The questions below provide a summary of the availability of WASH services in health care facilities and suggested actions to improve services in low- and middle-income countries. It is based on the comprehensive, multi-country review by WHO and UNICEF; Water, sanitation and hygiene in health care facilities: status in low and middle income countries and way forward (WHO, 2015).

There are benefits in coordinating WASH with existing health initiatives, especially by drawing greater attention to inadequate conditions, developing joint training packages for health care staff, expanding upon WASH elements within existing facility infection prevention control plans and monitoring progress. Examples of such global health initiatives include the Global Action Plan to Eliminate Childhood Pneumonia and Diarrhoea (GAPPD), Global Task Force on Cholera Control, Energy for Women’s and Children’s Health and Clean Care is Safer Care.

Developing mechanisms to verify compliance with national standards, including the operation and maintenance of water and sanitation facilities and the correct practice of handwashing procedures, will help to ensure that improvements are maintained. Such efforts may involve the accreditation of facilities, with WASH serving as an important indicator in being able to provide quality care.

Training and sufficient staffing are fundamental to improving and maintaining WASH services in health care facilities and ensuring risk management plans are implemented. Training should equip individuals to operate and maintain essential services as well as to enable staff and patients to use WASH services properly.

National standards, targets, human resourcing and financing mechanisms provide the basis for improving and managing WASH services at the facility level. Such improvements would benefit from comprehensive, facility-based risk assessments, using approaches similar to those used for water safety plans. The water safety plan approach requires the identification of hazards and associated risks in the entire water supply chain. Sanitation, hygiene measures and health care waste management are also important elements to include in risk management plans. Further efforts are needed to develop facility and setting appropriate risk assessment tools which are linked to existing facility infection and prevention control plans and supported by financing and human resources to ensure that identified needs can be addressed.

The way forward requires a number of actions: strengthening national policies and standards, harmonizing and expanding monitoring, ensuring sufficient financing and trained staff to manage WASH in health care facilities and providing tools to prioritize and maintain improvements. Realizing improvements in WASH in health care facilities will require commitment from health and environmental partners at every level: local, national and global. Initial discussions indicate such commitment exists and WHO and UNICEF will strive, with partners, to harness this energy into a global action plan.

The existence and enforcement of national targets and national plans on WASH in health care facilities is one method to achieve a higher proportion of facilities with adequate WASH services. In analysing water targets, policies and coverage in a sub-set of 18 Sub Saharan countries in those countries where there is a water target and a national plan costed and regularly reviewed (Burkina Faso, Senegal and Zimbabwe) water coverage in health facilities is high (87% or greater). This is far above the African average of 58%. This suggests that the existence of national targets and national plans on WASH in health care facilities may be associated with a higher proportion of facilities served with water. Conversely, countries with no national plan have the lowest rates of facilities with water access.

The 2014 UN-Water Global Analysis and Assessment of Sanitation and Drinking-water (GLAAS) report led by WHO, showed that in the 86 responding countries, only a quarter had a plan for sanitation in healthcare facilities that is implemented with funding and regular review (WHO, 2014). The proportion of countries with plans for drinking-water and hygiene are even less.

Targets for basic coverage of WASH in health care facilities are also lacking. Over half (52%) of the countries (n=94) responding to this question in GLAAS do not have targets for hygiene in facilities and over a third of countries do not have targets for sanitation (35%) or water (44%). These figures indicate that policy development and planning is inadequate for WASH in health care facilities.

The WHO document Essential Environmental Health Standards in Health Care describes essential environmental health standards for health care in low-resource settings (WHO, 2008). It also describes methods for supporting the development and implementation of national government policies. The standards cover: water quality, water quantity, water facilities and access to water, excreta disposal, wastewater treatment and disposal, health-care waste disposal as well as other environmental issues.

There are large variations in provision of WASH in health care facilities within countries, by setting and by type of health care facility. Smaller facilities in rural areas have disproportionally fewer WASH services compared to larger facilities (e.g. hospitals) in urban areas. Larger facilities are more likely to have WASH services commensurate with their needs compared to smaller facilities. However, more country data sets are needed before global conclusions can be drawn.

Estimates of WASH in health care facilities should be interpreted with caution: the situation is likely to be much worse. The data available do not differentiate between facilities with on-site supplies and those having access to community sources within 500 meters. Furthermore, most of the data do not account for reliability, quantity or safety of supplies or functionality of sanitation services. Using more rigorous WASH standards causes the coverage rates to drop significantly. This suggests there are major hurdles for conducting even the most basic health care procedures in a safe and dignified manner.

In general, there is a lack of publicly available data, and the data that do exist do not use consistent indicators for WASH, making it difficult to compare data from different sources. Data were available in 54, 36 and 35 low resource countries for water, sanitation and hygiene, respectively. Countries in Africa are most represented (n=23) while those in Asia are the least represented. The lack of data is a barrier towards better understanding and addressing needs.

The three most common health care facility surveys are the Service Availability and Readiness Assessment (SARA), the Service Delivery Indicator survey (SDI) and the Service Provision Assessment (SPA); these are often nationally representative surveys conducted by international organizations. The specific definitions associated with water and sanitation indicators, and the way these indicators are measured, vary between assessments. In addition, the indicators they use often fall short of WHO minimum standards. However, SARA is in the process of updating their indicators to reflect WHO standards and all three are working to harmonize their definitions of WASH.

Globally, provision of WASH services in health care facilities is low, and the current levels of service are far less than the required 100% coverage. From the 54 countries represented in this report, 38% of health care facilities do not provide users access to an improved water source, 19% do not provide improved sanitation, and 35% do not have soap for handwashing. Provision of water was lowest in the African Region, with 42% of all health care facilities lacking an improved water source on-site or nearby. In comparison, provision of sanitation is lowest in the Americas, with 43% of health care facilities lacking such services. Some regions have very few countries surveyed and therefore it is difficult to provide a summary of access to WASH.

Health care associated infections affect hundreds of millions of patients every year, with 15% of patients estimated to develop one or more infections during a hospital stay (Allegranzi et al., 2011). Among newborns, sepsis and other severe infections are major killers estimated to cause 430,000 deaths annually. The risks associated with sepsis are 34 times greater in low resource settings (Oza et al., 2015). Lack of access to water and sanitation in health care facilities may discourage women from giving birth in these facilities or cause delays in care-seeking (Velleman et al., 2014). Conversely, improving WASH conditions can help establish trust in health services and encourage mothers to seek prenatal care and deliver in facilities rather than at home - important elements of the strategy to reduce maternal mortality (Russo et al., 2012).

Health care waste refers to all waste generated within healthcare facilities related to medical procedures and includes potentially infectious items such as used syringes, bandages and personal protective equipment (WHO, 2014). Health care waste is not a focus of the report nor included in the definition of WASH, yet it is a critical component of infection prevention and control.

WASH services provide for water availability and quality, presence of sanitation facilities and availability of soap and water for handwashing. Adequate water, sanitation and hygiene are essential components of providing basic health services. The provision of WASH in health care facilities serves to prevent infections and spread of disease, protect staff and patients, and uphold the dignity of vulnerable populations including pregnant women and the disabled. Many health care facilities in low resource settings have no WASH services, severely compromising the ability to provide safe and people-centered care and presenting serious health risks to both health care providers and those seeking treatment.