Our foundation has been thinking really hard about the gaps on the ground at this perilous time in global health. Never has it been more important for private philanthropy to leverage its ability to be nimble, flexible and responsive.

Part of the reason the global community finds itself in the midst of a pandemic and unable to provide even the basics of public health is because too many solution-seekers—including governments, multi-laterals, NGOs and philanthropists—go for what’s easiest to implement and measure, and then move on. So while many funders do focus on health in low-resource regions, effective and sustainable systems remain an eternal aspiration with some genuinely outrageous gaps, such as healthcare workers who cannot adequately wash their hands during a global pandemic. We have neglected global health systems at our peril.

Doctor washes hands while nurse waits behind him to do the same.
Dr. Daniel Bouare, 30, clinic director at the south extension community health centre, left, washes his hands after seeing a patient as Raki Diallo, 26, an infirmary nurse, waits to do the same in Kalabancoro, a town on the outskirts of Bamako, Mali, on Wednesday, March 11, 2015. Photo by Tara Todras-Whitehill, courtesy of Water Aid.

I believe private philanthropy is well-positioned to provide global health leadership, but it’s going to take bigger thinking. Strengthening health systems means using evidence-driven solutions, finding what works and what doesn’t, and relying on knowledge surfaced by those with firsthand experiences. Funders’ perspectives are often too narrow, not considering the experience of the person on the ground, and we still sometimes fall into the colonial mindset that wants to fund what “we” think “they” need. Based on personal biases or incentives, we may deploy solutions that address the symptoms of a problem and not the systemic root causes. 

To increase our effectiveness, especially now, as money is being thrown in all directions, global health funders need to embrace three broad strategies: Closely engage real-world realities; focus not just on low-hanging fruit, but on systems change; and strategize for the long game and work backward.

The Conrad N. Hilton Foundation has long focused on safe, reliable and affordable water services, and this pandemic has made inequality of access frighteningly clear. Three billion people, 40% of the world, do not have a place in their homes to wash their hands. It’s even worse inside healthcare facilities—43% of healthcare facilities worldwide do not have water and soap at points of care. In regions like sub-Saharan Africa, where much of our work is focused, 49% of healthcare facilities lack basic water services. It’s hard to imagine the toll on healthcare staff who attend to sick patients and frightened families, pregnant women and newborns, accidents and chronic health problems, while trying to keep everyone including themselves safe. 

We’ve got to break the long-established habit of funders giving with the urgency of now without sustainability plans in place. We’re apt to leave communities and facilities worse off in the long run. Clean water isn’t just a pump and tap. Successful implementation requires that water, sanitation and hygiene (WASH) be combined with ongoing training, management structures, incentives and funding mechanisms baked-in from the start. Otherwise, emergency actions—like portable handwashing sinks or temporary water storage capacity increases—substitute for long-term solutions until they inevitably fall apart, which can cause community tension, increased illness, and much more.

Even during this emergency response period, the Hilton Foundation is taking a systems-led approach to strengthen healthcare facilities to drive at long-term solutions. Here’s what that looks like:

District governments are best positioned to take the lead in coordinating emergency responses. Investing in locally led initiatives reinforces local leadership and long-term ownership of development processes, a key component of strong and resilient WASH systems. For example, the foundation is supporting the mayor of Banfora in Burkina Faso, a city with a population of nearly 100,000, to execute its COVID-19 Emergency Action Plan through collective action with partners Catholic Relief Services, IRC WASH, and local NGO Espace Culturel-Gambidi. The mayor’s office is in the driver’s seat as this strategic partnership provides 93 schools and 17 healthcare facilities with PPE and hand hygiene supplies, promotes proper handwashing techniques for the healthcare setting, and provides training on management and maintenance of handwashing stations during the pandemic. COVID-19 hand hygiene and behavior change messaging on the safe use of handwashing at public stations is also being offered to the broader community.

Both “hard” and “soft” components of health systems need to be addressed. Ensuring the role of water supply in infection prevention and control (IPC) requires the installation of pipes and taps, and ongoing management and behavior change. In the Wassa East District in Ghana, Hilton is funding Water4, which is providing technical and financial support to the private service provider Access Development Ghana. AD Ghana is extending piped-water services to 16 healthcare facilities that are without, under an existing contractual arrangement with district authorities so ownership and management of the new infrastructure is clearly defined. AD Ghana is also partnering with Global Communities on management and training to carry out IPC to build district capacity and systems for sustained hygiene improvement across 26 healthcare facilities. To advance behavior change, dozens of frontline health workers are being trained in proper handwashing techniques and disinfection in the clinic setting.

Our foundation, in partnership with grantees, other funders and governments are asking what outcomes we want five decades from now and working backward. We need to identify incentives, motivations and causes that drive poor services. To understand WASH/IPC resilience, IRC WASH is partnering with the district health and water authorities in the Kabarole district in Uganda. IRC WASH will focus on enhancing government structures—from local supply chain to management—and conduct an analysis to understand the underlying causes that perpetuate system breakdowns. The goal is to drive long-term interventions that will build and strengthen local systems responsible for responding to the current pandemic, curtailing future outbreaks and a wide range of health threats, and meeting daily health needs for decades to come. 

Importantly, these kinds of efforts to strengthen health systems are not a trillion-dollar agenda. We’re financing a slice of a slice of a Sustainable Development Goal (SDG) with other funders, like the Stone Family Foundation and the One Drop Foundation. We are facing a critical time in global health history that offers pivotal opportunities for many more funders concerned about global health to think bigger through WASH as a cost-effective force multiplier. Access to safe drinking water, the safety and dignity of a basic toilet, and a way to maintain hygiene is fundamental to so much that our funding efforts seek to advance—including gender equity, girls’ education, child marriage, food security, poverty reduction and increasing global markets. The growing threat of antimicrobial resistance calls us to systems strengthening to curtail the overuse and misuse of antibiotics. 

And this work is deeply humanitarian. Preventing costly and debilitating illnesses and diseases supports families and is far more humane than allowing painful diseases to simmer in unsanitary situations with debilitating and deadly results. If the long-game strategy does not include WASH, we’ve learned it’s an incomplete strategy and will fall apart as surely as a poorly maintained water pump.