Unsafe hospital wastewater (HWW) is a significant concern, especially in low and middle-income countries (LMICs) where the health impact is often underreported. Socio-technical systems (STS) theory, which examines the interplay between social and technical elements within complex systems, is widely used in developed countries but rarely applied in LMIC hospitals. STS theory was employed to evaluate the social and technical aspects of HWW treatment and management in Dhaka City, alongside a comprehensive assessment of WWT processes. A mixed-methods approach was used, combining quantitative (structured observations) and qualitative interviews. Structured observations assessed the availability and functionality of WWT systems in selected hospitals. The fieldworkers conducted 30 key-informant interviews across 13 hospitals, including 21 respondents from the government and nine from private hospitals. The respondents were cleaners, key health professionals, and the Public Works Department (PWD) engineers. We also analyzed relevant government reports and policies. Among the hospitals surveyed, 10 had some form of WWT system, while the remaining three lacked any treatment infrastructure. Of those with WWT, seven utilized anaerobic baffled reactors and three had septic tanks. Interviews revealed that hospital authorities prioritize patient care and medical equipment maintenance over WWT, with limited understanding among hospital staff regarding WWT. PWD engineers reported frequent staff shortages and bureaucratic delays, affecting the efficiency of WWT system repairs and desludging. Our study identified significant gaps in WWT in Dhaka hospitals, including the limited
use of adequate treatment technologies, poor wastewater management knowledge, and many systems in disrepair, leading to hazardous liquid being discharged directly into the environment. The STS approach highlighted the need for policy formulation for HWW regulation, government leadership, adequate financing, technical assistance, and staff capacity building. Addressing these issues comprehensively can lead to safer and more sustainable wastewater management practices in HCFs, ultimately benefiting public health and the environment.
Author Consent: Yes
Inadequate sanitation in healthcare facilities:A comprehensive evaluation of toilets inmajor hospitals in Dhaka, Bangladesh
Lack of access to functional and hygienic toilets in healthcare facilities (HCFs) is a significant public health issue in low- and middle-income countries (LMICs), leading to the transmission of infectious diseases. Globally, there is a lack of studies characterizing toilet conditions and estimating user-to-toilet ratios in large urban hospitals in LMICs. We conducted a cross-sectional study in 10 government and two private hospitals to explore the availability, functionality, cleanliness, and user-to-toilet ratio in Dhaka, Bangladesh.
From August to December 2022, we (researchers for this study) undertook infrastructure assessments of toilets in selected hospitals. We observed all toilets and recorded attributes of intended users, including sex, disability status, patient status (in-patient/out-patient/caregiver) , and/or staff (doctor/nurse/cleaner/ mixed-gender/shared). Toilet functionality was defined according to criteria used by the WHO/UNICEF Joint Monitoring Programme in HCFs. Toilet cleanliness was assessed, considering visible feces on any surface, strong fecal odor, presence of flies, sputum, insects,
rodents, and solid waste.
Amongst 2875 toilets, 2459 (86%) were observed. 68% of government and 92% of private hospital toilets were functional. Only 33% of toilets in government hospitals and 56%… in private hospitals were clean. A high user-to-toilet ratio was observed in government hospitals’ outpatients’ service (214:1) compared to inpatients service (17:1). User-to-toilet ratio was also high in private hospitals’ outpatients service (94:1) compared to inpatients wards (19:1). Only 3% of toilets had bins for menstrual-pad disposal and <1% of toilets had facilities for disabled people.
WASH in Health Care facilities Road Map & Guidelines Development current update for Papua New Guinea
Papua New Guinea has progress to stage 4 of the 8 Practical steps for WASH in HCF as per the World Health Assembly.
As per the the Development of WASH in HCF Road Map & the WASH in HCF Guidelines for Papua New Guinea an situational analysis was conducted in 2022. Upon the situational analysis it formed the basis of developing the Road Map & the Guidelines. After the situational analysis a Technical Working Committee was established to oversee the development of the Road Map & the Guidelines. The Committee consisted Government Departments, Agencies and International Organizations, Donors and WASH Stakeholders.
