often the case in tertiary facilities. This study used cost figures for secondary facilities in baseline analysis. Moreover, while some studies from the region report longer length of stay due to HAI (Karagiannidou et al, 2020), the study used a conservative estimate of 5 days based on Manoukian et al (2018).

A consensus is emerging on the key role that clean WASH facilities, overall health facility cleanliness, and the appropriate management of health care waste play in reducing the risks of spreading diseases within healthcare facilities (Watson et al, 2019; Monegro et al, 2023, Shreiber et al (2018), irrespective of a country’s income level. However, there are few studies from SSA that assess the efficacy of comprehensive measures to combat HAIs. Most studies evaluate hand hygiene interventions (Luangasanatip et al, 2015) and IPC (Thandar et al, 2022), while some also evaluate movement restrictions and staff exclusions (Adams et al, 2022) and surveillance. Studies from developed countries suggest that upward of 60% reduction may be achieved. Therefore, it is likely that the 50% HAI reduction chosen from comprehensive WASH and IPC interventions is likely to be a conservative indication of what can be achieved in SSA.

# 5. Conclusion

WASH, HCWM and environmental cleaning are lacking as central features of quality of care in healthcare systems throughout the world, especially in low-resource settings in SSA. In the countries included in this study well below 50% of health facilities have adequate WASH and HCWM. Indeed, these services are not among the 14 tracer indicators that make up SDG indicator 3.8.1 on quality of care. Yet, between 13% and 30% of hospital admissions in the region result in secondary infection by a microorganism during medical care, impacting patients, families, and healthcare providers. Rising antimicrobial resistance further exacerbates poor health outcomes and costs. In Eastern and Southern Africa, an estimated 3.1 million HAIs in 2022 incurred over 320,000 excess deaths. When all the direct and indirect costs are considered, it is likely that HAIs account for well over 7% of health spending and the economic costs of at least US$6 billion exceed 1% of GDP in the nine study countries. Implementation of WASH, HCWM and environmental cleaning is likely to prevent at least 50% of these costs and have multiple additional benefits on patient and healthcare worker safety and satisfaction. Investing in comprehensive WASH and HCWM can yield substantial benefits, with a benefit-cost ratio of 5.8 for all economic costs. The initial investments as well as ongoing operational costs are likely to be recuperated (wholly or in part) from the savings in monetary costs to the healthcare system and patients. Beyond preventing HAIs, improved cleanliness and infrastructure are crucial for patient satisfaction, impacting future healthcareseeking behavior and healthcare worker job satisfaction.

Given the additional burden on healthcare systems that are already under considerable strain in the nine study countries, it is critical to define and implement policies for reducing HAIs and AMR. This includes prioritizing infrastructure investment, allocating sufficient budget, staffing, and behavioral enhancements to improve the quality of healthcare and mitigate the associated costs. Additionally, national guidelines on WASH and IPC that are tailored to different levels of care and differently resourced contexts are required. These should be accompanied by cost assessments of the investments needed to provide and sustain WASH and IPC as per the guidelines, with budget allocations that are consistent with the resource needs.

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