WASH FIT

methodology
Core module

Add date & location

2
 Learning objectives
Group
By the end of this session, you should: work
1. Describe what WASH FIT is, where and how
it is used and the expected impacts and
outcomes

Icons to look out for

Link with a
2. Understand the five phases of the WASH country
FIT cycle and how to carry them out example

3. Understand how to adapt and use WASH

FIT in a range of different settings
4. Describe the enabling factors and possible Links with
barriers for implementing WASH FIT climate
resilience
successfully
3
Links with GEDSI
 Icebreaker: “Just a minute”
Turn to the person next to you

Pick one person to speak. Explain to your partner, for one minute:

Why is having adequate WASH services in health care facilities

important?

Try NOT to:

Hesitate (um…. er…. hmmm….) 3-5 mins

Deviate (dont discuss anything other than the question)
Repeat yourself/words you have already used

If you hesitate, deviate or repeat, pass to the other person to try to talk to
you about the question 4
 Part 1: Background
• What is WASH FIT?
• What resources are available to support
you?
• What is the purpose and scope of
WASH FIT?
• For those already familiar with WASH
FIT, what is new in the 2nd edition?
• Which parts of a facility does WASH FIT
address?
• How can WASH FIT support health
initiatives?
5
 “Before starting WASH FIT, I thought the way WASH
services were managed and the hygiene practices passed
on to me by previous health workers from [the facility] were
acceptable, and that nothing had to be changed or
improved.

After setting up the team & conducting the assessment

collectively we identified many items that need improving
[such as de-clogging drains, increasing ventilation and staff
training for waste management]. These are things we can
do ourselves that benefit the staff and the clientele we are
serving.

The time will come for me to be transferred to another

facility, I can hand over the facility to the next health worker
together with the WASH FIT plan, that he/she can use as
the baseline for further improvement”.

Nurse from the Philippines, 2019.

6
 What is WASH FIT?

• A planning and implementation guide

• A framework to be adapted
• A tool that supports infection prevention and control
• A stimulus for collaboration

WASH FIT covers:

Infrastructure
Behaviours
Operation and maintenance
7
Part 1: Background
 WASH FIT is not…
 A tool just for assessing - it
is about making improvements
 A one-size fits all approach
 A process that can be
completed in a day

8
 WASH FIT helpdesk
WASH FIT resources washinhcf@who.int

110 pages
50 minute read
WASH FIT 2nd ed.
READ THIS Practical Guide
FIRST Step by step guidance

What is WASH Tools Fact sheets Manual for WASH FIT

FIT? Trainers portal
Short introduction to WASH FIT Assessment, hazard & risk analysis 5 factsheets All the materials for training in one www.washinhcf.org/wash-fit
tools (support development & (within the WASH FIT place (slides, speaker notes,
implementation of improvement plan Practical Guide) assessment & evaluation tools, Country examples, case
& ongoing monitoring) sample agenda etc) studies & opportunity to share
experience
2 pages 5 minute read 3-5 pages each 50 pages
5 minute read 5 minute reads 30 minute read

Excel assessment tools

Sanitary assessment forms

Plan monitoring &
feedback template

Electronic version
on Kobo Toolbox

9
 WASH FIT 2nd Edition
What’s new?
• Guidance to adapt the tool for very rudimentary or temporary emergency facilities, larger
facilities (e.g., regional or district hospitals) and those in middle-income settings where
higher levels of services are sought
• A greater focus on climate resilience and change mitigation strategies
• Recognition of how to ensure WASH services prevent the spread of pathogens
(including COVID-19) and antimicrobial resistance.
• Updated assessment form including climate, gender and equity considerations and
indicators for more advanced facilities and tertiary settings
• Addresses additional WASH-related aspects of health care facilities, namely energy,
vector control and occupational health

10
What is the purpose of WASH FIT?

Background
11
 WASH FIT helps to improve all of these
Environmental
Outbreak response & Gender, equity,
sustainability &
resilience disability & social
climate resilience
Availability of basic services inclusion
Strengthens resilience and enables facilities to respond
sustainability of WASH and Planning, design and
to emergencies & outbreaks
energy services management of WASH
services for accessibility,
safety, privacy, social
appropriateness &
Infection acceptability

prevention &
control Quality of care
WASH is a core component - WASH preserves dignity, respect
and minimum requirement and provides a supportive
for IPC programmes environment
Also helps to reduce - Healthier more productive
antimicrobial resistance communities
- Dignified, safe pregnancy &
12 postpartum care
Which parts
of a facility
does WASH
FIT address?
Add suggestions in
the chat box/ flip
chart.
Time 1-2 minutes.

