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Transforming systems: the vital role of water, and countries. This report captures Summary and snapshots of where successful change has been seen. It outlines actions the health systems strengthening approach WaterAid has taken, and how this has supported sustainable improvements in WASH in healthcare facilities.

There is still much to do to achieve universal access to WASH and universal health coverage (UHC) by 2030 in line with the Sustainable Development Goals (SDGs). By capturing lessons learned and sharing the actions that have supported success, we hope to help to drive the In 2015, WHO and UNICEF launched step change required to, by 2030, the first global report on the status of reach the aim of the Global Action Plan water, sanitation and hygiene (WASH) for WASH in healthcare facilities: in healthcare facilities in low- and ‘...every facility, middle-income countries.1 It revealed that healthcare facilities often lack in every setting, has safely access to water, sanitation and the managed, reliable water, means to maintain good hygiene, sanitation and hygiene facilities seriously undermining the quality of and practices to meet staff and healthcare. needs in order to provide quality, safe people-centered Since then, WaterAid has been care with particular attention working with partners and ministries of health to improve WASH in to the needs of women, girls healthcare facilities in several and children.’2 UN Photo / Jean-Marc Ferré “We must work to prevent the spread of . Improved water, sanitation and hygiene in health facilities is critical to this effort.”

António Guterres, UN Secretary-General, March 2018

2 Transforming health systems We call on – led by ministries of health – and donor agencies, researchers and NGOs, to re-double efforts to ensure every healthcare facility has the water, sanitation and hygiene necessary to make UHC a reality. What you can do

Integrate WASH in healthcare facilities as a core component in health , Finance WASH programmes in healthcare and strategies facilities as relevant for part of broader achieving UHC. health systems investments, with sustainable Measure long-term WASH in domestic and healthcare international facilities financing. routinely within health monitoring Coordinate systems, and and align contribute to efforts across the expanding sectors, evidence base ministries and on what works. organisations to maximise impact.

3 Transforming health systems To address the situation revealed in the report, WHO and UNICEF 1. The context developed a Global Action Plan for WASH in healthcare facilities.2 The plan comprises five key change objectives (Figure 1) addressing: advocacy and leadership; and standards; monitoring; research and knowledge; and facility-level improvements. It clearly highlights that health stakeholders should lead and champion improvements to WASH in healthcare facilities, with support from the WASH sector. It recommends that all improvement efforts should contribute to increasing the quality of care, towards the achievement of UHC;i strengthen In 2015, WHO and UNICEF’s report existing health systems; and involve Water, sanitation and hygiene in health coordination between health, WASH care facilities: Status in low- and middle- and financing ministries. With our income countries and way forward partners, WaterAid has supported the revealed the dire state of WASH in development and implementation healthcare facilities in 54 countries. It of the Global Action Plan from the showed that almost 40% of healthcare outset, and the achievement of the facilities lacked a water supply, one in action plan is critical to our vision of five did not have improved sanitation everyone, everywhere with water, and more than a third did not have sanitation and hygiene by 2030. hand hygiene facilities.1 This report showcases ways in which In addition to the alarming findings we have catalysed and supported on infrastructure, the report showed -led action to improve that other elements WASH in healthcare facilities, and required to ensure adequate WASH outlines the approaches we have were also lacking. Countries often taken, in partnership with health did not have the necessary policies, stakeholders, to strengthen health standards and budgets,1 and systems and the quality of care. monitoring systems were absent or By focusing on country examples did not align with globally recognised of progress, and identifying where basic WASH service levels for health gaps remain, we hope the report facilities.1,3,4 Subsequent studies will inform future efforts to ensure have shown staff shortages and all healthcare facilities have safe, training gaps on WASH and infection reliable, accessible and inclusive prevention control (IPC),5 a lack of WASH by 2030. coordination and leadership within and across ministries for WASH in healthcare facilities,6 and the absence i According to WHO ‘Universal health coverage is defined as ensuring that all people have access to needed of the accreditation or of promotive, preventive, curative and rehabilitative 7 private sector healthcare providers. health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services.’

4 Transforming health systems By 2030, every health care facility, in every setting, has safely managed, reliable water, sanitation and hygiene facilities and practices to meet staff and patient needs in order to provide quality, safe people-centered care

WASH in health care facilities is prioritized as a necessary input to achieving all global and national health goals especially those linked to CO1 Universal Health Coverage. Key decision makers and thought leaders champion WASH in health care facilities.

All countries have national standards and policies on WASH in health care CO2 facilities and dedicated budgets to improving and maintaining services.

Global and national monitoring efforts include harmonizing core and CO3 extended indicators to measure WASH in health care facilities.

The existing evidence base is reviewed and strengthened to catalyze CO4 advocacy messages and improve implementation of WASH in health care facilities.

Health care facility staff, management and advocate for and champion improved WASH services. Risk-based facility plans are CO5 implemented and support continuous WASH improvements, training and practices of health care staff.

Figure 1: The overall aim and change objectives of the WHO and UNICEF Global Action Plan for WASH in healthcare facilities. Adapted from WHO/UNICEF (2015).2 WaterAid / Al Shahriar Rupam

Midwife Parboti Rani Dhali, checks on 8-day-old baby of mother, Shokla Mondol, at Dacope Upazila Health Complex, Chalna, Khulna, Bangladesh.

5 Transforming health systems WaterAid / Dennis Lupenga Gloria Mkukawa working in a labour Ntosa healthward, Nkhotakota, centre, Malawi. 9

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of

19% healthcare facilities do not have adequate sanitation. 1 10 in Sub-Saharan Africa or Africa in Sub-Saharan

up to 20 to develop Southern Asia from highly preventable highly Southern Asia from causes such as diarrhoea, sepsis, aremeningitis and tetanus – all of which to unhygienic conditions. linked strongly 38% five die every babies Three minutes of healthcare facilities in low- and in low- facilities of healthcare middle-income countries lack access tomiddle-income countries lack access a water source. than are - than are Transforming health systems Transforming

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of patientsof How born babies in high-income countries. times more likely times more of healthcare facilities do not have soap for handwashing. Babies born in in low- andBabies born in hospitals in low- middle-income countries are neonatal sepsis 35% 15% 2. inadequate WASH undermines healthcare in developing countries acquire at least one infection during a hospital stay. 6 Improving WASH in healthcare facilities contributes towards:

> Improved preparedness and > Reduced neonatal and maternal response to health emergencies. morbidity and mortality. > Improved patient satisfaction > Reduced development and and demand for care. spread of > Improved working conditions resistance (AMR). and occupational health and > Reduced risk of healthcare- safety for health professionals. associated infections.

