Water, Sanitation and Hygiene Improvements Are Key to Sustaining Healthcare’s Ascendency in Cambodia

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.


 Written by Channa Sam Ol, Manager, Water, Sanitation and Hygiene (WASH)
and Health Programs, WaterAid Cambodia

Over the past 20 years, Cambodia has made remarkable progress in improving health care, as evidenced by declines in maternal mortality from 900 to 170 per 100,000 live births and infant mortality from 115 to 35 per 1,000 live births.

Ongoing health system reforms have addressed the quality of care, access and affordability. The government has supported these reforms by introducing schemes that make care free for families with limited incomes and subsidize health facilities and the women who use them to give birth. This latter scheme has helped to dramatically increase the number of women delivering their babies in facilities, from 22% in 2004 to 83% in 2014[1].

But challenges still cast a shadow on the very positive trajectory that has been established. This manifests in the limited progress in newborn health when compared to the improvements in maternal health. It is much safer for a woman to deliver her baby in a Cambodian health center or hospital today than it was 20 years ago, but it is not as safe as it should be for a newborn baby. The United Nations estimates 1 in 6 newborn deaths are associated with blood infections during delivery and an unhygienic environment after birth[2].

While previous Cambodian health policies and standards rarely mentioned water, sanitation and hygiene (WASH)[3], the current National Health Strategy is the first to set targets for improving WASH. Despite this, many health facilities still do not have sufficient WASH infrastructure and lack good hygiene practices.

Most facilities have a water supply, but only half have enough water for use year-round. Fewer than half of facilities have three adequate latrines. Only 15% have handwashing stations at points of care and only 10% perform basic waste management.

According to a 2016 assessment of WASH in public healthcare facilities in five provinces conducted by the country’s National Institute of Public Health in collaboration with the Department of Hospital Services and health partners, the lack of knowledge and commitment to WASH and infection prevention control were a challenge among healthcare workers and cleaners.  

Neglecting these essentials and improving rural health services is hampering progress towards safe, clean healthcare for all. Without improving the basics, Cambodia will not achieve the objectives set in its health strategy, nor will it see improvements in health as it has in the past.

Clean healthcare is something every patient expects – and it is achievable, as these examples demonstrate.

WaterAid first visited the Peus Pi health centre in Tbong Khmom Province in late 2017. The facility didn’t meet basic hygiene or sanitation requirements. What did that mean? Handwashing stations or alcohol hand sanitizers weren’t available at points of care such as outpatient consulation rooms, near toilets or in the waiting area. Toilets weren’t accessible for all, didn’t have separate facilities for men and women, and there were no facilities supporting menstrual hygiene management or postpartum bleeding.

Waste was not being separated and waste bins were not color-coded according to the national standard for health care waste management. Moreover, most staff were reluctant to share about hand hygiene practices and their knowledge of infection prevention and control.

In collaboration with the Ministry of Health and the provincial health department, we have  been working to upgrade the centre’s facilities and build staff knowledge to improve infection prevention control.

Rodiya, a mother who uses the Peus Pi centre, told us about the significant change compared to how it was several years ago. To Rodiya, the “health centre looks cleaner, has more equipment and materials and staff pays more attention to patients.” And now she can use the latrine and handwashing station inside the postnatal room. These improvements gave her the  confidence to choose the centre when it came time to deliver her third child.



[1] Cambodia Health Demographic Survey 2004 and 2014

[2] UN Inter-Agency Group for Child Mortality Estimation. Levels and Trend in Child Mortality; UN Inter-agency Group for Child Mortality Estimation: New York, NY, USA, 2017

[3] Por, Ir (2015). Towards Safer and Better Quality Health Care Services in Cambodia: A Situation Analysis of Water, Sanitation and Hygiene in Health Care Facilities. Phnom Penh, Cambodia: WaterAid.


