GUIDELINES OF WASH FIT

Copyright 2021 by the Department of Health. All rights reserved. Subject to the acknowledgement of the Health Facility Development Bureau (HFDB), Department of Health, the Manual may be freely abstracted, reproduced or translated in part or in whole for noncommercial purposes only. If the entire Manual or substantial portions will be translated or reproduced, permission should be requested from the HFDB. Printed in the Republic of the Philippines.

Published by

Department of Health

Health Facility Development Bureau San Lazaro Compound Rizal Avenue, Sta. Cruz, Manila 1003 PHILIPPINES

PRODUCTION CREDITS

Project Leader: Dr. Ma. Bituin S. Reyes

Engr. June Philip O. Ruiz

Copy Editor: Mr. Glenn A. Cruz

Ms. Joana Joy A. Lico Ms. Georgina Mae R. Zulueta Engr. Maria Sonabel Anarna Engr. Bonifacio Magtibay Ms. Elmira Bacatan

Acknowledgement: World Health Organization, Philippines

UNICEF Philippines

Development of this Guidelines was initiated, completed and subsequently published through the HFDB.

For inquiries, contact the Health Facility Development Bureau:

Phone: +63 2 8651 7800 locals 1401, 1403, 1408

Email Address: hfdb@doh.gov.ph

Table of Contents

GUIDELINES OF WASH FITj
Table c	of Contents	i
List of I	Figures and Annexes	i
Purpos	e and Use of the Guidelines	1
Definiti	on of Terms	4
1. Int	roduction	6
1.1.	Water, Sanitation, and Hygiene in Health Facilities (WASH in HFs)	7
1.2.	Global Status of WASH in HF	8
1.3.	World Health Assembly Resolution on WASH in HF in 2019	9
1.4.	Water Efficiency, Sanitation and Hygiene for Health Facilities	10
1.5.	Water Safety Plan	10
1.6.	Sanitation Safety Plan	11
1.7.	WASH in HF Policies in the Philippines	11
2. Ov	verview of WASH FIT	21
Overvie	ew WASH FIT	22
2.1.	Objectives of WASH FIT	22
2.2.	Benefits of WASH FIT	22
2.3.	Coverage of WASH FIT	24
2.4.	Intended users of WASH FIT	25
2.5.	Adapting WASH FIT for different hf settings	25
2.6.	Task 1: Assemble WASH FIT team	27
2.6	Steps in Assembling the WASH FIT Team	27
2.7.	Task 2: Assess the existing WASH facilities and practices in the hf	31
2.7	7.1. Steps in the conduct of facility assessment	31
2.8.	Task 3: Undertake hazard and risk assessment	35
2.8	3.1. Steps in undertaking hazards and risk assessment	35

	2.9. Task 4: Develop an Improvement Plan 43
	2.9.1. Steps in the development and implementation of improvement plans43
	2.10. Task 5: Monitor progress of improvement plans47
	2.10.1. Steps in Monitoring and Revising of Improvement Plans47
3.	WASH FIT Web Application49
4.	References 51
	Annex 1: Other Technical Guides on WASH in HF53
	Annex 2: WASH FIT Tools Template (Tool 1A WASH FIT Team) 55
	Annex 2: WASH FIT Tools Template (Tool 1B WASH FIT Team Monitoring Record Sheet) 56

List of Figures and Annexes

List of Figures

Figure. 1: Impacts associated with WASH FIT

Figure. 2: Coverage of WASH FIT

Figure. 3: The WASH FIT Process

Figure. 4: WASH FIT Rating

Figure. 5: Sample of WASH Fit Portal

List of Annexes

Annex 1: Other Technical Guides on WASH in hf

Annex 2: WASH FIT Tool Templates

Tool 1A: WASH FIT Team List

Tool 1B: WASH FIT Team Meeting Record Sheet

Tool 2A: Indicators Assessment Forms

Tool 2B: Sanitary Inspection Forms

Tool 3: Hazard and Risk Assessment Hygiene

Tool 4: Improvement Plan

Tool 5: WASH FIT Form: https://bit.ly/WASHFITtool

WASH FIT Webpage Link: https://bit.ly/WASHFIT-Form2022

Purpose and Use of the Guidelines

Protecting Filipinos from health risks is one of the strategic thrusts indicated in the health sector strategy for 2023-2028. The health system shall be prepared and have the capacity for recovery and adaptation to future disasters and pandemics. One of the strategic interventions then is to build resilient and green health facilities to answer the strategic objective of health facilities and services that are safe and of high quality. The Department of Health through the Health Facility Development Bureau developed the Green and Safe Health Facilities Manual, 1st edition or Green Manual accompanied by the Green Viability Assessment tool was released through Department Circular No. 2021-0437, and contains performance standards in Governance, Energy Efficiency, Water Efficiency, Sanitation and Hygiene, Health Care Waste Management, Environmentally Resilient Health Facility, Site Sustainability, Materials Sustainability, and Indoor Environmental Quality.

Recognizing water efficiency, sanitation and hygiene as one of the performance standards of Green Manual, the Guidelines of Water and Sanitation For Health Facility Improvement Tool (WASH FIT) has been simplified to allow the straightforward application of the tool and the prompt development of WASH improvement plans. The value of WASH FIT in systematizing and harmonizing assessments and improvements of WASH in hfs, this localized version of WASH FIT has been developed with the objective of better aiding the Philippine health sector by taking into account the relevant local context.

Thus, the guidelines identified in this guideline shall contribute to the attainment of the country's goals towards sustainable development, climate action and universal health care. The development of the Guidelines of WASH FIT is aligned with the technical standards and guidelines of a green, safe and climate resilient health facility. This complements the Department of Health through the Health Facility Development Bureau's strategic deliverables – Philippine Health Facility Development Plan 2020-2040 as the country's roadmap to accessible health care anchors a modern, resilient, and sustainable healthcare system as a key principle and operations management of facilities underscores the necessity of efficient management and use of resources.

When fundamental infrastructure and hygiene in health facilities are not in place, access to high-quality health care will be undermined. A World Health Organization (WHO) - United Nations Children's Fund (UNICEF) 2015 global review reported that nearly 40% of facilities lack water supply, 19% are without sanitation, and 35% do not have hand hygiene services. Without adequate attention to water, sanitation, and hygiene (WASH), universal health coverage will be difficult to attain. ¹

In 2019, WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) indicate that globally, WASH services in health facilities (HFs) are sub-

¹ Water and Sanitation for Health Facility Improvement Tool (WASH FIT). Geneva: World Health Organization; 2017. License: CC BY-NC-SA 3.0 IGO.

standard in every region. An estimated 896 million people use health facilities with no water service and 1.5 billion use facilities with no sanitation service.

As a result of deficient WASH services (e.g., water, sanitation, hygiene, health care waste management, and cleaning services) in health facilities, populations face the risk of infection when seeking care in the said facilities that lack the basic necessities. The 2022 JMP Report cites that inadequate WASH and IPC contribute to health-care associated infections (HAI), which are a major public health concern globally. In low and middle income countries, 15% of patients in acute-care hospitals will develop one or more HAI during their hospital stays. Up to 30% of patients in intensive care can be affected by HAI, with an incidence that is 2 to 20 times higher in low and middle income countries than in high income countries, in particular among neonates. This situation is ironic as people do not visit health facilities to compromise their health, safety, and dignity. Furthermore, no one visits a health facility to potentially abet the spread of diseases or infections.

To help improve WASH services in health facilities, the WHO/UNICEF designed the Water and Sanitation for Health Facility Improvement Tool (WASH FIT), a risk-based approach for improving and sustaining water, sanitation, hygiene, health care waste management, environmental cleaning, and basic facility management services in health facility. WASH FIT guides multisectoral teams through a continuous cycle of assessing and prioritizing risks, defining and implementing improvements, and continually monitoring progress. WASH FIT was adapted from the water safety plan (WSP) and sanitation safety planning (SSP) approaches recommended in the WHO Guidelines for Drinking-Water Quality and WHO Sanitation and Health Guidelines. While WASH FIT is predominately used in nonemergency settings, it can be applied in emergency settings. It has also been used in peacekeeping efforts and military and civilian camps in South Sudan, reaching over 20,000 individuals and leading to improvements in the safety, reliability, and efficiency of water, wastewater, and waste management.

