Nepal’s Sarlahi and Dailekh districts respond to the threat of COVID-19 spread by accelerating water, sanitation, and hygiene investments in rural health centres. By delivering facilities and introducing more robust leadership and monitoring mechanisms, both districts raised the services benchmark for healthcare services and health security in rural areas.
Globally, one in four Health Care Facility (HCF) lacks basic water services, one in five has no access to sanitation services, and one in six has no access to hygiene services. In the districts of Sarlahi and Dailekh, SNV’s Beyond the Finish Line project baseline survey in 2019 found that 45 per cent of HCFs in eight rural municipalities had no handwashing facility near a toilet. None of those with access to a handwashing facility had soap available.
Access to water, sanitation, and hygiene facilities is doubly challenging for people with disabilities, senior citizens, and pregnant women in health care facilities. Because of the COVID-19 pandemic, infection prevention and control  protocols had taken on new meanings. Today, these more explicitly underpin health security and are critical to mitigate viral spread.
Four HCFs gained from WASH improvements
With project funding from the Australian government’s Water for Women Fund, SNV engaged local government officials and private sector to redress the state of Water, Sanitation, and Hygiene (WASH) in four healthcare facilities: two in Sarlahi and two in Dailekh.
Facility improvements delivered. Beyond the four inclusive and accessible toilets built, backup water storage tanks, soak pits and septic tanks, waste burial pits for the management of hazardous wastes, and placenta pits in HCFs with birthing centres were constructed. Pedal operated handwashing stations, waste segregation bins, and autoclaves were delivered.
Participatory accessibility audits introduced. To make local government commitment to inclusivity actionable, SNV introduced participatory accessibility audits for health care facilities. These audits evaluate the accessibility and safety of WASH facilities and its surroundings for different groups of people. For example, it brought to decision-makers’ attention the need for separate and spacious cubicles for women, with proper ventilation and lighting, reliable access to water, and bins for disposal of menstrual pads.
Findings of an audit at Parsa Health Post in Sarlahi led to structural improvements in favour of people with disabilities. Today, Ajay Kumar Shah, a health post employee, no longer needs to travel back home during working hours to use a toilet. Thanks to the wheelchair-accessible toilet built on-site and the constant availability of water, he said ‘Now, I don’t have to worry about the toilet while on duty.’
Participatory accessibility audit of WASH facilities in health post ongoing
Ajay Kumar Shar poses in front of newly built toilet structure in Parsa Health Post
WASH infrastructure operations and management, as well as monitoring practice reformed and strengthened. At the Parsa and Thantikandh health care facilities in the districts of Sarlahi and Dailekh, respectively, several committees were reconstituted to provide leadership in standards setting and monitoring:
- Health Care Facility-Quality Improvement Committee (HF-QIC),
- Health Care Facility-Operation Management Committee (HF-OMC), and
- Rural Municipality-Quality Assurance Work Committee (RM-QAWC).
With the above committees’ roles and responsibilities defined and now institutionalised, Laxmi Buda from the Thantikandh PHCC, emphasised that ‘it has been easy to track operation and management challenges after the formulation of this monitoring protocol and increased accountability.’
The multiplier effects
The design and successful delivery of inclusive WASH structures in HCFs led to a growth in demand for the services of SNV’s partner service provider. The provider’s services have been solicited by several development agencies to benefit other areas in Nepal, such as the Sudurpaschim Province.
Rajendra, promoter of inclusive WASH infrastructure in public institutions, shared, ‘With support from SNV, I am branding this design through my company to keep momentum behind this concept of inclusiveness.’ Conscious of the limitations of demand for inclusive toilets, Rajendra conveyed his desire to make inclusivity a standard in his company’s design and construction of facilities.
Further, the involvement of a wide range of WASH in HCFs stakeholders in Sarlahi and Dailekh in training activities, the restructure of inclusive monitoring mechanisms, and during accessibility audits led to greater ownership of processes. Partners helped to institutionalise and spread messages about inclusive WASH at HCFs, and wider themes, including COVID-19 prevention and control.
Inclusive toilet structure in Lakandra Primary Health Centre
The way forward
As more development agencies and local government institutions replicate SNV’s inclusive WASH approaches for health care facilities, it is imperative to take stock of some elements that contributed to this success. Some of these include:
- Meaningful participation of groups of people traditionally excluded from decision-making spaces.
- Strengthening institutional and technical capacity at local level, e.g., increasing know-how and the number of skilled professionals for design, construction, and operations and maintenance.
- Developing customised training modules on infection prevention and WASH that align with the recently launched National Standard for WASH in Health Care Facilities of Nepal.
- Strengthening the WASH market supply chain at local level.
- Institutionalising collaboration between public institutions to organise trainings for the scale-up of inclusive and disability-responsive WASH infrastructure in all institutional buildings.
- Setting in place a flexible timespan to allow thorough assessment of local risks while providing opportunities for effective participation of HCF staff members in project activities.
Written by Sunetra Lala, Ratan Budhathoki, Shova Chhetri, Aastha Chhetri, SNV and Rabin Bastola, Independent Consultant
Photos: SNV Nepal
 ] IPC includes hand hygiene of health workers; disinfection of equipment, tools, and surfaces; cleanliness of toilets and premises; and segregation and treatment of infectious waste from the point of generation