One of the founding principles of Inadequate WASH can lead to: healthcare is ‘First do no harm’.11 Without adequate WASH, this > Increased use, misuse and overuse principle cannot be upheld. If of antibiotics, accelerating AMR.15,16 healthcare facilities do not have: a safe and reliable water supply; safe > Compromised prevention, and accessible toilets for patients and preparedness and response to staff of all genders, ages and abilities; health emergencies, such as in good hand hygiene infrastructure the Ebola crisis in West Africa and and practices; effective cleaning; and recent cholera outbreaks in several safe waste management systems, the countries.17 health and safety of patients, carers and staff is severely compromised. > Decreased healthcare worker motivation and patient satisfaction WASH and IPC reduce the risk of and reduced uptake of care. acquiring healthcare-associated infections.12 Although evidence of the > Increased healthcare costs. links between WASH in healthcare facilities and health outcomes is > Longer stays in hospital and limited by a paucity of data,13,14 repeated visits due to healthcare- evidence is sufficient for urgent associated infections, especially action. antibiotic-resistant infections.

Increased risk of infection due to > Healthcare staff fetching water, inadequate WASH and IPC can affect which diverts precious time from many areas of good-quality health treating and caring for patients.14 service delivery.

7 Transforming health systems WASH is not just about infrastructure. healthcare facilities had higher Although this is an important WASH coverage.1 element, ensuring that good-quality service delivery and behaviour More recently, an analysis of change last requires strong health 129,557 healthcare facilities from systems. Strong health systems 78 low- and middle-income countries require good sector , revealed major gaps in environmental policies, financing and health hygiene and IPC: 73% of facilities information systems. Given this, it is lacked sterilization equipment; very concerning that the WHO and half lacked piped water; one third UNICEF report in 2015 found that lacked improved sanitation; 39% no national health management did not have adequate infectious information systems (HMIS) collected waste disposal; hand hygiene was data on WASH in healthcare facilities. compromised because 39% did not Conversely, it found that countries have soap for handwashing; and with fully implemented and financed more than half did not have reliable national policies on WASH in energy services.18, ii

ii For JMP service level definitions see washdata.org/monitoring/health-care-facilities WaterAid/ Anna Kari

Midwife Daniel Paul holds a newborn baby in the ward for women who have had caesarian sections or have been admitted with complications pre and post partum, at Kiomboi Hospital, Iramba, Tanzania.

8 Transforming health systems Systems-level approaches require 3. Why a all elements of WHO’s health system building blocks to be addressed: health systems leadership and governance; healthcare financing; health strengthening workforce; medical products and technologies; information and approach? research; and service delivery. Adaptable approaches are needed, recognising that the building blocks within a complex system interlink and overlap.

Addressing areas such as health system organisation, coordination, behaviours, financing, policies Health systems strengthening has and can increase been a priority for the quality of service delivery more community for the past decade, comprehensively than can vertical with global health practice seeing a programmes that target just one shift from disease-focused, vertical building block or disease, and can programmes towards broader, drive broader progress in health system-wide efforts to support outcomes.20 In addition, careful realising UHC and improved public consideration should be given to health outcomes. Achieving UHC by the perspectives of patients and 2030 is now a target all UN member healthcare workers, and ensuring states have agreed (under SDG 3.8), improvements meet the needs of the stated “top priority”19 of WHO marginalised and vulnerable people. under the leadership of Director- General Dr Tedros, and a major priority for several donor countries.

“Universal health coverage is ultimately a political choice. It is the responsibility of every country and national government to pursue it.” WHO / L. Cipriani Dr Ghebreyesus, Director-General of WHO.19

9 Transforming health systems The status of WASH in healthcare a different element of WaterAid’s facilities described here is health systems support, all form part indicative of systematic neglect of of much broader programmes and environmental determinants of partnerships. health throughout health systems. The solution to improving WASH What works in improving WASH and broader in healthcare facilities? conditions lies in a system-wide, WaterAid is deeply committed to holistic approach. catalysing and directly supporting improvements in WASH in healthcare WaterAid and partners have adopted facilities towards reaching SDG 6 such approaches in working to and SDG 3.8. We know that health improve WASH in healthcare sector leadership underpins facilities over the past three years. successful improvements to This report includes snapshots WASH in healthcare settings, so from WaterAid country-level work, we use a systems strengthening covering leadership and governance; approach to working with and working in partnership to influence primarily supporting the leadership ; monitoring; research of ministries of health, health to demonstrate and promote stakeholders and communities to good practice; and citizen-led drive progress. . While each highlights

Effective components of improving WASH in healthcare facilities Leadership, policies and standards

