and solid waste services in healthcare facilities.

Abstract

Persistent water, sanitation, and hygiene (WASH) and solid waste management (SWM) insecurities heighten healthcare-associated infections and environmental contamination and broader public health risks, compounded by the absence of comprehensive institutional metrics. The study therefore sought to identify and analyze gaps in WASH-SWM practices in healthcare facilities by assessing existing infrastructure against user experiences to identify insecurities, evaluating water quality alongside user perceptions of accessibility and safety and determining the impact of seasonality and multiple water source use on service reliability. Between August 2024 and February 2025, a mixed methods approach was used to study ten purposively selected private and government healthcare facilities (levels III–IV, as classified in the Uganda healthcare system), serving a catchment population of 20,000 to 100,000 people. Data collection comprised structured Institutional WASH Insecurity Experiences (INWISE) surveys administered to 383 participants (130 staff–medical and non-medical, 253 recently discharged patients), direct observations of Joint Monitoring Programme (JMP) WASH service ladders and water quality testing (pH, turbidity, residual chlorine, E. coli and total coliforms). Cognitive interviews refined survey data collection instruments and statistical analyses such as univariate, bivariate comparison (e.g. Spearman's correlation) and multivariate modelling (e.g. ordinal regression). Partial correlation analysis was employed to isolate the direct relationships between WASH infrastructure components and insecurity measures while controlling for facility level. All the analyses were conducted using Stata 15.0 and Excel 2016. The JMP classification for water supply showed that 40% of the healthcare facilities met basic levels, while sanitation, hygiene, solid waste management and environmental cleaning remained severely inadequate. No , facility met basic sanitation criteria and only 30% attained basic hygiene, environmental cleaning services and solid waste management at 20%. Water satisfaction showed moderate negative correlations with the JMP water ladder (ρ = –0.399 to –0.169, p < 0.01). E. coli in supplied water during the dry season fully complied with WHO guidelines, while rainy season samples ranged from safe to medium risk. There were significant, negative, correlations between measured water quality and perceived water insecurity among patients and staff, with stronger associations observed among patients. The impact of source type, seasonality and location on WASH insecurity was more than moderate in the rural and urban healthcare facilities with peri-urban showing only moderate impacts. Critical gaps in WASH-SWM infrastructure and service reliability compromise healthcare quality and safety. The results of this study show the importance of including user experience measures in WASH-SWM evaluations to complement existing infrastructure-based indicators is highlighted.