WATER,SANITATION,ANDHYGIENEINHEALTHCARE

FACILITIESThegloballandscapeofsustainability

July2019

2

TableofContentsIntroduction.................................................................................................................................................3Part1:Background.......................................................................................................................................4Part2:TrendsinWASHservicesustainability..............................................................................................7Part3:Overcomingchallengesandpromotingsustainability....................................................................13Conclusion..................................................................................................................................................16References..................................................................................................................................................17

3

IntroductionTheWorldHealthOrganizationandUNICEFJointMonitoringProgramme(JMP)recentlyreleasedWASHinHealthCare Facilities - Global Baseline Report 2019, a global assessment presenting the stark inadequacy of water,sanitation,andhygiene (WASH)services inhealthcare facilities (HCFs). Usingdata fromover560,000facilitiesacross125countries,thereportshowsthatasof2016,therewerelargegapsacrosswater,sanitation,hygieneandwastemanagementservicesthroughoutlow-andmiddle-incomecountries,supportingtheUNSecretary-General’s2018calltoactionforprioritizingworkonWASHinhealthcarefacilities.AchievingWASHcoverageacrossallHCFsiscrucialforreachingSustainableDevelopmentGoals(SDGs)3,ofensuringhealthylivesandpromotingwell-beingatallages,and6,ofensuringavailabilityandsustainablemanagementofwaterandsanitationforall.IthasbecomeclearthatWASHcoveragehasimplicationsforhealthoutcomes,viapatients’health-seekingbehavior,aswellashealthcaredeliveryitselfatthefacility. Thus,thegapsfoundintheJMPreportarealarming,andhighlighttheneed to act immediately to ensure that HCFs in low-resource settings obtain the WASH coverage that theydesperatelyneed.WhilevariousorganizationshavebeenmakingeffortsoverthepastdecadetoachieveSDG6,theJMPreportshowsthatthereisstillmuchworktobedone.Thisprojecthasbeenundertakenwiththefollowinggoals:

1. Reviewcurrentliterature(academicandgrey)tounderstandwhathasbeenlearnedbyothersaboutWASHinHCFsandhowbesttoincreasesustainability;

2. WorkwiththenorthernMalawiTransformteamtoprovideabaselineregardingservicesandconditionsofallHCFsinRumphiDistrict,Malawi;

3. DevelopaMonitoring,Evaluation,Resolution,andLearning(MERL)tool thatcanbeappliedto increasesustainabilityofWASHservicesinHCFs;

4. Testthetoolandevaluateitsusefulness.Thislandscapedocumentaddressesitem1above.Itidentifiesfactorsthatareassociatedwithgapsincoverage,assesses the various tools, programs, and frameworks that have been implemented to address the gaps, andidentifieswhatmustbeaddressedonanongoingbasistoensurethatWASHserviceatHCFsissustainedoverthelongterm.InPart1ofthisreport,wediscussthegapsincoveragehighlightedbytheJMP,theimplicationsoftheseonpublichealth,andtheneedforsustainabilityofWASHinHCFs.InPart2,wereviewcasestudiesanddiscussfactorsthatinfluencethefailuresandsuccessofsustainedWASHserviceprovision,bothwithinandoutsidethecontextofHCFs. InPart3,wediscusshowtomeasuresuccessandsustainabilityofWASH inHCFs,aswellasmethodsforovercomingthepreviouslyidentifiedchallengestosustainingservice.Many of the challenges in sustainingWASH services at HCFs are similar to those found acrossWASH serviceprovision in low-resource settings, whether they are communities or schools. Yet there are challenges andopportunitiesuniquetoHCFs,andmanyvaluablelessonstobelearnedfromthehealthsectoratlargethatcanbeapplied toWASH service sustainability. It is evident that there is a need to incorporateWASH operation andmaintenancetasksfromvariouslevelsintoabroader,facility-wideQualityImprovementframework,supportedbylocalgovernmentorregionalinstitutions.In June2019, numerous stakeholders gathered inWashington,D.C. to solidify their commitments to achievinguniversal WASH coverage in HCFs. Transform International and the Desert Research Institute have jointlycommittedtoworktowardsdevelopingaframeworkforsustainabilitywithinthisfield.Thislandscapereportisthefirststeptowardthatgoal.Followingthislandscape,incollaborationwithourpartnersinthefield,TIandDRIwilldesignaframeworktoaddressthesegaps,andimplementapilotprojecttotesttheframework.

4

Part1:BackgroundGlobalcoverageofWASHinHCFsTheWHO/UNICEFJMP’s2019globalassessmentpresentsthelargegapsincoverageacrossfiveWASHdomainsinHCFs:water,sanitation,hygiene,wastemanagement,andenvironmentalcleaning. Each isgradedona ladder,having basic, limited, or no service; definitions for each level of service vary depending on theWASH servicecategory.

Figure1.JMPserviceladdersformonitoringWASHinHCFintheSDGs(Corequestionsandindicatorsformonitoring

WASHinhealthcarefacilitiesintheSustainableDevelopmentGoals,2018)

Forthepurposesof this report,and intheWHOreport,HCFs“encompassall formally-recognizedfacilities thatprovide health care, including primary (health posts and clinics), secondary, and tertiary (district or nationalhospitals),publicandprivate(includingfaith-run),andtemporarystructuresdesignedforemergencycontexts.”Thereportshowsthatin2016,asignificantglobalproportionofHCFscompletelylackorhaveonlylimitedwater,sanitation,andhygieneservices.Inparticular:

5

• 74%ofHCFshadbasicwaterservice,indicatingthattheremaining26%hadlimitedornoservice.Amongtheleastdevelopedcountries,only55%hadbasicwaterservice.

• 21%ofHCFshadunimprovedtoiletsornotoiletsatall.• 16%ofHCFshadnohygieneservice.Theylackedhandhygienefacilitiesatpointsofcare,andsoapand

waterattoilets.• 40%ofHCFslackedsystemsforsegregatingwaste.• Data on environmental cleaningwas insufficient; only 4 counties had sufficient data to estimate their