The Technical Working was established in late 2022 and the Development of the WASH in HCF Road and the WASH in HCF guidelines was developed concurrently. The WASH In HCF Road Map and the WASH in HCF Guidelines was completed in 2023 and went through the validation and approval process of the National Department of Health. The approval of the Documents was done the PNG National Health Board in December 2023. And finally the documents was launch in 13th of April 2024 (this year) for implementation. The documents are currently available for implementation. This the current update for Papua New Guinea
Story shared by Mr. Ray Kangu
WASH Program Officer
National Department of Health
Papua New Guinea
Sierra Leone: Enabling good hygiene practices in healthcare facilities
African Development Bank (AfDB) funding support to WASH in HCF intervention
As part of the Emergency COVID-19 Relief Assistance for Water, Sanitation and Hygiene (WASH) Improvement Program funded by the African Development Bank (AfDB), UNICEF worked with implementing partners, Community Empowerment and Development Agency (CEDA) and Community Organization for Development and Empowerment (CODE-SL) to construct over 55 modern toilets, 33 showers, 11 laundries, and 11 waste management facilities, including incinerators for treating waste in 11 Peripheral Health Units (PHUs) across eight districts in the country. The partnership also enabled the installation of water supply systems in the 11 PHUs and the distribution of Infection Prevention and Control (IPC) materials through the District Health Management Teams (DHMTs) covering the eight districts. More information on this can be accessed at: here
UNICEF Bolivia: Relevance of strengthening WASH services in healthcare facilities.
In Bolivia, WASH in healthcare facilities intervention in 58 health centers which include construction, rehabilitation, or refurbishment of WASH components per the need of each of the healthcare facilities enabled 97% of the first-line healthcare facilities in El Alto City to have optimized condition of access to water, sanitation, hygiene, and solid waste disposal and improve the quality of health care for more than 1 million inhabitants of 14 neighborhoods. Find more here
UNICEF’s Strategic Framework: Healthy Environments for Healthy Children
Addressing the challenge of environmental sustainability is imperative not only to keeping our Global Goals promise, but also to realizing the right to health and well-being of every child. At UNICEF, we recognize that fulfilling our mandate and protecting the most vulnerable children requires action on climate change and environmental degradation to be integrated across our global health programme. This Strategic Framework aims to support programme teams to do just that.
The State of WASH in Cameroon
Introduction
In 2019 the World Health Assembly (WHA 72/A72 R7) urged member countries and organizations to conduct comprehensive assessments to quantify the availability, quality and needs for IPC/WASH in health care facilities and develop roadmaps for improvement (WHO, 2019). By 2020, all countries were supposed to have done their baseline WASH assessments, and by 2022, 60 % would have attained basic WASH coverage, 80% by 2025 and 100% by 2030. A few years away from 2030, many countries are still lagging behind these targets and the attainment of agenda 2030 is still questionable.
Infection Prevention & Control, Water, Sanitation & Hygiene (IPC/WASH) are the foundation of quality/universal health care and the determinant for the attainment of many health interventions like hand hygiene, environmental cleaning and disinfections, antimicrobial stewardship, clean hospitals etc. Every health care facility needs necessary and functional IPC/WASH services to provide essential and quality health services to all at all times. Unfortunately, globally, nearly half the world’s population lives without a safe toilet, at least 2 billion people still use a drinking water source contaminated with feces, and only 50% of the health facilities have hand washing facilities. (WHO, 2020). According to the WHO, 2 billion people still do not have access to basic sanitation and 5% of the world population from 55 countries still practice open defecation (WHO/UNICEF, 2020). Many of them are found in developing countries like Cameroon. The absence of WASH services seriously compromises patient safety and contributes to health care associated infections, antibiotic resistance and maternal and neonatal mortality (WHO, 2019; USAID, 2018).
The Goal of the assessment
This survey is the first to be done in Cameroon and therefore aimed to generate baseline WASH data which could be used to advocate for WASH improvements in Cameroon.
Design and methods
103 health facilities from 35 health districts in six of ten regions in Cameroon were assessed from November 29 to December 31, 2020. WHO/UNICEF WASH Facility Improvement tool (WASHFIT) and Hand Hygiene Self-Assessment tool was used. All health facilities were included irrespective of type and ownership. The teams were well received and accepted in all the facilities visited. Access permission was obtained on the day of the assessment. Each facility was assessed by a trained monitor accompanied by a staff of each facility designated by the head of the facility. The trained monitor gave some brief orientation on how to use the tool on the spot and both the staff and the monitor independently graded the facility and compared their observations at the end of the session, to ensure that the staff was comfortable with the monitor observation. Where there was any disparity, the monitor discussed his or her score with the staff to arrive at a consensus All the components of the WASHFIT tool including water, sanitation, hand hygiene, environmental cleaning and disinfection, health care waste, and management were covered. The indicators that were fully met were then used to calculate WASH coverage for each facility.
Results(see details on power point)
We found that WASH coverage is low in Cameroon, the lowest in health posts, followed by integrated health centers compared to hospitals.
Conclusion
There is a serious need to improve wash in Cameroon with particular attention at health posts and integrated health centers.
