Cholera’s lessons must not be rejected

Dr Afia Zakiya and Dr Chaka Uzondu from WaterAid Ghana discuss the importance of water, sanitation and hygiene in the prevention and treatment of cholera and achieving the goal of universal health coverage.

12 Dec 2014

Today, 12 December 2014, Universal Health Coverage (UHC) Day will be officially and globally recognised for the first time. Universal health coverage is based on a belief that everyone, everywhere should have the best possible health-care and that accessing quality health-care, if and when necessary, should not cause anyone financial difficulty.

Why is it extremely critical that Ghana embraces universal health coverage? Here are a few ideas for consideration.

Anyone reading this article should already know that, “Health-care is not a commodity or privilege, but a human right.” Still, it is not a bad thing if Dr Julio Frenk, the Dean of Harvard University’s School of Public Health, quoted, gives a reminder. Yes, Dr Frenk is a strong supporter of universal health coverage. And, standing beside him holding aloft the banner of universal health coverage, is Dr Margaret Chan, Director-General of the World Health Organization. In her own words, “Universal health coverage [is] the single most powerful concept public health has to offer.”

Yet we don’t have to leave Ghana to get this insight. Public Health and Hygiene Behaviour Change Specialist, Mrs Martha Osei has always maintained that, "Adequate access to portable water and proper sanitation is the viable foundation for good health; achieving universal health without these is impossible."

According to, the Ghanaian Health Service is considering introducing two cholera vaccines next year and perhaps focusing their use especially in the areas that were hardest hit by the cholera epidemic this year. At WaterAid Ghana, we are troubled by this thinking and hope that a quick fix is not mistaken for a substantive solution.

You might be wondering what the cholera epidemic has to do with universal health coverage. Well, this year’s cholera epidemic highlighted the massive negative consequences to public health when the foundations of an effective health system are ignored. In other words, access to adequate and appropriate water, sanitation and hygiene (WASH) is the foundation for an effective health-care system.

Building a universal health coverage system is extremely important for realising the rights of all to the best possible health. Therefore, achieving a ‘Better Ghana’ agenda would have to include support for universal health coverage. This must also include the realisation that systematic investment in the provision of not only water but sanitation and culturally sensitive hygiene promotion is the starting point for ensuring public health and safety. For curative health services to function well, access to WASH is also of critical importance.

This is why WaterAid Ghana is very concerned that the Ghanaian Health Service is considering investing in vaccines against cholera. It is possible that in emergencies, for example, the use of vaccinations could be considered. However minimising, if not preventing, the outbreaks of cholera and other diseases spread by fecal-oral route requires provision of adequate sanitation, safe water and effective hygiene promotion in culturally sensitive ways.

WaterAid Ghana is pleased to see that the Ghanaian Health Service is concerned with the plight of those most affected by cholera. Research indicates clearly that those most affected are mainly marginalised people – people living in informal settlements with little security of tenure and with low incomes.

However, securing the lives of those most at risk of contracting cholera will not in the short or long term be best realised by vaccinations. This is a band-aid solution that solves little if anything. For example, do cholera vaccinations prevent contracting worms (soil transmitted helminths)? Will these cholera vaccinations reduce infant and maternal mortality by reducing sepsis? Honest answers to these questions are likely to be no.

Thus, WaterAid Ghana strongly hopes that the Ghanaian Health Service resists the lure of the quick fix and focuses on the basics, the proven foundation of every good health system – the provision of water, sanitation and hygiene. We recognise that WASH is not within the remit of the Ghanaian Health Service or the Ministry of Health. Yet, the provision of WASH is central to the realisation of the Ghanaian Health Service’s objectives. Therefore, it and the Ministry of Health have important roles to play in fostering greater collaboration and coordination between the relevant ministries and their respective agencies. Working in ‘ministerial silos’ is not effective – it fails to meet the needs of the good people of Ghana.

Universal health coverage is an opportunity for all to do what is necessary to embed WASH deeply into our health-care system. More than preventing cholera is at stake. Prioritising the place of water, sanitation and hygiene as we build a universal health coverage system, which is particularly focused on the most marginalised, is an important step in securing the health of the nation.

Today, Universal Health Coverage Day, WaterAid Ghana proudly stands with all those working to implement universal health coverage in Ghana, and we remind all that the rights of everyone, everywhere to health is only possible when the rights to water, sanitation, and hygiene are realised.

Dr Afia Zakiya is the Country Representative of WaterAid Ghana and Dr Chaka Uzondu is the WASH and Health Focal Person.

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