In mid-2019, the Philippine Department of Health (DOH) and the WHO conducted an assessment² of healthcare facilities in selected areas. The assessment report recommended improvements or upgrading, and greening of WASH facilities visited in order to further improve the performance of health facility in the delivery of quality health care. WASH FIT was used to structure and guide the conduct of the assessment as well as to facilitate the immediate consultation with, and feedback to, local health authorities and hf staff immediately after field interviews and ocular trips.

In 2020, UNICEF supported DOH in adopting the global WASHFIT indicators using a digital reporting platform and a reduced number of indicators that are essential in the light of the COVID-19 pandemic. Recognizing the value of WASH FIT in systematizing and

² One of the strategic priorities of the DOH that is supported by the WHO, with funding support from the Australian Government through the Department of Foreign Affairs and Trade (DFAT), is a project entitled "Strengthening the Quality and Sustainability of Water, Sanitation and Hygiene (WASH) Services, including health facility (hf)." This is a 4-year project (2018-2022) which aims to improve the "sustainability of drinking-water safety approach and strengthen WASH and greening approach in hf in selected areas of the country" particularly in the areas of drinking water quality surveillance and WASH in hf. Part of the technical assistance was the conduct of an assessment for DWQS and WASH in hf in selected areas in CAR, and in Regions 7, 8, 9 and 11, from April to September 2019.

harmonizing assessments and improvements of WASH in hfs, this localized version of WASH FIT has been developed with the objective of better aiding the Philippine health sector by taking into account the relevant local context. This guideline echoes the purposes, objectives, and processes of the 2017 WHO/UNICEF WASH FIT and cites policies and examples that are pertinent to the Philippine setting. It has been simplified to allow the straightforward application of the tool and the prompt development of WASH improvement plans by WASH FIT multi-sectoral teams and other users, such as policymakers and health program implementers. The suggested forms (or task-specific tools) presented as annexures were formulated in consideration of current and increasing concerns such as the greening of hfs, pandemics (e.g., COVID-19), impacts of climate change, and emergency situations. It is in the annexures where adjustments or modifications in the WASH FIT are more noticeable as a result of reflecting local context.

This guideline is divided into three major sections:

Section 1: Introduction - This section introduces the importance of quality WASH services in health facility, the current global status of WASH in hfs as monitored by the WHO/UNICEF JMP, the global and country action plans committed at the 2019 World Health Assembly Resolution, and Philippine policies, issuances, and guidelines concerning WASH.

Section 2: Overview of the WASH FIT - This section presents an overview of WASH FIT. It lays down the benefits of adopting WASH FIT, the coverage and intended users of the tool, and ways of using WASH FIT for different hf types in the Philippines.

Section 3: WASH FIT Process - Step-by-step procedures are suggested in this guideline serving as a guide in developing and implementing WASH FIT as a risk management tool for hfs. It also points out the responsibilities in the subsequent monitoring and review of improvement plans identified during assessments. Consistent with the WHO/UNICEF WASH FIT Practical Guide³ (2017), the process is divided into five (5) main tasks that are performed in sequential order as follows:

• Task 1: Assemble the WASH FIT Team
• Task 2: Assess the existing WASH facility and practices in the hf
• Task 3: Undertake hazard and risk assessment
• Task 4: Develop an improvement plan
• Task 5: Monitor progress of the improvement plan

Detailed information and some recommendations are provided for each of the tasks to offer a basis in decision-making. For easy reference and increased understanding, sample forms and questionnaires are also provided, which may be readily modified according to the type of hf

³ Water and Sanitation for Health Facility Improvement Tool (WASH FIT). Geneva: World Health Organization; 2017. License: CC BY-NC-SA 3.0 IGO; Updated cover and introduction on 2018.

Definition of Terms

Green Health Facilities

• promote the greening of hospitals and health facilities, including the improvement of energy and water efficiency and conservation, sustainable cooling systems, and sustainable healthcare waste management in hospitals

Healthcare-Associated Infection (HAI)

• An infection occurring in a patient during the process of care in a hospital or other health facility, which was not present or incubating at the time of admission. Health care- associated infections can also appear after discharge. They also include infections acquired by patients in the hospital or facility but appearing after discharge, and occupational infections among staff.⁴

Health Facilities (HFs)

• Health care provider which may be public or private, devoted primarily to provision of services for health promotion, prevention, diagnosis, treatment, rehabilitation and palliation of individuals suffering from illness, disease, injury, disability, or deformity, or in need of obstetrical or other medical and nursing care.⁵
• An institution that has health care as its core service, function or business. Health care pertains to the maintenance or improvement of the health of individuals or populations through the prevention, diagnosis, treatment, rehabilitation and chronic management of disease, illness, injury and other physical and mental ailments or impairments of human beings.⁶

Improved water source

• Defined by the WHO/UNICEF Joint Monitoring Programme as a water source that by its nature of construction adequately protects the source from outside contamination, particularly fecal matter. Examples include: public taps or stand pipes, protected dug wells, tube wells or boreholes. ⁷

Water and Sanitation for Health Facility Improvement Tool (WASH FIT)

• is a risk-based approach for improving and sustaining WASH services in health facilities. WASH FIT was adapted from the water safety plan (WSP) and sanitation safety planning (SSP) approach recommended in the WHO Guidelines for Drinking Water Quality and WHO Sanitation and Health Guidelines.
• is a multistep, iterative process to facilitate continuous improvements in WASH services, quality, and experience of care.
• facilitates a comprehensive process to assess, prioritize and improve basic water, sanitation and hygiene services at healthcare facilities and to improve quality of

⁵ Sec. 4.k.1 of Republic Act 11223, Universal Health Care Act

⁴ (World Health Organization, 2016)

⁶ DOH Administrative Order 2019-0060, Guidelines on the Implementation of the National Health Facility Registry

⁽WHO/UNICEF. Progress on sanitation and drinking water: 2015 update and MDG assessment, 2015)

care through safer, environmentally sustainable & climate-smart WASH infrastructure and services

Primary Care Facilities

• This refers to the institution that primarily delivers primary care services which shall be licensed or registered by the DOH⁸

⁸ (RA 11223 IRR and AO No. 2020-0047)

WATER AND SANITATION FOR FACILITY IMPROVEMENT TOOL DEPARTMENT OF HEALTH

1. Introduction

1.1.Water, Sanitation, and Hygiene in Health Facilities (WASH in HFs)

The provision of water, sanitation, health care waste management, hygiene, and environmental cleaning infrastructure and services across all parts of a facility⁹ . Provision of basic WASH services is important to ensure that quality care is provided and that the risk of the spread of infection, both within the facility and in surrounding communities, is reduced or prevented.

Benefits of Improved WASH in HFs 10

The availability of and accessibility to WASH services strengthens the capacities of hfs to prevent disease outbreaks and carry out basic infection prevention and control (IPC) procedures necessary to prevent the spread of infections, especially those that have developed antimicrobial resistance (AMR). They are also essential components of quick and effective responses during emergencies (including natural disasters, outbreaks, and pandemics) and help bring emergencies under control when they occur. Emerging and growing threats from antimicrobial-resistant infections, infectious disease outbreaks, and pandemics (e.g., COVID-19) may be significantly reduced by reliable WASH services.