5 mins

13
 Seven WASH FIT “domains”
2. SANITATION
(toilets, treatment,
1. WATER wastewater)
(supply,
storage, quality, 3. WASTE
conservation) MANAGEMENT
(from generation to
final disposal)
+ 2 cross-
cutting themes

Climate
4. HAND
Gender equality, HYGIENE
(infrastructure,
disability and compliance,
social inclusion training)
(GEDSI)

6. ENERGY &
7. MANAGEMENT &
ENVIRONMENT 5. ENVIRONMENTAL
WORKFORCE
(lighting, pumping, CLEANING
(training, occupational
heating, (staff, protocols,
health, protocols)
ventilation)14 equipment, training)
What problems have you experienced that
are linked to WASH in health care 8-10 mins

facilities?
Think about your own facility, district
or country.

Where are the main gaps that

you/staff/patients face across the 7
domains?

How would addressing these gaps

improve health and the climate?
15
 Part 2: WASH FIT cycle
• What are the five steps of the WASH FIT
cycle?
• What are the key outputs and tasks for
each step?
• What resources are available to help
and how do you use them?

16
 WASH FIT improvement cycle
Step 1
Establish and train the
team and document
decisions

Step 2
Step 5 Undertake an
Monitor, review, assessment of the
adapt, improve facility

Step 3
Step 4
Conduct a risk
Develop an incremental assessment to identify
improvement plan and and prioritize areas for
take action improvement
17
 Step 1 summary
• A team responsible for WASH FIT and
quality improvement is established and
trained
• Team meets regularly and documents
decision making
• Team is the driving force behind all
WASH FIT activities
• Size and makeup of team will vary
according to the size of facility –
external expertise may be sought
• Training the team is important.

18
 Step 2 summary
• A comprehensive assessment of the
facility is undertaken which informs
all subsequent phases
• A facility WASH FIT score is
calculated to give an overall picture
of performance
• Assessment shows where gaps and
problems exist
• Results of assessment should be
shared with relevant stakeholders
• Assessment repeated after 6-12
months

19
 Step 3 summary
• A risk score is assigned to all the
problems identified in the assessment
• Risks scores are based on 1) risk to
facility users and the environment
and 2) likelihood of occurrence
• Total risk score is between 0-20.
• Problems are ranked according to
risk score (highest to lowest) to
determine what needs to be
addressed first
• Climate change will affect present
and future risk

20
 Step 4 summary
• For each problem identified, team
decides improvements needed to
address risk
• Prioritize quick win/low-cost solutions
• Some problems require incremental
improvements – break down
improvements into short-term and
long-term measures
• Action plan is implemented in a
timely manner
• Improvements should be GEDSI and
climate friendly
21
 Step 5 summary
• Regular and continuous monitoring
of progress to troubleshoot problems
• WASH FIT processes are modified
review identifies problems
• Daily and weekly spot-checks of the
facility help to maintain progress and
identify new problems arising
• Data are shared with local and
national level and partners

22
Step 1 Step 1
Establish and train the
team and document
decisions

Step 2
Step 5 Undertake an
Monitor, review, assessment of the
adapt, improve facility

Step 3
Step 4
Conduct a risk
Develop an incremental assessment to identify
improvement plan and and prioritize areas for
take action improvement
23
 Step 1: Establish and train the team and
document decisions
Outputs
• A team responsible for WASH FIT and QI is established and
trained, has a set of clear roles and responsibilities and meets
regularly to assess make progress, prioritize tasks, and sustain
progress
• Documentation of team meetings and decisions (written reports,
photos and videos)
Tasks Supporting tools
• Identify and train a group of people (staff and  Simple form to record roles &
community members) with the necessary expertise to responsibilities of team members
form the WASH FIT team  Record of team meetings
• Conduct regular meetings with these staff
 Training manual
• Document results & decisions taken
• Annual refresher training
24
 Who should be in the WASH FIT team?
What external expertise could be needed?

