WASH IN HEALTH CARE FACILITIES - UNICEF Scoping Study in Eastern and Southern Africa

 
WASH IN HEALTH CARE FACILITIES - UNICEF Scoping Study in Eastern and Southern Africa
WASH IN HEALTH CARE FACILITIES
UNICEF Scoping Study in Eastern and Southern Africa

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WASH IN HEALTH CARE FACILITIES - UNICEF Scoping Study in Eastern and Southern Africa
WASH in Health Care Facilities
UNICEF Scoping Study in Eastern and Southern Africa

August 2019

© United Nations Children’s Fund

UNICEF Eastern and Southern Africa Regional Office (ESARO)
Nairobi, Kenya

Author: Magdalene Matthews Ofori-Kuma, UNICEF ESARO

Co-Author: Tsion Gebreyesus, UNICEF Ethiopia Country Office

Cover Image: ©UNICEF/UN0318391/Ramasomanana
Mother and newborn baby, Moramanga Hospital, Madagascar

Reviewers and Contributors: Samuel Godfrey, Bernard Keraita, Gabriele Fontana, Fatima Gohar, Lara Burger and Shem Okiomeri.

The ESARO Team extends its gratitude to the governments, line ministries, technical resource persons and dedicated UNICEF WASH and health
colleagues working to advance WASH in health care facilities in the 21 UNICEF programming countries in Eastern and Southern Africa Region for
their valuable contributions, insights and inputs to the study.

Special acknowledgements to the following UNICEF staff for their contributions of time, content, knowledge and experience to the enrichment
of the final publication:

Angola			                          Tomas Lopez de Bufala, Edson Monteiro
Burundi			                         Daniel Spalthoff, Yves Shaka, Remegie Nzeyimana
Comoros			                         Sylvain Bertrand, Maarouf Mohamed
Eritrea			                         David Tsetse, Hanna Berhe, Yirgalem Solomon
Eswatini			                        Boniswa Dladla
Ethiopia			                        Kitka Goyal, Jane Bevan, Netsanet Kassa, Getachew Hailemichael
Kenya			                           Andrew Trevett, Maya Igarashi Wood, Agnes Makanyi
Lesotho			                         Nadia AlHarithi, Ubong Ekanem, Anthony Asije
Madagascar		                       Brigitte Pedro, Bodovoahangy Andriamaroson, Tata Venance (Ministry of Public Health),
			                                Ranarison Volahanta Malala (WHO)
Malawi			                          Michele Paba, Blessius Tauzie, Chimwemwe Nyimba
Mozambique		                       Chris Cormency, Mayza Tricamegy, Jesus Trelles
Namibia			                         Matheus Shuuya
Rwanda			                          Cindy Kushner, Jean Marie Vianney Rutaganda
Somalia			                         Mahboob Ahmed Bajwa, Charles Mutai
South Sudan		                      Victor Kinyanjui, Robert Taban Lominsuk, Prakash Raj Lamsal
Uganda			                          Shiva Narain Singh, Mary Nawembe
United Republic of Tanzania        Amour Seleman, John Mfungo, Francis Odhiambo
Zambia			                          Murtaza Malik, Lavuun Verstraete
Zimbabwe		                         Aidan Cronin, Shelly Chitsungo, Moreblessing Munyaka, Jennifer Barak, Mitsuaki Hirai
WASH IN HEALTH CARE FACILITIES - UNICEF Scoping Study in Eastern and Southern Africa
WASH IN HEALTH CARE FACILITIES
UNICEF Scoping Study in Eastern and Southern Africa
WASH IN HEALTH CARE FACILITIES - UNICEF Scoping Study in Eastern and Southern Africa
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    © UNICEF/UN0306399/Abdul
WASH IN HEALTH CARE FACILITIES - UNICEF Scoping Study in Eastern and Southern Africa
Table of Contents

LIST OF FIGURES & TABLES										VI
ABBREVIATIONS AND ACRONYMS									VII
INTRODUCTION											1
1. WASH AND HEALTH: CURRENT CONTEXT								4
1.1 GLOBAL FRAMEWORK FOR WASH IN HEALTH CARE FACILITIES						                    4
1.2 UNICEF’S VISION FOR WASH IN HEALTH CARE FACILITIES						                     6
1.3 WASH IN HEALTH IN EASTERN AND SOUTHERN AFRICA							                         8
2. WASH COVERAGE IN HEALTH FACILITIES								9
2.1 JOINT MONITORING PROGRAMME SERVICE LADDERS FOR WASH IN HEALTH				            9
2.2. GLOBAL BASELINE FOR WASH IN HEALTH CARE FACILITIES						                    10
2.3 WASH IN HEALTH COVERAGE IN EASTERN AND SOUTHERN AFRICA					                  12
3. THE ENABLING ENVIRONMENT FOR WASH IN HEALTH CARE FACILITIES IN EASTERN AND
SOUTHERN AFRICA											14
3.1 DEFINITION AND SCOPE										14
3.2 METHODOLOGY											15
3.2.1 REGIONAL SURVEY AND ANALYSIS									15
3.2.2 CASE STUDIES											16
3.3 SOURCES OF INFORMATION										17
3.4 SPECIAL ACKNOWLEDGEMENT									17
4. FINDINGS												20
4.1 REGIONAL ENABLING ENVIRONMENT FOR WINHCF IN ESAR						                       20
4.2 SECTOR POLICY/STRATEGY										22
4.3 INSTITUTIONAL ARRANGEMENTS									24
4.4 SECTOR FINANCING											25
4.5 PLANNING, MONITORING AND REVIEW								27
4.6 BUILDING CAPACITY FOR WASH IN HEALTH CARE FACILITIES						                   29
5. CROSS-CUTTING & EMERGING ISSUES								32
5.1 WASH AND MATERNAL, NEWBORN AND CHILD HEALTH (MNCH)					                      32
5.2 GENDER INCLUSIVITY AND MENSTRUAL HEALTH AND HYGIENE						                    32
5.3 DISABILITY INCLUSION IN WINHCF POLICY FRAMEWORKS						                       33
5.4 ANTIMICROBIAL RESISTANCE										33
5.5 CLIMATE-RESILIENCE PROGRAMMING FOR WASH IN HEALTH CARE FACILITIES				        33
5.6 COUNTRY PERSPECTIVES										34
6. DESCRIPTIVE CASE STUDIES										35
UGANDA												35
KENYA													39
ERITREA													42
7. RECOMMENDATIONS										45
REFERENCES												48
ANNEX 1: SUMMARY OF WHO PUBLICATIONS ON HEALTH CARE AND WASTE				                50
ANNEX 2: SDG CORE QUESTIONS FOR MONITORING WINHCF						                          52
ANNEX 3: INDICATORS IN REGIONAL ENABLING ENVIRONMENT SURVEY				                  53
ANNEX 4: A CLOSER LOOK AT ETHIOPIA’S ENABLING ENVIRONMENT FOR WASH IN
           HEALTH CARE FACILITIES									54
ANNEX 5: STAKEHOLDER PERSPECTIVES ON BOTTLENECKS AND RECOMMENDED ACTIONS
           FOR WINHCF SCALE-UP									56
ADDITIONAL WASH IN HEALTH CARE FACILITIES RESOURCES						                        59

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WASH IN HEALTH CARE FACILITIES - UNICEF Scoping Study in Eastern and Southern Africa
List of Figures and Tables