⁹ Water, sanitation and hygiene in health care facilities: practical steps to achieve universal access. Geneva: World Health Organization; 2019. License: CC BY-NC-SA 3.0 IGO

¹⁰ WASH FIT. WHO; 2017

1.2.Global Status of WASH in HF¹¹

The importance of WASH in HF is now increasingly being recognized in achieving national health goals and the 2030 Agenda for Sustainable Development. Safe water, functioning sanitation facilities, implementation of proper hygiene and cleaning practices (SDG 6) are important in improving health outcomes linked to maternal, newborn, and child health (SDG 3). The terms "universal" and "for all" in the SDG targets 6.1 and SDG 6.2 suggest that the monitoring of the WASH must go beyond the household and must be expanded to non-household settings such as health facility.

SDG Targets related to WASH in hf
Sustainable Development Goal		Target
	3: Ensure healthy lives and promote well-being for all at all ages.	3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births. 3.2: By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births. 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and, access to safe, effective, quality, and affordable essential medicines and vaccines for all. 3.9: By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination.
	6: Ensure availability and sustainable management of water and sanitation for all.	6.1: By 2030, achieve universal and equitable access to safe and affordable drinking water for all 6.2: By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations.

¹¹ World Health Organization and the United Nations Children's Fund, WASH in health facility: Global Baseline Report 2019, WHO and UNICEF, Geneva, 2019. License: CC BY-NC-SA 3.0 IGO.

As part of its mandate to monitor the global progress on achieving SDG targets 6.1 and 6.2, the WHO and UNICEF through its Joint Monitoring Programme (JMP) has been monitoring globally the access of the hfs to water supply, sanitation, and hygiene (WASH). The highlights of the JMP 2022 Progress on WASH in HF include the following:

In the Philippines, three out of ten HCFs or about 4% have no toilet facilities and 68% of the HCFs practices wastes segregation (JMP, 2019).

• One out of five health facilities lack basic water service, impacting 1.7 billion people
• An estimated one in ten health facilities have no sanitation service in 2021, impacting about 780 million people
• About 49% of the hfs globally do not have basic hygiene service at the points of care affecting 3.85 billion people
• One out of four health facilities globally lack systems for segregating waste
• Not all healthcare facilities have environmental cleaning protocols and not all staff have received training.

1.3.World Health Assembly Resolution on WASH in HF in 2019

In March 2018, the Secretary General of the United Nations launched a global call to action for WASH in all health facility,10 noting that health facility are essential tools in reducing disease, and that without basic WASH, health facility can instead contribute to more infections, prolonged hospital stays and preventable deaths, including of mothers and babies.¹²

During the 72nd World Health Assembly (WHA) on WASH in hfs held last May 2019, the WHO and UNICEF agreed that among the strategies to ensure the competence of hfs is to integrate WASH within quality care and/or universal health care coverage strategies, indicators, and budgeting to ensure intersectoral action. Further, WASH in hf has to be institutionalized, creating a demand for improvements and accountability mechanisms for when services are lacking.

The premise is that WASH is best implemented through good governance where actions are health-centered using quality care as the overall frame. Based on this, the following five areas of work were suggested: leadership and systems understanding; technical support; evidence and knowledge; community engagement and social and behavior change, and monitoring.

In response to the global call for action on WASH in hf during the 72nd WHA, the following were committed by the Philippines as part of its action plan for WASH in hfs. The DOH identified some key partners such as WHO, UNICEF, and Health Care Without Harm as key partners to achieve these commitments.

¹² World Health Organization and the United Nations Children's Fund, WASH in health facility: Global Baseline Report 2019, WHO and UNICEF, Geneva, 2019. License: CC BY-NC-SA 3.0 IGO.

• Enhanced coordination to develop or strengthen the existing group/s involved in the preparation and implementation of the Philippine Road Map to attain functional WASH Service and practices in all hf
• WASH FIT implementation across hfs
• Develop strategies to strengthen the health workforce

1.4. Water Efficiency, Sanitation and Hygiene for Health Facilities

To lessen the carbon footprints from the health facilities and be resilient to climate change impact and promote infection prevention and control, compliance to this Green and Safe Health Facilities Manual or Green Manual is enjoined based on the existing laws and regulations. Improvement of water efficiency and hygiene in HF, provide quality of care and reduce infections, HFs must have the appropriate infrastructure and staff capacities to provide safe, effective, equitable and people-centered services. WASH services strengthen the resilience of health care systems in preventing disease outbreaks, allow effective responses to emergencies including natural disasters and outbreaks and bring emergencies under control when they occur.¹³

Recognizing the value of WASH FIT in systematizing and harmonizing assessments and improvements in health facilities, this localized version of WASH FIt will aid the health sector taking into account the current situation of WASH services.

The Philippine version of WASH FIT (can be accessed through this link https://enketo.ona.io/x/hvztbGc7). Moreover, in line with the DOH Green Manual, this Guidelines of WASH FIT for the use of Health Facilities will complement the compliance and implementation of WASH in health facilities.

1.5. Water Safety Plan

Water Safety Plan (WSP) was first introduced by the World Health Organization (WHO) to address issues and problems due to unsafe quality of drinking-water. The WSP approach involves the application of a comprehensive risk assessment and management approach that encompasses all steps in the water supply system from the catchment to consumers. The concept is a cost effective and preventive strategy that ensures safety and quality of drinking- water.¹⁴

The development of WSP for healthcare facilities e.g. hospitals is a milestone on consistently addressing the need for the safe access to drinking-water. Thus, this guideline provides a step-by-step process on the formulation of WSP tailored fit on hospital settings which will also serve as a model for other health facility on the formulation of their own WSPs. The guidelines for the Guidelines for Water Safety Plan Development of Health Facilities can be accessed at https://bit.ly/PLANwater.

¹³ Water and Sanitation for Health Facility Improvement Tool (WASH FIT), 2017

¹⁴ Bartram, J., et al., et al. Water Safety Plans Manual: A Step-by-step risk management for drinking-water suppliers. [Online] 2009. [Cited: November 9, 2015.] http://apps.who.int/iris/bitstream/10665/75141/1/9789241562638\_eng.pdf.

1.6.Sanitation Safety Plan

Sanitation Safety Planning (SSP) is a step-by-step risk-based management tool for sanitation systems. It can be applied to the entire sanitation chain to ensure that all systems are managed to meet the required health objectives. SSP is a guide to facilitate drafting and implementation of health risk assessment and management plans along the sanitation chain to meet the Sustainable Development Goal 6 (SDG 6) – to ensure the availability and sustainable management of water and sanitation for all.

SSP will ensure safely managed and safely treated wastewater. Specifically, it will provide assurance to the authorities and the general public on the safety of effluents for discharge or re-use. The guide in developing Sanitation Safety Plan of Health facilities can be accessed at https://bit.ly/SSPplanHF.

1.7.WASH in HF Policies in the Philippines

The following are the national policies and issuances that are particularly relevant to the provision of WASH in HFs. Other technical guides related to WASH in HFs are attached in Annex 1.

A. Presidential Decree No. 856: Code on Sanitation of the Philippines

The Code on Sanitation was promulgated on 23 December 1975 with the ultimate objective of improving and directing public health services towards the protection and promotion of peoples' health. The Code on Sanitation compiled and updated all public health laws and regulations on sanitation in the Philippines that used to be scattered in numerous volumes in statute books. With the promulgation of PD 856, it was hoped that compliance of concerned parties to, and enforcement by health officers of, a consolidated sanitation policy, will become easier

❖ DOH AO 2018-0017: Revised Implementing Rules and Regulations (ERR) of Chapter VII — Industrial Hygiene 0f the Code on Sanitation of the Philippines, RD. 856

The Revised Implementing Rules and Regulations (RIRR) prescribe the rules and regulations on Chapter VII — Industrial Hygiene of the Sanitation Code of the Philippines, PD 856, to promote and protect workers' health.