How might the team differ between a PHC and a district/national hospital?

© Shumon Ahmed/CDD
25
Group exercise: who is • Rural primary health care
centre
responsible for WASH FIT? 1 • 1 nurse, 1 health assistant
• Who should be responsible for WASH
• No births 10 mins
FIT activities? • 3 hours drive from the capital
• What external expertise would you need
to bring in?
• What management structures or teams • District hospital situated in a large
are already in place? town, 2 hours from the capital
• How could you integrate WASH FIT into 2 • 100 beds, 10 deliveries per week,
these structures? large town 2 hours from the capital

1 26 2
What challenges might the WASH FIT team face?
3 mins

27
What challenges might the WASH FIT team face?
• Technical capacity of team members
• Engaging stakeholders & senior management
• High workload – limited time for WASH FIT activities
• Turnover of staff – need for retraining
• Maintaining a consistent and effective communication between the
WASH FIT team members
• Ensuring all voices are heard – gender, ethnicity, age, clinical vs.
non-clinical
• Scheduling regular meetings of the WASH FIT team together and
sustaining initiatives
28
 Example WASH FIT teams
Primary health care facility District/national hospital

• Facility manager, doctor or clinician • Member of senior management

• Nurse or health assistant • Nurse or other clinician
• Community engineer or technician • IPC or IPC/WASH focal point
• Community leader/focal point • Quality lead
• District health authority/district health • District health officer representative
officer (may not attend every WASH FIT • Engineer with WASH and energy skills
meeting) (ideally with climate expertise)
• Health care waste technician and/or
cleaner
• Community and/or patient groups
• Local authority representative

29
 Key  All team members have specific roles and responsibilities that are
clearly defined at the start, written down and endorsed by senior
principles management.
 A leader is appointed to drive the process with full support from
senior management
 Team has diversity and gender balance and involves clinical
and non-clinical or auxiliary staff
 Community and local government representatives are
involved and provide broader community context

Making the team more GEDSI-friendly

The team reflects the diversity of the community & users with specific WASH
requirements or constraints;
• members of disabled people’s organisations (DPOs)
• women’s groups and human rights activists
• civil society to speak up for marginalised and indigenous groups.
30
 Leadership to drive change in Ethiopia

1.Committed leader created a 4. Regular audits of WASH & IPC

culture of quality improvement 5. Wards ranked according to
2.Staff incentivized with awards for WASH FIT score & shown at
good performance facility entrance
3.A formally recognized quality 6. Hand hygiene activities
management system includes
WASH
1 2 4 5 6

31
 Community engagement in Ghana
In a rural PHC, a community committee:

• Planned a cleaning campaign to improve

health care waste management
• Engaged a local engineer/technician
who helped fixed blocked taps, mend
windows and build a fence around the
facility to prevent animals entering
• Appeared on the local radio station
asking community members to report
problems they had encountered at the
HCF
Members of the community committee inspect the
32
waste pit with the IPC focal point to plan improvements
 Step 1
Establish and train the
team and document
decision making

Step 2
Step 5 Undertake an
Monitor, review, assessment of the
adapt, improve facility

Step 3
Step 4
Conduct a risk
Develop an incremental assessment to identify
improvement plan and and prioritize areas for
take action improvement
33
 Step 2: Undertake an assessment of the facility

Outputs
• An adapted version of the assessment form, tailored to the facility’s
needs
• Regularly completed assessment and records of previous
assessments to compare progress

Tasks Supporting tools

• Review and adapt the assessment form to the local or  Assessment form
facility context
 Excel
• Regularly conduct an assessment of the facility to
provide the basis for improvement planning
 Kobo (online version)

34
 Structure of assessment form
• Available in Excel or Kobo Toolbox
• > 90 indicators sorted in 7 domains
• Not all indicators relevant for all facilities (PHC / hospitals; basic / advanced services)
• Scored according to three levels:
Meets minimum standards (2/2) Maintenance needed to sustain score
Partially meets standards (1/2) Needs minor improvement
Does not meet standards (0/2) Needs major improvement