coverage–highlightingtheneedtoimproveglobalmonitoringonthisdomain.Further,thereportshowsthatbeyondasimple“presence/absence”assessmentofWASHservices,functionalityposesaproblemaswell.Infacilitieswhereanimprovedwatersupplyisavailable,theremaybeservicedisruptions,renderingtheirservicelevel“limited”;whereimprovedsanitationisavailable,latrinesmaynotbeusableduetouncleanliness;handwashingstationsmaylackwater,soap,orevenbesopoorlylocatedastoinhibitusage.Insomecountries,handhygiene ispromoted,buthandwashingfacilitiesarenotavailable. Detailedstatisticsonservicelevelsandconditionscanbefoundinthereport,whichmakesitevidentthatWASHservicesarelackingnotonlyininfrastructure,butalsoinproperusage,operation,andmaintenancepractices.Thesedeficienciesposesignificantbarrierstothelong-termsustainabilityofWASHatthesefacilities.Theyneedtobeaddressednotonlybyfixingimmediateproblems,butalsobyimplementingframeworkstoensurecontinualfunctionality.ImplicationsofpoorWASHserviceWithouttheproperinfectionpreventionandcontrolthatissupportedbyaccessandproperuseofcleanwater,sanitationfacilities,properhygienepractices,cleaningroutines,andsafewastedisposal,patientsandhealthcarestaffareatriskforhealthcare-acquiredinfection.A2011meta-analysisfoundthatindevelopingcountries,15%ofpatientssufferedfromhealthcare-acquiredinfectionscomparedto7.1%inEuropeand4.5%intheUnitedStates,andthatsurgical-siteinfectionswereamongtheirleadingcause(Allegranzi,Nejad,etal.,2011).Atthesametime,riskofwater,foodandhand-borneinfectionisheightenedwithinadequateenvironmentalhygienicconditionsandpoorinfrastructure.Apartfromthelackofhandwashingfacilitiesandtreatedwater,poormanagementofhumanandmedicalwastecancausecontaminationtothelocalwatersupplyandcauseacycleofdisease.In addition to the obvious impact to health, inadequateWASH infrastructure can also adversely affect patientsatisfaction of HCFs, thus indirectly impacting their health outcomes. Poor WASH service provision has beenidentifiedasareasonforwomentochoosehomedeliveryinsteadofhospitaldelivery(Bouzid,Cumming,etal.,2018).Whilethedataonhealthcare-acquiredinfectionssupporttheircaseformakingthischoice,womeninsub-SaharanAfrica still haveahigher chanceof survivalwhendeliveringatahealth facility compared todeliveringoutsideahealthfacility(Doctor,Nkhana-Salimu,etal.,2018).Thus,improvingWASHatHCFswillimprovepatientoutcomesnotonlybypreventingthespreadofinfections,butalsobyencouragingpatientstoseekprofessionalcare.ApproachtoimprovingWASHservicesatHCFsManyinitiativesbybothgovernmentsandnon-governmentalorganizationsareseekingtoimproveWASHcoverageat health care facilities in low andmiddle-income countries. TheWHOandUNICEFpropose a target of 100%coverageofbasicWASHservicesby2030,whichwillhelpachieveSDGs3and6.ThebarrierstoachievingfullWASHservicecoveragearemulti-faceted,withinfrastructureonlybeingapartoftheproblem.TheWHOandUNICEFciteissuessuchasincompletestandards,inadequatemonitoring,disease-specific

6

budgetsanddisempoweredworkforce,aswellasotherbarriers (Water,Sanitation,andHygiene inHealthCareFacilities:Practical steps toachieveuniversalaccess toqualitycare,2019).Evenwhen focusingonproblemsofinfrastructure,abundantliteratureshowsthatwatersystemsinruralsub-SaharanAfricahaveahighrateoffailureafterimplementation(Montgomery,Bartram,etal.,2009),andthe2019JMPreportitselfalsoshowsthatdisrepair,servicedisruptions,anduncleanlinessoftenrenderexistinginfrastructureoflimitedvalue.Allofthispointstoaneedforimprovementandmaintenanceofexistingservices,inadditiontothedevelopmentofnewinfrastructure.TheWHOandUNICEF,intheir2019report,havedefinedthefollowingeightpracticalstepsatthenationallevel:

1.Conductsituationanalysisandassessment2.Settargetsanddefineroadmap3.Establishnationalstandardsandregulation4.Improveinfrastructureandmaintenance5.Monitorandreviewdata6.Develophealthworkforce7.Engagecommunities8.Conductoperationalresearchandsharelearning

Thedocumentalsostatesthat“[a]crossalleightpracticalsteps…,stronginstitutionalleadershipfromtheMinistryofHealthandgoodgovernanceatalllevels(national,sub-national,andfacility)ofthehealthsystemisrequired….Overallcoordinationrequiresahighlevelof leadershipbeyondanyoneministrytoensureacommon,cohesiveapproach.”Inexaminingfactorsthatimpactsustainability,wewilllookattheneedforcoordinationofhighlevelleadership,andgoodgovernanceatalllevels.Whatissustainability?Putmostsimply,sustainabilitycanbedefinedastheabilityofsomethingtocontinueworkingovertime.WaterAid’sSustainabilityFrameworknotes:“SustainabilityisaboutwhetherornotWASHservicesandgoodhygienepracticescontinuetoworkanddeliverbenefitsovertime.Notimelimitissetonthosecontinuedservices,behaviorchangesandoutcomes.Inotherwords,sustainabilityisaboutpermanentbeneficialchangeinWASHservicesandhygienepractices”(Carter,Casey,etal.,2011).Sustainabilityisnotastaticconcept,andenablingWASHsystemstocontinuefunctioningovertimemayrequireevolvingandadaptivedeliverymechanisms (Carter,Tyrrel, etal.,1999). As such, theyneed tocontinuebeingmonitored,evaluated,andadapted. On-goingtrainingisnecessarytoensurestaffretaintheskillstheyneed.Amonitoring,evaluation,resolution,andlearning(MERL)program,involvingfieldstaffbutsupportedstronglybythelocalgovernmentorHealthDepartment,willhelpmaintaintheseprocesses.

7

Part2:TrendsinWASHservicesustainabilityTheJMPreportprovidesathoroughoverviewofthegloballandscape.Whileglobaldatademonstratethescaleofthe issue, a ground-level examination is necessary to understandwhat the gaps in service actually look like inpractice.AfewstudiesconductedacrossHCFsinAfricahighlightsthem.An evaluation was conducted by Improve International of 20 HCFs in Kenya and Ethiopia that had previouslyreceivedsupportinwaterandwastemanagementfromMillenniumWaterAllianceandotherNGOs(Davis,2018).Thefindingsshowedthatacrossbothcountries,HCFsgenerallyscoredpoorlyonavailabilityofsoap,cleanlinessoftoilets,andfunctionalityofwateraccesspoints. InKenya,consistentwateraccesswasalsoaproblem,whileinEthiopia, facilities severely lacked incinerators as well as functional and accessible toilets. As these HCFs hadreceivedexternalsupportinthepast,theinadequaciesuncoveredinthisevaluationindicatethatsustainingWASHservicespastthedepartureofsuchsupportcanbeachallenge.InRwanda,anassessmentwasperformedacross17ruralHCFsthathadpipedwaterandapowersupplyinorderto determine the suitability of theHCFs to receive a donation of awater treatment system (Huttinger, 2017).DespitehavingmoreadvancedinfrastructurethantheaverageruralHCF,theyshowedsignificantgapsinwaterqualityandhandhygiene.For instance,only20 litersofwaterweretreatedeachdayat theHCFs,only32%ofhandwashingstationshadbothsoapandwater,andonly44%ofsanitationfacilitieswerehygienicandaccessibletopatients.InanassessmentconductedbyEmoryUniversityacross15HCFsinNorthernMalawiusingtheWASHConditions(WASHCon)tool,handhygieneandwatersupplywereagainfoundtohavethelargestgaps,withunimprovedornohygieneservicesavailablein7ofthe15facilities,andlimitedserviceinalmostallfacilitiesacrossthedomainsofwatersupply,sanitation,andwastemanagement(Ferrey,etal).Meanwhile,aseparatestudyconductedwithintheNtcheudistrictofMalawifoundthateventhough99%ofthe81surveyedclinicshadayear-roundsourceofwater, only 11% of them had water and soap for handwashing, and 42% had an improved sanitation facility(Mmanga,Holm,etal). Further,71%of theclinicsdisposedofmedicalwaste in thepit latrines insteadof inaseparatecollectionarea.TheseexamplessupporttheJMPglobalfindingsthattherearesignificantgapsinWASHcoverageatHCFs.Moreover,theyhighlight thechallenge inmaintainingqualityWASHservicesevenwhen infrastructuredoesexist. Whatfactorscontributetotheselowratesofservice?AreviewoflessonsfromthebroaderWASHsector,inadditiontosomespecificallyfromthehealthsector,providesvaluableinsight.LiteratureonthefailuresandsuccessesofWASHservicesisabundant,andcanbebrokendownintothehardwareandsoftwarefactors.HardwareInfrastructure must be appropriate for the context, with considerations not only for the physical design andconstruction,butalso for thepracticalityof itsoperationandmaintenance,considering theavailable resourcessuchaswaterorenergysupplies,supplychainforsparepartsandanymaterials,andlocaloperationalskills.Further,theinfrastructuremustbeenvironmentallysustainablesuchthatnaturalresourcesarenotirreversiblydepleted,andthesurroundingenvironmentisnotirreparablydamaged.