The “Quick Fix” for Care, Productivity, Hygiene and Inequality: Reframing The Entrenched Problem of Antibiotic Overuse

Written by Dr. Laurie Denyer Willis and Dr. Clare I.R. Chandler


This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

A key global health objective related to antimicrobial resistance (AMR) is to reduce antibiotic use. Many interventions to lower antibiotic use are based on models of behavior change. Our extensive ethnographic research over 10 years in East Africa shows why these interventions often have limited impact.

We found that antibiotics are often used as a “quick fix” – they paper over underlying structural issues related to marginality, inequality, violence, health systems and infrastructures. Antibiotics can be understood as a quick fix for care in fractured health systems; for productivity at local and global scales for humans, animals and crops; a quick fix for hygiene in settings of minimized resources; and a quick fix for inequality in landscapes scarred by political, economic and post-colonial violence.

Understanding antibiotic use in this context requires shifting attention to the structural dimensions that antibiotics are currently fixing, like equality, care, hygiene and increasing demands for productivity. These dimensions tend to be obscured when following an individual behavior change approach – often going unaddressed when antibiotic use is described in the language of “good” and “bad” behavior.

It is important to appreciate the extent to which daily life has become intertwined with antibiotic use to understand the consequences of resistance and the best ways to reduce the threat of AMR. This is particularly true in low- and middle-income countries, where antibiotics are put to work to correct deficient infrastructures of care, water and sewage, hygiene and demands for ever-increasing productivity.

We can connect this entrenched use of antibiotics to neoliberal reforms, the legacies of structural adjustment programs and the marginalization of the poor and vulnerable. For them, antibiotics have made life liveable in contexts of scarcity, uncertainty and inequality.

During our fieldwork in Uganda we met Grace, who lived in an urban settlement in downtown Kampala. The few fee-for-use latrines were filthy. Most people could not afford them or avoided them, choosing instead to use buckets or polythene bags for toileting, and then disposing their waste either in drainage channels or rubbish piles.

The channels are the same ones people use to wash clothes and take water for their livestock and gardens. During heavy rain, they overflow into homes, gardens and livestock pens.

Many adults and children in the settlement live with chronic diarrhea and abdominal pain.  Grace showed us her plastic basket of medicines she keeps at home. It was a small collection of Panadol (paracetamol), some amoxicillin tablets and a full box of metronidazole.

Antibiotics make unavoidable diarrhoeal disease bearable, enabling people in the settlement to carry on with life. There is little political will to tackle these issues, as the local press describes the settlement as a problematic “slum” and those live there as “illegal squatters” and criminals.

Low-income and middle-income countries have been identified as a specific target for AMR and antibiotic use policies due to a range of factors that locate them as particularly vulnerable to the effects of AMR, as well as the perception of them as posing a risk to other countries through the connectivity rendered so apparent in previous pandemic scares.

Recognizing many of our AMR solutions as quick fixes allows us to raise our line of sight to the longer term, generating more systemic solutions that have greater chance of achieving equitable impact.


To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.

The Clean Clinic Approach: All Guatemalan Health Facilities In Project Achieve ‘Clean Clinic’ Status Within One Year

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by Dr. Sergio Tumax Sierra, Water, Sanitation and Hygiene Manager, Guatemala

As the water, sanitation and hygiene (WASH) manager for Save the Children’s Clean Clinic program in Guatemala, I saw firsthand how this novel, low-cost strategy delivered very encouraging results over a short period of time in 2018-19.

Clean Clinic – one of the three pillars of the BASICS initiative – is our proven process that empowers healthcare staff to make infection prevention improvements through easy-to-use monitoring, accountability and rewards systems.

In Guatemala, we implemented Clean Clinic at 11 Ministry of Public Health and Social Assistance health facilities, including district and department hospitals. It enabled and motivated the facilities to set WASH goals and make incremental improvements towards the ultimate goal of obtaining “Clean Clinic” status.

