Health care facilities

Achieving and maintaining WASH services in health care facilities is a critical element for a number of health aims including those linked to quality universal health coverage, infection prevention and control, patient safety, and child and maternal health, in particular the time around child delivery. WASH also extends beyond health impacts to issues of dignity and respect, staff morale, and performance and safety. Accordingly, SDG targets 6.1 and 6.2 include WASH in health care facilities as part of universal WASH access for all.

JMP monitoring of WASH in health care facilities includes tracking basic water, sanitation, hand hygiene, health care waste management, and environmental cleaning services. Definitions of basic services were developed in 2018 by a global task team convened by the JMP and incorporated into new JMP service ladders for WASH in health care facilities. JMP estimates for WASH in health care facilities are now based on the new harmonized core indicators.

Health care facilities need to be adequately equipped with WASH services, which must be available at every stage during labour, delivery and postnatal care to meet the needs of the woman and her newborn child and enable a clean and safe birth. The JMP has developed a set of draft questions and indicators for monitoring WASH and related infection prevention and control (IPC) measures in delivery rooms. These indicators build on and complement the core set of general WASH in health care facility questions and the questions in the WHO Infection Prevention and Control Assessment Framework (IPCAF) and are designed to be measured in tandem with the assessment of WASH and IPC in general service areas.

Water

Health care facilities with an improved water source on premises with water available at the time of the questionnaire or survey are classified as having basic service. Health care facilities with an improved water source without water available or that is off-premises (but within 500 metres) are classified as having a limited service, and those with an improved source that is more than 500 metres from the premises, an unimproved source or no water source will be classified as having no service. In countries where basic service is already the norm, a country-defined advanced service level may be appropriate based on the national context, priorities and resources. Criteria for an advanced level might include normative elements such as water quality and water quantity.

• Advanced

  To be defined at national level.

• Basic

  Water is available from an improved source on the premises.

• Limited

  An improved water source is within 500 metres of the premises, but not all requirements for basic service are met.

• No service

  Water is taken from unprotected dug wells or springs, or surface water sources; or an improved source that is more than 500 metres from the facility; or the facility has no water source.

Sanitation

Health care facilities with improved latrines or toilets which are usable, separated for patients and staff, separated for women with menstrual hygiene facilities, and meet the needs of people with limited mobility are classified as having a basic service. The term usable here refers to toilets or latrines that are accessible to patients and staff (doors are unlocked or a key is available at all times), functional (the toilet is not broken, the toilet hole is not blocked, and water is available for flush/pour-flush toilets), and private (there are closable doors that lock from the inside and no large gaps in the structure).

Health care facilities with improved latrines or toilets which do not meet all the criteria for basic service are classified as having a limited service. Health care facilities with unimproved or no toilets are classified as having no service. In countries where an advanced service level is appropriate, elements might include toilet cleanliness, toilet lighting, or patients per toilet ratios.

• Advanced

  To be defined at national level.

• Basic

  Improved sanitation facilities are usable with at least one toilet dedicated for staff, at least one sex-separated toilet with menstrual hygiene facilities, and at least one toilet accessible for people with limited mobility.

• Limited

  At least one improved sanitation facility, but not all requirements for basic service are met.

• No service

  Toilet facilities are unimproved (pit latrines without a slab or platform, hanging latrines and bucket latrines), or there are no toilets or latrines at the facility.

Hygiene

Basic hand hygiene in health care facilities is defined by two main criteria: (1) either alcohol hand-rub or a basin with water and soap are available at points of care, and (2) handwashing facilities with water and soap are available at toilets. Points of care are defined here as any location in the health care facility where care or treatment is delivered (i.e. consultation/exam rooms), with priority given to outpatient departments.

Health care facilities with hand hygiene materials at either points of care or the toilets, but not both are considered to have a limited service, while those with no hand hygiene stations or with no cleansing materials are classified as having no service. An advanced level for hygiene might include availability of hand hygiene promotional materials near hand hygiene stations and/or the patient waiting area, or actual hand hygiene compliance.

• Advanced

  To be defined at national level.

• Basic

  Functional hand hygiene facilities (with water and soap and/or alcohol-based hand rub) are available at points of care, and within 5 metres of toilets.

• Limited

  Functional hand hygiene facilities are available at either points of care or toilets, but not both.

• No service

  No functional hand hygiene facilities are available at either points of care or toilets.

Health care waste management

Health care facilities where waste is safely segregated into at least three bins (sharps, infectious, and non-infectious) in the consultation area, and that safely treat and dispose of sharps and infectious waste are classified as having a basic service. Facilities that segregate waste but do not treat and dispose of it safely, or that do not effectively segregate waste, are considered to have a limited service. If waste is not segregated or safely treated and disposed of, the facility is classified as having no service. An advanced level for health care waste management might include whether functional needle cutters or hub cutters are available near sharps bins, or if bins are out of reach of patients, particularly children.

• Advanced

  To be defined at national level.

• Basic

  Waste is safely segregated into at least three bins, and sharps and infectious waste are treated and disposed of safely.

• Limited

  There is limited separation and/or treatment and disposal of sharps and infectious waste, but not all requirements for basic service are met.

• No service

  There are no separate bins for sharps or infectious waste, and sharps and/or infectious waste are not treated/disposed of safely.

Environmental cleaning

Health care facilities with basic protocols for cleaning and where all staff with cleaning responsibilities have been trained are classified as providing a basic service. Facilities with cleaning protocols and/or where at least some staff with cleaning responsibilities have received training have a limited service. If there are no cleaning protocols available and no staff have received training, the facility is considered to have no service. An advanced level for environmental cleaning might include whether disinfectants are available, or observed cleanliness of points of care. 

• Advanced

  To be defined at national level.

• Basic

  Protocols for cleaning are available, and staff with cleaning responsibilities have all received training.

• Limited

  There are cleaning protocols and/or at least some staff have received training on cleaning.

• No service

  No cleaning protocols are available and no staff have received training on cleaning.

Integrating and harmonizing data from facility surveys and censuses   

Data sources for JMP estimates on WASH in health care facilities include facility surveys, such as country-specific national surveys, the USAID Service Provision Assessment (SPA), the WHO Service Availability and Readiness Assessment (SARA) and the World Bank Service Delivery Indicator (SDI) survey. Existing national censuses such as the Health Management Information System (HMIS) or annual health facility inventory surveys may provide an opportunity to track progress toward the SDG criteria for WASH in health care facilities through existing national monitoring systems.

Data are harmonized to the extent possible based on the indicator definitions for ‘basic’ services, though further harmonization is needed to improve the cross-country comparability of data and development of regional and global coverage estimates. Harmonized core questions have been developed for use in surveys and/or national censuses. Core questions currently focus on the outpatient setting, but a set of question for the birth setting is in development as well as additional guidance for integrating the SDG indicators into national monitoring systems.

JMP methods

JMP progress updates include an Annex summarizing the methods used to produce national, regional and global estimates. The JMP will publish a detailed methodological note for WASH in health care facilities in 2024.