Water Currents: WASH in Health Care Facilities

In celebration of World Health Day on April 7—the World Health Organization's (WHO) annual campaign day highlighting priority health concerns—this issue of Water Currents focuses on water, sanitation, and hygiene (WASH) in health care facilities (HCF), a topic that is gaining wider interest and support. This year’s theme is universal health coverage, which means that all people and communities have access to quality health services where and when they need them, without suffering financial hardship.

To deliver quality health care, institutions require safe water and sanitation services, handwashing facilities, and a process for safely managing and disposing of health care waste. A brief from USAID’s Maternal and Child Health Program notes that one of the major challenges to providing WASH in HCF is that WASH, as a sector, rarely has an institutional home. Instead, its governance gets bundled under “water and sanitation” or “water resources,” which in turn are divided among multiple ministries, government bodies, and interests, e.g., urban planning, public works, energy, forestry, etc.

Global Water 2020 contributed to this issue, which features studies, webinars, country assessments, toolkits and training materials, reports, and other resources published from 2017 to 2019. Two key WHO publications published in 2008 and 2015, respectively, are particularly noteworthy: Water, Sanitation and Hygiene in Health Care Facilities: Status in Low- and Middle-Income Countries and the Way Forward and Essential Environmental Health Standards in Health Care

World Health Day 2019 (WHD). This WHO–sponsored international campaign day falls annually on April 7, and this year’s theme aims to help people better understand what universal health care means—what services and support should be available and where. Resources on the site include fact sheets, key messages, communications materials, and more.

WASH in Health Care Facilities: Global Baseline Report 2019WHOUNICEF, April 2019. This first Joint Monitoring Programme (JMP) report on WASH in health care facilities introduces new service ladders for basic services and establishes national, regional, and global baseline estimates that contribute toward global monitoring of Sustainable Development Goal (SDG) targets 6.1 and 6.2universal access to WASH.

WASH in Health Care Facilities: Practical Steps to Achieve Universal Access to Quality CareWHOUNICEF, April 2019. The purpose of this document is to present practical actions that can be taken at the national and subnational level to improve WASH in health care facilities. This document is a companion to the WHO and UNICEF global baseline report 2019 for WASH in health care facilities (see above), which provides the first national, regional, and global baseline estimates for monitoring SDG 6 in health care facilities.

Environmental Conditions in Health Care Facilities in Low- and Middle-Income Countries: Coverage and InequalitiesInternational Journal of Hygiene and Environmental Health, April 2018. A study of nationally representative data from 78 countries found that 50 percent of HCFs lacked piped water, 33 percent lacked improved sanitation, 39 percent lacked soap for handwashing, and 39 percent lacked adequate infectious waste disposal.

Water, Sanitation, and Hygiene at the Health CenterUSAID Maternal and Child Survival Program (MCSP), February 2017. This two-page brief outlines the challenges facing WASH in maternal and perinatal health settings and proposes actions to address them, including through improved WASH in HCFs.

Safe Management of Wastes from Health-Care Activities: A SummaryWHO, 2017. This document highlights the key aspects of safe health care waste management to guide policymakers, practitioners, and facility managers to improve waste management services in HCFs.

Transforming Health Systems: The Vital Role of Water, Sanitation and HygieneWaterAid, May 2018. Released at the 2018 World Health Assembly, this report is a manifesto of change for governments and donors to ensure that all health centers around the world have safe, reliable, accessible, and inclusive WASH by 2030, as part of the drive to achieve universal health coverage.

What Is the Impact of Water Sanitation and Hygiene in Healthcare Facilities on Care Seeking Behaviour and Patient Satisfaction? A Systematic Review of the Evidence from Low-Income and Middle-Income CountriesBMJ Global Health, March 2018. A systematic review of maternal health services found that poor WASH provision often prompted women to choose home delivery. However, providers’ attitudes and interpersonal behaviors were the main drivers of patient dissatisfaction with maternal health services.

Country/Regional Implementation
National Guidelines for WASH Services in Health Care Facilities in TanzaniaTanzanian Ministry of Health, Community Development, Gender, Elderly and Children, October 2017. These guidelines have put in place a uniform and harmonized approach for the provision of WASH services in public and private HCFs across Tanzania.

Water, Sanitation, and Hygiene in Rural Health-Care Facilities: A Cross-Sectional Study in Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and ZambiaAmerican Society of Tropical Medicine and Hygiene, October 2017. Researchers found that fewer than 50 percent of rural HCFs surveyed in sub-Saharan Africa had access to improved water sources on premises, improved sanitation, and consistent access to water and soap for handwashing.

Health Care Waste Management Among Health Workers and Associated Factors in Primary Health Care Facilities in Kampala City, Uganda: A Cross-Sectional StudyBMC Public Health, February 2019. A study of health care waste (HCW) management in HCFs found HCW practices to be largely satisfactory, especially among health workers with diploma-level education, previous HCW management training, and those who perceived HCW management as important.

Water Treatment and Handwashing Practices in Rural Kenyan Health Care Facilities and Households Six Years after the Installation of Portable Water Stations and Hygiene TrainingJournal of Water and Health, February 2018. Handwashing and drinking water stations were installed in 53 HCFs in Kenya in 2005, with hygiene education provided to health workers and clinic clients. Results of this assessment indicate that, six years after implementation, 80 percent of HCFs had at least one functional handwashing station and 83.3 percent had at least one functional drinking water station.