Within the year, after our close work with the Ministry to develop a weighted evaluation for conducting standardized ward evaluations in each health facility, all 11 had achieved one of three “Clean Clinic” certification levels. Facility staff, from cleaners and nurses to doctors and management personnel, were motivated to make actions sustainable.

We found that even small improvements made a difference in providing patients with better quality services. For example, facilities enrolled in Clean Clinic:

  • Improved the management of water quality for consumption
  • Improved solid and liquid waste management processes
  • Ensured that hand-washing stations were identified and functional and had the necessary supplies
  • Assigned operation and maintenance roles and responsibilities

Clean Clinic’s 10-step improvement process and monthly action plans made it easier for facilities to make WASH improvements despite limited external financing. These activities contributed to quality of care improvements and very likely the reduction of puerperal and neonatal sepsis infections.

The innovativeness of the strategy was also seen in the establishment or revitalizing of infection prevention and control committees at each facility. They monitored bi-monthly evaluations and made plans for timely improvements to achieve Clean Clinic standards in the least time possible.

Evaluations were conducted by personnel outside the healthcare facility, including regional Ministry of Health staff, after which committees made their improvement plans and assigned responsibilities for their management and monitoring. Likewise, a monitoring team was established at the Ministry’s head office to help manage resources and for sensitizing staff on the topic of infection prevention.


To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.







BASICS: Helping the Fight Against Antimicrobial Resistance

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.


Written by the BASICS Team

Every use of an antibiotic, whether appropriate or inappropriate, gives resistant bacteria an advantage and accelerates the development of resistance. Drug-resistant infections are associated with higher morbidity, mortality and health expenditures, and resistant infections are becoming a significant cause of death, particularly for children.

An estimated 700,000 lives are lost to these antimicrobial resistant (AMR) infections every year. Around 200,000 newborns die annually because they catch infections that simply do not respond to drugs. According to the World Health Organization, around 40% of infections contracted by newborn babies resist available treatments[1]

The burden of resistance falls heavily on low- and middle-income countries (LMICs). Here, some population groups suffer from frequent and rapid spread of infectious disease and poor nutrition. Healthcare systems in these countries are often less able to manage this burden, and the situation is exacerbated by increasing rates of antibiotic consumption in humans and animals and by limited standards and regulations that govern access, use and quality of antibiotics[2].

Many infections, both drug-resistant and drug-susceptible, are acquired in hospitals. Healthcare-acquired infections (HAIs), particularly sepsis, are a danger for both neonates and their mothers, who are increasingly being encouraged to seek birth and delivery care at hospitals. Increasing rates of drug resistance render many such infections untreatable.

Professor Clare Chandler, Co-Director of the London School of Hygiene and Tropical Medicine’s Antimicrobial Resistance Centre, and Dr. Laurie Denyer Willis, Assistant Professor at the School, have conducted extensive research in East Africa on the roles that antibiotics play in LMICs beyond their immediate curative effects. Their findings suggest that antibiotics have become a “quick fix” for care available through fractured health systems and, among others, for the lack of hygiene in settings of limited resources.

Although there is no single silver bullet, the most obvious solutions – improved infection prevention and control practices – remain among the most effective interventions[3]. All health care facilities, at a minimum, must have clean running water and sanitation services, and healthcare professionals must follow good hygienic practices such as handwashing[4].  Many LMICs face significant challenges in setting up effective systems that can achieve these basic objectives.

This is the core of what BASICS aims to achieve: supporting the institutionalization of simple, inexpensive hygiene measures in healthcare facilities through effective training platforms, monitoring and accountability systems, reliable supply chains and upgraded water, sanitation and hygiene infrastructure. This will create a clear roadmap for national healthcare systems to take comprehensive action to improve infection prevention and control and dramatically lessen the burdens that HAIs place on under-resourced systems and impoverished families.

BASICS projects a 50% reduction in HAIs in participating facilities based on robust evidence linking improvements in hygiene and cleanliness in healthcare facilities with improved patient outcomes.[1-4] These improvements will significantly reduce the usage of antibiotics – and, in turn, dramatically curb the development of new AMR pathogens.