8

Designandconstructionofinfrastructurehavedirectimplicationsontheiruseandsustainability. Forexample,research in South Africa has shown that suboptimal design and construction of latrines led to poor structuralintegrity,odors,andflies,makinglatrinesundesirabletouse(Bhagwan,Still,etal.,2008).InthecontextofanHCF,forhealthreasonsalonepatientsshouldexpectacleanandfunctional latrine,butunpleasantfacilitieswillonlyfurther discourage use. Beyond the physical construction, all factors for operation and maintenance of theinfrastructureneedtobeinplaceforcontinualfunctionality.Studiesofruralwatersuppliesinsub-SaharanAfricahave found that apart from hydrogeological factors that cause eventual deterioration in hand pumps, factorspreventingregularmaintenance,includingdistanceofthepumpfromspareparts,lackofatechnician,andlackofafeecollectionsystemwereassociatedwithpumpfailure(Foster,2013;Foster,Willetts,etal.,2018).Examplesof theapplicationsofmedical technologyalsohighlight the importanceofappropriatehardware inahealthcarecontext.Areviewofdevicesforperinatalcareinlow-incomecountriesshowsthatdevicesmustberobust, simple touse, andhavea long lifespan inorder toaddress the challenges that facilities face, includingconstrainedbudgets,ruggedenvironments,andshortagesofstaff(Wyatt,2008),notunliketherequirementsandchallengesofWASHinfrastructure.However,forhardwaretobesustained,robustsoftwarefactorstosupportitarerequiredaswell.SoftwareThesoftwarecomponentstoaWASHsystemensurethatthehardware,whethertheyaresinks,latrines,orwastecollectionpits,aresustainablyusedandoperated.Theremustbefinancialresourcestosupportoperations,strongleadershipandpropermanagement,adequateon-sitecapacityandtrainingavailableasneeded,adequatesupportandmotivation,andtheproperattitudesandbehavioramongstaffandusers.FinancingFinancesmustbeinplacetopayfortherecurrentcostsofcontinuallyoperating,maintaining,andrepairingWASHinfrastructure. Sincebreakdownsare inevitable, theremustbea cost recoverymechanism inplace topay forrepairs;otherwise,theinfrastructurewillcertainlyfail.Itiscriticalthatadequatefinancialplanningtakeplacefromthebeginning,includingdeterminationoflifecycle-costingoftheWASHinfrastructureandservices.Forexample,anin-depthstudyofruralwatersuppliesinTanzaniashowedthatfinancialmanagementwashighlycorrelatedwithfunctionality, indicating that communities without collected fees were unable to rehabilitate dysfunctionalinfrastructure (Haysom, 2006). Apart from costs associated with hardware, finances are needed to supportcapacitybuildingefforts,training,andstaffincentives.Fundingisoftenamajorchallenge,anditthereforemustbeplannedforthoroughlyinadvance.InEthiopia’sCleanandSafeHealthFacilities(CASH)program,whichworkstoimproveWASHservicesacrossHCFsnationwide,initialfundingwasprovidedinlargepartbytheMinistryofHealth,butsubsequentlyhealthfacilitieshavebecomeresponsibleforreinvestingtheirownrevenueintotheprogram.Thisisachallengethathasbeenidentifiedintheprogram;facilitiesoftendonothavesufficientfundingtomakealloftheimprovementstheyneed,suchasthesimplereplenishmentofsoap.AdedicatedandconsistentbudgetwithintheMOHforsuchongoingneedswouldbehelpfulforsustainingtheimprovements.Insomecontexts,sellingwatertothecommunitymaybeafeasibleoptionforgeneratingrevenueasitwasin8outof9HCFsinRwandainvolvedinastudyassessingtheperformanceoftheirwaterkiosks(Huttinger,2017).This