Example indicator Meets Partially meets: Does not meet:

Domain: health care waste standards:

Waste correctly segregated at Yes (2) Some sorting but Waste not
all waste generation points not all correctly or correctly sorted at
not practiced any waste
throughout the generation points
facility (1) (0)

35
 Adapt the assessment tool
• Align indicators with national standards

• Change scoring criteria to make more achievable or more aspirational

• Add missing indicators for other areas of interest and higher service levels

• Reduce number of indicators for small facilities (remove those that are not relevant, e.g.
in-patients, on-site waste treatment)

• Focus on a specific WASH domain, e.g. water or health care waste or area within facility
(e.g. maternity)

• Use local terminology and translate to local language

Adaptation usually happens at

Refer to WASH FIT Guide:
national level by Ministry of Health -
Annex 2 for further
instructions all partners should be mandated to
36 use the same version
Country example: Mali

Simplifying the assessment for smaller facilities

• Target facilities: very small, PHCs in rural areas, extremely limited
resources & capacity. Full set of indicators was found to be
overwhelming
• Reduced the number of indicators by half

• Used locally drawn illustrations to show necessary improvements

37
 Hospitals & bigger facilities
• Include more indicators
• Start WASH FIT in one ward or
department before assessing full
facility
 Chose department with obvious
needs + motivated staff
• Some indicators will need to be
assessed multiple times (e.g. once
per ward) & average given across
indicator
 Helps identify poor performing
wards & allocate resources
Maternity services are often underserved –
38
a good place to prioritize WASH FIT
 Assessing gender, equality and disability
inclusion
• Pay special attention to the delivery
rooms, neonatal care unit and postnatal
care rooms
• Check for gender-specific facilities and
infrastructure (e.g., toilets, MHM)
• Check accessibility of services
• Speak to healthcare workers and facility
management to understand and
challenge harmful attitudes and

(c) WHO/Sebastian Liste

discrimination towards certain groups
• Recognise that not all staff will feel
comfortable highlighting problems due to
power imbalances
39
 WASH FIT facility score
How to calculate the score?
• Can be calculated for whole facility or by
ward or domain Total score of all indicators assessed
• Track progress over time Max possible score [no. of indicators
• Enables comparisons between facilities assessed x 2]

Suggested cut offs

> 75% Good Facility is doing well but continue making improvements to meet
minimum standards
67-75% Average Additional efforts are needed and ongoing maintenance
< 67% Poor Major efforts and resources needed for improvements, poor quality
of care 40
WASH FIT score and data visualization in Kenya
Comparison of 16 district hospitals in Kenya

• % of indicators scoring 0, 1 or 2 across

four domains
• Highest scoring domain = water
• Helpful for government/policy makers to
compare facility performance
• Drives interest and consistent
performance for facility staff

Meets target
Partially meets target
Does not meet target

41
Group exercise: does this picture meet
the standards? 5 mins
In groups, look at the photos on the See next slide for enlarged photos
next slide:

What indicators / standards are

relevant?
What will you DO to get the information
at this location?
What will you ASK to get information?
WHO will you ask?
What challenges might be faced when
trying to do the assessment?

Refer to the WASH FIT assessment tool for

42 the full list of indicators.
 1. Bins for segregating waste at
outpatient point of care

2. Onsite water supply

3. Women’s toilet block

43
 Step 1
Establish and train the
team and document
decision making

Step 2
Step 5 Undertake an
Monitor, review, assessment of the
adapt, improve facility

Step 3
Step 4
Conduct a risk
Develop an incremental assessment to identify
improvement plan and and prioritize areas for
take action improvement
44
 Step 3: Conduct a risk assessment to identify
and prioritize areas for improvement
Outputs
• A list of problems and gaps identified during the facility assessment
• An understanding of the risks associated with each of these
problems, ranked according to the severity of these risks
• A list of problems that are sorted in order of the priority needed to
address them.