Figure 1: Map of the 21 Countries in Eastern and Southern Africa						                                        3
Figure 2: Multiple benefits of adequate WASH in health care facilities					                                   4
Figure 3: WASH FIT five step process for improving facility-level WASH Servicess				                          6
Figure 4: Causes of newborn deaths in the region								                                                      7
Figure 5: New JMP service ladders for global monitoring of WASH in health care facilities			                  9
Figure 6: Water services in health care facilities by SDG region 						                                       10
Figure 7: Proportion of health care facilities in sub-Saharan Africa with basic water supply			               11
Figure 8: Sanitation coverage in health facilities in select countries in ESAR					                           11
Figure 9: UNICEF’s Strategy for WASH (2016-2030): A Snapshot						                                            12
Figure 10: Water coverage in health facilities in selected countries in Eastern and Southern Africa		         13
Figure 11: Sanitation coverage in health facilities in selected countries in Eastern and Southern Africa 		   13
Figure 12: UNICEF’s Strategy for WASH (2016-2030): A snapshot						                                           14
Figure 13: WASH sector-strengthening building blocks and expected results					                                15
Figure 14: Regional WASH in health care facilities enabling environment scorecard for countries in ESAR       18
Figure 15: Regional enabling environment scorecard for WASH in health care facilities				                     19
Figure 16: Map of country performance for overall enabling environment indicators for WinHCF in ESAR          20
Figure 17: Country performance for enabling environment indicators on sector policy and strategy in ESAR      22
Figure 18: Proportion of countries with policy instruments and frameworks addressing WinHCF in ESAR		         23
Figure 19: Country performance for enabling environment indicators on institutional arrangements in ESAR      24
Figure 20: Country performance for enabling environment indicators on sector financing in ESAR 		             26
Figure 21: Country performance for enabling environment indicators on planning, monitoring and review         27
Figure 22: Proportion of countries in ESAR with HMIS indicators on usage and functionality for WinHCF		       28
Figure 23: Country performance for enabling environment indicators on capacity development in ESAR            29
Figure 24: JMP service ladders for water services in health care facilities in Uganda				                     36
Figure 25: KJMP service ladders for sanitation services in health care facilities in Uganda			                36
Figure 26: JMP service ladders for waste disposal in health care facilities in Uganda				                     36
Figure 27: Kenya Essential Package for Health (KEPH) Health Service levels, Source: Kenya HRH Strategy		      39
Figure 28: JMP service ladders for water services in health care facilities in Kenya 				                     40
Figure 29: Country scores for enabling environment indicators for WASH in healthcare facilities in Eritrea    42
Figure 30: WHO/UNICEF practical steps to achieve universal access to quality care 				                        46
Figure 31: SDG core questions for monitoring WinHCF							                                                    51

Table 1: Essential Environmental Health Standards in Health Care Facilities					               5
Table 2: Enabling environment survey response, score and colour-coding guideline 				          16
Table 3: Regional WinHCF Enabling Environment Scores by Sector Strengthening Building Blocks		 21
Table 4: Uganda’s referral health care system based on level and services provided 			35

 vi
WASH IN HEALTH CARE FACILITIES - UNICEF Scoping Study in Eastern and Southern Africa
List of Abbreviations and Acronyms

DHS      Demographic and Health Survey
DHIS     District Health Information Software
ESAR     Eastern and Southern Africa Region
ESARO    Eastern and Southern Africa Regional Office
HCWM     Healthcare Waste Management
HMIS     Health Management Information System
IPC      Infection Prevention and Control
JMP      Joint Monitoring Programme
MDGs     Millennium Development Goals
MHH      Menstrual Health and Hygiene
MICS     Multiple Indicator Cluster Surveys
M&E      Monitoring and Evaluation
MoH      Ministry of Health
MoW      Ministry of Water
O&M      Operations & Maintenance
RO       Regional Office
SDGs     Sustainable Development Goals
UNICEF   United Nations Children’s Fund
WASH     Water, Sanitation and Hygiene
WHO      World Health Organization
WinHCF   WASH in Health Care Facilities

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WASH IN HEALTH CARE FACILITIES - UNICEF Scoping Study in Eastern and Southern Africa
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    © UNICEF/UN0306439/Abdul
WASH IN HEALTH CARE FACILITIES - UNICEF Scoping Study in Eastern and Southern Africa
INTRODUCTION

Availability of sustainable water, sanitation and                                               a global issue, in his remarks, the Secretary General
hygiene (WASH) services is essential to quality of care                                         stated: “We must work to prevent the spread of disease.
and infection prevention and control in health care                                             Improved water, sanitation and hygiene in health
facilities. The linkage between safe water for hygiene                                          facilities is critical to this effort.”
and handwashing in health facilities and reduction
in disease transmission has long been established in                                            In April 2019, the WHO/UNICEF Joint Monitoring
literature. Given the importance of water availability and                                      Programme for Water Supply, Sanitation and Hygiene
good hygiene during childbirth in particular, WASH is                                           published the Global Baseline Report on WASH in Health
considered both a precondition and an entry point for                                           Care Facilities, the first ever harmonized estimates for
good quality of care.                                                                           water, sanitation, hand hygiene, health care waste
                                                                                                management and environmental cleaning services in
According to the World Health Organization (WHO), one                                           health care facilities across the world. The report findings
of the leading global actors working to improve WASH in                                         helped raised further awareness on the magnitude of
health care facilities, clean and safe healthcare facilities,                                   the problem on the global scale.
equipped with adequate WASH services, can: a) increase
demand for and trust in services; b) reinforce the role of                                      Meanwhile, at the 72nd World Health Assembly in
healthcare services and staff in setting societal hygiene                                       May 2019, Ministers of Health from Member States
norms; c) increase the motivation and retention of health                                       unanimously approved a resolution on WASH in Health
workers; d) result in cost savings from infections averted;                                     Care Facilities, committing to advancing WinHCF
and e) lead to more efficient service delivery. Sustainable                                     programming through: a) the development of national
Development Goal (SDG) 3 (ensure healthy lives and                                              roadmaps; b) the setting and monitoring of national
promote well-being) and SDG 6 (ensure availability and                                          targets; c) increased investments in infrastructure and
sustainable management of water and sanitation for all)                                         human resources; and d) targeted systems strengthening
reinforce the need to ensure safe management of water                                           to improve and sustain WASH services in health care
and sanitation, reduction in maternal mortality, ending                                         facilities.
preventable newborn deaths, and providing quality                                               In response to these unfolding developments, WHO and
universal health coverage.                                                                      UNICEF are co-leading global efforts on monitoring,
Despite the critical role that water, sanitation, hygiene,                                      standard setting, advocacy and learning. Under the
waste disposal and environmental cleaning services play                                         SDGs, the global targets are to ensure that at least 50
in the continuum of healthcare, access to WASH services                                         per cent of all health care facilities globally and in each
globally remains alarmingly poor. The gaps in current                                           SDG region1 have basic WASH services by 2022, 80 per
WASH services in health care facilities are significant.                                        cent by 2025, and 100 per cent by 2030. In countries
According to the 2019 Global Baseline Report on WASH                                            where WASH services exist, the target is advanced levels
in Health Care Facilities, one in four health care facilities                                   of service, with the aim of 100 per cent by 2030. As
lacks basic water services, and 896 million people have                                         a children-focused organization, UNICEF is committed
no water service at their health care facility. For children,                                   to helping every child gain access to drinking water,
this has far-reaching effects on their level of growth,                                         sanitation and hygiene, including in schools and health
development, morbidity and mortality, especially at the                                         centres, and in emergency/humanitarian situations
very start of life.                                                                             where children are most vulnerable. In the words of
                                                                                                UNICEF Executive Director Henrietta Fore: “Every birth
In recent times, several developments have helped                                               should be supported by a safe pair of hands, washed
strategically position WASH in health care facilities                                           with soap and water, using sterile equipment, in a clean
(WinHCF) as a priority on the global developmental                                              environment.”
agenda. In March 2018, at the Launch of International
Decade for Action, 2018-2028, United Nations Secretary                                          As part of UNICEF’s Global WASH Strategy (2016-2030),
General Antonio Guterres issued a global call to action                                         the organization will continue working with WHO and
for WASH in all health facilities. Elevating WinHCF as                                          ministries of health to formulate, promote and support

1
 SDG Regions: a) Sub-Saharan Africa; b) Northern Africa and Western Asia; c) Central and Southern Asia; d) Eastern and South-Eastern Asia; e) Latin America and the Caribbean; f) Oceania;
g) Europe and Northern America; h) Least Developed Countries (LDC); i) Landlocked developing countries (LLDC) and j) Small island developing States (SIDS).