Adequate, well trained human resources Research to inform effective practice

Strong Citizen-led monitoring accountability mechanisms

Linking with health priorities

10 Transforming health systems From our experience, we believe 5 Support evidence-based design of the following steps are crucial behaviour change interventions, for success: which will help identify behavioural determinants specific to the 1 Advocate at all levels of context. This will include, for government for the prioritisation, example, sustainable handwashing financing, implementation and behaviour change of health staff maintenance of WASH services in all and patients. healthcare facilities. Governments must embed this across all health 6 Target efforts across all elements efforts, including maternal and of the health system through newborn health, AMR, improving monitoring mechanisms preparedness, IPC, sexual and to include WASH, supporting the and rights, development and adoption of WASH quality of care and UHC. in healthcare facilities guidelines, developing a skilled workforce, 2 Map and understand existing ensuring standard building health system priorities, policies, guidelines are in place and that political economy, health system national health targets and policies organisation and service delivery include and prioritise WASH. systems from the outset, to identify gaps and contextualise plans and 7 Convene regular reviews reform agendas to strengthen the of the progress of health system- functioning of the health system. strengthening efforts, formulate remedial reforms, and share learning 3 Craft multisector coordination and research about what works at mechanisms between health both national and global levels. and WASH stakeholders, across government and ministries, 8 Work with communities and involving multiple actors including marginalised groups to ensure researchers, UN agencies, NGOs duty-bearers uphold the human and healthcare professional rights to health, water and groups. These stakeholders must sanitation by providing services for remain actively involved for joint all, leaving no-one behind. decision-making and aligned action to maximise impact. 9 Underpin all efforts with focus on equity, and on inclusive and 4 Generate country-specific gender-transformative approaches. evidence on the status of WASH This can be achieved by targeting conditions in healthcare facilities, efforts where access to WASH and using globally and nationally health services is poorest; engaging recognised standards and using communities and service users – methods that enable identification especially women and marginalised of system and individual groups – in holding duty-bearers determinants of poor WASH, and to account and participating in recommendations targeted from decision-making fora; and ensuring the facility to national level. infrastructure and behaviour change programmes meet the needs of people of all genders, ages and abilities.

11 Transforming health systems Leadership, policy and standards 4. Lessons from for WASH in healthcare facilities The Global Action Plan for WASH in WaterAid’s health care facilities2 emphasises the importance of ensuring WASH experience is incorporated in national health policies, that standards or guidelines exist that guide facility-level improvements, and that accreditation and regulation mechanisms are established and enforced. WaterAid has learned that building strong relationships and coordination processes between WASH and health stakeholders, and understanding the political economy and priorities of health decision-makers, supports advocacy efforts for greater prioritisation, financing and action for WASH in healthcare facilities.

Cambodia: working in partnership to influence health policy and leadership

Key lesson: action in several areas, including: supporting Investing in the Ministry of Health to identify the gaps in partnerships WASH infrastructure and resources; securing enables coherent, WASH facility improvements; integrating effective action on WASH into new and existing guidelines, WASH in healthcare standards and strategies; and training health facilities that centre staff on WASH as it relates to IPC. improves impact, reach and quality. WaterAid Cambodia have used their experience in delivering improvements to In Cambodia, WaterAid commissioned a WASH in healthcare facilities to support situational analysis of policies, standards and revisions to the WASH components in the monitoring for WASH in healthcare facilities. national IPC guidelines and the revised The results showed a worrying lack of data Minimum package of activities for health on the status of WASH coverage in healthcare centres. It has also supported the Ministry of facilities. And no single policy document Health to create new national guidelines for existed that comprehensively described WASH in healthcare facilities to complement national policies and planning, including the IPC and minimum package of activities standards and coverage targets. (MPA) guidelines.

Since 2016, WaterAid Cambodia has worked in partnership with WHO Cambodia, UNICEF and Emory University, USA, to address these gaps in collaboration with the Cambodian Ministry of Health. A working group was created with these partners and is taking

12 Transforming health systems “When we used the water from WaterAid/ Tom Greenwood the pond, the patients were sick often but now they are less sick. And they have more money because they don’t have to spend money to buy water. We always inform the patients that they can drink this water. It makes me very happy.”

Peu Aranhya, nurse, Thmor Kol Referral Hospital, Cambodia.

13 Transforming health systems Myanmar: positioning WASH as an issue of maternal and newborn quality of care

Key lesson: researchers used WHO Quality Standards Understand health for Maternal and Newborn Care21 to analyse priorities and WASH gaps and needs. The resulting health system evidence enabled the development of clear, structures, pragmatic recommendations at national and and tailor sub-national levels for WASH in healthcare WASH activities facilities policy, infrastructure, systems, to support leadership, training, research and behavioural achievement of actions targeted at improving maternal and these goals. newborn care.

In 2016 WaterAid Myanmar, in partnership With the Ministry of Health and Sports, with WHO and UNICEF, commissioned a WaterAid is partnering with maternal and national-level health systems analysis to newborn health specialist organisations understand the extent to which policies, Jhpiego and The SoapBox Collaborative to put guidelines, monitoring, standards and roles the recommendations into action. Together, and responsibilities existed for WASH and they will establish quality improvement IPC, and to identify where these could be mechanisms in hospitals focussed on safe strengthened. Simultaneously, a national childbirth and gender-inclusive and socially multi-sector, cross-departmental working inclusive WASH, in order to improve maternal group was formed. Chaired by the Ministry and newborn care. for Health and Sports with representation from the Government, research organisations Framing the WASH in healthcare facilities and NGO and UN partners, the working programme within the Government’s health group’s main focus is to drive and align priorities and plans has enabled focussed and WASH in healthcare facilities activities with achievable national- and facility-level actions government systems and priorities. that WASH and health stakeholders can jointly carry forward and take to scale. Improving maternal and newborn health is a top priority for the Government, so the

Integrating with security; and UHC. WASH and health health priorities stakeholders cannot assume that the Embedding WASH within existing importance of this issue is obvious to health priorities and programmes is health decision-makers, nor that they essential to ensure the sustainability are aware of the WASH challenges. of WASH in healthcare facilities’ improvements and to avoid WASH Ensuring integration of WASH with and health sectors operating in health efforts requires targeted silos. Improving WASH in healthcare advocacy, careful framing of how facilities underpins almost all health WASH underpins health goals and priorities that governments and creation of country-specific evidence of donors give high political attention how gaps in WASH compromise health. to, such as: improving quality of care; maternal and newborn health around WASH and health stakeholders at the time of childbirth; slowing the national and international levels need development and spread of AMR; to actively engage in dialogue with , preparedness political leaders about the political and response; global health priorities for health in any given