Integrating Disaster Risk Reduction and climate change adaptation in WASH in Healthcare assessment and planning
Introduction
In Vanuatu, health-care facilities are struggling to adequately function during normal operation due to poor WASH services. Worse yet, natural disasters can substantially impose stress on existing WASH services impacting water supply, sanitation and hygiene infrastructure. In April 2020, Tropical Cyclone (TC) Harold hit Vanuatu and caused significant damage to WASH infrastructure in 98 health facilities. Of the 98 facilities assessed, 18% reported non-functioning toilets and 45% reported damage to the facilities water systems. With WASH infrastructure damaged, health facilities ceased to provide essential medical care to the injured and sick or resorted to alternative, less safe water options, including rivers and streams. Provincial Emergency Operations Centers (PEOC) situation reports recorded numerous casualties, five deaths, and cases of diarrhoea, acute respiratory infections, acute fever amongst children and adults in affected areas as a result of inadequate water, sanitation, and hygiene conditions in health facilities and communities.
Vanuatu is the most at-risk country for natural hazards in the world, an estimated 64% of the population is impacted by a disaster each year. The direct damage cost to WASH infrastructure in health care facilities during TC Harold was estimated at $ 1, 611, 930 USD. With climate change increasing the risks, an effective method for identifying and mitigating these risks in health facilities preparedness is crucial.
This case study highlights key actions undertaken by Vanuatu government to integrate Disaster Risk Reduction and Climate Change Adaptation measures in assessment and planning to improve long-term sustainability of WASH services in HealthCare facilities in both peace and emergency.
Method
A national WASH in Healthcare facilities assessment tool, WASH in Heltkea (WinHK) template was developed by adapting the Vanuatu Department of Water Resources Drinking Water Safety and Security Plan template and WASH FIT template. Additional data and feedback was collected through key informant interviews with key staff from the Ministry of Health (MoH), Department of Water Resources (DoWR), and EWBNZ, and Hexagon WASH Specialist who led the development of the assessment tool. This additional feedback was incorporated into the tool.
Results
Recognizing the need to create resilient and strong water, sanitation, and hygiene (WASH) systems in healthcare facilities, the government of Vanuatu created a national WASH in Healthcare facility (WinHK) assessment tool in collaboration with EWBNZ and UNICEF. The WinHK tool is a participatory process for healthcare facility (HCF) committees to review WASH and IPC related risk including climate risks and create an action plan to address those risks as part of continuous improvements and disaster preparedness. When facilitated at the facility level, it triggers disaster risk reduction actions whilst setting infrastructure provision standards that are climate resilient for system upgrades. In water stressed areas, solar pumped groundwater and other alternatives are recommended improvements to complement existing rainwater harvesting systems and to meet the water demand at the healthcare facility. Rainwater harvesting storage tanks have been reinforced with cyclone strapping to withstand strong gale force wind. The disaster risk reduction planning component of the WinHK tool encourages health committees to proactively carry out key early warning preparedness measures to safely manage and secure WASH infrastructure prior to onset of disasters. They are also encouraged to consider the location of WASH infrastructure in relation to natural disasters such as flooding and landslides. The template strongly supports participation of women and girls in healthcare facility planning and overall decision making. This combined approach all works towards achieving resilient and “Safely Managed” service provision as key target of the SDGs. The government of Vanuatu is implementing an innovative approach for WASH resilience focusing on providing health care facilities with the capacity to adapt and manage to climate risk, rather than just providing infrastructure.
Conclusion
To ensure sustainable and equitable service at HCF, governments, stakeholders, and communities need knowledge and skills to identify and manage WASH risks associated with climate change and natural hazards prominent in Vanuatu. The WinHK tool contextualized and tested in four provinces will be used to develop climate sensitive improvement plans to support upgrade of resilient WASH services in healthcare facilities
Learning Note: Improving water, sanitation and hygiene in primary care health facilities during the COVID-19 pandemic in Indonesia
Key steps for the implementation of the WASH FIT included:
1. National training of the trainer (ToT) program on WASH FIT
2. Sub-national training on the WASH FIT
3. Implementing the WASH FIT Approach
4. Workshops on WASH FIT
5. Action plan implementation
Case study on the use of innovative approaches to enable safe water and environmental cleaning practices
A path for scaling-up technology, capacities and solutions
Different type electric chlorinators were installed in targeted health care facilities in response to Covid19. A total of 35 electrolytic chlorinators were installed in 35 Hospitals across the country during 2020/21.
- The machine allows the production of 4 liters of CL for 1KG of table salt, which is used for disinfection of water and cleaning surfaces.
- Patients and surrounding communities were engaged to understand their needs for the product
- Communities provide salt to hospitals, and also exchange salt with other commodities (soap and hand sanitizer)
- Win-win situation for both communities and HCF
Author
Co-authors
- Pedro Ogando dos Santos (WASH specialist) pogando@unicef.org
- Dr. Ana Cristina Guillen (WASH-IPC officer) aguillen@unicef.org
- David Simon (Chief WASH) dsimon@unicef.org