                                                                                                                                                                                    1
WASH IN HEALTH CARE FACILITIES - UNICEF Scoping Study in Eastern and Southern Africa
viable approaches for ensuring adequate WASH in                region (Eritrea, Uganda and Kenya). Assessment was
health care facilities, with a focus on facilities providing   based on UNICEF’s Enabling Environment Framework,
maternal and newborn health services. UNICEF’s                 using the five sector strengthening building blocks: a)
initiatives to improve water, sanitation and hygiene           Sector policy/strategy; b) Institutional arrangements; c)
practices in health care facilities will focus on improving    Sector financing; d) Planning, monitoring and review;
the safety and dignity of childbirth, with provisions made     and e) Capacity development.
to sponsor targeted research to improve the knowledge
base in the area for enhanced programme design and             The study forms part of evidence generation and
more effective advocacy.                                       knowledge sharing within the region and contributes
                                                               to UNICEF’s global strategic focus (2016-2030) as
On this premise, UNICEF Eastern and Southern Africa            well as to the 2018-2021 Regional Priorities for
Regional Office conducted a regional scoping study             Eastern and Southern Africa Region which call for the
and deep dive on the Enabling Environment for                  institutionalization of WinHCFs programming, the
WASH services in Health Care Facilities across its 21          prioritization of health facilities that provide maternal,
programming countries in Eastern and Southern Africa           neonatal and child health services; and the establishment
Region. The aim was to assess the status of the enabling       and enforcement of national standards for WASH
environment for WASH services in health facilities,            services in health care facilities.
identify related gaps and explore avenues to enhance
programming in the region. The objectives of the study         This report summarizes the findings of the study and
were:                                                          consists of five main parts:
1. To assess the status of the enabling environment for        1. A literature review of the current global,
    WinHCFs programming in the region;                             organizational and regional frameworks for WinHCF
                                                                   programming;
2. To document best practices on WinHCFs
    programming from selected countries for further            2. A summary of regional WASH coverage in health
    learning, and knowledge-sharing in the region; and             care facilities based on the 2019 Joint Monitoring
                                                                   Programme global baseline findings;
3. To increase awareness of WinHCFs programming
    through evidence generation for enhanced                   3. An analysis of the enabling environment for WinHCF
    programming and targeted advocacy.                             derived from an administered online survey;
                                                               4. Descriptive case studies of selected countries within
The study consisted of an online survey completed                  the region; and
through multi-stakeholder consultations in countries
                                                               5. Strategic       recommendations     for   advancing
in the region, followed by visits to health care facilities
                                                                   sustainable WinHCFs programming in the region.
in rural and urban settings in selected countries in the

 2
Figure 1: Map of the 21 Countries in Eastern and Southern Africa2

2
    Swaziland is the current Kingdom of Eswatini.

                                                                    3
WASH AND HEALTH: CURRENT
         Chapter 1
                                                           CONTEXT

1.1 GLOBAL FRAMEWORK FOR                                                                          “the provision of water, sanitation, health care waste,
                                                                                                  hygiene and environmental cleaning infrastructure, and
WASH IN HEALTH CARE FACILITIES                                                                    services across all parts of a facility.” The organic role
As defined by the World Health Organization (WHO),3                                               WASH plays in ensuring quality of care, strengthening
the term ‘health care facilities’ refers to “all formally                                         infection prevention and control, enhancing maternal,
recognized facilities that provide health care, including                                         child and adolescent health and minimizing antimicrobial
primary (health posts and clinics), secondary, and                                                resistance cannot be overemphasized (Figure 2). Research
tertiary (district or national hospitals), public and private                                     shows that the benefits extend far beyond the point of
(including faith-run), and temporary structures designed                                          care to boosting staff morale and the performance of
for emergency contexts (e.g., cholera treatment                                                   health care workers, minimizing the national health care
centers).” ‘WASH in health care facilities’ is defined as                                         burden and providing a platform to promote improved
                                                                                                  hygiene practices within the community.

    Figure 2: Multiple benefits of adequate WASH in health care facilities, Source: WHO/UNICEF Factsheet4

Given the linkage between patient care service delivery and public health in any given context, several global guidance
documents have been developed to help streamline quality of care within health facilities, including WASH service
delivery. WHO and partners, including UNICEF, have, over the years, developed numerous frameworks to help reduce
the disease burden caused by inadequate infection prevention and control (IPC) measures and poor health care waste
management (HCWM) through enhanced safety standards. Annex 1 provides a summary of publications addressing
WASH, IPC and HCWM developed over the last decade and a half.5

3
    WHO WASH in Health Care Facilities, www.who.int/water_sanitation_health/facilities/healthcare/en/
4
    WHO/UNICEF Global WinHCF Action Plan Factsheet, www.wsscc.org/wpcontent/uploads/2015/11/WASHinHCFGlobalActionPlanOct20151.pdf
5
    WHO Publications, www.who.int/water_sanitation_health/facilities/health-care-waste-publications/en/

     4
WHO Essential Environmental Health Standards in Health Care Facilities

One of the key guidance documents on WinHCF is the WHO Essential Environmental Health Standards in Health
Care Facilities. This was developed as guidance on essential environmental health standards required for health care
in medium- and low-resource countries to guide the development and implementation of national policies. It lists the
recommended minimum standards for water, sanitation and hygiene services in health facilities as follows:

    Item                       Recommendation                                                          Explanation
    Water                      5–400 litres/person/day.                                                Outpatient services require less water, while operating
    quantity                                                                                           theatres and delivery rooms require more water. The
                                                                                                       upper limit is for viral haemorrhagic fever (e.g. Ebola)
                                                                                                       isolation centres.
    Water access               On-site supplies.                                                       Water should be available within all treatment wards
                                                                                                       and in waiting areas.
    Water quality              Less than 1 Escherichia coli/ thermotolerant                            Drinking water should comply with WHO Guidelines
                               total coliforms per 100 ml.                                             for Drinking-water Quality for microbial, chemical
                               Presence of residual disinfectant.                                      and physical aspects. Facilities should adopt a risk
                               Water safety plans in place.                                            management approach to ensure that drinking water is
                                                                                                       safe.
    Sanitation                 1 toilet for every 20 users for inpatient setting.                      A sufficient number of toilets should be available for
    quantity                   At least 4 toilets per outpatient setting.                              patients, staff and visitors.
                               Separate toilets for patients and staff.
    Sanitation                 On-site facilities.                                                     Sanitation facilities should be within the facility grounds
    access                                                                                             and accessible to all types of users (females, males,
                                                                                                       those with disabilities).
    Sanitation                 Appropriate for local technical and financial                           Toilets should be built according to technical
    quality                    conditions, safe, clean, accessible to all users                        specifications to ensure excreta are safely managed.
                               including those with reduced mobility.
    Hygiene                    A reliable water point with soap or alco-                               Water and soap (or alcohol-based hand rubs) should
                               hol-based hand rubs available in all treatment                          available in all key areas of the facility for ensuring safe
                               areas, waiting rooms and near latrines for                              hand hygiene practices.
                               patients and staff.