14 Transforming health systems context, and make a powerful case line with WHO basic standards. that improving WASH is a critical foundation for achieving health goals. WHO and UNICEF, through the Joint Activities must be context-specific Monitoring Programme for Water and tailored to each health priority, Supply, Sanitation and Hygiene not one-size-fits-all; only then will the (JMP), have agreed a core set of issue gain the political traction and indicators for monitoring WASH in attention necessary for it to translate healthcare facilities to track progress into financing and action. towards SDG 6.3 The challenge now lies in embedding these indicators Strengthening monitoring of in the routine monitoring of health WASH within existing health systems, and in creating nationally monitoring mechanisms relevant indicators tailored for higher Tracking progress on WASH in level healthcare facilities for more healthcare facilities improvements sophisticated WASH standards. is essential at all levels – from the This will be critical, particularly for facility level for improvements, secondary- and tertiary-level hospitals decision-making and budget that provide sophisticated healthcare allocation, to global level for services such as major surgery monitoring the SDGs. In 2015, no and intensive care support. Under known national HMIS monitored the JMP, these extended indicators WASH, and no globally agreed determined at the national level are indicators existed to monitor WASH in termed ‘advanced service levels’.

Uganda: effective monitoring for planning and investment

Key lesson: Coordinating Committee (DPCC). WaterAid Develop a small acted as a facilitator for a DPCC task team task team with formed to examine the issue of improving government and data and developing indicators suitable for external partners national use. In 2016, the task team agreed to contextualise on a standardised list of indicators to be indicators to be recommended for use nationally as part of included in HMIS. the HMIS. Discussions focused on a range of issues such as adequate quality levels In Uganda, a major barrier to improvement for water and disaggregation of sanitation of WASH in healthcare facilities has been facilities by gender. Debate also took place on the paucity of available and good-quality how to balance the need to standardise with data for monitoring progress. The Child the global measurement system outlined by Health Division of the Ugandan Ministry of the JMP while retaining sufficient flexibility to Health has recognised this gap and has been reflect national context. seeking to establish an efficient measurement framework and improve availability of reliable In 2018, the latest review and update of data for planning and investment. the HMIS has provided an opportunity for WaterAid to update the WASH in healthcare WaterAid Uganda, together with the facilities indicators developed in 2016 to bring UWASNET civil society network, AMREF, Water them in line with the latest JMP indicators. for People, UNICEF and WHO, has worked WaterAid and UNICEF are now engaging closely with the Government to address this the Ministry of Health to develop national issue through the Diarrhoea and Pneumonia standards for WASH in healthcare facilities.

15 Transforming health systems Research to inform effective and systems-level interventions practice can sustainably and cost-effectively Understanding what works to drive improve WASH in healthcare facilities. and sustain improvements and Such evidence supports national-level collecting evidence on the impact progress and scale up. However, it is of improved WASH are essential to also beneficial globally, where gaps scaling up activities across the health remain in technical expertise and system. Attention should be directed knowledge of how best to improve to operational research designed to WASH in healthcare facilities across understand how facility-, behavioural- all levels of the health system.

Tanzania: scaling up, sharing good practice

Key lesson: with little privacy and no water supply, and Evaluating the toilets were unusable, forcing women programmes, to defecate in the open. Expectant mothers capturing lessons often had to ask female relatives to help learned and them collect water from a river for drinking, using robust cooking and washing themselves. research techniques enables Since WaterAid’s intervention, which effective and improved WASH services at the hospital, the evidence-based number of women coming to give birth at scale up of successful WASH in healthcare the hospital has doubled. The number of facilities activities. unsafe home-based deliveries has fallen, and the number of women using early antenatal In Tanzania, research to inform effective services increased. Although not measured practice has been at the heart of WaterAid’s as part of the WaterAid project, the District approach. After mapping the status of WASH Medical Officer has noted a marked decrease in healthcare facilities in Zanzibar, WaterAid in neonatal mortality at the hospital since the drew on this research to support the Zanzibar rehabilitation of the facilities, with far fewer Ministry of Health to develop an improvement cases of sepsis. Although this can’t be directly plan. In 2014 WaterAid launched a pilot attributed to the project, WASH is important intervention to improve WASH in healthcare to support such improvements to newborn settings in Singida region, central Tanzania, health. drawing on the lessons from Zanzibar. We implemented the project in 22 health centres WaterAid has worked with a range of across Singida and Iramba districts. From the partners to advocate scale up. Together start, WaterAid Tanzania focused on how to with WHO, UNICEF, UNFPA, Jhpiego and use the results of this work to advocate for the two ministries of health (Zanzibar and national scale up and make a powerful case Tanzania mainland), the Government has now that WASH is fundamental to UHC. launched National Guidelines for WASH services in Health Care Settings.22 Next, WaterAid will At Kiomboi district hospital, WaterAid and work with the Government to strengthen partners have worked to improve very poor and promote national accreditation and conditions, such as the hospital receiving monitoring systems for WASH in healthcare piped water for just one hour a day. Women facilities. were giving birth in cramped conditions

16 Transforming health systems WaterAid / Sam Vox

“I brought water to clean the plastic mat that they used because there is no water at the hospital. I brought one 10L bucket. They didn’t tell me how much, they just told me it was to clean the sheets and cloths. It’s mandatory to go to the with water, they tell us to clean all the covers. My sister in law helped me. There’s a well here near our home but there is no pump. We have to pull up the water with buckets.”

New mother Eva Paulo, Nyarugusu, Geita District, Tanzania.

17 Transforming health systems Mali: a capacity-building approach

Key lesson: > Building capacity to operate and maintain Focussing on long-term, safe, sustainable water services training and and monitor and evaluate interventions. building capacity of a wide range of > Increasing planning and coordination workers – including between local government and healthcare staff, implementing partners to strengthen the journalists and enabling environment. specialists – improves behaviour and One crucial aspect of WaterAid Mali’s work accountability. has been its capacity-building approach. WaterAid has trained healthcare staff on It is estimated that 61% of healthcare facilities hygiene promotion, healthcare waste in Mali have poor water quality, 24% have management and how to use assessment and insufficient water to meet patients’ basic improvement tools for WASH in healthcare requirements and 68% have inadequate facilities. WaterAid Mali is now training handwashing facilities.23 The Ebola trainers at the national level so that other in West Africa highlighted the urgent need agencies working on this issue can draw on a to address the lack of WASH in healthcare pool of trainers. Local committees in charge facilities. of governing healthcare facilities have been trained on healthcare system management, WaterAid is working in Mali with the Ministry budgeting and planning. WaterAid has also of Health, WHO and the Center for Disease trained journalists to improve coverage Control and Prevention, with financial support and public awareness of the links between from the Conrad N. Hilton Foundation. WASH and health. We are now partnering Working in partnership with the Ministry of with human rights specialists to train health Health and Public Hygiene, we are promoting workers and communities to lobby the a comprehensive approach, which includes: Government for their rights to safe water and sanitation in healthcare facilities. > Conducting a situational analysis of WASH

in healthcare facilities and recommending WaterAid / Basile Ouedraogo actions to improve access.

