Development and application of tools to cost the delivery of environmental health services in healthcare facilities: a financial analysis in urban Malawi

Does WASH FIT Improve Water, Sanitation, and Hygiene and Related Health Impacts in Healthcare Facilities? A Systematic Review

Environmental health services in healthcare facilities are important, but coverage gaps remain. The World Health Organization and UNICEF developed the Water and Sanitation for Health Facility Improvement Tool (WASH FIT) to assess and improve environmental health services in healthcare facilities. Over 70 countries have adopted it. However, there is little evidence of its effectiveness. This systematic review evaluates whether WASH FIT improves environmental health services and associated health outcomes and impacts. We extracted data from 31 studies on inputs, activities, outputs, outcomes, and impacts associated with WASH FIT and summarized findings using a logic model framework. Twenty-three studies reported quantitative outputs for environmental health services. Of these, only nine reported longitudinal changes in these outputs throughout WASH FIT implementation. Six studies reported quantitative outcomes; the remainder described outcomes qualitatively or not at all. No studies directly measured impacts or evaluated WASH FIT against a rigorous control group. We found that available evidence was insufficient to evaluate WASH FIT's effectiveness. Further effort is needed to identify the inputs and activities required to implement WASH FIT and to draw specific links between changes in outputs, outcomes, and impacts. Opportunities exist to improve evidence by more comprehensively reporting WASH FIT assessments and exploiting data on health impacts within health management information systems.

Budgeting and Advocacy to Improve Water, Sanitation, and Hygiene in Health Care Facilities: A Case Study in Nepal

Barriers to achieving and sustaining access to water, sanitation, hygiene, cleaning, and waste management (WASH) in health care facilities include a lack of supportive policy environment and adequate funding. While guidelines exist for assessing needs and making initial infrastructure improvements, there is little guidance on how to develop budgets and policies to sustain WASH services. We conducted costing and advocacy activities in Thakurbaba municipality, Nepal, to develop a budget and operations and maintenance policy for WASH in health care facilities in partnership with the municipal government. Our objectives for this study were to (1) describe the process and methods used for costing and advocacy, (2) report the costs to achieve and maintain basic WASH services in the 8 health care facilities of Thakurbaba municipality, and (3) report the outcomes of advocacy activities and policy development. We applied bottom-up costing to enumerate the resources necessary to achieve and maintain basic WASH services and their costs. The annual costs to achieve, operate, and maintain basic access to WASH services ranged from US$4881-US$9695 per facility. Cost findings were used to prepare annual budgets recommended to achieve, operate, and maintain basic services, which were presented to the municipal government and incorporated into an operations and maintenance policy. To date, the municipality has adopted the policy and established a recovery fund of US$3831 for repair and maintenance of infrastructure and an additional US$153 per facility for discretionary WASH spending, which were to be replenished as they were spent. Advocacy at the national level for WASH in health care facilities is currently being championed by the municipality, and findings from this project have informed the development of a nationally costed plan for universal access. This study is intended to provide a roadmap for how cost data can be collected and applied to inform policy.

Does WASH FIT improve water, sanitation, and hygiene and related health impacts in healthcare facilities? A systematic review

Introduction

Environmental health services (e.g., water, sanitation, hygiene, cleaning, waste management) in healthcare facilities are important to improve health outcomes and strengthen health systems, but coverage gaps remain. The World Health Organization and United Nations Children's Fund developed WASH FIT, a quality improvement tool, to help assess and improve environmental health services. Fifty-three countries have adopted it. However, there is little evidence of its effectiveness. This systematic review evaluates whether WASH FIT improves environmental health services or associated health outcomes and impacts.

Methods

We conducted database searches to identify relevant studies and extracted data on study design, healthcare facility characteristics, and inputs, activities, outputs, outcomes, and impacts associated with WASH FIT. We summarized the findings using a logic model framework and narrative synthesis.

Results

We included 31 studies in the review. Most inputs and activities were described qualitatively. Twenty-three studies reported quantitative outputs, primary WASH FIT indicator scores, and personnel trained on WASH FIT. Nine studies reported longitudinal data demonstrating changes in these outputs throughout WASH FIT implementation. Six studies reported quantitative outcomes measurements; the remainder described outcomes qualitatively or not at all. Common outcomes included allocated funding for environmental health services, community engagement, and government collaboration, changes in knowledge, attitudes, or practices among healthcare staff, patients, or community members, and policy changes. No studies directly measured impacts or evaluated WASH FIT against a rigorous control group.

Conclusions

Available evidence is insufficient to evaluate WASH FIT's effects on outputs, outcomes, and impacts. Further effort is needed to comprehensively identify the inputs and activities required to implement WASH FIT and to draw specific links between changes in outputs, outcomes, and impacts. Short-term opportunities exist to improve evidence by more comprehensive reporting of WASH FIT assessments and exploiting data on health impacts within health management information systems. In the long term, we recommend experimental studies. This evidence is important to ensure that funding invested for WASH FIT implementation is used cost-effectively and that opportunities to adapt and refine WASH FIT are fully realized as it continues to grow in use and influence.

A toolkit for costing environmental health services in healthcare facilities

Environmental health services (EHS) are critical for safe and functional healthcare facilities (HCFs). Understanding costs is important for improving and sustaining access to EHS in HCFs, yet the understanding of costs is poor and no tools exist to specifically support costing EHS in HCFs in low- and middle-income countries. We developed a toolkit to guide the following steps of costing EHS in HCFs: defining costing goals, developing and executing a data collection plan, calculating costs, and disseminating findings. The costing toolkit is divided into eight step-by-step modules with instructions, fillable worksheets, and guidance for effective data collection. It is designed for use by diverse stakeholders involved in funding, implementation, and management of EHS in HCFs and can be used by stakeholders with no prior costing experience. This paper describes the development, structure, and functionality of the toolkit; provides guidance for its application; and identifies good practices for costing, including pilot testing data collection tools and iterating the data collection process, involving diverse stakeholders, considering long-term costs, and disaggregating environmental costs in records to facilitate future costing. The toolkit itself is provided in the Supplementary Material.