❖ Implementing Rules and Regulations of PD 856 Chapter 17: Sewage Collection and Disposal, Excreta Disposal and Drainage (1995)

This Chapter of PD No. 856 sets the guidelines for the provision of individual excreta disposal systems and proper disposal of wastewater, including hospital wastewater. It also sets the proper design for the construction of septic tanks and processes for sewage treatment facilities.

❖ Implementing Rules and Regulations of PD 856 Chapter 18: Refuse Disposal (1998)

Section 4 of this chapter sets the minimum standards and requirements for the segregation and storage of refuse/solid waste. It indicates the standard color-coding of the waste containers per type of waste.

Section 9 of Chapter 18 sets the specific requirements for the management of biomedical wastes from health facilities and other similar establishments. Management of these wastes must conform with the standards and guidelines contained in the Health Care Waste Management Manual (4th edition) of the DOH.

❖ Implementing Rules and Regulations of PD 856 Chapter 20: Pollution of the Environment (1998)

Section 5 of this chapter lists the sanitary requirements that must be provided by the establishments, including health facility, which includes the following:

• Adequate and potable water supply in accordance with Chapter 2 of PD No. 856 and PNSDW 2017
• Sewage collection and disposal compliant with Chapter 17 of PD No. 856
• Solid waste management in compliance with Chapter 18 of PD No. 856
• Handwashing facilities with an adequate water supply and soap
• Adequate and clean toilet facilities for male and female and disabled workers and clients
• Proper lighting and ventilation.

B. Republic Act (RA) No. 7160: Local Government Code of 1991

RA 7160 was enacted by the Senate and the House of Representatives of the Philippines in Congress assembled on 10 October 1991. The Code applies to all provinces, cities, municipalities, barangays, and other political subdivisions as may be created by law, and, to the extent provided therein, to officials, offices, or agencies of the national government. RA 7160 provides for territorial and political subdivisions of the State to enjoy genuine and meaningful local autonomy to enable attainment of full development as self-reliant communities and become more effective partners in the attainment of national goals. Moreover, to provide for a more responsive and accountable government structure, the State will institute a system of decentralization where local government units (LGUs) are given more powers, authority, responsibility, and resources. Furthermore, all national agencies and offices are required to conduct periodic consultations with appropriate LGUs, nongovernmental and people's organizations, and other concerned sectors of the community before any project or program is implemented in their respective jurisdictions.

Chapter II, General Powers and Attributes of Local Government Units, Section 16. General Welfare, of the Local Government Code of 1991, provides for LGUs to exercise its powers for its efficient and effective governance, and those which are essential to the promotion of the general welfare. Also, LGUs shall ensure and support, among other things, the promotion of health and safety, the enhancement of the right of the people to a balanced ecology, and the preservation of the comfort and convenience of their inhabitants. Furthermore, Section 17. Basic Services and Facilities, provides for LGUs to endeavor to be self-reliant and continue exercising powers and discharging duties and functions currently vested upon them. LGUs are also endeavored to discharge the functions and responsibilities of national agencies and offices devolved to them according to this Code. LGUs shall likewise exercise such other powers and discharge such other functions and responsibilities as are necessary, appropriate, or incidental to efficient and effective provision of basic services and facilities enumerated in the Code.

Among the basic services and facilities enumerated that shall be provided by the LGUs, funded out by their respective funds, are:

a. For a Barangay:

• health and social welfare services which include maintenance of barangay health centers and daycare centers;
• services and facilities related to general hygiene and sanitation, beautification and solid waste collection, and;
• maintenance of water supply systems

b. For a Municipality or City:

• health services including implementation of programs and projects on primary health care, maternal and child care, and communicable and noncommunicable disease control services, access to secondary and tertiary health services, purchase of medicines, medical supplies, and equipment needed to carry out the services;
• solid waste disposal system or environmental management system and services or facilities related to general hygiene and sanitation, and;
• infrastructure facilities intended primarily to service the needs of residents including clinics, health centers, and other health facilities necessary to carry out health services, communal irrigation, small water impounding projects and other similar projects, artesian wells, spring development, rainwater collectors, and water supply systems, drainage and sewerage, flood control, and other facilities.

c. For a Province:

• health services which include hospitals and other tertiary health services;
• infrastructure facilities intended to serve the needs of the province including inter-municipal waterworks, drainage and sewerage, flood control, and irrigation systems.

Section 102 of RA 7160 also provides for the establishment of Local Health Boards (LHB) in provinces, cities, or municipalities. Functions of the LHB include a) to propose annual budgetary allocations for the operation and maintenance of health facilities and services, b) to serve as an advisory committee to the Sanggunian (LGU legislative body) concerned on health matters, and c) to create committees which shall advise local health agencies, which are consistent with the technical and administrative standards of the Department of Health, on matters such as personnel promotion and selection, bids and awards, grievance and complaints, personnel discipline, budget review, operations review, and similar functions.

C. Republic Act No. 4226: Hospital Licensure Act

This act requires all hospitals and other health service establishments to acquire a licensure permit before operations and this permit must be renewed regularly. Requirements for licensing of a hospital and other health service establishments include (a) the provision of potable drinking water and records of water analysis that is updated every 6 months, (b) proper management of health care waste management in accordance to the management manual of DOH and environmental laws of EMB, (c) and provision of proper sanitation facilities including hand washing.

❖ Department Health Administrative Order No. 2012-012: Rules and Regulation Governing the New Classification of Hospitals and Other Health Facilities in the Philippines

This AO provides guidelines on the classification of the healthcare facilities. It also includes the requirements of the health facility to provide safe, effective, and efficient services to its patients.

Regarding information management, the health facility must maintain technical records/ logbooks on the results of the water analysis.

• For environmental management, each health facility must observe the following:
• Well ventilated, lighted, clean, safe and functional areas;
• Adequate, safe and potable water supply;
• Proper disposal of hazardous, toxic, and infectious wastes following RA 6969;
• Solid waste management based on the latest Health Care Waste Management Manual of DOH, RA 9003 and other pertinent policy and mandates;
• Liquid waste management following the Health Care Waste Management Manual of DOH and DENR-EMB policy;
• Implementation of no smoking policy.
  • ❖ Department of Health Circular No. 2016-042: Guidelines in the Application for Department of Health Permit to Construct

This DOH circular order sets the guidelines on the requirements and process of applying for permit to construct which is required for all health facilities before its construction. The issuance of the permit to construct is done by the regional offices of the DOH.

Annex B to G of this DOH circular order provides the planning and design guidelines for hospitals and other health facilities. The checklist for the floor plans of the health facility is shown in annex H. The said checklist indicates the service areas in the health facility where toilet and handwashing facilities are required.

❖ Department of Health Circular No. 2018-0103: Revised Licensing Assessment Tools for Hospitals

In support of RA 4226, the revised assessment tool for the hospital licensure was developed. This sets the criteria and indicators that the hospital must comply with. Among others, the following are required to be provided by the hospital for them to be licensed:

• Provision of safe and potable water;
• Water analysis every 6 months;
• Health care waste management complaint to the DENR-EMB standards and DOH's HCWM manual, and;
• Provision of toilet facilities including hand washing.
• D. Republic Act No. 6969: Toxic Substances and Hazardous and Nuclear Wastes Control Act of 1990
  • ❖ DENR Administrative Order (DAO) No. 2013-22: Revised Procedures and Standards for the Management of Hazardous Wastes

DAO 2013-22 serves as the procedural manual for the Republic Act No. 6969 also known as the "Toxic Substances and Hazardous and Nuclear Waste Control Act of 1990". This acts as a guide for the proper management of hazardous wastes including pathological or infectious wastes (M501) and pharmaceuticals and drugs (M503). Procedures and standards for the proper storage, transport, treatment, and disposal of hazardous wastes are included in the DAO.

❖ Joint DENR-DOH Administrative Order No. 2005-02: Policies and Guidelines on Effective and Proper Handling, Collection, Transport, Treatment, Storage and Disposal of Health Care Wastes

This JAO harmonizes the efforts of DOH and DENR on the management of health care wastes. It clarifies the jurisdiction, authority, and responsibilities of the DENR and DOH in terms of the management of health care wastes.