Tasks Supporting tools

• Review the results of the assessment and identify all  Risk assessment
the indicators that do not meet the targets (across the
facility, ward or domain), which constitute problems or
gaps.
• Determine the level of risk associated with each
problem
• Rank the problems according to their risk score to
45
show which to prioritize for improvements
 Calculating risk
Category Score Description
Severity of 0–3 = low severity No major health effects are anticipated, and no urgent attention is
consequenc required, but improvements are needed to reach standards and to
es to facility improve quality of care.
4–6 = medium severity It is likely that there will be moderate negative health effects, discomfort
users and
from unsatisfactory services (e.g. unpleasant odours, unsatisfactory
environment
working conditions, potential for minor injuries), impact on staff morale
and performance, or impact on the environment.
7–10 = high severity The problem is very likely to result in injuries, illness or infection in staff,
patients and visitors, and an inability to provide essential services. It
affects the dignity and safety of all facility users. There may be
significant environmental contamination and impact on surrounding
communities.
Likelihood of 0–3 = likely to occur The problem is likely to occur only rarely.
occurrence only rarely
4–6 = may occur half The problem is somewhat likely to occur.
the time
7–10 = highly likely to The problem is constant and ongoing and has a very high likelihood of
occur occurring.
46
 Overall risk score
0–7 = low risk Minimal harm to humans or the
environment.
8–14 = medium risk Some harm will occur to humans and/or
the environment.
15–20 = high risk Significant harm is likely to humans and/or
the environment.

Additional tips

• Excel tool will calculate total score automatically

• Avoid tendency to categorize everything as “high risk”
• Alternative risk assessment methods may be developed by team

47
 Alternative method used in Indonesia

• Staff wrote a list of all problems

identified on strips of paper
• Staff ranked these according to
risk/priority for addressing them
• Staff decided their own criteria for
ranking
48
 Don’t forget - climate change may affect the
risk over time

New problems will arise in the future,

each with their own risks

New risks may be linked to existing

problems

When calculating the risk score,

consider will the risk increase or
decrease over time?

49
Photo: flooding at a HCF in Mozambique after cyclone
Idai
 Prioritize items for action
• Sort list of problems according to risk score: highest risk scores take priority for
urgent action
• Problems can be further sorted by domain (e.g. all water-related problems) or
by area in a facility (e.g. all out-patient department)
• Lower risk scores should be addressed subsequently when resources become
available
• Some problems which have low risk scores may only require simple/low-cost
improvements and can be done at the same time

50
 How to prioritize according to level of risk
Risk Immediacy Action Cost of inaction
LOW Address as resources May be addressed Inaction unlikely to
(0-7) become available with no/low-cost result in cost
actions implications
Lowest priority but in reality,
often easiest to address
MEDIUM Action needed but less Take action to ensure Some cost savings
(8-14) urgency than high risk risk does not get by addressing
problems worse problem
HIGH Urgent & immediate May require Serious cost
(15-20) significant, time, implication from
Takes priority expertise and inaction
resources to address

51
 Group exercise: Conduct a risk assessment
At your facility, you have identified the following problems: 15 mins
1. No improved water supply on premises;
water collected off-site; quantity is limited
especially during dry season

2. No functioning waste treatment technology;

autoclave is broken and has been for some
time; all waste burned together in an open pit

3. Septic tank is not emptied regularly or

functioning properly; fecal waste overflows
during heavy rain

4. Lack of lighting in toilets; toilets are 30

metres away from consultation areas 52
 Suggested answers

Likelihood of
Severity of risk occurrence Total risk
No improved water supply 9 10 19
on premises
No functioning waste 8 10 18
treatment technology
Septic tank is not emptied 8 6 14
regularly
Lack of lighting in toilets 4 3 7

53
 Step 1
Establish and train the
team and document
decision making

Step 2
Step 5 Undertake an
Monitor, review, assessment of the
adapt, improve facility

Step 3
Step 4
Conduct a risk
Develop an incremental assessment to identify
improvement plan and and prioritize areas for
take action improvement
54
 Step 4: Develop an incremental improvement
plan and take action
Outputs
• An incremental improvement plan with a set of time-bound
activities, agreed by the team with endorsement from senior
management
• Timely action on activities listed in the plan.
Tasks
• Develop a detailed incremental improvement plan
with a defined improvement aim and specific, time-
limited activities, outlining what improvements will be
made within a given time frame. Supporting tools
 Improved plan (Excel)
• Identify measures that improve management of
current climate risks and will help to manage long-
term future risks and resilience.
55
WASH FIT is about taking improvement action
…otherwise, it’d be called
WASH FAT: facility assessment tool!