Table 1: Essential Environmental Health Standards in Health Care Facilities, Source: WHO6

WHO/UNICEF Water Sanitation and Hygiene Facility Improvement Tool (WASH FIT)

With several frameworks addressing different components of health care service delivery, to bridge the gap between
environmental health, IPC and health care waste management at facility level, in 2018, WHO and UNICEF jointly
published the Water and Sanitation for Health Facility Improvement Tool7 (WASH FIT) as a practical guide for
improving quality of care through WinHCF. WASH FIT is a risk-based approach for improving and sustaining water,
sanitation and hygiene and health care waste management infrastructure and services in health care facilities in low-
and middle-income countries (LMICs). It is designed as an improvement tool to be used on a continuous and regular
basis, to help HCF staff and administrators prioritize and improve services, and to inform broader district, regional
and national efforts to improve quality health care.

WASH FIT guides multi-sectoral teams through a continuous cycle of assessing and prioritizing risks, defining and
implementing improvements, and continually monitoring progress. WASH FIT provides a systematic approach to
improving WASH through a health lens. According to WHO, since it was first developed in 2015, WASH FIT, as a tool,
has been piloted in over 20 countries across the world.8 In eastern and southern Africa, Comoros, Ethiopia, Kenya,
Madagascar, Malawi, Rwanda, Uganda and the United Republic of Tanzania have all piloted WASH FIT to some extent
in health care facilities, making gains at facility level while learning implementation lessons along the way for further
scale-up.

WASH FIT implementation involves a five-step process beginning with the enabling environment and culminating in
the desired health-based objectives, thus emphasizing the role of the enabling environment as a starting point for
sustainable WinHCFs (Figure 3). A strong enabling environment at national, sub-national and facility levels, is key to

6
    WHO (2008), Essential Environmental Health Standards in Health Care Facilities, www.who.int/water_sanitation_health/publications/ehs_hc/en/
7
    WHO/UNICEF (2018), WASH FIT www.who.int/water_sanitation_health/publications/water-and-sanitation-for-health-facility-improvement-tool/en/
8
 According to WHO, countries in which WASHFIT has been piloted are Bangladesh, Bhutan, Cambodia, Chad, Comoros, the Democratic Republic of the Congo, Ethiopia, Ghana, Guinea, India,
Indonesia, Iraq, Kenya, Lao People’s Democratic Republic, Liberia, Madagascar, Malawi, Mali, Nepal, the Philippines, Senegal, Tajikistan, the United Republic of Tanzania, Togo and Viet Nam.

                                                                                                                                                                                       5
ENABLING ENVIRONMENT
                                                     Leadership, political commitment and community engagement

                                                                            1. Assemble and train
                                                                                the WASH FIT
                                                                                team and hold
                                                                                regular meetings

                                             5. Continuously                                                  2. Conduct an
                                                 evaluate and                                                     assessment of the
                                                 improve the plan                                                 facility

                                                           4. Develop and                     3. Identify and
                                                               implement an                        prioritize areas for
                                                               improvement plan                    improvement

                                                                                                                                                                                          ANNEX 3
                                                                HEALTH-BASED OBJECTIVES
                                           Make improvements to meet accreditation scheme or national quality standards

  Figure 3. WASH FIT five-step process                                                                                                                                                    47
Figure  3: WASH FIT five step process for improving facility-level WASH Services9

                                                                                                                                                                                          PRACTICAL STEPS TO ACHIEVE UNIVERSAL ACCESS TO QUALITY CARE
improving the quality of care and internal IPC measures                                       Human Potential12 was developed. The Framework has
in health facilities, and to promoting overall well-being                                     a special emphasis on early childhood development
within a given context.                                                                       (ECD). To protect children’s health and support their
     every six months) visits to the facility by local or national                          Mobile
                                                                                              development,   application
                                                                                                                   it is essential that they have access to
Several   other or
   government    global  frameworks
                   supporting  partnersspeak  to WinHCF
                                        can help   guide andwith                              clean water and sanitation, good hygiene practices,
theencourage facilities through the WASH FIT process. with
      aim  of further  integrating WASH     interventions                                   A clean
                                                                                               mobileair application
                                                                                                             and a safe of WASH   FIT is available
                                                                                                                            environment.            and free Care
                                                                                                                                             The Nurturing
maternal,    newborn
   These visits are also and child for
                         important health
                                       data(MNCH),
                                             collectionnutrition
                                                        and                                 toFramework
                                                                                               download (www.washfit.org).          The application
                                                                                                               calls for an integrated,               allows whole-
                                                                                                                                           multi-sectoral,
and    early childhood    development    (ECD).
   evaluation of WASH FIT (see Practical Step 3,  The  end goal
                                                    Liberia                                 facility  teams toapproach
                                                                                              government         track more  toeasily  and rapidly by
                                                                                                                                ECD supported      andactions
                                                                                                                                                         follow from
is case
    to secure   a more profound impact on child health
        study) (47).                                                                        upthe
                                                                                                on health,
                                                                                                    actions and     government
                                                                                                               nutrition,         and partners
                                                                                                                            education,    social to provide child
                                                                                                                                                 protection,
outcomes in the first 1,000 days of life.                                                   real-time
                                                                                              welfare,support.       In addition,
                                                                                                           agriculture,    labour,it finance
                                                                                                                                      can be used
                                                                                                                                              andby   facilitysectors,
                                                                                                                                                   WASH
                                                                                            teams    to share
                                                                                              including      theapproaches
                                                                                                                 availabilityonof overcoming
                                                                                                                                  WASH serviceschallenges
                                                                                                                                                     in healthor care
Every Newborn Action Plan (ENAP)
     WASH FIT training                                                                      engage     in friendly
                                                                                              facilities            competitions.
                                                                                                           at the time     of birth and at community level for
Under the broader Every Woman, Every Child global                                             mothers and newborns.
  A set of training
movement             modulesofis the
               in support         available
                                       Unitedonline  in English,
                                                 Nations    Secretary-
  French  and   Russian.  The  training modules
General’s Global Strategy for Women’s, Children’s,  are provided and                        Related    reading: VISION FOR WASH IN
                                                                                             1.2 UNICEF’S
  as a guide andHealth
Adolescents’       should10be  adapted to thethe
                             (2016-2030),        local context,
                                                     Every        for
                                                            Newborn
  example   swapping
                                                                                             HEALTH CARE FACILITIES
Action   Plan   (ENAP)photos    with more It
                         was launched.       relevant  examples
                                               calls for  a reduction                       Water and Sanitation for Health Facility Improvement
infrom  the regionnewborn
   preventable      and replacing   technical
                                deaths    with guidance
                                                a focus on withsurvival
                                                                 local                      Tool
                                                                                              The(WASH
                                                                                                    UNICEFFIT):  A practical
                                                                                                              WASH            guide(2016-2030)
                                                                                                                        Strategy    for improving
  standards,
and   health,whereand applicable.
                       advocatesThe   fortraining  package
                                            maternity        also
                                                          facilities   to                   quality of care through water, sanitation and hygiene in
beincludes  an overview
     equipped             of the WASH infrastructure
                   with appropriate        FIT methodology     and
                                                             including                        The UNICEF
                                                                                            health          Strategy
                                                                                                    care facilities      for Water,
                                                                                                                    [Internet].      Sanitation
                                                                                                                                Geneva,          and Hygiene
                                                                                                                                         World Health
  a module for
electricity,      eachsanitation
             water,    of the WHO     Essential
                                    and           Environmental
                                          hand-washing        facilities,                     (2016–2030)       articulates    the  organizational
                                                                                            Organization and UNICEF, 2018 [cited 1 March 2019].        thinking
clean
  Healthtoilets,
          Standardsappropriate
                      (e.g., water,spaces     forenvironmental
                                    sanitation,     women to give                           Available from: http://www.who.int/water_sanitation_ WASH
                                                                                              and   approach    to  WASH     in health  care facilities.
birth  with health
  cleaning,   privacy,
                     careand  dedicated
                          waste).  Materials areas   to manage
                                               for running   a       sick                     in institutions – consisting of WASH in schools (WinS),
                                                                                            health/publications/water-and-sanitation-for-health-
newborns      safely.11sample agendas, evaluation sheets, and
  training, including                                                                         WASH in health care facilities (WinHCFs) and WASH in
                                                                                            facility-improvement-tool/en/
  a pre- and post-test quiz are also available. For technical                                 early childhood care centres – is one of the five strategic
The Nurturing Care Framework                                                                  results areas: 1) Water; 2) Sanitation; 3) Hygiene; 4)
  assistance or to share experiences of using the tool, please
                                                                                              WASH in institutions; and 5) WASH in emergencies.
Incontact
    2018,washinhcf@who.int
            the Nurturing Care  and visit www.washinhcf.org.
                                     Framework      for Helping
Children Survive and Thrive to Transform Health and
9
  WHO/UNICEF (2019), WASH in health care facilities: Practical steps to achieve universal access to quality care, www.who.int/water_sanitation_health/publications/wash-in-health-care-
facilities/en/
10
     The Global Strategy for Women’s, Children’s, and Adolescents’ Health, http://www.everywomaneverychild.org/wp-content/uploads/2017/10/EWEC_GSUpdate_Brochure_EN_2017_web.pdf
 Every Newborn Action Plan, www.who.int/docs/default-source/mca-documents/advisory-groups/quality-of-care/every-new-born-action-plan-(enap).pdf?sfvrsn=4d7b389_2
11