The JAO also specifies the standards and guidelines for the proper management of the health care wastes from the point of generation up to the treatment and disposal. This applies to all the health care waste generators, transporters, and owners of the TSD.

E. Republic Act No. 9275: The Philippine Clean Water Act of 2004

❖ DENR Administrative Order No. 2016-08: Water Quality Guidelines and General Effluent Standards

This Administrative Order (AO), among others, sets the standards of the effluent that must be complied by all point sources of water pollution when discharging to receiving water body or land. This SO applies to all types of industries regardless of the quantity of wastewater discharged.

F. Republic Act No. 11223: Universal Health Act

Passed by the Senate and House of Representatives of the Philippines on 10 December 2018 and Approved by the President on 20 February 2019, RA 11223 or the Universal Health Care Act prescribes reforms in the healthcare system and appropriated funds therefor. This Act effectively declares that it is the policy of the State to protect and promote the right to health of all Filipinos and aims to realize better performance in health systems that include proactive and effective health promotion programs or campaigns. To regulate safety and quality, RA 11223 also promotes the establishment of an incentive scheme to acknowledge and reward health facilities that provide better quality, efficiency, and equity. For governance and accountability measures, the UHCA counts on the DOH to strengthen national efforts in providing a comprehensive and coordinated approach to health development.

The WASH FIT approach is consistent with and must be able to contribute to the realization of, better health promotion and health care system reforms envisaged by the UHCA. By exploring its adoption, the DOH strengthens its position in meeting the objectives of RA11223 along the directions prescribed by the law. Testing of the WASH FIT approach in selected or pilot project areas should also be a venue and opportunity for learning and optimizing its benefits, with special consideration of the local context.

G. Philippine Green Building Code

To complement Presidential Decree No. 1096 National Building Code, the Philippine Green Building Code sets the minimum standards to improve the building's efficiency and sustainability and minimize its negative impacts on human health and the environment. This code includes efficient practices, designs, methods, and technologies that will enhance the building's performance without a significant increase in cost.

The Green Building Code has 6 performance standards: (1) energy efficiency, (2) water efficiency, (3) material sustainability, (4) solid waste management, (5) site sustainability, and (6) indoor environmental quality.

❖ Department of Health Department Circular No. 2019-0059: Green Certification of Government health facility Projects

This DOH circular order requires all healthcare facilities with a total building area of 10,000 square meters to integrate into their design and operation the greening initiatives following the Philippine Green Building Code. A green certification must be secured to the DOH by the concerned health facility.

❖ DOH DC 2021-0437: Dissemination of the Green and Safe Health Facilities Manual 1st edition

The first edition release includes the Green Viability Assessment Tool that will serve as the users' aid in the application of the Manual. The Green and Safe Health Facilities Manual or referred to as the Green Manual was developed to respond to the global call of developing green and safe hospitals and health facilities. This manual is a reference for planning a safe, sustainable, climate-resilient health infrastructure concomitant to the country's goal of meeting the health demand of the population, and closing the supply gaps in health facility and services The Green Manual contains performance standards in Governance, Energy Efficiency, Water Efficiency, Sanitation and Hygiene, Health Care Waste Management, Environmentally Resilient Health Facility, Site Sustainability, Materials Sustainability, and Indoor Environmental. Copy of the manual can be accessed athttps://bit.ly/DOHGreenManual

H. Water, Sanitation and Hygiene Policies

❖ Department of Health Administrative Order No. 2010-0021: Sustainable Sanitation as a National Policy and a National Priority Program of the DOH

DOH AO 2010-0021 was issued on 25 June 2010 declaring sustainable sanitation as a national policy and program priority. The policy is anchored on the principle that sustainable sanitation is a public good and is a fundamental human right. Likewise, it is an essential component of total human development with a focus on the poorest population groups and the poorest barangays, with sensitivity to gender and cultural norms. Under this AO, DOH shall provide sustainable sanitation with adequate support in 1) program planning, implementation, and coordination, 2) capacity building, 3) research & development, 4) knowledge management and advocacy, and 5) monitoring and evaluation. Among the objectives of this AO is a) halving, by 2015, the proportion of the population without sustainable access to drinking water and basic sanitation, b) realizing universal access, by 2028, to safe and adequate sanitary facilities, and c) adoption of local sustainable plans with budgets of all LGUs, by 2022, under their investment plans for health.

❖ Department of Health Administrative Order No. 2014-027: National Policy of Water Safety Plan (WSP) for All Drinking-Water Service Providers

The policy requires all drinking-water service providers to develop Water Safety Plans (WSP) and implement them in managing or operating their water supply systems. The AO's objectives include i) to set a national policy requiring all drinking-water service providers to develop and implement water safety plans, ii) to increase the awareness of the stakeholders on the WSP approach as a management tool to ensure the supply and distribution of clean and safe water, iii) to develop, adopt, and implement systems and procedures for WSP, and iv) to strengthen the capacity of drinking-water service providers and partners in the development and implementation of WSP. Moreover, the AO stipulated that it shall apply to the development and implementation of WSP by all public and private drinking-water service providers that are managing or operating a) Level I, II, or III water systems, b) retail drinking-water service providers (e.g., water refilling stations), c) bulk water systems, and d) mobile water systems.

❖ DOH Administrative Order No. 2017-0010: Philippine National Standards for Drinking Water (PNSDW) of 2017

Administrative Order (AO) No. 2017-0010 of the Department of Health, also known as the Philippine National Standards of Drinking Water of 2017, sets the norms for drinking water quality and for water sampling and examination. This AO applies to all drinking-water service providers. Under this AO, all drinking water service providers are required to regularly monitor the quality of the drinking water in terms of microbiological, physical, chemical, and radiological constituents. The parameters of drinking water quality were further classified as (1) mandatory, (2) primary, and (3) secondary parameters. The minimum frequency of sampling for the different parameters depends on the level and mode of water supply. Analysis of the water samples must only be done by DOHaccredited laboratories.

I. DOH AO 2022-0051: Revised National Policy on Infection Prevention and Control in All Public and Private Health Facilities

The revision of Administrative Order (AO) No. 2016-0002, known as the "National Policy on Infection Prevention and Control (IPC) in Healthcare Facilities," is precipitated by the need to align with the eight (8) core components of the World Health Organization's (WHO) Infection Prevention and Control, formulated in 2016 and developed further in 2019, which arevital in the effective and efficient implementation of IPC program in all health facilities in the country. The health facility shall ensure constant access to a clean and sufficient quantity. of water from an improved source on the premises to allow the performance of basic IPC measures, including but not limited to hand hygiene, environmental cleaning, laundry, decontamination of medical devices, and health care waste management. detailed in the Manual of National Standards in Infection Prevention and Control for Health Facilities (2021) — https://bit.ly/IPCManual3rdEdition

J. DOH AO No. 2017-007: Guidelines in the Provision of the Essential Health Service Packages in Emergencies and Disasters

This AO was issued on 23 May 2017 as a result of gaps found in the capacity and capability of the government in conducting concerted multi sectoral responses to emergencies, including the health system, by several post-Yolanda evaluation workshops and reports. There are identified areas without clear policies, guidelines, and standards that caused ineffective policy implementation and weak coordinating mechanisms hence the need to formalize the guidelines in the provision of essential services and to set standards for the effective, efficient, and timely delivery of essential health services in emergencies and disasters. The guidelines apply to all actors in the health sector, both government and private. Specific AO guidelines included defining essential service components for health, nutrition, WASH, mental health, and psychosocial support that need to be available and accessible before, during, and after emergencies and disasters.