BASICS is where it can start and it should start now.

To learn more about AMR and how to fight back, watch this roundtable discussion with Professor Chandler – one of our BASICS team members at the London School of Health and Tropical Medicine.


Acknowledgements: Professor Wendy Graham and Professor Clare Chandler from LSHTM – a BASICS partner – provided comments and review.

 To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.



[1]        P.C. Carling et al., “Improving environmental hygiene in 27…,” Crit. Care Med., vol. 38, no. 4, Apr. 2010. https://www.ncbi.nlm.nih.gov/pubmed/20081531

[2]        R. Orenstein et al, “A targeted strategy to wipe out Clostridium…,” Infect. Control Hosp. Epidemiol., vol. 32, no. 11, Nov. 2011. https://www.ncbi.nlm.nih.gov/pubmed/22011546

[3]        S. J. Dancer et al., “Measuring the effect of enhanced cleaning…” BMC Med., vol. 7, p. 28, Jun. 2009. https://www.ncbi.nlm.nih.gov/pubmed/19505316

[4]        B. Allegranzi et al., “A multimodal infection control and patient safety…,” Lancet Infect. Dis., vol. 18, no. 5, May 2018. https://www.ncbi.nlm.nih.gov/pubmed/29519766


[1] https://www.who.int/mediacentre/commentaries/antibiotic-resistant-bacteria/en/

[2] https://www.ncbi.nlm.nih.gov/books/NBK525181/

[3] https://www.infectioncontroltoday.com/antibiotics-antimicrobials/antimicrobial-resistance-stewardship-and-strategies-conquering-global

[4] https://www.who.int/mediacentre/commentaries/antibiotic-resistant-bacteria/en/

Integrating Water, Sanitation and Hygiene (WASH) and Health for Improved Universal Health Outcomes: What Governments Must Do to Deliver Quality Care

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by Blessing Sani, WaterAid Communications Officer, Nigeria


As the world accelerates progress toward quality healthcare, governments must prioritize increased access to inclusive and sustainable water, sanitation and hygiene (WASH) services in healthcare facilities.

Clean water, decent toilets and good hygiene help to control and prevent diseases and their spread. They protect health workers and patients and allow the delivery of quality health care services. Sadly, these normal things are the forgotten foundations for good health. The impact on women and children is alarming – estimates are that one in five births globally takes place in least-developed countries and, each year, 17 million women in these countries give birth in health centers with inadequate water, sanitation and hygiene.1

In Nigeria – one of the four countries that BASICS initially targets – half of healthcare facilities lack clean water, 88% are without basic sanitation and 57% lack handwashing facilities with soap. In a corroborative assessment by WaterAid in 2016 in six Nigerian states (Bauchi, Benue, Ekiti, Enugu, Plateau and Jigawa), primary healthcare centers assessed in urban, semi-urban and rural areas generally had low access to piped water within the facility; more than 20% lacked toilets. In addition, our assessment found there were no structured systems for the operation and maintenance of water and sanitation facilities.

For health workers like Gloria Samuel, the lack of water makes it difficult for her to carry out her duties as a cleaner at the Bwari Town Clinic in Abuja.

“We don’t have water so we buy it from the vendor or practice rain harvesting during the rainy season,” Gloria says. “The rain-harvested water is used to clean the toilets and water bought is used for cleaning more sensitive instruments and for patients who need clean water to wash up, but we still do not know how clean the water is.

“With the water situation, I only wash the toilets once a day and that is not good enough, but if we have constant water flow, we will be happy. When we work without water, it is difficult because this is a hospital. A hospital can’t stay without water because the work will not move forward.”

Globally, an estimated 896 million people use healthcare facilities with no water service, and one in five facilities has no sanitation service, impacting 1.5 billion people.2  Diseases like Ebola, Lassa Fever and cholera spread fastest when these services are lacking. This cycle ensures improvements in health are not sustainable. Often times, the dire consequences are manifested in ill health, deaths, economic losses and a lifetime legacy of disease and poverty.