> The revival of the National Taskforce on WASH in healthcare facilities in Mali to coordinate sector efforts, share lessons from the field and promote efforts to improve WASH in healthcare facilities nationwide. This taskforce serves as a discussion platform, chaired by the WASH point person at the National Health Directorate (Direction Nationale de la Santé [DNS]).

> The Ministry of Health and Public Hygiene’s endorsement of the DNS’s proposed minimum package of WASH interventions in healthcare facilities.

Women with their babies waiting for surgery > Providing short-term and long-term WASH in the Communal Health Centre of Kemeni, in services in healthcare facilities. the circle of Bla, Segou region, Mali.

18 Transforming health systems WaterAid / Basile Ouedraogo

“As a health agent, it felt very bad to see people coming to look for health but then, unfortunately, picking up from drinking unsafe water in the health centre. Now, thanks to the WASH project, the health centre of Kemeni has a water tower and taps that allow everybody to access safe water.”

Mariam Diarra, nurse obstetrician, Communal Health Centre of Kemeni, Bla, Segou region, Mali.

The right mix and number of Gaps in human resources for adequately trained staff across healthcare in low- and middle-income all levels of the health workforce countries are well documented,24 Because WASH in healthcare facilities and WASH-related human resources is a cross-cutting and system-wide and training are similarly deficient. issue, ensuring the health workforce Health workforce planners and has the right skills, and enough managers must therefore understand staff trained in WASH-related how WASH issues relate to different responsibilities and behaviours, is staff roles and responsibilities. critical. The range of healthcare staff Responsibilities to consider include who need to be involved in delivering hand hygiene and waste disposal WASH in healthcare facilities is broad, for , frequent thorough including policy-makers, planners, cleaning routines for cleaners, and administrators, frontline health staff budgeting skills for prioritising (including doctors, nurses, surgeons infrastructure upgrades for WASH and midwives), for managers. A needs specialists, researchers, cleaners, and skills assessment is necessary to orderlies and engineers. ensure strengths are capitalised on and efforts are made to strengthen pre-service and in-service training where gaps remain.

19 Transforming health systems Citizen-led accountability ensure services and health system Health systems strengthening processes are gender-sensitive, activities tend to focus on socially inclusive and responsive to government-led health efforts the needs of all. and actions to improve areas such as monitoring, financing, policies WaterAid, through existing strong and leadership. Involving relationships with communities and communities, healthcare users, its human rights based approach, has health workers and vulnerable prioritised community engagement groups in decision-making, planning and empowerment in several and accountability is a critical part countries. As highlighted in the of strong health systems. Without following examples, there are many this engagement it is not possible to ways to do this. WaterAid / Dennis Lupenga

“In terms of sanitation, the hospital doesn’t have enough toilets and bathrooms. Yesterday when I was having contractions, I visited one of the toilets and they were all occupied. I ended up visiting the nearest bush to relieve myself. It was scary but I couldn’t hold it. A lot of women do that as well.”

Ruth Anderson, new mother, Ngokwe Health Centre, Malawi.

20 Transforming health systems Malawi: coordinating bottom-up and top-down pressure for change

Key lesson: use of development funds and lack of action Mobilising a to improve the cleanliness and condition of community and a local hospital. After an initially defensive its leaders to hold reaction, the MP accepted the criticisms and duty-bearers to committed to taking action. National media account for poor reported the story, bringing further attention WASH conditions to the issue. can result in government WaterAid Malawi have established influential leadership and action and greater citizen relationships with the Health Minister, the representation at decision-making fora. chairperson of the parliamentary committee for health and the parliamentary women’s WaterAid Malawi’s approach has caucus. Working with partners, we have combined direct service delivery of WASH secured a place in major health policy fora in healthcare facilities, improving citizens’ such as the Health Sector Working Group, capacity to hold duty-bearers to account for Safe Motherhood Sub-Committee under provision of WASH access, and improving the the Reproductive Health Technical Working coordination of policies and practice across Group, Quality Management Technical Government and other key stakeholders at Working Group, Health Promotion Technical the national level. By taking a ‘bottom-up’ Working Group and community-led approach and engaging Taskforce, and are acting as a catalyst for directly with national decision-makers to action and a convenor across sectors. influence ‘top-down’ change, WaterAid Malawi has helped to deliver significant WaterAid / Dennis Lupenga improvements for women and children.

At the local level, WaterAid has worked with patients and communities to strengthen their understanding of their rights and to develop advocacy capacity. Working with community leaders near healthcare facilities, WaterAid has run sessions on rights to WASH in healthcare environments and how people can raise these issues with duty-bearers (such as health centre staff, health centre advisory committees, village and area development committees, councillors, members of parliament [MPs], the district council secretariat and district health management teams).

Using evidence from national-level studies and from healthcare facilities where WaterAid has worked has created a strong feedback cycle between local communities and decision-makers. One example is the work of WaterAid’s partner, National Initiative for Civic Education, who facilitate ‘citizens’ fora’. Bertha Mwale speaking on behalf of her In one such forum, the local people, their community at a Joint Parliamentarian chiefs and traditional authority held their local Committee meeting with the people of MP to account for poor representation, poor Kapyanga in Kasungu, Malawi.