Specifically, for WASH, the AO stipulates that requirements of the general population shall be met primarily through hygiene promotion, water supply, excreta disposal, vector control, solid waste management, and drainage in accordance with national and international standards. It is important to note that these elements are also the priority variables or indicators being targeted by the WASH FIT approach. Proficiency in the application or implementation of the WASH FIT should also prepare hfs and healthcare professionals when disasters or emergencies materialize. The WASH FIT approach may be applied to evacuation centers and other facilities to ensure that WASH needs of affected populations are met and provided or improved to meet norms for health and safety.

K. DOH AO 2021-0032: Implementation of the Philippine Health Facility Development Plan (PHFDP)

To ensure that health infrastructure inputs are available and appropriate to deliver the necessary health services and goods, the Department of Health (DOH) developed the Philippine Health Facility Development Plan (PHFDP), which articulates the required investments for responsive, equitable, and resilient health facilities. Climate-Resilient Health Facility as stated in the AO refers to a health facility that can withstand disasters such as earthquakes and typhoons and has the following features that remain functional: (1) structural and non-structural components, (2) energy source, and (3) water, sanitation and chemical waste management. An electronic copy of the PHFDP is accessible through https://bit.ly/PHFDP2020\_2040.

L. DOH DC 2020-0176: Circulation of the Manual of Standards for Primary Care Facilities

The Health Facility Development Bureau has finalized the Manual of Standards for Primary Care Facilities, which shall serve as a guide for the licensing and regulatory system that will be instituted for Primary Care Facilities. incorporation of the Sanitation and Infection Control for the provision of spaces for Water, Sanitation and Hygiene (WASH) such as, but not limited to, toilets, handwashing facilities, clean up areas, janitor's closet, waste holding area, materials recovery facility among others.

A copy of the Manual of Standards is accessible through http://bit.ly/PCFManualofStandards.

M. DOH DC 2020-0191: Circulation of the Health Care Waste Management Manual 4th Edition

The Health Care Waste Management (HCWM) Manual, 4th Edition. This Manual shall serve as the most comprehensive set of guidelines on the safe management of waste generated from health care activities in the country. The concept of risk management in the hf setting is best defined as the overall approach to identify, assess, and reduce the exposure to hazards of the patients, visitors and health care workers, the hazards being specific to HCW in this aspect. Among its purposes is to identify areas for quality improvement in facilities, including strengthening WASH and infection prevention and control policies and standards that will lead to lower infection rates, better health outcomes for patients and improved staff safety and morale. WASH FIT covers four broad areas: water, sanitation (including HCWM), hygiene (hand hygiene and environmental cleaning), and management. This Manual can be downloaded at http://bit.ly/HCWMmanual4thed.

N. DOH DM 2020-0286: Observance New normal for health facility

This guidance provides guidance on health facilities across the Health Care Provider Network (HCPN) as they transition into the New Normal phase. This includes installation of hand washing facilities or sanitizing stations in common areas and other strategic places such as walkways, entrances and exits, information desks, waiting areas and dining areas and ensure 24/7 availability of soap and running water or alcohol-based sanitizers

2. Overview of WASH FIT

WATER AND SANITATION FOR FACILITY IMPROVEMENT TOOL DEPARTMENT OF HEALTH

Overview WASH FIT 15

WASH FIT is a risk-based approach for improving and sustaining WASH services in healthcare facilities. WASH FIT was adapted from the water safety plan (WSP) and sanitation safety planning (SSP) approach recommended in the WHO Guidelines for Drinking Water Quality and WHO Sanitation and Health Guidelines.

WASH FIT is a multistep, iterative process to facilitate continuous improvements in WASH services, quality, and experience of care. As an effective tool for risk management, it shall be used on a regular basis to first and foremost help health facility staff and administrators prioritize and improve services, and, second, to inform broader district, regional and national efforts to improve quality health care. However, successful implementation of the WASH FIT process can only be realized by creating an enabling environment such as leadership, political commitment, and advocacies that generate awareness on the value of WASH FIT for hfs. The improvement activities will be integrated into the facility's existing efforts on IPC and quality improvement plans.

2.1.Objectives of WASH FIT

The specific purposes of using the WASH FIT are the following:

• To provide a framework to develop, monitor, and continuously implement an improvement plan and prioritize specific actions when resources are limited.
• To identify areas for quality improvement in facilities, including strengthening WASH and IPC policies and standards that will lead to lower infection rates, better health outcomes for patients, and improved staff safety and morale.
• To facilitate the development of an enabling environment by bringing together all those who share responsibility for providing services, including legislators/policymakers, district health officers, hospital administrators, water engineers, and community WASH and health groups.
• To improve the day-to-day management and operation of facilities, by systemizing the process of managing WASH services.
• To engage community members in advocating for and demanding better WASH services and in triggering positive changes in hygiene practices in households.
• To strengthen the adaptive capacity of hfs in reducing and/or eliminating adverse impacts of climate change, health emergencies such as outbreaks, pandemic, AMR, and infectious diseases as well.

2.2.Benefits of WASH FIT

The most important requisites to quality health care are the availability of clean and safe water supply, and proper sanitation, which includes safe disposal of healthcare waste and good hygiene practices among others, all of which are the significant areas of interest in the WASH FIT.

¹⁵ The contents of this section are mostly taken from: WASH FIT. WHO; 2017

The WASH FIT will assess the existing WASH facilities and practices of the hf to determine what are the necessary actions that must be done to improve its services. The findings of the assessment can be used to determine what WASH infrastructures must be upgraded or provided to deliver quality services and what WASH practices of the staff and patients need to be enhanced to reduce possible infections.

Furthermore, the immediate impacts of well-implemented WASH FIT in the healthcare delivery system will be evident in an improved IPC and AMR plan, more efficient use of resources and lower healthcare costs, and improved staff morale and performance. Welldeveloped WASH services will strengthen the resilience of the health care delivery system to prevent disease outbreaks, allow effective responses to emergencies (including natural disasters, outbreaks, and pandemics) brought by climate change, and bring emergencies under control when they occur.

Figure. 1 Impacts associated with WASH FIT¹⁶

WATER AND SANITATION FOR FACILITY IMPROVEMENT TOOL DEPARTMENT OF HEALTH

¹⁶ Water and Sanitation for Health Facility Improvement Tool (WASH FIT). Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.

2.3.Coverage of WASH FIT

The WASH FIT covers four broad areas namely, (1) water, (2) sanitation including health care waste management, (3) hygiene including hand hygiene and environmental cleaning, and (4) management. Each area includes indicators and targets for achieving minimum standards for maintaining a safe and clean environment.

Figure. 2 Coverage of WASH FIT

WASH FIT also integrates streamlining of greening concepts espoused by the DOH in its objective to improve the adaptive capacity of the healthcare delivery system to climate change, wherein WASH is one among the packets of intervention linking health with other sectors impacted by climate change. WASH FIT also includes monitoring indicators for greening activities.

Integration of Greening Initiatives and Climate Considerations into the WASH FIT process

One of the identified issues and challenges in the climate change and health sector of the National Environment and Health Action Plan (NEHAP) 2017-2022 is the inadequate adaptive capacity of the healthcare delivery system to climate change. For the climate considerations in the health care system, two things can be done. The hf may implement improvements to its infrastructures and practices to become climateresilient in response to natural disasters and hazards. Also, the hf must be built and operated in a manner that reduces their harmful impact on the environment and surrounding communities.

With this, the NEHAP had considered it as necessary for the health facility to adopt greening initiatives in their operations to become climate-resilient. The WASH FIT can be implemented in all hfs as a guide on how to be more resilient to the challenges by having competent risk assessment and sustainable improvement plans in all domains of WASH.

Source: National Environment and Health Action Plan 2017-2022

2.4.Intended users of WASH FIT

The following are the intended users of the WASH FIT:

• a. Healthcare facility managers and staff – to make improvements in its WASH services (i.e. facilities and practices).
• b. National and local agencies data collected through the assessment can be used for monitoring and national-level planning.

