Hi Elisabeth,

The Soapbox Collaborative is an evidence-based charity focused on improving hygiene practices around childbirth in low and middle income countries. A colleague of mine at WaterAid working on Health started working with them when common goals, yet different and complementing value adds / skills were identified. The rationale for bridging Soapbox's research capacity with WaterAid's policy and programming capacity was strong.

You can find more reading materials on the project here . The main report I wanted to direct you to just recently had to be taken offline for an amend but will be made available again soon. I didn't work on developing the toolkit so I am probably not best suited to field many questions on methodology. I can say though that the tools used in Zanzibar were adapted from the original tools developed for use in India (you can download the toolkit for use here ).There may be a case for adapting existing tools as needed. I think soapbox intends to develop some recommendations around how this can be done. As I get more information for sharing externally I will let you know.

So why Zanzibar - The government of Zanzibar had prioritised improvements in maternal and newborn health, which really facilitated and supported this work. The ministry of Health was fully engaged in the project. This, coupled with us having access through our WaterAid Tanzania office contributed to the decision for working in Zanzibar.

As I mentioned, at WaterAid we are just starting to explore our role in healthcare settings. We recently had a webinar series to discuss this. In discussions we identified some potential next steps for starting to develop policy and programming capacity in healthcare settings. One ask coming from country programmes was to develop an inventory of existing tools. I think as we increase our capacity and policy / programming in healthcare settings we will develop a better understanding of how to get available tools routinely used. I suspect it will be largely context driven, and will require comprehensive and collaborative efforts ... and political prioritization.

Dear John and Robyn and all,

Interesting conversation. (jbr is John Brogan from Terre des Hommes in Switzerland)

Robyn, could you please explain a bit more about these tools? The website that you linked to states that:

The tools are to be used to perform a situation analysis of the state of hygiene (outcomes) on the maternity unit, as measured by visual cleanliness and the presence of potential pathogens, and individual and contextual/systems level determinants.

And SoapBox is a small NGO from the UK, did I understand that right from their website?

How did the connection with WaterAid come about and how have the tools been used in Zanzibar? Why Zanzibar in particular?

There are generally lots of tools around, but the hard part is to get them into practice and to get them used routinely by the intended target audience. How have you achieved this step?

Kind regards,
Elisabeth

Definitely Agree Jbr!

Great to hear about work with Terres des Hommes - there is for sure lots of potential for collaborating. We have collaborated with the SoapBox on assessment tools as well! Check this out for what has been done so far - the toolkit has since been adapted and used in Zanzibar as well

soapboxcollaborative.org/?page_id=3232

Excellent initiative by WHO and the researchers at the Water Institute at UNC. Thanks for posting this, Mughal.

Robyn, it will be very interesting to hear back about WaterAid's internal discussions. Terre des hommes has begun to develop and test a risk monitoring tool for WASH in health faclities, mainly focusing on hygiene practices and proper use and maintenance of equipment. In the early stages, we could use some collaborative support in this direction.

Moreover, as Marijn mentions, the push for and monitoring of better WASH practices in health facilities will need to come from the Ministries. Wouldn't it be great to see national level WASH practitioner alliances forming with support from WHO and development community to engage with authorities?

While the findings of the new WHO report on WASH in healthcare facilities are indeed grim (and might I actually add that there are so many limitations to the current data presented in the report that conditions are most likely a lot worse than reported) I am very excited that this report has come to light. All data in the report is secondary - meaning it's not new information, rather we have just finally collated sources and are starting to paint the bigger picture of conditions in healthcare facilities. The report and summit held in Geneva the week of the launch has instigated the development of a global action plan on WASH in healthcare facilities (it should be out in the next few weeks). Like all WHO action plans or guidelines, this will surely provide and entry point for WASH integration with the health sector at a national level. Working with national ministries of health to identify how and why it is so important to include WASH in policy, planning and monitoring will be a vital next step. Thankfully there are loads of ways we can support and illustrate the incentives for improved WASH in healthcare facilities - moving forward we should be making the links of how the WASH sector can support work of healthcare facilities. After all, if a healthcare facility can't provide safe care and protect their patients for infection, they aren't really healthcare facilities are they?