9

wouldonlybefeasibleinHCFsthathaveanadequateandreliablesupplyofwater,andthestudyauthorsstatethattheprofitswereunlikelytobesufficienttocoverfuturemaintenanceandrepaircosts.However,intherightcontextandwithothersourcesoffunding,thismodelcouldbeapossiblefundingstream.Whiletherearevariousmodelsforfinancingthehealthcaresystems,anin-depthdiscussionoftheseisoutsideofthescopeofthisproject.However,ashealthinstitutionsmakebudgetingdecisions,theyshouldkeepinmindthatWASHserviceprovisionisanimportantbranchofpreventativehealthcare,andshouldbeallocatedassuch.LeadershipandmanagementAnyWASHsystemrequiresstrongleadershipandpropermanagementofthesystem.Ethiopia’sCASHProgrammentionedabove,launchedin2014,providesanexcellentexampleoftheeffectsofstrongleadershipspecificallywithinthecontextofWASHinHCFs.CASHisaMinistryofHealthinitiativewithextensivesupportfrompartnerorganizations,wellknownpublicfigures,andcommunityrepresentatives.RecognizingtheneedtoimproveWASHwithin their HCFs, the program involves nation-wide staff training, implementation of an audit tool, anddevelopmentofcleanlinesscharters.Asanationalprogram,oneofCASH’sstrengthisthefactthatleadershipatthe highest level is invested in setting and achieving targets. Further, it has beenobserved that facilities thatachievedthemostchangewerethosethathadthemost“dynamicandengagedleadersandseniormanagement”(WorldHealthOrganization,2017).To further support this point, lack of strong leadership can evidently lead to poor service coverage. In India,misplacedmotivationsandlackofleadershipcapacityfortheTotalSanitationCampaignledtopoorandhaphazardconstructionoflatrines,preventingtheachievementofthesanitationcoveragethatthenationhopedfor(Huesoand Bell, 2013). Successful construction, on the other hand, was found in villages with strong governmentfacilitation. Meanwhile, in their studyonMalawianHCFs,Mmanga,etal,observed that the furtherdownthatWASHresponsibilitieswerepushed,thelargergapstherewereincoverage:whereaswatersupplywasmanagedby the national government and reflected very high coverage, distribution of soap was managed by HealthSurveillanceAssistantsatthefieldlevelwithlimitedbudgets,potentiallyexplainingthelowavailabilityofsoapattheobservedHCFs.LeadershipandmanagementwhoaremotivatedtoimproveWASHconditionscansettherightpriorities,allocatesufficientresources,andencouragestaffbehavior,thuscontributingto long-termsustainability. ThesuccessofTanzania’suseofthe5Smanagementtooltoimprovehealthservicesqualityprovidesagoodexample. AmongfifteencountrieswhereJapanInternationalCooperationAgency(JICA)implemented5S,Tanzaniawasthequickesttoachievetheirgoalsandextendtheprogrambeyondthepilotsite,duetotheirestablishmentofpoliciesandinstitutionalframeworksforqualityimprovementpriortothestartoftheprogram(Honda,2012).Thisillustratesthatwhenleadershipareinvestedfromthebeginningoftheprogram,programsaremorelikelytosucceed.On-sitecapacityEven with strong leadership, a system cannot work continually without adequate on-site capacity. Skills andknowledgepertainingtoWASHservicesmustbeavailablewithinthecommunityorinstitutionmanagingtheWASHsystem.AsstatedbyWaterAid,“thereisnosuchthingasmaintenance-freetechnology”andassuch,theremustbepersonnelwhoareavailableanddedicatedtoconductingmaintenance.Routineoperationandmaintenanceprovidedbyon-sitepersonnelhelpspreventsystemsfromfalling intodisrepairand leadingtoaneedforcostlyrepairs. On-sitecapacitycanalsosustainuserdemandsandappropriateWASHbehavior. For instance,havingdedicatedpersonnelwhoensurethefunctionalityofhandwashingstationswouldencouragepeopletocontinueusingthem,whereastheabsenceofsuchpersonnelleadstodysfunctionalityandthusdiscouragessustaineduse.

10

Medical staff’s capacity and willingness to comply with processes is important too. Though they may not beresponsibleforconductingrepairs,theystillplaytheirroleinmaintaininghygienicenvironmentsbywashinghands,disposingofwastecorrectly,practicingcleanhabits,andreportingproblemsthatarisetotheresponsibleparty.InNigeria,a lackof thenecessaryknowledgeamongstaffatanHCF led to theirhandlingofwaste incorrectly,exposingthemselvesandotherstohealthrisks(Coker,Sangodoyin,etal.,2009). Whilecleaningstaffareoftenoverlooked,theirresponsibilitieshaveadirectimpactoninfectionpreventionandcontrol,andthereforeshouldbeengagedwith,acknowledged,andtrainedproperly,thusbuildingupcapacityatthegroundlevel(Cross,Gon,etal.,2019). Thus, in maintaining WASH services at HCFs, capacity must be built at every level of staff: cleaners,technicians,medicalstaff,andadministrators,aseachplayauniqueroleinthesystem.Adequatecapacityalsoimpactsongoingmanagement,leadership,andbehaviorchange,whichareallkeyissuesforbuildingsustainability.TechnicalandAdministrativeSupportHavingadequatesupportcanbethedifferencebetweensuccessandfailure,asinevitablytherecomesatimewhenacommunityorafacilityfacesissuestheydonothavetheabilitytomanage,evenifthereisstronglocalcapacity.HCFs often have staff on site for regularmaintenance activities such aswater treatment, cleaning, andwastemanagement, butmay not have the capacity to dealwithmore complex problems, nor plumbing or electricalrepairs.Supportmayalsobeneededforguidanceonmanagementissues,suchasmaterialprocurementandstafftraining.ItcanalsofacilitatetheadherenceofWASHstandards,andthesharingoflessonslearnedbetweenvariousHCFs.WhiletheCommunity-LedTotalSanitation(CLTS)approacharguesagainstexternalsupportinfavorofheightenedcommunitymotivation,evidenceshowsthatwithoutsuchsupport,communitiesendupwithfaultydesignsandareunabletomaintaintheinfrastructureproperly(Papafilippou,Templeton,etal.,2011).Further,post-constructionsupport(PCS)hasshowntobeassociatedwithbetterperformingwatersystems,withhigherratesoffunctioningtaps,costrecovery,andusersatisfaction,amongruralcommunitiesinBolivia(Davis,Lukacs, et al., 2008; Kayser, Moomaw, et al., 2014). Such post-construction support systems involved thesupervisionbyaskilledindividualwhowasabletooffertechnicalandadministrativeassistanceoncommunities’infrastructure.Becausewaterinfrastructurecaninvolvetechnicalknowledgeandsignificantfinancialresourcestomaintain,skilledandknowledgeableindividualsshouldbeavailable.Localtechnicianscanprovideregularoversight,but external supervisory support may be necessary for more in-depth knowledge. Also, since communityenthusiasmcanwaneafterafewyears,thesesupportagentsshouldberesponsibleforfollowuptoensurethatsystemscontinuetofunctionwell(Carter,Tyrrel,etal.,1999).Withinahealthcarecontext,supportvisitsandperiodicmonitoringweresomeofthemanyfactorsattributedtothesuccessfulimplementationofthe5SqualityimprovementmodelinSriLankaandTanzania.InadditiontovisitsbyexpertsfromtheimplementingagencyJICA,periodicmeetingsbetweenHCFleadersprovidedanopportunityforthemtodiscusslessonslearnedandwaysforward.Thus,aforumofsupportoutsideoftheHCFiscrucialtosustainability.AttitudesandbehaviorAttitudesandbehaviorsofusersandprovidersofaserviceunderliealloftheotherfactors,encompassingdemandforservices,consistent,correctandsustaineduse,senseofownership,andmotivationtotakeaction.Interactionsbetweenhealthcarestaff,patients,andfamiliesandothervisitors,alsopresentauniqueopportunitytoenhance

