Hospitals and health centers in the developing world need safe water. Actualizing that goal is easier said than done, even for water professionals. To complicate matters, most of these facilities will require on-site treatment, given the minimal treatment of water in the community. At the Center for Global Safe Water, Sanitation and Hygiene at Emory University, we have been working on safe water in health care facilities for nearly 10 years — most recently in Cambodia and Uganda. From our experiences in the field, we have noticed several challenges and pitfalls that occur for those working on safe water issues in these settings. Along with plumbing engineers, we hope to work with implementers to tackle these issues with best-practice solutions. From water access to treatment and protection, we want to help ensure that the approaches and technologies used are appropriate and, most importantly, sustainable.

The three-step safe water process

Imagine a hospital in rural Cambodia. It sources water from a borewell, supplemented by a nearby pond in dry season; accessing sufficient water is the first step. A 2015 World Health Organization (WHO) report on water, sanitation and hygiene in health care facilities (HCF) in developing countries estimated that 38 percent of HCF in these contexts do not have access to an improved water source. Countries such as Cambodia struggle with this urgent need. 

Further, this 2015 report does not take into account seasonality (and climate change), which can cause water scarcity in these regions. The situation in 2017 is likely worse; since the report was published, the global definition of “improved water source” has been revised for health care facilities. The new definition requires a water source on facility premises (the old definition of “within 500 meters” was drawn from the household definition of an improved water source and is unrealistic when considering the existing burdens upon the facility staff.) To provide the most suitable water treatment system, it’s important to understand how the facility currently accesses water and if that source is sufficient to meet its needs throughout the year. Alternative or supplemental sources are often required to support the facility. 

The next step of process is the initial treatment of the water. The specific quality of water needed in health care settings depends on the intended use. In the developing world, providing water that is of drinking water quality is the first consideration. To achieve this level of quality, water treatment can vary widely and may include filtration, disinfection (chlorination or UV) and boiling. Treatment can happen at the point of use, such as at a hand-washing station for surgery or at a drinking water station. Or the facility may receive treated water from a point of entry system, serving larger parts of the facility through the pipe network.

Once the water has been treated, protecting the water from recontamination is the final step in providing sustainable safe water to the facility. To ensure water access during times of power outages or the dry season, water storage tanks are common. Water stored post-treatment or distributed through existing pipe networks is at a greater risk for recontamination, particularly if maintenance of the plumbing infrastructure is minimal. 

Challenges in safe water provision

Throughout the process of accessing, treating, and protecting water for the health care facility, implementers will find themselves facing a variety of challenges. From as-built to cross contamination, here are some recommendations for addressing these challenges in the field. 

Budget and supply chain

When providing safe water requires treatment systems, as often it does, taking time to select the appropriate technology should not be overlooked. Installing a treatment system that the facility cannot afford to maintain, regardless of its effectiveness, will set the facility up for failure. By understanding budget constraints, as well as other priorities that impact the health care facility’s finances, the implementer and the facility can together determine the best option for water treatment. Because treatment systems typically are imported into countries like Cambodia, the supply chain for spare parts is crucial to making sure these systems last their full lifespan. Identifying supply partners in-country and connecting them to the facilities is critical. At the same time, ensuring that those spare parts are financially reasonable and that the facility can take responsibility of their recurring costs will impact whether the facility will purchase these parts in the years to come. 

As-built drawings

Facilities with piped water often do not have “as-built” drawing. Figuring out the pipe layout requires speaking with the person who built it or investigating the layout yourself. A building that is “dual-piped,” with two systems of treated and untreated water, should be handled with the same precautions used in the U.S. in facilities where there are both potable and reclaimed water piping. Generally, the reclaimed water is run in purple pipes or, in the case of existing copper installation, the non-potable water pipe would be wrapped in purple tape to avoid confusion. Additionally, test ports should be provided to confirm that there is not a cross connection between the two systems.

Existing infrastructure

Facilities with older pipes can have a biofilm, causing recontamination of treated water. While laying new pipe may not be feasible, it is worth considering what affect the existing pipe will have on the integrity of the safe water. At a number of facilities where we have worked, some of which are more than 50 years old, we have needed to shock the system after the installation of the treatment system. It takes time and supervision, but reduction in the biofilm is possible. It’s important is to know what you are in for and include that in your plans. 

Cross contamination

The demand for health care in the developing world is not decreasing, and facilities may need to expand over time. At one of our hospitals in Cambodia, treated water was extended from beyond the maternity ward to the nearby eye unit. However, the plumber mistakenly extended the pre-treatment rather than the post-treatment line. It was only after we tested the water several months later that the cross connection was discovered. By then the contamination had undermined the quality of the water throughout the system. Lines might even be extended to buildings off the facility premises, if community members decide they want treated water at the nearby school for example.  

If as-built designs are non-existent or the facility staff have not been trained on the treatment system and its network, cross contamination is more likely than not. Test ports should be provided to confirm that there is not a cross connection between the two systems. These ports include a pressure gauge and normally a closed valve piped to a drain. If the treated water system is isolated and drained, it should read zero pressure when the test drain is opened, while the non-treated system should maintain system pressure. If the treated water system does not read zero pressure, then there is a cross connection between the two systems that must be identified and repaired.

The role of health care staff 

As you work to bring safe water to the health care facility, the leadership and staff need to be engaged. Facility directors understand the importance of clean water and the benefits of a water treatment system. However, they tend to be more concerned about providing essential health services with limited resources and budget. Water supply or quality often does not top their list of priorities. Gaining their attention and commitment to safe water from the start and re-engaging them throughout the installation process will have a big impact on the success of the treatment system. The facility’s leadership and staff are ultimately responsible for the upkeep and maintenance of the system. 

Meanwhile, if the facility has a maintenance staff on the payroll, they may have limited plumbing skills and may be tasked with additional jobs like driving the ambulance. A pipe breakage can go unnoticed for months, if a maintenance worker doesn’t know the signs. Taking ample time to thoroughly train the staff responsible for the system will go a long way to guaranteeing the longevity of the treatment system. 

Water supply and management at health care facilities in the developing world is not easy. However, with appropriate sustainable technology, consideration of anticipated plumbing issues, and strong support from facility leadership and staff, providing continuous safe water is possible. For those who are interested in addressing the need for safe water in health care facilities, we commend and encourage you. We also hope that our experiences can help to ensure that your work will benefit these facilities in a sustainable way, while building capacity within the community. 

An improved water source is one that, by nature of its construction or through active intervention, is likely to be protected from outside contamination, in particular from contamination with fecal matter; this includes piped water, borehole/tubewell, protected dug wells, protected spring, rainwater collection and bottled water. Definition from WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation.     

Lindsay Denny is a public health professional at the Center for Global Safe Water, Sanitation and Hygiene at Emory University. She lives in Cambodia, managing the Center’s Safe Water for Hospitals program, funded by the General Electric Foundation. You can reach her at  ldenny@emory.edu. Visit cgswash.org.