When clean water, decent toilets and good hygiene services are available, the ripple effect is transforming. Risks of infection for patients and their families, staff and surrounding communities are greatly reduced; people are kept safe from deadly diarrhoeal diseases and are better able to break free from poverty.


Accelerating Quality Healthcare
In 2017, Nigeria launched a scheme to revitalize 10,000 primary healthcare centers across the country to make quality and affordable healthcare accessible to the poor and vulnerable. This commitment presented a window to integrate inclusive and sustainable WASH services into the program plans and design. However, despite this and other efforts around improving maternal and child health and nutrition, achieving the goal of Universal Health Coverage requires increased political commitment, practical policies, strong coordination and partnerships, financing and preventive interventions.

There’s need for better coordination, collaboration and integration between WASH and health actors based on the recognition that WASH underpins quality health outcomes. Furthermore, improving healthcare requires a multi-sector approach that incorporates investments in WASH alongside other sub-sectors like nutrition, maternal and child health, menstrual hygiene management and gender. WASH is an essential building block for patient safety, quality of care, for tackling undernutrition and threats like antimicrobial resistant infections, and for realising Sustainable Development Goal 3 – ensuring healthy lives and promoting well-being for all.

United Nations Secretary-General António Guterres says “Water, sanitation and hygiene services in health facilities are the most basic requirements of infection prevention and control, and of quality care. They are fundamental to respecting the dignity and human rights of every person who seeks health care and of health workers themselves.”

We couldn’t agree more! Only by making clean water, decent toilets and good hygiene available for everyone, everywhere, can we prevent diseases from spreading, transform lives and livelihoods and deliver quality health services that keep people well and unlock their potential.

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.


1,2. World Health Organization and the United Nations Children’s Fund, WASH in health care facilities: Global Baseline Report 2019

Year-long Hospital Pilot Documents Highlight®’s Role in Reducing Failure Rate of Cleaning Sampling to Zero

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.


Written by Jason Kang, Co-founder and CEO, Kinnos


The World Health Organization estimates that 10 out of every 100 hospitalized patients in developing countries will acquire at least one healthcare-associated infection (HAI). Studies have shown that less than 50% of surfaces in healthcare settings are effectively cleaned, but that better cleaning technique could prevent 40-80% of HAIs.

Highlight® addresses this gap in cleaning by providing real-time visual feedback to empower health workers to disinfect surfaces correctly every single time they use a disinfectant. It does this by colorizing existing disinfectants so that workers can easily see exactly what has and has not been covered, so no spots are ever missed. The color then fades after several minutes to provide an approximation of when disinfection is complete.

In 2018, Highlight® was piloted in a 500-bed academic hospital based in Boston, Massachusetts, in 11 medical and ICU inpatient wards.[1] In the U.S., a common method of determining cleaning efficacy is ATP bioluminescence. After a surface has been cleaned, a sample of the surface is taken using a swab, which is then placed in a device that generates a number in relative light units (RLUs). The higher the number, the “dirtier” the surface. The sample is recorded as a pass or a fail depending on a certain RLU threshold.

Across a period of 55 weeks at the hospital, ATP bioluminescence was used to quantify thoroughness of cleaning on over 1,000 high-touch surfaces, such as bedside tables and door knobs, comparing disinfectant alone vs. disinfectant with Highlight®. The study found that introducing Highlight® completely eliminated the failure rate – from 5.7% to 0%.

The breakthrough that Highlight® represents – the ability to overcome training and language barriers to empower health workers and those who clean facilities with a feeling of confidence through disinfection they can see – can have a profound impact in reducing HAIs globally as part of the BASICS solution.


To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.

[1] Tyan et al. Infect Control Hosp Epidemiol. 2019;40(2):256-258.