No hygiene, no health: Fixing the foundations of care

When disease outbreaks strike, systems must hold. But in too many places, the absence of basic services, such as clean water, safe sanitation, reliable energy, and proper waste management, undermines the resilience of health services. 

Yemen is a case in point. Years of conflict decimated the country’s water and sanitation infrastructure, and health systems were ravaged. In response, the World Bank provided critical support to help contain the world’s largest cholera outbreak. Still, the scale of the crisis revealed how fragile health systems become when foundational services like water, sanitation, and hygiene (WASH) break down. 

By late 2018, more than 1.3 million suspected cholera cases were reported in the country, with over 2,600 deaths. In many areas, raw sewage contaminated shallow wells and nearly half of all health facilities had no clean water or functioning toilets. The spread of disease was not just fast, it was inevitable.

WASH facilities are fundamental for effective infection prevention and control, countering global threats like Ebola, mpox, and pandemic influenza, and to provide essential health services. But globally, half of health care facilities lack basic hygiene services. Over 850 million people receive care at facilities without water, placing them, and the health workers who care for them, at greater risk. 

Significant economic impact

The economic consequences of preventable infections are considerable. In 2022, health care-associated infections in 14 Sub-Saharan African countries led to an estimated $13 billion in economic losses—equivalent to 1.14 percent of their combined gross domestic product—due to treatment costs, productivity losses, and premature deaths. These conditions also fuel the rise of antimicrobial resistance, undermining decades of health gains. 

But ensuring that health care facilities are safe and functional is both achievable and affordable. In the world’s 46 least developed countries, the estimated cost to reach full coverage of basic WASH and waste services in public health facilities by 2030 is $7.9 billion, or less than $1 per person annually. 

While momentum is building, essential services often remain fragmented across sectors and face systemic underinvestment in national planning and budgeting—a challenge many countries and partners are now working to overcome.

We need to do things differently, ensuring health systems are emergency-ready, to prevent the next pandemic and to achieve our target of delivering quality, affordable health services to 1.5 billion people by 2030. Meeting these goals will require going beyond business-as-usual and ensuring health ministries and local governments have the support they need to integrate and sustain infrastructure investments. This also requires engaging with the private sector through the International Finance Corporation (IFC), the World Bank Group’s private sector arm, for critical aspects of delivery like decarbonization and resource efficiency. 

Working across sectors

This is why a new approach is taking shape. Through joint Water and Health Global Challenge Programs, the World Bank is supporting countries to invest in health systems that are safe, resilient, and sustainable, powered by improved access to electricity. This will enable countries to better prevent, detect, and respond to health emergencies, contributing to the wider ambition to address basic care at every stage of life. 

Funders like the World Bank and the United Kingdom’s Foreign, Commonwealth and Development Office  (FCDO) are working together to:

• Mobilize domestic and climate financing to support national priorities and plans;
• Embed WASH, energy, and waste in health emergency and health system reform programs;
• Drive collective agendas to recognize and address the threat of antimicrobial resistance; and
• Generate evidence and use results-based approaches to ensure transparency and accountability.

Signs of progress

Early progress has been encouraging. In Malawi, for instance, the government made a national commitment to achieve universal WASH in health care facilities by 2030. This initiative was complemented by the World Bank and other partner-supported efforts to strengthen epidemic preparedness and response, which have helped to significantly reduce cholera-related deaths in Malawi from about 1,800 in 2023 to under 20 in 2024.

Investments in preparedness and community engagement in Nigeria, Indonesia, the Democratic Republic of Congo, and Ethiopia have helped break the cycle of reactive and costly crisis management. Led by governments and supported by development partners, these programs are built to last—not just to respond.

Delivering health security requires not only sustained investments but also close coordination, aligning donor efforts behind national plans, strengthening implementation capacity, and promoting intersectoral collaboration.

Partnerships like the Global Water Security and Sanitation Partnership and the Global Financing Facility also play a critical role. By supporting analytics, bringing together stakeholders, and funding catalytic investments, they are enabling governments to move faster and smarter. 

FCDO is further promoting a multisector approach to help overcome silos and strengthen the systems that deliver sustainable and climate-resilient health and WASH services.

To fully realize these ambitions, we need to bring together those who can make a difference. As part of these efforts, the World Bank is chairing the next World Health Organization/UNICEF Strategic Leaders Network meeting in June 2025 to promote cross-sectoral alignment and reinforce impactful partnerships for WASH in health systems. 

By 2026, we must make real progress toward the United Nations Sustainable Development Goals on health and water. We must work in partnership to support countries to plan, finance, and deliver safe, resilient health services—grounded in the basics, and built to endure. Because health emergencies won’t wait for systems to be ready.

Source : World Bank