 Nurturing Care Framework (2018), https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf
12

     6
To advance the global agenda on WinHCF programming,                                                  Every Child Alive
UNICEF commits to:
                                                                                                     In addition, as part of its efforts on reproductive,
• Encouraging the institutionalization of WinHCF
                                                                                                     maternal, newborn, child and adolescent health
    within the national health sector;
                                                                                                     (RMNCAH), UNICEF recently launched, Every Child Alive,
• Advocating for and supporting the inclusion of                                                     a priority organizational integrated campaign aimed at
    WASH in health sector baseline studies and national                                              significantly reducing morbidity and mortality at the very
    surveys;                                                                                         start of life. Global statistics show that children face the
• Supporting the development of national standards                                                   highest risk of dying in their first month of life. In 2016,
    for WinHCFs and evidence-based models for scaling                                                there were 2.6 million newborn deaths, mostly within
    up with quality; while promoting cost-effective                                                  the first week. About 1 million died on the first day
    approaches; and                                                                                  and close to another million within the next six days.14
• Encouraging the implementation of hygiene                                                          Globally, while under-five mortality has fallen remarkably
    protocols, including hygiene practices of health                                                 in recent decades newborn mortality remains a critical
    workers.                                                                                         global challenge, predominantly in southern Asia and
                                                                                                     sub-Saharan Africa.
The UNICEF Health Strategy (2016-2030)
                                                                                                     In eastern and southern Africa, congenital (30 per cent)
UNICEF’s Strategy for Health (2016-2030), in turn,                                                   and intrapartum (29 per cent) neonatal causes and
stresses the importance of an integrated approach                                                    sepsis (16 per cent) rank as the three leading causes of
to early child health care, drawing on the diversity of                                              neonatal mortality. Current literature strongly indicates
the organization’s programmatic scope (nutrition,                                                    that with 50-70 per cent of hospital-acquired infections
education, early childhood development (ECD), HIV,                                                   (HAIs), including sepsis, linked to poor hand hygiene, the
child protection, and WASH) and calls for nutrition                                                  transmission of healthcare associated sepsis and related
screening and intervention, improved community-level                                                 HAIs could be reduced by adherence to IPC measures,
health literacy, support to community-level interventions                                            especially hand hygiene.15
related to early child development, and appropriate
support to community-level and health facility WASH
services and practices.13

Figure 4: Causes of newborn deaths in the region16

In line with SDGs 3.117 and 3.2,18 Every Child Alive seeks to accelerate UNICEF’s contributing efforts to achieving a
world in which no child dies of a preventable cause and in which no preventable stillbirths occur; a core advocacy
output being to work to guarantee the uninterrupted provision of electricity and clean water in all health facilities.
13
     UNICEF Strategy for Health (2016-2030), www.unicef.org/health/files/161201_Strategy_for_health_2016-30_report.pdf
14
     UNICEF (2017), Levels and Trends in Child Mortality Report 2017, p. 8.
15
     A. Peters et al. (2018) International Journal of Infectious Diseases 70 (2018) 101-103
16
     WHO (2018), Estimates generated by the WHO and Maternal and Child Epidemiology Estimation Group (MCEE), 2018
17
     SDG 3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births.
 SDG 3.2 By 2030, end preventable deaths of newborns & children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births,
18

under-5 mortality to at least as low as 25 per 1000 live births.

                                                                                                                                                                                     7
UNICEF Health Systems Strengthening Approach                                                   •     To design, implement and monitor synergistic WASH
                                                                                                     models20 that promote cost-effective approaches
Under its Health Systems Strengthening Approach,                                                     and allow the health and WASH sectors to work
UNICEF also envisions contributing to evidence-based                                                 together efficiently and effectively to undertake
and equitable national strategic plans and policies for                                              comprehensive, facility-based risk assessments
children’s and women’s health; leveraging national                                                   and implement context-specific critical actions to
and international resources, while linking with other                                                improve WASH in health facilities and promote
UNICEF programming sectors including WASH. The                                                       behaviour change through community health
aim is to establish strong health systems which include                                              worker outreach;
preventive and promotive services, curative care, family
practices and produces equitable health, nutrition and                                         •     To develop policies for institutionalizing WASH
development outcomes for infants, children, adolescents                                              in healthcare facilities, prioritizing those health
and women of reproductive age.19                                                                     facilities that provide maternal, neonatal and
                                                                                                     child health services; and establish and enforce
1.3 WASH IN HEALTH IN EASTERN                                                                        national standards for WASH in healthcare facilities,
                                                                                                     accompanied by adequate funding, human
AND SOUTHERN AFRICA                                                                                  resources and institutional arrangements to ensure
As stated in the 2018-2022 Regional Priorities, in                                                   that standards are implemented;
Eastern and Southern Africa Region (ESAR), UNICEF’s
                                                                                               •     To support the development of national WASH
commitment is to support countries in the region to
                                                                                                     targets that prioritize the most vulnerable (areas
improve access to basic service levels of drinking water
                                                                                                     with high maternal and newborn mortality rates,
and sanitation, reduce open defecation and promote
                                                                                                     cholera outbreaks and so on) and take into account
good hygiene practices, including menstrual health
                                                                                                     human, financial and technological capabilities;
and hygiene (MHH), especially for the most vulnerable
populations, in emergency/humanitarian settings,                                               •     To advocate for including WASH indicators in
urban/rural households, communities, schools and                                                     key health sector studies and national surveys
health facilities.                                                                                   and health sector real-time monitoring systems,
                                                                                                     and strengthen joint monitoring for WASH in
The 21 UNICEF programming countries in ESAR are:
                                                                                                     health facilities, through the WHO–UNICEF Joint
Angola, Botswana, Burundi, Comoros, Eritrea, Eswatini,
                                                                                                     Monitoring Programme.
Ethiopia, Kenya, Lesotho, Madagascar, Malawi,
Mozambique, Namibia, Rwanda, Somalia, South Africa,                                            •     To promote implementation of hygiene protocols,
South Sudan, Uganda, the United Republic of Tanzania,                                                including hygiene practices for health workers
Zambia and Zimbabwe. WASH programming, with the                                                      in health facilities and in the community, and
presence of WASH staff, occurs in all these countries                                                strengthen the capacity of medical staff and
except Botswana and South Africa.                                                                    community health workers to adopt and promote
                                                                                                     good hygiene behaviours.21
UNICEF Eastern and Southern Africa Regional Office
(ESARO) will continue to support country offices (COs)                                         The indicator of success is the number of countries
to develop enhanced models and partnerships for                                                in which 80 per cent of health centres and facilities
evidence-based WASH in institutions programming at                                             have basic WASH services by 2022. Given that this is
scale. Regarding WASH in health care facilities, the focus                                     programmed as a regional priority for 2018-2022,
areas and critical actions are:                                                                judging from the current JMP findings significant efforts
                                                                                               will have to be made by all countries within the next two
                                                                                               years to meet the 80 per cent target.