2.5. Adapting WASH FIT for different hf settings

WASH FIT is primarily designed to be used in primary health facilities that provide outpatient services, family planning, antenatal care, maternal, newborn, and child health services (including delivery). But it can also be adapted for use in any type of hf by modifying the tool to suit their needs to meet quality improvement cycles and mechanisms implemented to improve quality care. However, the broad process and methodology of the WASH FIT should remain the same. To make the best of WASH FIT in different hf types, the following are recommended:

• a. Indicators may be modified to reflect the priorities and standards to be followed.
• Indicators that are not relevant to the facility can be removed and selecting "not applicable" in the response option.
• Additional indicators may be added as necessary, to represent a higher level of service and/or to cover services provided in larger facilities.
• The indicators can be inserted into existing service assessments and monitoring mechanisms used in the facility (e.g., IPC) to make it more doable and less daunting to the team.
• b. Revise assessment design depending on the capacity and/or size of the hf.
• With the limited capacity of primary health facilities and a small budget for improvements, it is more advisable for the facility to focus only on one domain rather than trying to monitor and improve all areas of the facilities at once. The facility must determine which domain (e.g., health care waste) may be prioritized. Once the WASH FIT process is established and the staff feels more confident, WASH FIT can be expanded to address other domains.
• In larger facilities such as hospitals, the assessment can be done by service area (e.g., outpatients, delivery room), wards, or departments rather than by domain. Streamlining

the assessment can help the team in covering all relevant indicators for a given service area, ward, or department in one go.

Figure. 3 The WASH FIT Process**¹⁷**

WASH FIT FRAMEWORK AND TASKS

The WASH FIT process consists of five tasks that must be done sequentially. The main objective of the WASH FIT process is to make improvements to meet the national quality standards. The following sub-sections will discuss in detail the objectives and process of conducting each task. Tools that will be used in performing each task are found in Annex 2.

The WASH FIT team needs to familiarize themselves with the process prior to the walkthrough of the facility, especially with the list of indicators to ascertain its appropriateness and relevance. If the facility has an existing and functioning IPC, it is highly recommended to create a single plan by including the WASH FIT process as part of the plan instead of separating the activity.

¹⁷ The contents of this section are mostly taken from: WASH FIT. WHO; 2017.

2.6.Task 1: Assemble WASH FIT team

The main objective of this task is to create a composite dedicated WASH FIT team that can successfully drive the WASH FIT process. All the team members must be involved in the process and in the joint decision making in implementing the WASH FIT in the facility.

2.6.1. Steps in Assembling the WASH FIT Team

1. Engage senior management support. Support from senior management is an important component in successfully implementing the WASH FIT. Management support is crucial in

Typical Challenges:

Adequacy of personnel Organizing the workload to fit into the WASH FIT activities Engaging stakeholders Maintaining a consistent and effective communication between the WASH FIT team members Scheduling regular meetings of the WASH FIT team together and sustaining initiatives

making changes to work practices to align with WASH FIT initiatives and in the provision of financial and logistical resources when necessary.

The WASH FIT team can be integrated into the other existing teams in the facility such as in the IPC, quality improvement, health care waste management, and multi-sectoral planning committees. Additional members with WASH expertise may be added to the existing team.

2. Identify the team members based on the required expertise. Team members must understand the importance of water, sanitation, and hygiene in preventing and controlling infections in the facility. The team members must also be collectively aware of the potential WASH risks and hazards based on their expertise and should possess the skills to decide on appropriate improvement plans.

The participation of the operational staff and key personnel that are responsible for the vital operations of the facility is important to have a successful adoption of the WASH FIT and the formulation of sustainable improvement programs.

Considerations in choosing team members

• ●Involve diverse people with a range of experiences with WASH and IPC to contribute to better problem-solving and a range of potential solutions for WASH improvement issues in the facility.
• ●Involve the cleaning and maintenance workers because they are familiar with the ins and outs of the facility infrastructure, how WASH services are used, and which WASH sites and products are most or least used in a facility.
• ●Involve female¹⁸ staff in the facility, their perspective would ensure women's needs are met and included in the plan.

¹⁸ Where feasible, women should comprise 40% of team as suggested in Republic Act (RA) No. 9710 or the Magna Carta of Women of 2009.

●Consider involving the participation of external stakeholders and partners. This is for additional support, especially in small healthcare facilities. Involving external stakeholders will contribute to the overall health system improvement.

RECOMMENDED WASH FIT DESIGNEE/TEAM COMPOSITIONS
Primary Care Facility19	Hospital20
Head of the facility (as Team Leader) -	Chief /Medical Director (as Team -
Health Care Worker/s -	Leader)
Maintenance and/or cleaning personnel -	Facility Administrator -
	Head of Engineering and maintenance -
	Member/s of the IPC Committee
	Pollution Control Officer (PCO) or -
	Waste Management Officer (WMO)

HF Stakeholders (For Consideration as external members)

• Local government unit (LGU)/ LDWQMC representative
• A representative from non-government organizations (NGOs) or professional organizations related to public health interest
• Local WASH experts/representative from the academe/representative from medical or allied medical schools
• Representative from Water Districts/ Water Suppliers
• 3. Appoint a Team Leader. A team leader must be appointed to drive the activities and ensure focus. The leader should have the authority, organizational and interpersonal skills to ensure that WASH FIT plans are implemented and sustainable.

Responsibilities of the WASH FIT Team Leader

• Establish the vision and commitment of the team to implement the WASH FIT plan into the day-to-day operations of the hfs.
• Ensure that specific tasks and tools are being completed correctly and in a timely manner.
• Ensure that meetings are held on a regular basis and decisions are acted upon to drive the WASH initiatives and action plans to improve health outcomes for the facility.
• Expand WASH FIT adaptability by recruiting personnel with skills or expertise compatible to address emerging issues that may arise in the facility such as new pathogens and contaminants.
• Explore opportunities for external support to improve the skills of the WASH FIT team through benchmarking, partnering with an organization with resources to share, knowledge, and expertise.

¹⁹Primary health facility includes urban/rural health unit, barangay health station, medical outpatient clinic, medical facilities for overseas workers and seafarers, dental clinic and birthing homes (DOH HCWM Manual 4th ed)

²⁰Hospital includes general hospital (Level 1, 2 and 3) and specialty hospital (DOH HCWM Manual 4th ed)

4. Define the roles and responsibilities of the individual team members. The roles and responsibilities of the team members must be defined at the start of the process of the WASH FIT.

Tool 1A will be used to record the member of the WASH FIT team, their roles and responsibilities and their contact details.

Responsibilities of the WASH FIT Team Members

• Identify and evaluate the potential WASH hazards and risks in the facility.
• Use the WASH FIT to inspect and assess the state of infrastructure, services, maintenance, and management of the facility including behaviors or practices of staff, patients, and family visitors within the premises of the hf.
• Attend regular team meetings to discuss reports, findings, potential, and emerging health problems.
• Identify and prioritize actions and projects necessary to improve WASH in the facility.
• Agree on the decision-making process and communication methods as means in keeping track of completed tasks, analyzing key challenges, and prioritization of actions

Responsibilities of the WASH FIT Team Stakeholders

• Provide technical expertise on WASH FIT methodologies, management, and the use of new tools and technologies.
• Assist in the regular monitor, report, and review of indicators of WASH FIT in the facility.
• Assist in capacity-building for competent staff in WASH FIT
• Assist in mobilizing resources to help sustain WASH FIT in the healthcare facility and improve the quality of health services.
• Attend regular meetings of the WASH FIT team.

5. Define the time frame for the implementation of the WASH FIT. The WASH FIT team must be committed to meet regularly and to sustain the implementation and monitoring of the improvement plan of the facility.

Regular communication between team members is important in completing the tasks, identifying and addressing key challenges, and setting priority actions for the time between meetings. The team must set the frequency and schedule of their regular meetings. It will also be useful for the team to agree on decision-making processes and communication methods (e.g., minutes of the meeting, reports, etc.).