11

thecommunity’sunderstandingofthebenefitsofgoodWASHservices,andhencebuilddemandgenerallyaswellasencourageaccountabilityonthepartoftheHCFtoprovidetheseservices.Demandisthe“foundationforunderstandingandprioritizingneeds”(Montgomery,Bartram,etal.,2009),withoutwhichWASHinfrastructureatHCFswillfailtobeoperated,maintained,andusedbypatients,visitors,andstaff.Demandbyusers,whichcomesaboutasaresultofchangesintherelevantattitudesandbehaviors,isnecessaryformanagementandleadershiptoallocatetheresourcestosustainsuchsystems.IncaseswherepopulationsmaybeunfamiliarwithwhyWASHservicesarebeneficialorevennecessary,trainingandeducationareessentialforinfluencingdemand,aswellasforsustainingmotivationtoundertakerelevantactions.However,itisoftenthecasethatstaffarewellawareofthenecessitiesofWASHbehavior.Thisisillustratedinanexampleabouthandhygiene.Handwashingcomplianceathealthcarefacilitieshasbeenshowntoberemarkablylowat40%(Erasmus,Daha,etal.,2010),withhealthcareworkersreportingthattheycomplymorethanthereality.Whilehealthcareworkersunderstandthe importanceofhandhygiene,prioritizationofother taskssometimescausethetaskofhandwashingtobeneglected.IntheevaluationofHCFsinEthiopiaandKenyamentionedearlier,DavisalsoobservesthatWASHappearstobealowpriorityforstaff,andthismaybeinfluencingthepoorqualityofWASHservicesmorethanthelackoffunding.Theseexamplesshowthatthereareimportantimplicationsforinfrastructureplanning;bydecreasingbarrierstowardscertaintasks,suchasplacinghandwashingfacilitiesinmoreconvenientlocations,handwashingbehaviorcouldimprove,asdemonstratedthroughNudgetheory(Harris,2005).Userbehaviorspertaining toWASHarealsohighly influencedbyattitudesandperception, asdemonstrated inqualitativestudiesonlatrineuse.Barrierstotheuseof latrinesincludeperceptionsthattheyarefaraway,thepresenceofuserfees,andapreferencefordefecatingintheopen(Obeng,Keraita,etal.,2015).Whileknowledgeofthelatrines’preventionofspreadingdiseasewascited,reasonsforusingorowningalatrineamongcommunitymemberswereoverwhelminglyduetodignity,prestige,andwell-being(JenkinsandCurtis,2005).Favorable attitudes, essentially user demand, toward any kind of WASH infrastructure can therefore have aprofoundeffectonhowitisused.AnecdotalevidencefromHCFsinMalawiprovidesanotherinterestingexample:intheabsenceofcolorfulbinsforwasteseparation,innovativefrontlinestaffcreatedhand-madelabelsforexistingcontainers to designate separate streams of waste, showing that the right attitudes are key to making andsustainingpositivechangeespeciallyinthefaceofconstrainedresources.Thesuccessfulimplementationofthe5SmanagementmodelinSriLankanHCFsdocumentedbyWithanachchi,etal,demonstratetheimportanceofinfluencingstaffbehaviorandattitudesasafirststeptomakingsystem-widechange.Theauthorsnotethatstaffresistedimplementinganychangesinitially,butuponseeingthebenefitsofthe5Smodel,feelingempoweredasemployees,andgainingastrongsenseofteamspirit,theyweremuchmoreinclinedtoparticipate.Therestofthe5Smodel,whichinvolvescontinualassessmentandimprovement,hingeonthesecrucialmotivationandattitudes,andsenseofownershiponthepartofthestaff.SummaryBeingarelativelynewfieldoffocus,WASHwithintheHCFcontextstilllacksanabundanceofliteratureaboutitssuccesses and failures, particularly around sustainability. Numerous similarities between HCF and community-basedWASHsystemsexist,andthefactors influencingtheirsustainabilityareverymuchalike,asshownabove.However,itisalsoimportanttokeepinmindthatunlikecommunities,healthcarefacilitieshaveawiderangeofstaff,haveadirecteffectonpublichealth,andrequiresomespecializedinfrastructure,suchashealthcarewastemanagement,showers,andcleanwaterforsterilization.

12

The figurebelow,developedbyUSAID’sMaternal andChild Survival Program,outlines the key componentsofsustainableWASHservicesinahealthcarefacility,andcapturesthepointsraisedabove.

Figure2.USAID'sMaternalandChildSurvivalProgram'sframeworkforprovidinghigh-qualityhealthcareviaWASH.(WASHinHealth

CareFacilities:AToolboxforImprovingQualityofCare,Accessed2019)

13

Part3:OvercomingchallengesandpromotingsustainabilityMeasuringsuccessandsustainabilityIn2018, the JMPpublished“Corequestionsand indicators formonitoringWASH inhealthcare facilities in theSustainable Development Goals.” The global indicators are primarily used tomonitor the availability ofWASHservices.Theydonothowevermonitorthequality,conditionoruseanddependingonthefrequencyofmonitoringmaynotprovideafullpictureofWASHservices(i.e.,availabilityofwaterduringdryandrainyseason).Althoughtheseareimportantdatatocollect,theindicatorswillnotnecessarilyhelpafacilityassesssustainabilitynorthestatusoffactorsthatresultinlong-termsustainedimprovementsunlessitisintegratedintoaframeworkthatissuitableforfacility-leveluse.Therefore,additionaltoolsareneededtoprovideongoingmonitoringdatathatleadtoevaluation,resolutionandlearning(MERL).Foramorethoroughunderstandingofaparticularhealthcarefacility,successcanbemeasuredthroughtwolenses:firsttoassessthesystem’sfunctionality,andsecondlytoassessitssustainability.Thebroadquestionareas,whichshouldbeansweredthroughongoingmonitoringandevaluation,maybeposedassuch:Functionality:

• Istheinfrastructureadequateandwellplacedtomeetneeds,andisitfunctioningproperlyenoughofthetime?

• Areadequateprocessesinplace?• Aretheinfrastructureandprocessesusedcontinually,correctly,andconsistently?

Sustainability:

• Is thereadequate leadership,clear rolesandresponsibilities,andsupervisionofprocessesandfacilitiesusage?

• Isthereadequatemotivationandeducationtosustainchangedbehaviors?• Istheresustainedhumancapacitytouse,operateandmaintainWASHservicesatthisfacility?• IstheresufficientfundingtosupportWASHservicesatthisfacility?

Byaddressingthebroadquestionareasabove,wecandetermineifappropriateresources,appropriateskilledandmotivatedhealthworkers,andappropriateprocessestodelivercareareinplace.Regarding monitoring and evaluation itself, there are still barriers to implementing sustainable practices. AnevaluationofM&EinWASHinschoolsprograms(Deroo,Walter,etal.,2015)revealedseveralchallengesincludinglogistics,M&Ecapacity,andfunding.Inparticular,humanresourcecapacityposedachallengeintermsofthetimeconstraintsandhigherworkloadthatM&Eactivitiesledto,aswellasalackofsufficienttrainingbyfieldstafftocarryoutM&E. The study suggests that a key to sustainability is to integrateM&Epractices into governmentsystems,thusincorporatingexternalsupportintoWASHservices.FurtherincorporatingtheresolutionandlearningaspectsofMERLintotheseprocesseswillensureastrongersystemofWASHservices,aschangesarecontinuallyincorporated,adaptationsmade,andlessonsshared.Itwillnotbesufficienttoaddressthegapsindividuallyoronaone-timebasis;rather,theyneedtobeaddressedinacontinuousandholisticmannerkeepinginmindtherolethatWASHplaysinalargerhealthcaredeliverysystem.Inthissection,wewilldiscusshowexistingtoolscanbeadaptedtoimprovesustainabilityofWASHservicesinHCFs.