19
     The UNICEF Health Systems Strengthening Approach (2016), https://www.unicef.org/health/files/UNICEF_HSS_Approach.pdf
20
  Synergistic programming models maximize the potential for synergy between different sectors’ activities. Synergistic models achieve this by securing a common vision and agreement to
work together, joint planning and aligned financing and monitoring; and strengthened accountability and capacity. Emphasis is placed on removing bottlenecks in the enabling environment
to minimize the practice of delivering sector-based interventions and services in silos.
21
     UNICEF Eastern and Southern Africa Regional Priorities (2018-2022)

     8
WASH COVERAGE IN HEALTH
        Chapter 2
                                                                           FACILITIES

          Annex 1 . Key Definitions
2.1 JOINT MONITORING                                                                                                                  facilities (e.g. hospitals) in urban areas.
PROGRAMME SERVICE LADDERS                                                                                                             In 2019, the WHO/UNICEF Joint Monitoring Programme
FOR WASHBasic   WASH services in
           IN HEALTH
          health care facilities
                                                                                                                                 the(JMP)
                                                                                                                                     JMP “Core
                                                                                                                                             forquestions
                                                                                                                                                  Waterand     indicators
                                                                                                                                                            Supply,        for monitoringand Hygiene released
                                                                                                                                                                         Sanitation
                                                                                                                                 WASH in health care facilities in the Sustainable
                                                                                                                                    the first comprehensive global baseline report on WASH
                                                                                                                                 Development Goals” (39) and the 2019 JMP SDG
In 2015, WHO and WHO hasUNICEF
                            developedjointly         published
                                         a set of minimum,               the first
                                                                global standards                                                    in health
                                                                                                                                 Baseline          care
                                                                                                                                          report for WASHfacilities,
                                                                                                                                                           in health carepresenting
                                                                                                                                                                          facilities (1). the first harmonized
                 for environmental
multi-country review     of WASH      healthinin health
                                                  health carecare
                                                               facilities (38).
                                                                        facilities,                                                   picture of water, sanitation, hand hygiene, health
                 Deriving from this standards, a “basic” level of service                                                        At the national level, countries are encouraged to define
focusing on 54haslow           andandmiddle-income
                     been defined                                      countries
                                          is achieved when key conditions
                                                                                                                                    care waste management, and environmental cleaning
                                                                                                                                 more ambitious, higher levels of service and to set and
(LMICs) across the
                 aresix
                     met global       WHO
                          in five areas: water, regions.        22
                                                                     According
                                                  sanitation, hygiene,    waste                                                     services
                                                                                                                                 monitor           in health
                                                                                                                                           corresponding            care
                                                                                                                                                           indicators.      facilities
                                                                                                                                                                       Higher              across the world. JMP
                                                                                                                                                                               levels of service
                 management
to the review, data    were and  moreenvironmental
                                            numerous    cleaning.
                                                                on access to                                                     may   consider further
                                                                                                                                    estimates        areimportant
                                                                                                                                                            arrived  aspects, including
                                                                                                                                                                        at from          water
                                                                                                                                                                                      national    data sources and
                                                                                                                                 quality (e.g. legionella, pseudomonas), including medical-
water than for sanitation         and hygiene
                 To allow for inter-country                in LMICs.
                                               comparability     and globalLarge
                                                                                                                                    a   linear    regression        model,       to
                                                                                                                                 grade water, water efficiency, safe plumbing, climate
                                                                                                                                                                                      generate     estimates for all
variations were also    observed
                 monitoring    WHO and at      sub-national
                                           UNICEF    have created setlevel,
                                                                          of     by                                                 yearsofwithin
                                                                                                                                 resilience     water andthe   reference
                                                                                                                                                           sanitation services,period.     The methodology used
                                                                                                                                                                                sustainability
                                                                                                                                 (including non-burn estimates
                                                                                                                                                        waste destruction
                                                                                                                                                                        formethods),   and safe
settings and by questions
                 type ofthathealthclassify facilities in relation to “service
                                             care facility within the                                                               to produce                                WinHCFs         builds on established
                 ladders” (see Figure 2). For more information on how                                                            collection, transport and treatment and the quality of
same country, with    smaller
                 the service       facilities
                              ladders  are defined inandrural    areasrefer
                                                           measured,       having
                                                                              to                                                    methods         developed
                                                                                                                                 disposed wastewater.                  by   the    JMP      for  monitoring WASH
disproportionally fewer WASH services than larger                                                                                     services in households and schools.

                                                                                                                                                                                                                            ANNEX 1
                                                                                                                                                         WASTE                                ENVIRONMENTAL
                                                WATER                                SANITATION                          HYGIENE
                                                                                                                                                         MANAGEMENT                           CLEANING

                                                Higher levels of                     Higher levels of                    Higher levels of                Higher levels of                     Higher levels of              41
                                                service                              service                             service                         service                              service
                                                To be defined at                     To be defined at                    To be defined at                To be defined at                     To be defined at

                                                                                                                                                                                                                            PRACTICAL STEPS TO ACHIEVE UNIVERSAL ACCESS TO QUALITY CARE
                                                national level                       national level                      national level                  national level                       national level
                                 Basic          Water is available from              Improved sanitation                 Functional hand                 Waste is safely                      Basic protocols
                                 service        an improved source6                  facilities7 are usable,             hygiene facilities              segregated into at                   for cleaning are
                                                on the premises.                     with at least one toilet            (with water and                 least three bins, and                available, and
                                                                                     dedicated for staff, at             soap and/or                     sharps and infectious                staff with cleaning
                                                                                     least one sex-separated             alcohol-based hand              waste are treated and                responsibilities have
                                                                                     toilet with menstrual               rub) are available at           disposed of safely.                  all received training.
                                                                                     hygiene facilities,                 points of care, and
                                                                                     and at least one toilet             within five metres
                                                                                     accessible for people               of toilets.
                                                                                     with limited mobility.
                                 Limited        An improved water                    At least one improved               Functional hand                 There is limited                     There are cleaning
                                 service        source is within                     sanitation facility is              hygiene facilities              separation and/                      protocols and/
                                                500 metres of the                    available, but not                  are available either            or treatment and                     or at least some
                                                premises, but not all                all requirements for                at points of care or            disposal of sharps and               staff have received
                                                requirements for basic               basic service are met.              toilets but not both.           infectious waste, but                training on cleaning.
                                                service are met.                                                                                         not all requirements for
                                                                                                                                                         basic service are met.
                                 No             Water is taken from                  Toilet facilities are               No functional hand              There are no separate                No cleaning
                                 service        unprotected dug wells                unimproved (e.g. pit                hygiene facilities              bins for sharps or                   protocols are
                                                or springs, or surface               latrines without a slab             are available either            infectious waste,                    available and no
                                                water sources; or an                 or platform, hanging                at points of care or            and sharps and/or                    staff have received
                                                improved source that is              latrines, bucket                    toilets.                        infectious waste are                 training on cleaning.
                                                more than 500 metres                 latrines) or there are                                              not treated/disposed
                                                from the premises; or                no toilets.                                                         of.
                                                there is no water source.