21 Transforming health systems India: community mobilisation for WASH in healthcare facilities

Key lesson: WaterAid / Ronny Sen Supporting public campaigns improves government accountability and enables greater community involvement in monitoring and improving WASH in healthcare facilities.

WaterAid India has run assessments of 426 healthcare centres in 13 districts across six states, revealing often appalling conditions. Capitalising on the political attention of the Swachh Bharat (Clean India) Mission launched in 2014 by Prime Minister Modi, in 2016 WaterAid India launched its ‘Healthy Start’ campaign to call for concerted action on WASH in healthcare facilities to reduce maternal and neonatal mortality. Public launch events were held across five states, with attendance by the Ministers of Health “People hush me up. I and Family Welfare in Delhi and Bhopal, speak my mind and they parliamentarians, senior bureaucrats, dislike it. But unless I speak members of the public, a live band in Uttar up, how else will the crisis Pradesh and vibrant media coverage. here get solved?” The campaign, run for and with the public, aims to change the narrative on health among health decision-makers, increase Aruna B, Auxiliary Nurse Midwife, public awareness of the critical role of Nizamabad District, India. WASH in delivering good-quality healthcare and challenge the perception that curative should take precedence over preventative healthcare. Community action is delivering results in accountability. For example, after the WaterAid India has worked with communities campaign launch the Swachh Bharat and health professionals to strengthen the Mission Director and National Health social status and self-confidence of sanitation Mission in Sehore district assessed WASH workers engaged in healthcare. WaterAid in healthcare facilities. This resulted in has also established community monitoring development of improvement plans, involving of WASH in health facilities by users, patient welfare committees and elected care-givers, hospital management representatives to ensure accountability. In committees, elected representatives and the 2017 the Government-run scheme for public community. Community action has included healthcare facilities gave ‘Kayakalp awards’ more than 80,000 people signing a petition to for cleanliness to two health facilities where the Minister of Health and mobilising young WaterAid India worked intensively with the people through campaigns. community.

22 Transforming health systems Nicaragua: improving conditions in partnership with communities

Key lesson: The workshops focused on strengthening Engaging and knowledge sharing, identifying WASH-related training women needs in communities and health posts and to participate in promoting community management for decision-making sustainable WASH solutions. fora is key to ensuring health WaterAid has helped to improve water services meet their systems (rehabilitation of wells) and specific needs. sanitation services (construction and improvement of modules) in health posts In Nicaragua, the Government has launched in several communities. Women in the a health and hygiene initiative called communities are now becoming more active ‘Live Well, Live Beautiful, Live Happy’. It is in promoting good hygiene practices and safe working with NGOs and the private sector to water consumption as crucial to women’s improve access to water at and health. Relationships between NGOs and institutional levels, including in hospitals, government institutions have also improved health posts, maternity homes and schools. at the coordination and technical levels. Although Managua is making good progress, Nicaragua’s Northern Autonomous Caribbean The project’s focus is on improving women’s Region is lagging behind. health, so most people who benefit and participate are women. This means women To address this, WaterAid has formed are engaged in improving the health and an alliance with Salud Sin Limite (Health wellbeing of other women through activities Action) and the women’s movement including promotion of hygiene practices Nidia White, focusing on the links between such as personal hygiene, menstrual hygiene, WASH and maternal and child health. The genital hygiene, hygiene during sexual initiative works to improve living conditions intercourse, handwashing, and hygiene through implementing improved practices during pregnancy, childbirth and puerperium. of safe water consumption, hygiene Midwives focus on health leadership, and the and basic sanitation in 24 communities. project supports them to visit women during WaterAid Nicaragua and partners have held pregnancy and post-partum to ensure good workshops and community discussions with hygiene practices at home. commissions, midwives, health personnel and schoolteachers.

“I can’t my hands and I am treating one patient and then another – what

we are doing is practically WaterAid / Nathalie Fernandes contamination.”

Hazel Claribel Sarante, doctor, Sol Naciente Health Post, Bilwi, Nicaragua.

23 Transforming health systems Citizens and civil society 5. The challenges: organisations must raise their voices and hold duty-bearers to account for areas for action their promises. Advocates need to re-double efforts to ensure decision-makers understand that WASH is not purely an infrastructure issue. They must make clear that sustainable WASH services require functioning health systems and financial and policy commitments, and that improvements will only occur when these are secured alongside changes in behaviours and practices. Governance and regulation Despite substantial progress on Attention has often focussed on improving WASH in healthcare public providers of healthcare. Most facilities in many countries since health systems are diverse, with a the launch of the WHO and UNICEF combination of public and private Global Action Plan and agreement sector providers delivering care. of the SDGs in 2015, a great deal WASH standards need to be included of hard work remains to achieve in accreditation and regulation UHC – underpinned by WASH in all systems for private and public healthcare facilities – by 2030. The healthcare providers, and, as a first experience of WaterAid and our step, governments should assess the partners across the world shows status of WASH conditions in both to that challenges remain at all levels of understand the baseline from which health systems. improvements must be made.

KEY AREAS FOR URGENT Financing Too often governments do not back ACTION INCLUDE: up national policies for WASH in Leadership and political will healthcare facilities with adequate Although ministries of health in financing for delivery. Governments several countries have shown and private health service providers leadership to improve WASH in must increase and improve use of healthcare facilities, as our examples domestic finances to support WASH show, much remains to be done. improvements. They must budget Political leaders and policy-makers not only for new or upgraded must ensure action on WASH in infrastructure and operation and healthcare facilities within priorities maintenance, but also for the health such as tackling AMR, improving worker capacity-building, training maternal and newborn health, IPC, and behaviour change initiatives quality of care and UHC. necessary for sustainable change.

24 Transforming health systems Greater donor financing for macro level, including for major WASH in healthcare facilities, infrastructure investments and aligned to national health systems broader system improvements, such strengthening efforts, is also key to as upskilling the health workforce filling the funding gap. To support and behaviour change initiatives, are the necessary increase in financial urgently needed. These tools and allocation, health policy-makers and estimates will aid decision-making and planners should develop costing provide evidence to better understand tools for facility-level improvements. the cost-benefits of improving WASH Estimates for WASH costs at the in healthcare facilities. WaterAid / Al Shahriar Rupam

Midwife Bimola Kobiraz delivers a baby to Hera at Dacope Upazila Health Complex, Chalna, Bangladesh.