14

ExistingToolsWhattoolsareavailabletoassistWASHinHCFwork?Dothesetoolsaddresssustainability?Whatarethegaps?NumeroustoolshavebeendevelopedtoimproveWASHconditionsatHCFs.SummarizedinthetablebelowbyEmoryUniversity,thesetoolsaredesignedtoconductassessmentsonexistingWASHfacilities(WASHCon,WASHFIT,FACET),provideguidanceonprogrammingimprovements(WASHFIT,CleanClinicApproach),andfacilitatetraining(TEACH-CLEAN).ThesetoolshavebeenreviewedinmoredepthinAppendixA.OthertoolsthataddressWASHsustainabilityalsoincludedintheappendixareEmory’sSafeWaterSustainabilityMetric,EngineersWithoutBorders’healthcenterwatersystemrehabilitationmanual,andschool-specificO&Mmanuals.Programsandmodelsarealsoreviewedintheapppendix:WaterAidMalawi’sDeliverLifeProject,USAID’sCleanClinicApproach,theCircuitRiderMethodology,andthe5Smanagementmethod.

Figure3.WASHinHCFToolComparisonChart.(Denny,2018)

Though each of these tools is effective in achieving their intended purposes of assessment, programming, ortraining, there still remains a gap in MERL at the facility level. Once a facility uses any of these tools (or acombination)toconductaninitialassessmentandplanimprovements,therearefewmechanismsprovidedtothefacilitythatareintegratedwiththeirexistingdailyoperationstoenablecontinualself-assessmentsonwhethertheirimprovementsareontrack,andonceimprovementshavebeenmade,whethertheyaresustained.WhileWASHFIT,forexample,doesoutlineaframeworkforimplementingandtrackingimprovements,itlacksguidanceonhowthoseactivitiescanbeincorporatedintoday-to-dayactivitiesofHCFstaffwiththerequirementoffewresourcesandminorbehaviorchanges.

WASH in HCF Tool Comparison Chart FACET WASH & CLEAN WASHCon Clean Clinic

Approach WASH FIT TEACH-CLEAN

Type of tool Assessment Assessment Assessment Programming Programming Training

Degree of developer involvement1 ● ●● ●● ●● ● ●●

ASSESSMENT

Facility-level assessment to inform interventions ● ● ● ● ● ●

Assessment tool for national monitoring ● ● ● ●2

Inclusion of JMP indicators ● ● ● ●3 ●

Inclusion of additional topics (e.g., management) ● ● ● ●

Mobile platform for data collection/visualization ● ● ●

Data to inform advocacy ● ● ● ● ● ●

PROGRAMMING

Creation of facility WASH committee ● ●

Progress monitoring for WASH committee ●3 ● ●

WASH improvement planning and continuous follow-up based on minimum package/WASH standards

● ● ● ●

Competitions between facilities ●

Behavior change training ●

Integration into district/national-level activities ●

LANGUAGES

EN, FR, AR, Nepali

EN EN, FR EN, FR, SP EN, FR, Khmer Russian, Lao;Forthcoming:

SP, AR

EN, FR, Gujarati

1 These tools require varying levels of involvement and support from the organizations which developed them. 2 Data collected through WASH FIT can be used at the national level, however for more regular or larger scale data collection, FACET or WASHCon would be more suitable.3 CCA is a programming tool that incorporates the JMP standards by leveraging WASH FIT, WASH Clean, WASHCon, or other tools. CCA refers to JMP indicators and WHO Standards for Environmental Health and IPC.4 WASH & CLEAN doesn’t require a facility to create a WASH committee but does include tools that can be used as part of the continuous quality improvement cycle within facilities driven by WASH and/or IPC committees.

15

Another important consideration is the requirement for human resource capacity in making and sustainingimprovements.Someexistingtools,suchasCleanClinicApproach,relyonanexternalentityreturningtoassessthefacility and determine its achievements. Though this is a motivating factor and an important component tofacilitatingimprovements,itisnotsufficienttobuildlocalcapacitytoenableacontinualimprovementprocess.Asdemonstratedintheprevioussections,supportfromalocaladministrativebodyshouldbeavailableinconjunctionwith strong local capacity, so thatWASH services can be routinelymaintained but backed by higher levels ofexpertise,knowledge,orresourceswhenneeded.A framework that centers its approach towards WASH improvement via strong support services by localgovernment(orotherentity)andbuildingoflocalcapacityisneeded.Localcapacity,attheHCFlevel,needstobestrengthenedsothateverydaystaffareabletoperformtheroutineactivitiesthatensuresmoothoperationofafacilityandminimizestheneedformajoroverhauls.Relevantknowledge,skills,andattitudesmustbecontinuallyimprovedsothatpositiveWASHbehaviorspersist,enablingthenecessaryroutineoperationstotakeplace,andremindingstaffthatmaintainingWASHservicesisasharedresponsibility.Whiletrainingisessential,aone-timetrainingisinsufficienttomakethelastingchangesthatcontinuoustrainingcouldachieve.Trainingplansatboththefacilitylevelandgovernmentlevelarecrucialforensuringthatthehumanresources factorscontributingtosustainabilityofWASHaremaintained.Notonlyshouldhealthcareproviders,maintenancetechnicians,andcleanersparticipateintraining,butalsoHCFmanagersandleaderswhosetthetoneforhowWASHservicesareoperated.Localgovernmentadministratorsmustalsoreceivetraining,sothattheyarewellequippedtosupportHCFsinissuesbeyondtheireverydaycapacity,whetheritisinafinancial,technical,oradministrativecapacity,andofcourse,tofacilitatecontinualtrainingforHCFs.Effectivemonitoringdataisalsoneededonaregularbasistotrackprogressandtriggerreviewandresponse.ItisimportanttoconsiderthattheultimategoalofWASHserviceswithinHCFsistoprovidequalityhealthcaretopatients.Unlikecommunityorschool-basedsystems,WASHsystemsatHCFsdonotexistonlytoprovidewaterandsanitationservices,buttoachievethehighergoalofimprovingthepublichealthofthecommunitiestheyserve.Therefore,auseful toolwouldbe incorporated intoahealthcaredelivery framework, rather thanbeadistinctprogram.IntegratingWASHimprovementsintothehealthcareframeworkHealth systems globally are working on improving their quality of care through Quality Improvement (QI)frameworks.ThisisevidentthroughtheavailabilityofavarietyofWHOguidelines,including“Deliveringqualityhealthservices:Aglobalimperativeforuniversalhealthcoverage”,and“Handbookfornationalqualitypolicyandstrategy: A practical approach for developing policy and strategy to improve quality of care”. From nationalministries of health, to district HCFs, Quality Assurance departments and Infection Prevention and Controlcommitteearebeingestablishedwiththeultimategoaltoimprovepublichealth.Withintheseefforts,WASHisrecognizedasatenetof“accessibleandwell-equippedfacilities”thatisoneofthefoundationstoqualitycareandisthereforecompatiblewithexistingQIefforts(Deliveringqualityhealthservices:aglobalimperativeforuniversalhealth coverage, 2018). Embedding WASH as such would contribute to long-term sustainability more thandevelopingaseparate,stand-aloneprogram.There is strong evidence on the effectiveness of QI frameworks in low-resource settings. Leatherman, et al,compiledareviewofQIinterventionsandfoundthattheyledtoimprovementsacrossthedomainsofemergencyobstetriccare,acutechildillness,primarycare,healthsystems,andprescribingpractices(Leatherman,Ferris,etal.,

