RESUMO
Infrastructure for water, sanitation, hygiene, cleaning, and waste management is essential for supporting safe environmental conditions in healthcare facilities. Routine maintenance is important for preventing infrastructure breakdowns, but few studies have examined healthcare facility maintenance practices. This study documented environmental maintenance tasks in healthcare facilities in Niger, described bottlenecks to maintenance, and assessed strategies for coping with breakdowns. At 34 rural healthcare facilities in Niger, we conducted quantitative surveys to assess frequency of maintenance tasks and held qualitative interviews with healthcare facility staff to understand bottlenecks to maintenance. On at least a monthly basis, 4% of healthcare facilities inspected their water source and pump for the purpose of detecting and replacing worn parts, 15% inspected water taps and basins, and 29% inspected incinerators. Healthcare facility staff described barriers to accessing government funds for maintenance. Instead, they paid out of their own salaries or raised funds through appeals to community members or revenue generation initiatives. Other bottlenecks included ill-defined management responsibilities and difficulty of finding skilled technicians for maintenance. Findings highlight opportunities to support healthcare facilities in budgeting, advocacy, and training skilled technicians. Initiatives to install infrastructure at healthcare facilities will be more sustainable if they are accompanied by postconstruction planning, training, and funding for maintenance.
RESUMO
Environmental conditions (water, sanitation, hygiene, waste management, cleaning, energy, building design) are important for a safe and functional healthcare environment. Yet their full range of impacts are not well understood. In this study, we assessed the impact of environmental conditions on healthcare workers' wellbeing and quality of care, using qualitative interviews with 81 healthcare workers at 26 small healthcare facilities in rural Niger. We asked participants to report successes and challenges with environmental conditions and their impacts on wellbeing (physical, social, mental, and economic) and quality of care. We found that all environmental conditions contributed to healthcare workers' wellbeing and quality of care. The norm in facilities of our sample was poor environmental conditions, and thus participants primarily reported detrimental effects. We identified previously documented effects on physical health and safety from pathogen exposure, but also several novel effects on healthcare workers' mental and economic wellbeing and on efficiency, timeliness, and patient centeredness of care. Key wellbeing impacts included pathogen exposure for healthcare workers, stress from unsafe and chaotic working environments, staff dissatisfaction and retention challenges, out-of-pocket spending to avoid stockouts, and uncompensated labor. Key quality of care impacts included pathogen exposure for patients, healthcare worker time dedicated to non-medical tasks like water fetching (i.e., reduced efficiency), breakdowns and spoilage of equipment and supplies, and patient satisfaction with cleanliness and privacy. Inefficiency due to time lost and damaged supplies and equipment likely have substantial economic value and warrant greater consideration in research and policy making. Impacts on staff retention and care efficiency also have implications for health systems. We recommend that future research and decision making for policy and practice incorporate more holistic impact measures beyond just healthcare acquired infections and reconsider the substantial contribution that environmental conditions make to the safety of healthcare facilities and strength of health systems.