25 Transforming health systems Monitoring and targets Maternal and Child Survival Core indicators for WASH in Program’s Clean Clinic Approach26 and healthcare facilities and guidance The SoapBox Collaborative’s WASH for integrating them into routine and Clean Toolkit,27 are promising health monitoring, such as by HMIS, tools for driving change. Robust present a great opportunity for evaluation of their effectiveness is still countries to embed this monitoring to come, but it is clear that embedding into their existing systems and track strong monitoring, evaluation and progress towards national targets knowledge sharing into efforts to and the SDGs. strengthen WASH in healthcare facilities will help to take evidence- The JMP will release its first report based interventions to scale. using the core indicators in late 2018. Given that only 54 countries Technical solutions and had data available in the 2015 report building design for water in healthcare facilities Despite the development of tools for – and fewer for sanitation and facility improvements, gaps remain hygiene – we anticipate that major in technical solutions for WASH data gaps will remain for many infrastructure. These needs span countries. Further advocacy will be all elements of WASH, and include necessary to encourage monitoring appropriate sanitation designs for of WASH in healthcare facilities people with limited mobility and in all countries, disaggregated women during labour, waste disposal by different districts and levels of systems including environmentally care. And advocacy alone will not designed incinerators and facilities be sufficient – indicators must be in challenging environments such as agreed with governments, decisions floating , as well as designs that made on how and when to collect can withstand changes in climatic data and capacity-building activities conditions and water shortages. initiated to ensure good-quality data are collected, analysed and used. Furthermore, standardised building Integrating indicators into HMIS may designs for WASH are often missing be one avenue, but if stronger, more or do not meet minimum quality effective mechanisms exist, especially guidelines, resulting in hospitals and at the subnational level, these should health centres being built without also be explored. adequate WASH infrastructure. Standardised designs relevant Research and learning to a facility’s environment that Global momentum on WASH in meet minimum requirements, healthcare facilities has escalated with operation and maintenance since the launch of the WHO and guidelines, will support better UNICEF status report. Yet gaps planning. Donors and international remain in knowledge on effective institutions investing in improving approaches for driving facility-level infrastructure must also ensure improvements. their designs meet national design standards and adequately address WHO and UNICEF’s Water and WASH. No new healthcare facility Sanitation for Health Facility should be built without adequate Improvement Tool (WASH FIT),25 WASH. alongside other tools such as USAID’s

26 Transforming health systems WaterAid / Tom Greenwood

Phat and granddaughter Saymom drink water from the hospital tap. Thmor Kol Referral Hospital, Battambang, Cambodia.

27 Transforming health systems > Beyond providing basic WASH 6. The way services, agree advanced levels of service and WASH infrastructure, forward: actions training and practice requirements for high-level facilities, including for a step hospitals and specialist treatment change in WASH centres. > Strengthen coordination between in healthcare ministries responsible for health, finance and WASH to ensure facilities adequate finance to support the delivery of all aspects of WASH across the health system.

> Invest in a sufficient and well trained health workforce with the WaterAid’s global experience of skills and training to address WASH supporting governments to improve issues as necessary. This includes WASH in healthcare facilities strong pre-service and ongoing shows that significant progress is in-service education and training possible with political leadership, programmes for all levels of staff. strong accountability and sufficient > Establish transparent national financing. However, it is equally clear minimum standards for WASH in all that achieving UHC by 2030 requires government and private healthcare a step change in commitment and settings. Build WASH standards action. into accreditation and regulation We call on health decision- systems. makers in particular to commit > Support and facilitate citizen-led now to strengthen health accountability mechanisms to systems by ensuring sustainable ensure standards for WASH in improvements in water, healthcare facilities are enforced. sanitation and hygiene in all healthcare settings. > Integrate WASH in healthcare facilities indicators in existing Governments, led by ministries national and sub-national of health, should monitoring mechanisms and use Ensure every healthcare facility > data to prioritise efforts and track has: an adequate, safe and reliable health system performance. water supply; safe and accessible toilets for patients and staff of > Integrate targets for WASH in all genders, ages and abilities; healthcare facilities into policies good hand hygiene infrastructure and strategies for all relevant and practices; routine, effective health priorities. cleaning; and safe waste management systems. They should ensure procedures are in place to maintain these services, so they continue to work.

28 Transforming health systems > Establish strong cross-ministerial > Develop evidence on how to coordination mechanisms with sustainably improve hand hygiene active involvement of ministries and broader environmental hygiene responsible for WASH, to coordinate behaviour change. and align efforts of all relevant actors to take action. > Disseminate research findings to both health and WASH Donor agencies and policy-makers and practitioners, international financial encouraging cross-sectoral institutions should collaboration and cross-country > Prioritise WASH in healthcare learning about good practice in facilities in health strategies and improving WASH in healthcare funding mechanisms, especially facilities. those linked to maternal and newborn health, AMR, health NGOs should security and UHC. > Support communities to hold health and WASH > Design funding to support duty-bearers to account and government-led health systems to be included in decision-making strengthening efforts that prioritise activities, particularly to ensure and target WASH. improvements meet the needs of the poorest and support accessible > Support cross-sectoral coordination and inclusive services for all. and action through flexible funding mechanisms that support > Direct efforts towards system-wide approaches, including strengthening the health system national policy, guidelines, as a whole, rather than focussing monitoring and training support. on vertical or siloed programming approaches. > Incentivise governments to contribute domestic financing > Coordinate with WASH or health for WASH in healthcare facilities partners to deliver integrated, improvements and maintenance. holistic programming to improve quality of care. WHO and UNICEF should > Continue global leadership and > Catalyse and foster strong national technical guidance development and sub-national cross-sectoral through the Global Action Plan for working groups to ensure all WASH WASH in healthcare facilities. in healthcare facilities efforts align with and strengthen government > Support efforts to coordinate health efforts and service delivery. action at the country level and share best practice guidance through global platforms. Researchers should > Prioritise operational and implementation research that focuses on how to sustain WASH improvements at all levels.