56
Step 4: Develop an improvement plan and take action

Based on step 4, you have prioritized where urgent action is needed

Other items will be addressed later
What actions are required? (immediate & longer term)
Estimated budget (and source of funding)
What other resources are needed (e.g. technical, human)
Deadline for completion

57
 Suggested improvements
Building new infrastructure
Upgrading old infrastructure to make more climate resilient or GEDSI friendly
Reviewing protocols and SOPs
Staff training in new techniques or procedures
Improving management methods

Simple, low-cost improvements can have

a big impact

But may require some imagination and

creativity!
58
What incremental You work in a primary health care facility in
a small town
improvements • There is no waste segregation

would you suggest • No safe storage of waste

• All waste is combined and burnt in an
to address the open pit in facility grounds

waste problem? • Autoclave existed once but it is long

broken, and no one knows how to fix it

What environmentally sustainable improvements are there?

59
 Incremental improvements Long term,
most expensive
for waste
Medium term Develop reverse logistics
system:
Build lockable,
covered storage Waste is regularly & safely
areas transported to centralized
plan with non-burn technology
Immediate
improvements, Build low-cost
incinerator as
minimal cost interim solution

Training on waste
segregation & rationale use
of PPE

Reminders at points of care

60
Waste improvements in Indonesia

After
Before

• Waste outside nutrition clinic identified

as a major problem
• Cleaning campaign for 1 month
• Bins installed for general waste in
grounds
• Clean surroundings, risk of infection and
injury decreased
61
Improvements in an extremely low-resource
setting

Planting plants by HCF Clear signs demonstrating Hand washing poster drawn by
entrance gender separation of latrines head of HCF

Chad
62
Photos: Chad 2016, © WHO
 Improvements in a lower-middle income
setting

Sanitation facility adapted for

Water tanks with lid and
patients with physical impairment
tap accessible for patients Hand washing posters

Tajikistan
63
Photos: Tajikistan 2019, © WHO
Technical factsheets provide example
improvements

1. Strengthening climate resilience

2. Gender equality, disability and
social inclusion (GEDSI)
3. Health care waste
4. Safe plumbing
5. Hand hygiene

64
 Step 1
Establish and train the
team and document
decision making

Step 2
Step 5 Undertake an
Monitor, review, assessment of the
adapt, improve facility

Step 3
Step 4
Conduct a risk
Develop an incremental assessment to identify
improvement plan and and prioritize areas for
take action improvement
65
 Step 5: Monitor, review, adapt, improve
Outputs
• Regular WASH FIT team meetings, senior management and
relevant stakeholders to discuss the progress being made
• An annual/ bi-annual review of progress with modifications to the
WASH FIT methodology as needed
• WASH FIT data shared across the facility, local and national level

Tasks
• Regular and continuous monitoring of progress
(weekly/monthly), including spot-checks to verify
improvements are being made
• Identify additional facilitation, training, coaching or
supportive supervision to help appropriate health
workers conduct measurement
• Document / share best practices with all staff, facility
leadership, other facilities and with local/district
Supporting tools
authorities and/or the national level, as appropriate  No specific tools provided
66
 Step 5: Monitor, review, adapt, improve
• Every 6 months, conduct assessment and
re-calculate the WASH FIT score
• How has the facility score changed since
the last assessment?
• Which has improved?
NB: the overall score may improve,
but important indicators can still go
down
• Which domains (or indicators) are scoring
less well and why?
• Do you need to ask for external help? Is
there particular expertise missing?
• Is there capacity to address new areas of
the facility? 67
ROLE PLAY
Person 1: You are the manager of
Can you convince the facility, and you must explain
the WASH FIT methodology and
10 mins
your colleagues of the benefits of using it to your staff

the benefits of
WASH FIT? Person 2 & 3: You are staff
members at the facility. You have
never heard of WASH FIT before
and you do not understand the
approach. You ask person 1
questions about WASH FIT to try
and understand more.