16

2010).Amongthesesuccesses,keyapproachesinvolvedaddressingproviders,patients,andsystemsconcurrently,aswellasestablishingcontinuousmeasurementandfeedbackmechanisms.WhileQI canencompassa largevarietyof interventions, the5Smanagement toolprovidesagoodexampleofsuccess. In Sri Lanka, it led to reduced rates of infection, stillbirth, and maternal mortality 2 years after itsimplementation,andinTanzania,itledtoreductionsinpatientwaittimesasaresultofsmootheroperationsthatcameaboutfrom5Sactivities.Thesuccessof5SasaQItoolisbaseduponitsseamlessintegrationofthefactorsthatcontributetosustainabilitythatwerementionedinPart2.Followingtheestablishmentofbuy-infromuppermanagement(ensuringstrongleadershipfromtheonset),frontlinestaffareimmediatelyincludedthroughcleaningandsortingtheirworkenvironment, therebyacquiringtheirmotivationandestablishingtherightattitudesandbehavior.Next,thedevelopmentofteamguidelinesandactivitiesformaintainingcleanlinessensuresthatallstaffareinvolvedincapacitybuilding,thusstrengtheningtheskillsofon-sitestaff.Thecontinuingimplementationofthemodel involves experts conductingmonitoring and supervisory visits periodically. All of these steps canbeappliedtoWASHservices:beyondperformingabasiccleaningofWASHinfrastructure,checklistsandprotocolscanbeestablishedtoensuretheircontinuingoperationthroughtheinvolvementofdesignatedstaff.Suchchecklistscanbeusedformonitoringandevaluationprocedures,bywhichHCFscancontinuallylearnwhatarethestrengthsandgapsintheirWASHservices.Therearea varietyofQI tools thatarealready inuse, and5S isonlyoneexample.WhileWASHhasnotbeenexplicitlyappliedtoaQIframeworkbefore,aspectsofexistingtoolslikeWASHFITandCCAalreadyincorporatetasksthatareverymuchlike5S,illustratingthatembeddingWASHintoexistingQIframeworkswouldindeedbeappropriate.SinceQIframeworksarealreadyfamiliartogovernmentinstitutions,itmayberelativelyseamlesstoincorporateWASHwithinthem.Doingsowouldensuresustainabilitybecausegovernmentsupportisembeddedfromthebeginning,makingitmorelikelythatHCFshavethetechnicalsupportandfinancialresourcestheyneedtoachievetheirWASHgoals.

ConclusionThereisstillalongwayuntiltheachievementofuniversalWASHcoverageathealthcarefacilities,andensuringsustainabilityof thoseWASHserviceswillbeanongoingchallenge.However, this landscape reviewshows thattherearenumerousopportunitiesforsuccess,particularlybecauseframeworkstoimprovequalityofcareatHCFsalreadyexist.TheseframeworksprovideanentryforWASHtobecomeembeddedmoresustainablyinthedailyoperationsofHCFs,andmayeventuallyleadtosignificantlyimprovedcoverageofWASHservicesglobally.

17

ReferencesAchievingqualityuniversalhealthcoveragethroughbetterwater,sanitationandhygieneservicesinhealthcare

facilities:AfocusonEthiopia(2017)Geneva,WorldHealthOrganization.

Allegranzi,B.,Nejad,S.B.,Combescure,C.,Graafmans,W.,Attar,H.,Donaldson,L.,andPittet,D.(2011)Burdenofendemichealth-care-associatedinfectionindevelopingcountries:systematicreviewandmeta-analysis.TheLancet,377(9761),228–241.

Bhagwan,J.N.,Still,D.,Buckley,C.,andFoxon,K.(2008)Challengeswithup-scalingdrysanitationtechnologies.WaterScienceandTechnology,58(1),21–27.

Bouzid,M.,Cumming,O.,andHunter,P.R.(2018)Whatistheimpactofwatersanitationandhygieneinhealthcarefacilitiesoncareseekingbehaviourandpatientsatisfaction?Asystematicreviewoftheevidencefromlow-incomeandmiddle-incomecountries.BMJGlobalHealth,3(3),e000648.

Carter,R.C.,Tyrrel,S.F.,andHowsam,P.(1999)TheImpactandSustainabilityofCommunityWaterSupplyandSanitationProgrammesinDevelopingCountries.WaterandEnvironmentJournal,13(4),292–296.

Carter,R.,Casey,V.,andHarvey,E.(2011)SustainabilityFramework.

Coker,A.,Sangodoyin,A.,Sridhar,M.,Booth,C.,Olomolaiye,P.,andHammond,F.(2009)MedicalwastemanagementinIbadan,Nigeria:Obstaclesandprospects.WasteManagement,29(2),804–811.

CorequestionsandindicatorsformonitoringWASHinhealthcarefacilitiesintheSustainableDevelopmentGoals(2018)Geneva,WorldHealthOrganization.

Cross,S.,Gon,G.,Morrison,E.,Afsana,K.,Ali,S.M.,Manjang,T.,Manneh,L.,Rahman,A.,Saxena,D.,Vora,K.,andGraham,W.J.(2019)Aninvisibleworkforce:theneglectedroleofcleanersinpatientsafetyonmaternityunits.GlobalHealthAction,12(1),1480085.

Davis,J.,Lukacs,H.,Jeuland,M.,Alvestegui,A.,Soto,B.,Lizárraga,G.,Bakalian,A.,andWakeman,W.(2008)Sustainingthebenefitsofruralwatersupplyinvestments:ExperiencefromCochabambaandChuquisaca,Bolivia.WaterResourcesResearch,44(12).[online]http://doi.wiley.com/10.1029/2007WR006550(AccessedFebruary1,2019).

Davis,S.M.(2018)CaseStudyofWater,Sanitation,andHygiene(WASH)inHealthcareFacilitiesinEthiopiaandKenya:KeyFindingsandRecommendations,ImproveInternational.[online]https://www.washinhcf.org/documents/WASH-in-Healthcare-Facilities-Key-Findings-Takeaways.pdf(AccessedDecember13,2018).

Deliveringqualityhealthservices:aglobalimperativeforuniversalhealthcoverage(2018)Geneva,WorldHealthOrganization,OECD,andTheWorldBank.

Denny,L.(2018)WASHinHCFToolComparisonChart.

Deroo,L.,Walter,E.,andGraham,J.(2015)MonitoringandevaluationofWASHinschoolsprograms:lessonsfromimplementingorganizations.JournalofWater,SanitationandHygieneforDevelopment,5(3),512–520.

Doctor,H.V.,Nkhana-Salimu,S.,andAbdulsalam-Anibilowo,M.(2018)Healthfacilitydeliveryinsub-SaharanAfrica:successes,challenges,andimplicationsforthe2030developmentagenda.BMCPublicHealth,18(1).

18

[online]https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5695-z(AccessedMarch20,2019).

