Access to safe drinking water, sanitation and hygiene determines good health (WHO, 2017). Hence people’s right to health is inextricably linked to their right to water and sanitation. Both rights, among others, strengthen (or weaken) the conditions for people to lead a humane and dignified life.
From 6-9 May, almost 50 international WASH experts engaged on the topic of WASH in health care facilities (HCFs) at a learning event in Punakha, Bhutan. Below are the accounts of Anne Mutta – participant and Multi-Country Programme Manager of SNV’s Sustainable Sanitation and Hygiene for All Results Programme, and Le Huong, WASH Sector Leader in Vietnam – on the third learning block of the event.
Entry points for change based on HCF needs
Opportunities to strengthen service delivery of health care facilities (HCFs), with support from the WASH sector, abound. In the search for entry points for change, participants of the learning event broke out in four groups (10-14 members each) to learn from the realities of decision-makers and staff working in the different levels and types of HCF in Bhutan:
- a national referral hospital (and the Ministry of Health) in Thimphu
- a district hospital (and the District Governor’s Office) in Phojikakha
- basic health unit 1 at the Shengana subdistrict (run by health assistants)
- basic health unit 2 at the Phobjikha subdistrict (with doctors, health assistants, and a larger number of patients)
Bhutanese officials listen to key findings/ opportunities from field assignment
Overall, the following opportunities/ entry points for change were identified:
- Decentralised governance systems help strengthen the role of district stakeholders to shape WASH in HCF priorities. Enhanced decision-making powers and closer proximity to budgets create a far more responsive service delivery process by HCFs.
- Similar to other countries, Bhutanese districts are in the midst of aligning their HCF design protocols, standards and guidelines with the national framework. This alignment may also result in the retrofitting or building of new facilities.
- There is greater understanding that cleanliness on the surface (i.e., what is visible) does not translate automatically to microbiologically disinfected facilities. That training of HCF cleaners is needed. And, a departure from the overwhelming notion that cleaning (mostly undertaken by people with little or no access to education) is a “menial task” must be addressed urgently.
Entry points for change based on continuous development research
During the first quarter of 2019, the World Health Organization (WHO) launched several publications that offer insight into the status of WASH in HCFs, a monitoring methodology, and some practical steps to realise universal access to quality health care (delivered by HCFs). Together, these materials provide a comprehensive reading of the current state of affairs, and potential ways forward.
For HCFs that lack a WASH lens in maintaining and/ or improving their services, WaterAid developed a four-step model to help create the space for WASH inclusion . The WaterAid stepwise process (in chronological order) includes: a) Health System Scoping [systems, structures, people, and procedures]; b) Health Systems Analysis [review of health systems through a WASH lens]; c) Needs and Situation Assessment; and d) Action/ Implementation.
Time to act now
With the links between WASH and HCFs established, it’s increasingly becoming accepted that the time to act is now. Below are some points to consider when introducing and/ or improving HCF services through a WASH lens.
Based on Swachchhata project’s initial findings, SNV in Nepal 
- Some investment considerations: multi-stakeholder engagements and planning, basic infrastructure that stave off infection, regular operations and maintenance
- Capacity strengthening: all staff to receive training on infection prevention
Based on a Save the Children US study in Nigeria 
- Although infrastructure is critical, presence does not translate to hygienic practice
- Increase presence of handwashing with soap facilities in maternity wards
- Develop a comprehensive training exercise for health workers on hygiene (including retraining opportunities)
- Enforce compliance with hygiene protocols
How is your organisation enhancing WASH’s contributions to improve HCF services? Stay engaged  and register now to the SNV WASH e-group to enrich conversations and exchange.
This blog is the second installment in the three-part participant account of the learning blocks tackled during the learning event, WASH in Health Care Facilities. View other accounts here: Entry points for change: WASH in HCFs learning event, and Exploring waste stream technologies and management models: WASH in HCFs learning event.
 During the learning event, Alison MacIntyre from WaterAid Australia shared WaterAid’s four-step model approach in incorporating WASH perspectives in HCF service improvements. This approach is currently being implemented in a Water for Women-supported project in Myanmar.
 Swachchhata (or cleanliness in Nepali) is a project in Nepal supported by USAID that looks at infection prevention and hygiene promotion. Ways forward highlighted above are part of a larger research study that is in progress.
 Presented by Robert Driebelblis from the London School of Hygiene and Tropical Medicine, Save the Children research findings in Nigeria were used to inform ongoing research in Cambodia by Water for Women and WaterAid.
 Proceedings of the learning event are forthcoming. This will include a fuller discussion of presentations from the abovementioned research, and ways forward.
Photo credits: (banner photo) Black and white doors signifying opportunities, downloaded from pexels; (group photo) All four field assignment groups presenting their key findings, challenges and their recommendations - along with photo journals - to Bhutanese officials (SNV/ Tashi Dorji)