68
 Part 3: Initial implementation to
national roll out
• What needs to happen outside of the
facility (e.g. at national level) for WASH
FIT to succeed?
• What is the process from preparation
and initial implementation to sustaining
and scaling up?

69
 Factors for success
• Tool adapted to national & local context
• Political commitment and leadership
• Training and capacity building (national &
local level)
• Sustainable financing & investment
• Supportive supervision and mentorship
• Data sharing to improve resource
allocation
• Human resources
• Community participation
70
 Political commitment & leadership
Drives WASH FIT process and fosters
ownership through existing health
systems processes and people.
Ensures long-term success and
regular financing, technical support &
Engage local, district or provincial authorities
mentorship
Government adopts WASH FIT as the In Lao PDR, by including the deputy
national tool to achieve standards  director of the local health office in the
mandates partners to use a common WASH FIT team, who then advocated
approach to training, assessment, for greater investments, local
improvements and sharing data government decided to provide extra
funding for necessary improvements.

71
 Training and capacity building
• Starts with national level
sensitization  government &
partners able to adapt framework
to national context
• MoH runs training of trainers
• Trainers cascade training to facility
Liberia’s Ministry of Health convened multi-
• Conduct regular refresher trainings stakeholder meetings to develop a national
for facility staff as needed WASH and environmental health package which
included use of WASH FIT. A national training
package was developed and rolled-out to every
district. District health teams were engaged to
follow-up on WASH FIT processes and progress
Refer to WASH FIT on key WASH indicators was reported back and
training manual for analyzed at the national level.
more information 72
 Sustainable financing & investment

Where should the money come from?

Needed for training, Recurrent: from facility discretionary
infrastructure upgrades, O&M, budget, municipality, district health or
national budget
hygiene training, supportive
supervision Capital: larger costs, requiring multiple
ministries and donors

Start-up costs: On-going:

• Initial WASH FIT training • Operation and maintenance of infrastructure
• Workshop or event to launch WASH FIT • Hygiene or other training
• Printing of materials and dissemination • Consumables (e.g. spare parts,
• Infrastructure upgrades soap/handrub, chlorine for water treatment)
73 • Supportive supervision to facilities
 Mali
Examples of supportive supervision

Lao PDR
• Regional health authorities organise periodic
meetings with all facility management
committees and mayors in their region.
• Assessments and improvement plans are
reviewed with support of a local implementing
partner.
• Learning about the process through success
stories helps create a demand for WASH FIT in Regular visits to facilities found to be a crucial
other health districts. 74 factor in maintaining progress
 Sharing data Electronic WASH FIT assessment
available at
www.washinhcf.org/wash-fit

Share data from WASH FIT

assessments & other
documentation with district
health office and/or national level

Quarterly or biannually

Electronic tools (e.g. Kobo Toolbox)

facilitate real time data sharing

Implementing partners have an

obligation to share data with Photo: Submitting data to an online portal in the WHO
government Middle East Region

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 Leadership creates a culture of quality
• Leadership of senior
management
• Ensures problems identified
are acted on
• Supports WASH FIT team
• Creates a culture of quality
• Encourages dialogue,
openness, accountability
• One committed individual can
make a huge difference In Chad, facilities with leaders committed to the
WASH FIT process made greater progress than
those without.

Improvements in overall cleanliness of the facility

and improvements in sanitation services and
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hand hygiene facilities were observed.
ROLE PLAY
Can you convince 10 mins
senior management
Person 1: You have been to a WASH FIT
why WASH is training and return to your facility. You
important? have to convince the facility manager of
the important of WASH in HCF and why
they should invest in WASH.
Person 2: You are the facility manager,
and you think you have already got too
much work to do. You are not interested in
putting time and money into improving
WASH.