Dreibelbis,R.,Winch,P.J.,Leontsini,E.,Hulland,K.R.,Ram,P.K.,Unicomb,L.,andLuby,S.P.(2013)TheIntegratedBehaviouralModelforWater,Sanitation,andHygiene:asystematicreviewofbehaviouralmodelsandaframeworkfordesigningandevaluatingbehaviourchangeinterventionsininfrastructure-restrictedsettings.BMCPublicHealth,13(1).[online]http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-1015(AccessedApril11,2019).

Erasmus,V.,Daha,T.J.,Brug,H.,Richardus,J.H.,Behrendt,M.D.,Vos,M.C.,andvanBeeck,E.F.(2010)SystematicReviewofStudiesonCompliancewithHandHygieneGuidelinesinHospitalCare.InfectionControl&HospitalEpidemiology,31(03),283–294.

Ferrey,S.,Denny,L.,Nyirenda,D.,Msukwa,M.,McGriff,J.,andMoe,C.((unpublished))InitiatingtheWASHFITProcess:ACaseStudyof15HealthcareFacilitiesinMalawi,

Foster,T.(2013)PredictorsofSustainabilityforCommunity-ManagedHandpumpsinSub-SaharanAfrica:EvidencefromLiberia,SierraLeone,andUganda.EnvironmentalScience&Technology,47(21),12037–12046.

Foster,T.,Willetts,J.,Lane,M.,Thomson,P.,Katuva,J.,andHope,R.(2018)Riskfactorsassociatedwithruralwatersupplyfailure:A30-yearretrospectivestudyofhandpumpsonthesouthcoastofKenya.ScienceofTheTotalEnvironment,626,156–164.

Harris,J.(2005)ChallengestotheCommercialViabilityofPointofUseWaterTreatment.[online]https://www.sswm.info/sites/default/files/reference_attachments/HARRIS%202005%20Challenges%20to%20the%20Commercial%20Viability%20of%20Point%20of%20Use%20Water%20Treatment.pdf(AccessedMay4,2018).

Haysom,A.(2006)AstudyofthefactorsaffectingsustainabilityofruralwatersuppliesinTanzania,CranfieldUniversity.

Hueso,A.andBell,B.(2013)Anuntoldstoryofpolicyfailure:theTotalSanitationCampaigninIndia.WaterPolicy,15(6),1001–1017.

Huttinger,A.,Brunson,L.,Moe,C.,Roha,K.,Ngirimpuhwe,P.,Mfura,L.,Kayigamba,F.,Ciza,P.,andDreibelbis,R.(2017)SmallWaterEnterpriseinRuralRwanda:BusinessDevelopmentandYear-OnePerformanceEvaluationofNineWaterKiosksatHealthCareFacilities.InternationalJournalofEnvironmentalResearchandPublicHealth,14(12),1584.

Huttinger,A.,Dreibelbis,R.,Kayigamba,F.,Ngabo,F.,Mfura,L.,Merryweather,B.,Cardon,A.,andMoe,C.(2017)Water,sanitationandhygieneinfrastructureandqualityinruralhealthcarefacilitiesinRwanda.BMCHealthServicesResearch,17(1).[online]http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2460-4(AccessedJuly8,2019)

Jenkins,M.W.andCurtis,V.(2005)Achievingthe‘goodlife’:WhysomepeoplewantlatrinesinruralBenin.SocialScience&Medicine,61(11),2446–2459.

Kadzandira,J.M.andChilowa,W.R.(2001)TheRoleofHealthSurveillanceAssistants(HSAs)intheDeliveryofHealthServicesandImmunizationinMalawi,CentreforSocialResearch,UniversityofMalawi.[online]https://www.unicef.org/evaldatabase/index_14066.html(AccessedDecember13,2018).

19

Kayser,G.L.,Moomaw,W.,OrellanaPortillo,J.M.,andGriffiths,J.K.(2014)CircuitRiderpost-constructionsupport:improvementsindomesticwaterqualityandsystemsustainabilityinElSalvador.JournalofWater,SanitationandHygieneforDevelopment,4(3),460–470.

Kok,M.C.,Namakhoma,I.,Nyirenda,L.,Chikaphupha,K.,Broerse,J.E.W.,Dieleman,M.,Taegtmeyer,M.,andTheobald,S.(2016)HealthsurveillanceassistantsasintermediatesbetweenthecommunityandhealthsectorinMalawi:exploringhowrelationshipsinfluenceperformance.BMCHealthServicesResearch,16(1),164.

Leatherman,S.,Ferris,T.G.,Berwick,D.,Omaswa,F.,andCrisp,N.(2010)Theroleofqualityimprovementinstrengtheninghealthsystemsindevelopingcountries.InternationalJournalforQualityinHealthCare,22(4),237–243.

Malawi’sCommunity-basedHealthSystemModel(2017)

Marks,S.J.,Onda,K.,andDavis,J.(2013)Doessenseofownershipmatterforruralwatersystemsustainability?EvidencefromKenya.JournalofWaterSanitationandHygieneforDevelopment,3(2),122–133.

Mmanga,M.,Holm,R.,andDiBella,V.Frontlineruralhealthclinics:Water,sanitationandhygieneaccessinNtcheuDistrict(Malawi).

Montgomery,M.A.,Bartram,J.,andElimelech,M.(2009)IncreasingFunctionalSustainabilityofWaterandSanitationSuppliesinRuralSub-SaharanAfrica.EnvironmentalEngineeringScience,26(5),1017–1023.

Nyirenda,D.andFerrey,S.(2018)“WASHinhealthcarefacilities:reinforcingexistingstructuresandbestpracticies”inTransformationtowardssustainableandresilientWASHservices.Nakuru,Kenya,WEDC,LoughboroughUniversity.[online]https://dspace.lboro.ac.uk/dspace-jspui/bitstream/2134/35888/1/Nyirenda-2984.pdf.

Obeng,P.A.,Keraita,B.,Oduro-Kwarteng,S.,Bregnhøj,H.,Abaidoo,R.C.,Awuah,E.,andKonradsen,F.(2015)UsageandBarrierstoUseofLatrinesinaGhanaianPeri-UrbanCommunity.EnvironmentalProcesses,2(1),261–274.

WASHinHealthCareFacilities:AToolboxforImprovingQualityofCareUSAIDMaternalandChildSurvivalProgram.[online]https://washforhealthcare.mcsprogram.org/(AccessedApril12,2019).

WASHinHealthCareFacilities:GlobalBaselineReport2019(2019)Geneva,WorldHealthOrganization.[online]https://www.washinhcf.org/wp-content/uploads/2019/04/9789241515504-eng.pdf.

Water,Sanitation,andHygieneinHealthCareFacilities:Practicalstepstoachieveuniversalaccesstoqualitycare(2019)Geneva,WorldHealthOrganization.

Water,sanitationandhygieneinhealthcarefacilities:statusinlowandmiddleincomecountriesandwayforward(2015)Geneva,WorldHealthOrganization.

Wyatt,J.(2008)Appropriatemedicaltechnologyforperinatalcareinlow-resourcecountries.AnnalsofTropicalPaediatrics,28(4),243–251.