29 Transforming health systems 6 WaterAid (2015). Towards safer and better References quality health care services in Cambodia: a situation analysis of water, sanitation and hygiene in health care facilities. Report. Cambodia. Available at washmatters. wateraid.org/publications/towards-safer- and-better-quality-health-care-services-in- cambodia-2015 (accessed 12 Mar 2018).

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30 Transforming health systems 14 WHO, UNICEF, SHARE (2016). Workshop 21 WHO (2016). Standards for improving Report: Global strategy, burden of disease, quality of maternal and newborn care in and evidence and action priorities. health facilities. Geneva: World Health Available at www.who.int/water_ Organization. Available at www.who.int/ sanitation_health/facilities/wash-in-hcf- maternal_child_adolescent/documents/ london.pdf?ua=1 (accessed 12 Mar 2018). improving-maternal-newborn-care- quality/en/ (accessed 12 Mar 2018). 15 Pearson M, Doble A, Glogows R, et al. (2018). Antibiotic Prescribing and Resistance: 22 Tanzania Ministry of Health, Community Views from LMIC Prescribing and Dispensing Development, Gender, Elderly and Professionals. Report to World Health Children (2017). The National Guidelines Organization AMR Secretariat. Available for Water, Sanitation and Hygiene in Health at www.who.int/antimicrobial-resistance/ Care Facilities. Available at washmatters. LSHTMAntibiotic-Prescribing-LMIC- wateraid.org/publications/national- Prescribing-and-Dispensing-2017.pdf guidelines-for-wash-services-in-health- (accessed 12 Mar 2018). care-facilities-in-tanzania (accessed 12 Mar 2018). 16 Graham WJ, Morrison E, Dancer S, et al (2016). What are the threats from 23 WHO Mali (2013). Évaluation rapide de antimicrobial resistance for maternity units l’Accès à l’Eau, l’Hygiène et l’Assainissement in low- and middle- income countries? dans les structures de soins au Mali. Global Health Action. 9:10.3402/gha. v9.33381. Available at www.ncbi.nlm.nih. 24 Scheil-Adlung X (2013). Health workforce gov/pmc/articles/PMC5027331/ (accessed benchmarks for universal health coverage 12 Mar 2018). and sustainable development. Bulletin of the World Health Organization 91: 888– 17 Abrampah NM, Montgomery M, Balle A, 889. Available at www.who.int/bulletin/ et al (2017). Improving water, sanitation volumes/91/11/13-126953.pdf (accessed and hygiene in health-care facilities, Liberia. 12 Mar 2018). Bulletin of the World Health Organization 95: 526-530. Available at www.who.int/ 25 WHO, UNICEF (2017). Water and sanitation bulletin/volumes/95/7/16-175802.pdf for health facility improvement tool (WASH (accessed 12 Mar 2018). FIT) A practical guide for improving quality of care through water, sanitation and 18 Cronk R and Bartram J (2018). hygiene in health care facilities. Available Environmental conditions in health care at www.who.int/water_sanitation_health/ facilities in low- and middle-income publications/water-and-sanitation-for- countries: Coverage and inequalities. Int health-facility-improvement-tool/en/ J Hyg Environ Health. Available at www. (accessed 12 Mar 2018). ncbi.nlm.nih.gov/pubmed/29352706 (accessed 12 Mar 2018). 26 USAID (2017). Maternal and Child Survival Program Clean Clinic Approach. Available 19 Ghebreyesus TA, Director-General of at washforhealthcare.mcsprogram.org WHO, 17 July 2017. ‘All roads lead to (accessed 12 Mar 2018). universal health coverage’. Available at www.who.int/mediacentre/ 27 SoapBox Collaborative (2016). WASH commentaries/2017/universal-health- and Clean Toolkit. Available at www. coverage/en/ (accessed 12 Mar 2018). soapboxcollaborative.org/?page_id=3232 (accessed 12 Mar 2018). 20 Chee G, Pielemeier N, Lion A, Connor C (2013). Why differentiating between health system support and health system strengthening is needed. Int J Health Plann Manage. 28: 85–94. Available at www.ncbi.nlm.nih.gov/pubmed/22777839 (accessed 12 Mar 2018).

31 Transforming health systems This report showcases ways in which WaterAid and our partners have influenced and supported government-led action to improve water, sanitation and hygiene in healthcare WaterAid / Laura Summerton facilities. It outlines the approaches we have taken, in partnership with health stakeholders, to strengthen health systems and quality of care. We call on governments – led by ministries of health – and donor agencies, researchers and NGOs to redouble efforts to ensure every healthcare facility has the water, sanitation and hygiene necessary to make universal health coverage a reality. wateraid.washmatters.org/ transforming-health-systems

#HealthyStart

Cover images, top to bottom: “Water is important. Without

Nurse Chankna and daughter Srey Pick, water, I cannot do my work and midwife Sakon and son Ratanak, and Kimhong even the clinic cannot run, the with daughter Hor. Boeung Kontout Health Centre, Krokor District, Cambodia. toilets will not be clean, nurses WaterAid/ Tom Greenwood. cannot treat the patients and everywhere will not be clean.” Christine Sogoba, Nurse Obstetrician, standing next to Awa Traore and helping her to take care of her newborn baby girl, in Bougoura Communal Health Centre, Bougoura Village, Mali. WaterAid/ Basile Ouedraogo. Yeartee Barteh, cleaner at Pipeline Water stored for use at the Gwagwalada Health Centre, Monrovia, Liberia. township clinic, Abuja, Nigeria. WaterAid/ Simivija.

WaterAid is a registered charity: Australia: ABN 99 700 687 141. Canada: 119288934 RR0001. India: U85100DL2010NPL200169. Sweden: Org.nr: 802426-1268, PG: 90 01 62-9, BG: 900-1629. UK: 288701 ( and Wales) and SC039479 (Scotland). US: WaterAid America is a 501(c) (3) non-profit organization.