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 Community participation
• Active involvement and engagement
of community in project planning and
decision making
• Representation on WASH FIT team
• Community representative, local
leader or influencer
• Demand better services
• Encourage community buy-in to the
WASH FIT process and ultimately
increase care seeking

In Mali, the community successfully demanded

investment in improvement plans from the
municipality during a public hearing of WASH
78
FIT results
 Does WASH FIT need to be changed in
response to COVID-19?
• Existing WHO guidance on the safe
management of drinking-water,
sanitation and health care waste along
with hand hygiene recommendations all
apply to COVID-19.
• No additional or different measures are
needed
• Where rapid improvements are needed,
focus on a subset of indicators
• If possible, use electronic assessment to
enable better sharing of data when there
are movement restrictions

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 Further reading
WHO (2008). Essential environmental health standards in health care.
www.who.int/water_sanitation_health/publications/ehs_hc/en/.
WHO (2014). Safe management of wastes from health care activities. Second Edition. World Health
Organization, Geneva.
www.who.int/water_sanitation_health/publications/safe-management-of-wastes-from-healthcare-activities/en/
WHO (2017). Safe management of wastes from health care activities: a summary. World Health Organization,
Geneva. www.who.int/water_sanitation_health/publications/safe-management-of-waste-summary/en/
WHO (2019). Overview of treatment technologies for infectious and sharp waste from health care facilities.
www.who.int/water_sanitation_health/publications/technologies-for-the-treatment-of-infectious-and-sharp-waste/e
n/

WHO (2016). Standards for improving quality of maternal and newborn care in health facilities
http://www.who.int/maternal_child_adolescent/documents/improving-maternal-newborn-care-quality/en/#
WHO (2016). Global guidelines on the prevention of surgical site infection
http://www.who.int/gpsc/ssi-guidelines/en/
WHO SAVE LIVES: Clean Your Hands https://www.who.int/campaigns/world-hand-hygiene-day

Full list of relevant reading available at:

80
https://washinhcf.org/resource/summary-of-all-who-and-related-resources-on-wash-in-hcf/
 Further reading: source documents for WASH FIT targets and indicators

WHO Essential environmental health standards in health care

WHO Guidelines for drinking-water quality (4th edition)
WHO Guidelines on sanitation and health
WHO Guidelines on core components of infection prevention and control programmes at the national and acute
health care facility level
WHO Minimum requirements for infection prevention and control
WHO Guidelines on hand hygiene in health care
CDC Best Practices for Environmental Cleaning in Healthcare Facilities: in Resource-limited Settings
WHO Strengthening infection prevention and control in primary care facilities
WHO Safe management of wastes from health care activities and WHO Overview of technologies for the treatment
of infectious and sharp waste from health care facilities
WHO Standards for improving quality of care for mothers and newborns in health care facilities
WHO Standards for improving quality of care for children and young adolescents in health facilities
WHO Guidance for climate-resilient and environmentally sustainable health care facilities
WHO Access to Modern Energy Services for Health Facilities in Resource-Constrained Settings. A Review of
Status, Signi­ficance, Challenges and Measurement

Links to all documents can be found at:

81
https://washinhcf.org/resource/summary-of-all-who-and-related-resources-on-wash-in-hcf/
Supplementary slides
And further reading

82
Facility visit – conducting a WASH FIT
assessment

83
WASH FIT portal
www.washinhcf.org/wash-fit
washinhcf@who.int

84
What are the aims of WASH FIT?

Replace this
diagram with new
version from
document
85
 What is quality improvement?
WASH FIT is one example
of a quality improvement
tool An analysis of process and outcomes
data and application of systematic
efforts to improve performance

Involves everyone working to implement

iterative, measurable changes to make
health services more effective, safe and
people-centred

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 What is the difference between WASH FIT and the JMP global core questions?

JMP global core indicators WASH FIT

Purpose Harmonized national level assessments and Qualitative analysis and progressive improvement
monitoring & action for which comparison between facilities /
countries is less important

Suitable for national Yes, for comparisons within and between countries Not recommended
comparisons?
Indicators Five basic indicators: Five basic indicators + energy & environment and
Water, sanitation, hand hygiene, health care waste facility management. These additional indicators
and environmental cleaning necessary for more comprehensive assessments
(e.g. water quality, climate considerations)
(total 14 questions) (total > 90 questions)

Question format Yes / No Three-point scale (red/ yellow/green or 1/2/3)

Allows for coverage estimates to be calculated To inspire facilities to make incremental
improvements

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