Strengthening Healthcare Facilities Through Water, Sanitation, and Hygiene (WASH) Improvements: A Pilot Evaluation of “WASH FIT” in TogoHealth Security, November 2018. Findings suggest that WASH FIT, coupled with training and supervision, may help HCFs improve WASH services and practices, thus contributing to global health security.

Understanding the Cost of WASH in Health Care Facilities: Where Do We Start?Emory University Center for Global Safe WASH, February 2019. This webinar discusses the importance of cost data and sustainable WASH service delivery in HCFs.

The State of Handwashing in 2017: Annual Research SummaryGlobal Handwashing Partnership, 2018. This literature review provides a comprehensive summary of recent articles on hand hygiene, including a particular focus on health care settings.

Overcoming Hurdles in Handwashing: A Clinician’s Perspective in Driving Change on Healthcare FacilitiesEmory University Center for Global Safe WASH, October 2018. This webinar highlights the methodology and results of a successful intervention in a Cameroon HCF, which aimed at reducing the incidence of neonatal sepsis by targeting health care worker hand hygiene practices.

An Invisible Workforce: The Neglected Role of Cleaners in Patient Safety on Maternity Units. Global Health Action, February 2019. study of HCFs in Bangladesh, India, The Gambia, and Zanzibar argues that the low status of cleaners within facilities—with their wider societal marginalization, lack of training, and poor pay and working conditions contributes to the lack of prioritization placed on HCF environmental hygiene.

Indicators/Monitoring Resources
Core Questions and Indicators for Monitoring WASH in Health Care Facilities in the Sustainable Development GoalsWHOUNICEF, August 2018. This document presents recommended core indicators to support harmonized monitoring of WASH in HCF to help meet the goals of the 2030 Agenda for Sustainable Development. The indicators include definitions for “basic” water, sanitation, hand hygiene, health care waste management, and environmental cleaning.

Toolkits/Training Materials
Water and Sanitation for Health Facility Improvement Tool (WASH FIT): A Practical Guide for Improving Quality of Care Through Water, Sanitation and Hygiene in Health Care FacilitiesWHOUNICEF, November 2018. WASH FIT is a risk-based, continuous improvement framework with a set of tools for undertaking WASH improvements as part of wider quality improvements in HCFs. It is available in English, Russian, and French, with Spanish and Arabic forthcoming. The page also links to WASH FIT Digital, a free, open access tool.

Clean Clinic Approach BriefUSAID Maternal and Child Survival Program (MCSP), October 2016. This two-page brief explains MCSP’s Clean Clinic Approach, a programmatic tool that encourages health facilities to establish WASH goals and make incremental improvements toward the end goal of achieving “Clean Clinic” status, as defined by national ministries of health.

Developing a Participatory Management Tool for User-Friendly Water Sanitation and Hygiene in Healthcare FacilitiesWaterAid, March 2018. This report synthesizes key learning on making WASH in HCFs more user-friendly, accessible, and inclusive. It captures the participatory, inclusive, collaborative, and rigorous approach taken to develop a "Participatory Management Tool” to support progress toward user-friendly WASH in HCFs in Cambodia and beyond.

WASHcon – WASHcon is an assessment tool to evaluate WASH conditions within HCF in low- and middle-income countries.

Facility Evaluation Tool for WASH in Institutions (FACET) – A simple and adaptable analysis tool, FACET offers state-of-the-art online/offline mobile data collection on an open source platform.

Improving Management Systems for Better Water, Sanitation, Hygiene, and Infection Prevention for Mothers and Newborns: Trainer’s GuideUSAID MCSP, July 2018. This training guide aims to strengthen systems that support WASH and infection prevention and control, both within HCFs and in the broader health system.

The Teach Clean PackageThe Soapbox Collaborative, November 2018. This resource is designed to address the training of HCF cleaning staff in low- and middle-income countries. The package is tailored toward use with low-literate cleaning staff but can be applied to wider facility staff.

WASH in Health Care Facilities – This updated WHO and UNICEF knowledge portal is for all involved in this issue to exchange the latest standards, tools, approaches, achievements and learnings. It is also for making and tracking commitments.

WASH in Healthcare Facilities Initiative – Hosted by Emory University, this action-oriented learning platform includes monthly webinars, along with research tools, publications, and country summaries.

WASH in Health Care Facilities: A Toolbox for Improving Quality of Care– USAID’s MCSP created this microsite to host resources as well as perspectives and insights from MCSP’s experience integrating WASH in support of quality of care improvements that lead to improved health outcomes.

Globalwaters.org – The USAID Water Office supports Globalwaters.org to foster knowledge sharing and collaboration for sustainable WASH access for all, and provide water practitioners with the latest news, learnings, and resources from USAID and its partners. A search on health care facilities retrieves guidance, tools, and other resources.

Global Handwashing Partnership (GHP) – GHP is a coalition of international stakeholders working to promote handwashing with soap and advocate for hygiene as a pillar of international development and public health. The website includes case studies, blogs, publications, and other outreach materials to support handwashing programs.

Hand Hygiene in Healthcare Settings – This website from the Centers for Disease Control and Prevention includes a summary of the agency’s resources on hand hygiene.

SAVE LIVES: Clean Your Hands Campaign – WHO uses this webpage to promote its annual call to action for health care workers.


Water Currents
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USAID Bureau for Economic Growth, Education and Environment (E3) Water Office