“Globally, major gaps in basic water, sanitation and hygiene (WASH) services exist in health care facilities. A quarter of all healthcare facilities have no basic water services, which means 712 million people have no access to water when they use health care facilities”. 

This finding from the Global progress report on WASH in health care facilities should strike a chord with those working towards the elimination of trachoma as a public health problem. To achieve global elimination goals, all people requiring health services, including those with trachomatous trichiasis, the late blinding stage of trachoma, should be able to access interventions in environments practicing good hygiene and adhering to infection prevention and control practices. Yet today, we find that a quarter of the world’s healthcare facilities can’t provide basic water services to their users, and that 2.3 billion people lack basic services in their own homes, including 670 million people with no handwashing facilities at all.

The investment case for WASH is compelling. Access to WASH has cross-cutting development benefits that contribute to the achievement of multiple Sustainable Development Goals, including good health and wellbeing. And yet the economics of WASH are seldom incorporated into economic analyses or investment cases for disease. This is particularly true for trachoma, where the scale up of facial cleanliness and environmental improvement interventions - both requiring access to improved water supply services - has often been secondary to investments in surgery and antibiotics despite being integral parts of the WHO-endorsed SAFE Strategy.

Benefit-cost ratios (BCRs), which compare the socioeconomic gains from an investment against their costs, have shown that universal access to WASH offers excellent value for money, with BCRs ranging from USD $4–$8 for every dollar invested. In settings where trachoma is endemic, the benefit of WASH is likely even higher because such settings will benefit from reduced incidence of diseases, such as neglected tropical diseases (NTDs) that trap entire communities in cycles of poor health and poverty.

Photographer: Avijit Ghosh

BCRs also do not account for key societal impacts, such as improved gender equality, that are associated with WASH investments. Notably, a lack of basic WASH requires households to spend 1–2 hours per day on average collecting water, displacing time spent in employment or education. The incidence of these impacts on health and economic opportunity skews heavily towards women, meaning a lack of WASH is a critical barrier to female empowerment and gender equality.

In 2019, the International Coalition for Trachoma Control published toolkits to support trachoma programs to integrate SAFE strategy interventions, including facial cleanliness and environmental improvements, within existing government-run and community-based structures to ensure that progress is sustained and that incident cases are identified and managed. However, successful transition to full integration is complicated by limited health care infrastructure in the resource-poor settings in which NTDs are endemic. This includes health facilities frequently lacking water and sanitation services. 

A recent study by Chaitkin et al estimates the cost of achieving universal coverage of basic WASH services in health facilities to be US $6.5 – $9.6 billion in the 46 least developed countries. Although this is a modest investment compared to overall health and WASH spending and will yield numerous health benefits, it highlights a critical vulnerability to health systems, and specifically to global trachoma efforts. For example, investing in these health care facilities is of urgent importance to ensure they are equipped to manage the transition of trachoma interventions, and to ensure that surgeries to treat trachomatous trichiasis are conducted safely.

At the community level, urgent investments are also needed to identify and address gaps. This includes: the promotion of key behaviors through health outreach programs, social mobilization activities and mass media campaigns; increased access to improved sanitation services; and increased access to reliable improved water supply to enable hygiene behaviors. Going forward, these investments must be better accounted for in NTD advocacy and policy change, as key pillars of investment to achieve targets. The effectiveness of these approaches was evidenced in the Islamic Republic of Iran, which in 2018 was validated by WHO for eliminating trachoma as a public health problem. This was achieved through sustained investments in health and WASH infrastructure, and without a coordinated national trachoma program. 

Identifying the WASH costs associated with NTD programs is a methodological challenge that has likely contributed to WASH being largely excluded from previous investment cases. However, it is also short-sighted to attempt to disentangle the NTD-associated costs of WASH for investment case purposes. There is broad recognition that NTD programs should not operate in siloes, but it is equally important that advocacy not be conducted in siloes and that we recognize that the WASH investment case agenda is the NTD investment case agenda, because where WASH is insufficient, NTDs will thrive. 

Ending the neglect to attain the Sustainable Development Goals: a road map for neglected tropical diseases 2021-2030, published by the World Health Organization in 2021, and its accompanying Global Strategy on WASH and NTDs emphasize the importance of cross-sectoral collaboration to achieve NTD targets. To achieve these targets, however, increased coordination is needed across advocacy, policy and funding. Health stakeholders, including those working towards trachoma elimination, should recognize and equally advocate for comprehensive WASH, to ensure all people realize their human rights of access to water, sanitation and hygiene, and the highest attainable standard of health.