The challenges of monitoring WASH in Health Care Facilities (2/4)

This second blog is part of a four-part blog series on monitoring the Global Goal on water and sanitation & the challenge of data aggregation. This week’s blog is authored by Dr. Margaret Montgomery and Betsy Engebretson (WHO Water, Sanitation, Hygiene and Health Unit) with inputs from Ryan Cronk (University of North Carolina at Chapel Hill).  It offers some suggestions on how to overcome the challenges related to monitoring WASH in Health Care Facilities in low- and middle-income countries.  

Many health care facilities around the world lack access to water, sanitation and hygiene (WASH). Earlier this year, WHO and UNICEF published the first landscape review of WASH in low- and middle-income countries, which found that 38% of health care facilities surveyed lack a water source, 35% lack soap or alcohol-based hand rubs for handwashing and 20% lack improved sanitation. Inadequate WASH leads to increased risk of infection for patients and hinders efforts to improve quality of care. Adequate WASH at health care facilities has a number of benefits beyond improved health outcomes, including improved disaster resilience, increased uptake of services and more efficient services.

While the statistics are shocking, solutions exist and the time to act is now.  Tools, standards and methods are available to ensure WASH access in every facility, in every location. To meet the fundamental need for WASH in health care facilities, the WHO and UNICEF led the development of a global action plan. This includes four task teams: advocacy and leadership; monitoring; evidence and operational research; and policies, standards and facility improvements. Change requires health sector leadership, WASH sector support and engagement from the bottom up and top down.

There is potential to make rapid progress by improving monitoring. While some data on WASH in health care facilities are available, quality data are lacking. For example, health care facility surveys typically measure presence of a water source at or near the facility. However, the continuity, safety and provision of water in the actual rooms where it is needed most, such as maternity wards, is critical. Further, not all surveys and indicators are harmonized, making it difficult to compare across countries and over time. Monitoring should be harmonized and reflect global and national norms, such as water available at the point of care and gender-separated, functional toilets.

Steps are in place to improve indicators and increase their use in national health assessments and monitoring systems. The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) will monitor WASH in schools and health care facilities as part of Sustainable Development Goal six on WASH. This improves on the Millennium Development Goals where water and sanitation were only tracked at the household level.

With support from the monitoring task team, the JMP is developing core and expanded indicators for WASH in health care facilities. Draft indicators include:

  • Basic drinking water services in health care facilities, which means the percentage of facilities:
    • with an improved source providing sufficient water,
    • on premises,
    • accessible to all users,
    • at all times.
  • Basic sanitation in health care facilities are those that effectively separate excreta from human contact and ensure that excreta do not re-enter the immediate environment. An adequate sanitation facility at a health care facility:
    • is located in close proximity to the health care facility;
    • is accessible to all users, including adults and children, the elderly, and those with physical disabilities;
    • provides separate facilities for males and females, and for adults and children;
    • is equipped with handwashing stations that include soap and water and are inside or immediately outside the sanitation facility;
    • provides basic menstrual management facilities in sanitation facilities that are used by women and girls of menstruating age;
    • at in-patient health centres, includes at least one toilet per 20 users;
    • at out-patient health centres, includes at least four toilets – one each for staff, female patients, male patients, and child patients.

Data analysis exploring service levels of WASH in health care facilities, trends over time, equity in access, and determinants of low levels of service will enable governments and external support agencies to target investments where services are needed most. The sector will be able to assess the gains in improving access and most importantly ensure that all individuals benefit from quality, people-centred care. To learn more about this effort and to get involved visit: You can also read our editorial and the report, as well as the latest WaSH Policy Digest. The data for each country are also available on the WASHwatch platform.

By Dr. Margaret Montgomery and Betsy Engebretson (WHO Water, Sanitation, Hygiene and Health Unit) with inputs from Ryan Cronk (University of North Carolina at Chapel Hill).

-> Read last week’s blog in the series “WASH Monitoring and the Global Goals” (1/4)


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