SANITATION AND HEALTHCARE WASTE MANAGEMENT SYSTEMS AND THEIR EFFECTS ON HEALTH SERVICE DELIVERY IN HEALTHCARE FACILITIES IN UPPER NILE STATE, SOUTH SUDAN

This study evaluated the status of Water, Sanitation, and Hygiene (WASH) services, focusing on sanitation infrastructure and healthcare waste management practices, and to determine their implications for infection prevention and quality of healthcare delivery in a conflict-affected setting. A mixed-methods crosssectional design was employed, combining quantitative facility-based observations and qualitative key informant interviews. A total of 20 healthcare facilities (PHCCs and hospitals) were assessed. In addition, 64 key informant interviews were conducted with healthcare workers, inpatients, and lactating mothers. Quantitative data were analyzed using descriptive statistics, cross-tabulations, chi-square tests, and ordinal logistic regression, while qualitative data were analyzed thematically in line with established qualitative analysis frameworks. The findings revealed severe deficiencies in sanitation and waste management systems. Most facilities (85%) provided only limited sanitation services, while 15% had none. Although 75% had at least one usable toilet, only 25% were clean, and none had menstrual hygiene management facilities. Only 15% had gender-separated toilets, and 70% lacked staff toilets. Waste management systems were critically weak, with 100% of facilities failing to meet waste segregation standards, lacking PPE for waste handlers, and not using WHO-compliant incinerators. Regression analysis showed that facility type significantly influenced sanitation adequacy (p = 0.022), while the availability of staff toilets, functional cubicles, and waste kits significantly improved sanitation outcomes. However, no significant association was found between facility type and overall sanitation service level (p = 0.348), indicating systemic deficiencies across both hospitals and PHCCs. Qualitative findings confirmed these results, highlighting experiences of poor hygiene, lack of privacy, unsafe waste disposal, and occupational risk among healthcare workers. The study concludes that sanitation and waste management services in Upper Nile State are critically inadequate. These gaps reflect systemic health system weaknesses exacerbated by conflict and resource constraints. The study recommends urgent investment by the Ministry of Health, supported by development partners such as the World Health Organization and UNICEF, to strengthen WASH infrastructure, ensure provision of gender-sensitive sanitation facilities, establish proper waste management systems, and provide PPE and training for healthcare workers. Strengthening facility-level accountability and integrating WASH into health system recovery strategies are essential for improving healthcare quality and resilience in Upper Nile State.