                         2. Service ladders for WASH in health care facilities
Figure 5: New JMP Figure
                  service      ladders for global monitoring of WASH in health care facilities23
                             6
                                 Improved water sources are those which by nature of their design and construction have the potential to deliver safe water. These include piped water, boreholes or tubewells, protected
Under the SDG framework,                       the JMP redefined ‘improved’ services from the Millennium Development Goals (MDG)
                    dug wells, protected springs, rainwater, and packaged or delivered water.
                    Improved sanitation facilities are those designed to hygienically separate human excreta from human contact. These include wet sanitation technologies – such as flush and pour flush
                             7

terminology, according            to specific service levels, or benchmarks of no, limited, basic, and advanced service levels. The
                    toilets connecting to sewers, septic tanks or pit latrines – and dry sanitation technologies – such as dry pit latrines with slabs, and composting toilets.

purpose of the new service ladders (Figure 5) is to enable countries to track progress towards the SDG targets and to
facilitate the benchmarking and comparison of progress across countries globally and regionally. The JMP introduced
service ladders for the five core indicators for WASH in health care facilities: water, sanitation, hygiene, health care
waste management and environmental cleaning in health care facilities (Figure 5), along with core questions to
facilitate data collection and streamline monitoring during health facility surveys.24 (Annex 2)

 WHO (2015), Water, sanitation and hygiene in health care facilities Status in low- and middle-income countries and way forward, https://apps.who.int/iris/bitstream/
22

handle/10665/154588/9789241508476_eng.pdf?sequence=1
 WHO/UNICEF (2018) Core questions and indicators for monitoring WASH in Health Care Facilities in the Sustainable Development Goals, https://washdata.org/report/jmp-2018-core-
23

questions-monitoring-winhcf-en
24
     Ibid., p.9

                                                                                                                                                                                                                                                                                          9
Given the critical need for water for hand hygiene and                                                                                                              toilets at all. Notably, sub-Saharan Africa was the only
infection prevention and control in administering care,                                                                                                             SDG region with estimates for basic sanitation services
for a health facility to classify as having met the ‘basic;                                                                                                         in health care facilities. Meanwhile, in least developed
service ladder for water, water had to be available from                                                                                                            countries (LDCs), only 27 per cent of health care facilities
an improved source on the premise of the facility. As                                                                                                               had basic health care waste management services.
defined by the JMP, ‘improved water sources’ are
sources which, by nature of design and construction,                                                                                                                The 2019 Global Baseline Report compiles and
have the potential to deliver safe water, i.e. piped water,                                                                                                         analyses existing monitoring data that countries have
boreholes or tube wells, protected dug wells, protected                                                                                                             already collected and reviewed. It includes national
springs, rainwater, and packaged or delivered water.                                                                                                                data from 125 countries, drawing on assessments
‘Unimproved sources’ refer to unprotected dug wells                                                                                                                 of over 560,000 health care facilities, extracted from
or springs and surface water (e.g. lakes, rivers, streams,                                                                                                          260 nationally representative facility assessments and
ponds, canals and irrigation ditches). A basic sanitation                                                                                                           mapped to a standardized set of global indicators for
service is one in which improved sanitation facilities are                                                                                                          water, sanitation, hygiene, waste management and
usable with at least one toilet dedicated for staff, at                                                                                                             environmental cleaning services in health care facilities.
least one sex-separated toilet with menstrual hygiene                                                                                                               For all indicators, the data gaps were quite significant.
facilities, and at least one toilet accessible for people
                                                                                     Due to insufficient evidence, the global picture on the
with limited mobility.
                                                                                     indicators for basic sanitation, hygiene, waste disposal
Basic hygiene refers to functional hand hygiene facilities                           and environmental cleaning in health care facilities could
                     Globally, 38 countries, with a combined population              notInbe     established.
                                                                                             2016,     estimates ofGlobally,
                                                                                                                          basic water18              countries
                                                                                                                                               services    in health    and only one
(with water and soap        and/or alcohol-based hand rub)
                     of 2.6 billion people, had enough data to make
                                                                                     SDG care   facilities
                                                                                            region        –    were available for
                                                                                                              sub-Saharan              Africa38 countries,
                                                                                                                                                     –  had       sufficient   data to
which are availablenationally
                        at points        of care,
                                 representative         and for
                                                 estimates      within     five
                                                                  basic water            representing 2.6 billion people
metres of toilets. The    health
                     services         care
                               in health  carefacility
                                               facilitiesis  said (Figure
                                                          in 2016    to have 15).    estimate       coverage            of    basic       sanitation             services   in  health
                     More  countries    had data on   other
basic waste disposal only if waste is safely segregated      indicators,  with 69    care   facilities Basic (Figure 8). In 2016,            2.6      only       38    countries  and
                                                                                             services (n=38)
                     countries, representing 61% of the global population,           three     of   the      eight       SDG        regions           had       sufficient    data  to
into at least three bins,   and sharps and infectious waste
                     able to report on the proportion of health care facilities
are treated and disposed
                     with no waterof service.
                                       safely.TheA JMPbasic     service
                                                            produces        forand
                                                                       regional
                                                                                     estimate       coverage            of   basic       water         services        in health  care
                                                                                              Improved and
                                                                            data are facilities    (Figure          6); 14 countries                  had sufficient data to
                                                                                                                                             2.6
environmental cleaning       is one21inforwhich
                     global estimates                    basic provided
                                              new indicators,     protocols                 available (n=40)

                     available  for at least 30%  of
for cleaning are available, and staff with cleaning   the  relevant  population.  22
                                                                                     estimate      coverage            of  basic       hygiene          services in health care
                                                                                     facilities,    meaning            that     functional            hand        hygiene facilities
                       WATER SERVICES IN HEALTH CARE FACILITIES

responsibilities haveGlobally,
                        all received      training.
                                in 2016, 74% of health care facilities had basic
                                                                                              Improved   and
                                                                                         on premises (n=53)                                  3.1
                                                                                     were      available both at points of care and at toilets;
                     water services (Figure 16). One in eight (12%) health
2.2. GLOBALcare        BASELINE                 FOR
                          facilities had no water   service,   and the remaining 48 countries had sufficient data to estimate coverage
                                                            WASH
                     14% of health care facilities had limited services,             of basic
                                                                                          No services waste
                                                                                                      (n=69)         management              4.6 services in health care
IN HEALTH CARE       meaning they FACILITIES
                                     either had access to an improved water          facilities; and just 4 countries worldwide had enough
                     source that was off the premises (but within 500 metres)
                                                                                     data to estimate coverage of basic environmental
Findings from the JMP      Global
                     or from           Baseline
                              which water    was notReport
                                                       availableshow      thatof the
                                                                  at the time               Any data (n=73)
                     assessment.    Regionalcare
                                              valuesfacilities
                                                       for basic water   services    cleaning       services in health care                  4.6
                                                                                                                                                   facilities.
in 2016, 74 per cent        of health                               globally
                     ranged from 51% in sub-Saharan Africa to 87% in
had basic water services,        21 per cent had no sanitation
                     Eastern and South-Eastern Asia (see Annex 2 for lists of Like the findings
                                                                                                        Data coverage for water services in health care facilities, by
                                                                                                                      from the 2015 LMICS study, data on
                                                                                                        indicator (and number of countries with data available) and
service and 16 perthe cent    had     no   hygiene       service.
                         countries making up the eight SDG regions).
                                                                     25
                                                                          One        access to water
                                                                                          FIGURE  15
                                                                                                                    were more readily available than for all
                                                                                                        population with data available (billions), 2016

in five health care facilities had no sanitation service                             other indicators. Variations were also observed at the
              16
in 2016, meaning      they had unimproved toilets or no                              sub-national, geographic and health facility levels.
                       WASH IN HEALTH CARE FACILITIES

