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 is the account of Getachew Tessema – participant and SNV WASH Sector Leader in Rwanda – on the first two learning blocks of the event.

Block 1: collaboration between health care and WASH structures

Availability of data on WASH in HCFs is insufficient. To obtain a general overview of how represented countries in the learning event fare in strengthening the ties that bind health care and WASH, seven poster presentations across Africa (Mozambique, Ethiopia, Tanzania and Zambia) and Asia (Nepal, Laos and Bhutan) were made. Presentations were followed by a SWOT analysis to tease out commonalities and difference across countries.

Biplav Kafle, SNV in Nepal, presents on the status of WASH in HCFs in Nepal

Olivier Germain (C) and Jackson Wandera (R), co-presenters of the Tanzania case


Overall, there is engaged leadership across all countries. A national structure, complete with implementation or enforcement guidelines are in place. There is a clear delineation of roles and responsibilities between agencies and actors. Monitoring mechanisms at global level (based on the new JMP baseline) are there, with some countries, e.g., Tanzania and Zambia raising their accountability and monitoring mechanisms through the development of national-level monitoring systems, and facility-level monitoring systems respectively.


Competing priorities amongst different actors impede efforts to harmonise systems (including monitoring). HCF human resource issues, e.g., high turnover rates, traditional attitudes, and capacity deficiencies (budgeting/ planning) create great pressures. So does the need to maintain existing facilities that either have complex technical specifications (“no one knows how to operate it”), or are highly exclusionary (“designs don’t service everybody’s needs”). In terms of focus, the critical role of handwashing facilities is not recognised sufficiently (only 1 of the 7 countries mentioned this), waste management efforts are weak, and most focus on treatment over prevention.  


Disease focused initiatives are creating opportunities to increase WASH in HCFs. For example, discussions on quality, maternal and child health help position WASH as part of the treatment. There too is greater donor interest to dialogue on WASH in HCFs – an opportunity, yes, but also a threat.


Similar to changing government interests (linked to political will), donors’ shifting interests are a threat, especially with regards to sustaining good progress. Cost for large scale infrastructure development is a real barrier, so are the effects of natural disasters and climate change threats

Robert Driebelblis (LSHTM) and Alison MacIntyre (WaterAid) synthesise key points

Bhutan SWOT analysis in action

Block 2: health care facilities in Bhutan

Article 9 of Bhutan’s constitution stipulates that “the state shall provide free access to public health services in both modern and traditional medicines”. In the WASH domain, the country has been making great strides. This success is mainly attributed to the coordinated roll out of the country’s RSAHP Implementation Plan, and the state’s recognition of the leadership of gewogs (group of villages) and dzongkhags (administrative and judicial districts).

During the learning event, findings of a baseline survey on WASH in HCFs in Bhutan was shared (based on data collected by the Ministry of Health in 2019). Key facts uncovered are:

  • Access to water supply is good (with 94% of all HCFs connected to a piped water system), but adequacy is an issue (due to water shortages during the dry season, and the monsoon season when sources are disturbed).
  • Although water quality is not reported as a major issue (during the period of the research), spring water sources are at risk of E.coli contamination – there exists no treatment systems for water sources.
  • Access to toilets (predominantly, pour flush toilets) are high, but gender segregation of toilets low. Only 12% of toilets have (limited) menstrual hygiene management facilities, and 70% of all sanitation facilities don’t account for the needs of people with disability.
  • Hygiene and health care waste management is weak, with no data available on staff disposal methods of infectious wastes, including sharps.

Learning blocks 1 and 2 were designed to set the scene for WASH in HCFs discussions. In the coming days, participant accounts of learning blocks 3-5 will be posted. Stay engaged!

This blog is the first 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: Setting the scene: WASH in HCFs learning event, and Exploring waste stream technologies and management models: WASH in HCFs learning event.



Photo credits: SNV/ Tashi Dorji and Gabrielle Halcrow