Healthcare workers want to protect their patients and work to high standards. In current conditions of poor WASH this is not possible - and, not their fault. Building in strong policy, developing environments supportive of good care practices / infection prevention and control measures (i.e. facilities having WASH on hand), and integrating WASH into healthcare facility monitoring for improved accountability is the direction we are headed... and I cant wait!

At WaterAid we are embarking on internal discussions to identify opportunities and ways forward for policy and programming in WASH in Healthcare facilities. We will be drawing out examples of entry points for engaging local governments and lessons learned - I will report back on how findings and how discussions progress. We are also putting out an infographic jointly with WHO on the report findings and action plan.

Cheers,

Robyn

Dear Muhal,

How to engage a government, that often is a complicated question .

For the project at BIR, what happened (in summary) is that some very motivated Nepalis, with technical support from international organizations, convinced the hospital director that this could happen. Thankfully the director was convinced and supported the project fully, this was very important!

BIR is now an example in Nepal, and with a lot of lobby work from HECAF and some big and small international organizations the government is now pushing hospitals to follow the lead of BIR. The big question here now is how to manage the correct implementation of a quite complicated system (complicated in terms of behavior changes and management)in a large number of hospitals in a relatively small amount of time.

Dear Marijn,

That Bir Hospital video, though very short, is extremely interesting and useful. In the video, what you see in the first few frames, is the situation here in Pakistan. It was great to see how Bir Hospital changed its waste management. If possible, please post more such videos. Make sure, it is not on youtube, as it is banned in Pakistan.

The names of the editors of the WHO Blue Book are enough to suggest that the book is full of useful information. I see some big names as editors.

Just 1 minor query: how can be the government here be sensitized to improve the hospital waste management?

Smiles,

F H Mughal

Dear Mughal,


Thanks for sharing this report. Healthcare waste management is a field that is close to my heart. In Nepal, some very interesting and pioneering work is done by friends of mine. In the article linked below, you will find a video (vimeo.com/90137654) showing that healthcare waste management can be done right in the developing world.

noharm-global.org/articles/news/global/h...ty-health-care-nepal

Further, for anyone involved in waste, or waste water, management solutions in hospitals or other healthcare facilities, I would really recommend the “ WHO Blue Book”.

apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf

Regards

Marijn

Sanitation in Hospitals

Sanitation in government hospitals in poor developing countries is pathetic. Solid waste produced by the hospitals, is simply dumped outside, along the boundary wall of the hospitals. In some cases, a cement-concrete bunker, with open top, is constructed just outside of the hospitals’ premises, where all solid waste is dumped.

The sanitation aspect in hospitals is most hopeless. Inadequate and poorly ventilated toilets exist in most government hospitals. The toilets are cleaned only once in a day and, they remain dirty all day long. Coupled with safe water and hygiene, clean toilets are critical for health in hospitals.

A WHO brief (WHO/UNICEF Report: Water, Sanitation and Hygiene in Health Care Facilities: status in low-and middle-income countries and way forward - Question and Answer), gives health consequences of inadequate WASH services in hospitals. The brief says:

Healthcare associated infections affect hundreds of millions of patients every year, with 15% of patients estimated to develop one or more infections during a hospital stay (Allegranzi et al., 2011). Among newborns, sepsis and other severe infections are major killers estimated to cause 430,000 deaths annually. The risks associated with sepsis are 34 times greater in low resource settings (Oza et al., 2015). Lack of access to water and sanitation in health care facilities may discourage women from giving birth in these facilities or cause delays in care-seeking (Velleman et al., 2014). Conversely, improving WASH conditions can help establish trust in health services and encourage mothers to seek prenatal care and deliver in facilities rather than at home -important elements of the strategy to reduce maternal mortality (Russoet al., 2012).

A recent (2015) WHO-UNICEF publication titled: “Water, sanitation and hygiene in health care facilities Status in low- and middle-income countries and way forward – WASH in Health Care Facilities for better health care services,” is available at:

apps.who.int/iris/bitstream/10665/154588...1508476_eng.pdf?ua=1

The publication is useful and informative and, is expected to be of great interest to the forum users.


F H Mughal