                                                                  Globally, one quarter of health care facilities lacked basic water services in 2016

                                                                       100
                                                                                               6                  5        10
                                                                                    10                                                                                                        12              12
                                                                                                                                                                                    18
                                                                                     3                  26                                                                23
                                                                        80                    24                                                                                                              14
                                                                                                                                                                                              23

                                                                                                                                                                          22        36
                                                                                                        23
                                                                        60
                                                                                                                                                                                                                                       ■ INSUFFICIENT DATA

                                                                                    87                                                                                                                                                 ■ NO SERVICE
                                                                        40                                                                                                                                                             ■ LIMITED
                                                                                              70                                                                                              65              74
                                                                                                                                                                                                                                       ■ BASIC
                                                                                                        51                                                                55
                                                                                                                                                                                    46
                                                                        20

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                                                                   FIGURE 16         Regional water service coverage in health care facilities, 2016 (%)
Figure 6: Water services in health care facilities by SDG region, Source: 2019 Global Baseline Report, WinHCF
                                                                  21
                                                                       To prevent countries in a single region from having a disproportionate impact on global estimates, global estimates are calculated from regional estimates. See Annex 1: JMP Methods for more details.
25
     2019 WHO/UNICEF Global Baseline Report on WASH in Health Care Facilities, https://washdata.org/sites/default/files/documents/reports/2019-04/JMP-2019-wash-in-hcf-launch.pdf
                             22
                                                                       Since the global population in 2016 was 7.47 billion, global estimates can be made provided data are available for countries representing at least 2.24 billion people. Note that regional
                                                                       and global estimates are produced using national (or urban and rural) populations as weights, rather than the number of health care facilities (which would be more appropriate),
                                                                       because population data are more readily available than data on numbers of different types of health care facilities. For further details see Annex 1: JMP Methods.

     10
In sub-Saharan Africa, based on data from 2016 (i.e. the beginning of the SDG era), 51 per cent of health care
facilities had basic water services, 23 per cent had limited services, and 26 per cent had no service at all. Of the 51
per cent overall coverage, basic water coverage was found to vary widely between countries, with Zimbabwe (81 per
cent), Burundi (73 per cent), Kenya (66 per cent) and United Republic of Tanzania (65 per cent), having the highest
basic coverage in health care facilities of the countries listed from eastern and southern Africa.

Basic water coverage varies widely between countries

                                        Comoros                                        21
                                         Ethiopia                                              30
                                         Uganda                                                 31
                                           Congo                                                     37
                                          Zambia                                                          40
                                         Senegal                                                                    46
                                          Nigeria                                                                        50
                                   Côte d’Ivoire                                                                                  57
SUB-SAHARAN AFRICA                          Togo                                                                                   58
                                 United Republic                                                                                             65
                                     of Tanzania
                                           Kenya                                                                                              66
                                           Ghana                                                                                                   71
                                         Burundi                                                                                                     73
                                            Benin                                                                                                     74
                                   Burkina Faso                                                                                                             79
                                      Mauritania                                                                                                              81
                                      Zimbabwe                                                                                                                81

       LATIN AMERICA                  Peru                                                    46
Figure 7: Proportion of health care facilities in sub-Saharan Africa with basic water supply, Source: 201958Global Baseline Report
              AND THE           Honduras
            CARIBBEAN            Paraguay                                                                                                                             85

                 OCEANIA                   Papua                                                                                                   70
                                      New Guinea
  Globally, 21% of health care facilities had no sanitation service in 2016                                              51
                                          Viet Nam
            EASTERN AND
     100                                  Indonesia                                                                                                          80
SOUTH-EASTERN ASIA 5
                                             China                                                   14                                                                    91
                                                                                               21              24             21
                    29               32
            80                               40
                                        Maldives                                                                              55
        CENTRAL AND
                                      Bangladesh                                                     45                                           70
                                                                                                                                             ■ INSUFFICIENT DATA
        60
       SOUTHERN ASIA
                    48
                                        Sri Lanka                                                                                                                                                                               99
                                                                                                                                             ■ NO SERVICE
            40                                                                                                                               ■ LIMITED
                                         Armenia                                                          39                                 ■ BASIC
    NORTHERN AFRICA                     Lebanon                                                                                         61

                                                                                                                                                                                SANITATION SERVICES IN HEALTH CARE FACILITIES
       20                                                                                            41
   AND WESTERN
             23 ASIA                   Azerbaijan                                                                                                                                                                               10
             0                            Kuwait                                                                                                                                                                                10
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                                       Lithuania                                                                                                                                                                                10
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                                     Montenegro                                                                                                                                                                                 10
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                                     San Marino                                                                                                                                                                                 10

   FIGURE 28     Regional sanitation services in health0care facilities, 2016 (%) 20                  40                           60                       80                                                           100
Figure 8: Sanitation services in health care facilities by SDG region, Source: 2019 Global Baseline Report, WinHCF
FIGURE 19        Proportion of health care facilities with basic water services, by country and SDG region, 2016 (%)

  Four SDG regions had estimates of no sanitation service,                                  Coverage of basic sanitation services varied widely
  ranging from 5% in Eastern and South-Eastern Asia to 40%                                  among the 18 countries with estimates available in                                  29
  in Central and Southern Asia. In sub-Saharan Africa (the                                  2016 (Figure 29). In 10 of these countries, fewer than
                                                                                                                                                                                GLOBAL BASELINE REPORT 2019

  only SDG region to have an estimate for basic services)                                   one in four health care facilities had basic sanitation
  less than one in four health care facilities (23%) had basic                              services.
  services. Insufficient data were available to generate any
  regional estimates for the other four SDG regions.

                                                                                                                                                                 11

  Estimates of basic sanitation services were available for 18 countries in 2016
2.3 WASH IN HEALTH COVERAGE IN EASTERN AND SOUTHERN AFRICA
In ESAR, Zimbabwe was the only country with complete coverage data across all service ladders for four out of the five WinHCF indicators, water, sanitation, hygiene and
waste disposal (Figure 9). Complete26 estimates across all water service ladders were available for just eight countries, complete sanitation and waste disposal estimates were
available for just five countries, complete hygiene estimates were available for just Zimbabwe, and there were no estimates at all for environmental cleanliness. Globally, only
four countries had data on environmental cleaning; as a result, this could not be assessed at all at the regional level.

Figure 9: Available coverage data for WASH in health care facilities for countries in UNICEF’s Eastern and Southern Africa Region, Source: 2019 Global Baseline Report

26
     Complete: refers to data across all service ladders for a given indicator

      12
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