Tool 1B will be used by the team as meeting record sheet to document the progress and key decisions made every WASH FIT meeting. The team must write in this sheet the key issues discussed in the meeting, the decisions made and action points at each meeting.

2.7.Task 2: Assess the existing WASH facilities and practices in the hf

The objective of the task is to assess the current WASH facilities and practices in the hf based on the local and national standards as a starting point for making improvements. The WASH team will conduct a detailed assessment by doing a walk-thru of the facility.

2.7.1. Steps in the conduct of facility assessment

1. Review and finalize relevant indicators in the assessment form. In this particular task, the team shall use Tool 2A which contains the list of indicators for each domain of the WASH FIT.

The team must decide which indicators are applicable according to the level and size

do not apply to their facility.

Typical Challenges:

Availability and accuracy of relevant information

Lack of familiarity on WASH FIT process Lack of understanding on the importance of water, sanitation hand hygiene and hygienic practices to prevent and control infections. Time required by staff to undertake walk through

Important components that must be looked into during the assessment:

WASH infrastructure and condition of the facility

Availability of IECs and contents of hygiene promotion materials

WASH and IPC guidelines and budget Staff behaviors in observing protocols, rules and regulations

Patient behavior and family visitation protocols

Tool 2A: WASH FIT Philippines Version

of the health facility that will be assessed. The team may opt to skip the indicators that

• The global version of Tool 2A: Indicators Assessment has been modified by DOH, WHO, and UNICEF to integrate national standards for health facilities and prioritized those that are related to IPC measures for COVID-19.
• This includes the minimum required indicators to be assessed, regardless of the size of the hf. However, the team has the option to expand their indicators if conditions may warrant the inclusion of more.
• The forms are available in a digital format designed by WHO and UNICEF. These are downloadable and can be printed as a hardcopy for use during the walk-through assessment, but the final report shall be in the digital format. You may also access the WASH FIT Assessment Form through this link https://bit.ly/WASHFIT-Form2022
• The standards per indicator are also defined in this tool and will be used as the basis for rating.
• Guidance notes for each indicator were also provided in the tool. The team may refer to the guidance notes to help them to correctly assess the indicators.
• For computing the Water requirements, may refer to the developed water calculator for health facilities through this link https://bit.ly/WATERcalculator

Sample Indicators that may be Added
WATER	● All faucets/taps/ point of use have appropriate signs to indicate for drinking and/ or for washing only warning information ● Water is treated using approved treatment methods and technology prior to collection and use. ● The water has been tested for the mandatory parameters of the PNSDW 2017 and compliant to the water quality requirements.
HEALTH CARE WASTE	Waste bins and bags are properly labeled indicating date, ● type of waste, and point of generation Ensure that facilities for disposal of menstrual hygiene ● products are available in a private, hygienic place and that disposal systems are functional. ● Dedicated trolleys for infectious and non-infectious wastes are available during on-site collection and transport to storage.
MANAGEMENT	● A Water Quality Monitoring Plan is applied regularly to monitor the water quality of the facility in compliance to the PNSDW 2017 ● The facility adopts greening policies and programs to mitigate contribution to adverse climate change and environmental degradation. ● The facility observes energy conservation by utilizing low energy lighting systems (LED), use some form of renewable energy (ex. solar panels) and equipment that are energy efficient.

2. Conduct a comprehensive assessment of the existing WASH facility and practices.

The team will conduct a physical inspection of the entire facility to assess all WASHrelated areas using the agreed indicators. The team must be able to assess all the areas (rooms/wards/departments) of the hf including consultation rooms, outpatient and inpatient services, and waiting areas.

The team may ask questions from the people assigned to work in the area being assessed, however, generating positive or negative responses must be avoided. The team must also take pictures of the facility which can be useful during reviews as well as in doing time-series comparisons whether improvements have been affected.

3. Rate the indicators according to compliance with local and national standards. The team shall rate each indicator whether the facility has met the local and/or national standards defined in Tool 2A. The indicator must be rated whether it meets, partially meets, or does not meet the defined minimum standards. If an indicator did not meet the standard, the team must take note of the information or the reason for that rating.

Rating
2	Meets minimum standards
1	Partially meets minimum standards
0	Does not meet minimum standards

Some indicators would require calculations to be made and may need external information or support (i.e., water storage requirement versus capacity). The team must record the raw data used in the computation to be able to refer back to them later.

After the assessment, the team must review the forms to ensure that the information is clear and correct and that all the team members agree with the ratings.

4. Conduct a sanitary inspection (SI) or sanitary survey. Using the sanitary forms (Tool 2B), the team may conduct a sanitary inspection around the facility to determine the level of risk from water and sanitation sources at the facility. This activity may be considered optional for some healthcare facilities however, this activity may contribute to the correctness of the information used to rate some of the indicators for water and sanitation.

Tool 2B has five different SI forms. The team must only use the appropriate form based on the type of the water system used in the facility.

The questions in the SI forms must be answered with a "yes" if the team assesses that there is a potential risk and with a "no" if none or if there is a very low potential risk. After the risk assessment, the team must determine the overall risk score of the facility by counting the total number of questions with "yes" answers and categorize the level of risk of the facility using the computed risk score.

Level of Risk	Risk score
Very high risk	9-10
High risk	6-8
Medium risk	3-5
Low risk	0-2

5. Record the findings and schedule the re-assessment. The overall WASH FIT rating of the facility will determine the action required for the team to address the indicators that are not meeting the minimum national standards. It can also be used to compare the improvements in the WASH facilities over time.

The team must take note of the indicators that scored one and zero to come up with an improvement plan and to guide the team in implementing the plan. The team must also schedule the re-assessment based on the overall rating:

Figure. 4: WASH FIT Rating

RATING	DESCRIPTION	What does your rating mean?	When is the next assessment?
NO STAR	At least one of the national indicators are not meeting the minimum standards	Critical changes needed immediately	Do another assessment after 3 months
ONE STAR	50% of the national indicators are at least partially meeting minimum standards With at least one advanced (global) indicator partially meeting minimum standards	Continue making improvements	Do another assessment after 6 months
TWO STAR	100% of national indicators are fully meeting minimum standards With at least 31% of advanced (global) indicators fully meeting minimum standards	Minimum WASH standards met! Continue making improvements.	Do another assessment after 12 months
THREE STAR	100% of national indicators are fully meeting minimum standards With at least 75% of advanced (global) indicators fully meeting minimum standards	Congratulations! Maintain this rating.	Do another assessment after 12 months

2.8.Task 3: Undertake hazard and risk assessment

In this task, the team will be conducting a hazard and risk assessment to identify what actions must be done for the improvement. The team will identify WASH-related hazards or problems based on the assessment conducted and the potential risks that these hazards present to staff, general patients, pregnant mothers, newborns, caregivers, and possibly the community. After identifying all the hazards and risks, the team will evaluate the level of risks and how difficult it will be to address the problem.

A hazard is defined as a "condition, event or circumstance that could lead to or contribute to an unplanned or undesirable event." It may also be referred to as a problem. Any indicators that do not meet the target should be considered a potential hazard.

A risk is the potential of a set of unwanted circumstances or events occurring as the result of the hazard. All hazards have associated risks.

2.8.1. Steps in undertaking hazards and risk assessment

Typical Challenges:

Possibility of missing new hazards (problems) and risks associated with it. Uncertainty in risk assessment due to unavailability of data, poor knowledge of WASH practices of the facility and their relative contribution to the hazards generated.

Properly identifying degree of seriousness of the hazard and inconsistent or subjective assessment. Limited opportunity for collaboration with key stakeholders in the process of deciding which problems are of utmost importance.

• 1. Review all the information collected from Task 2. Prior to the hazard identification and risk assessment, the team must review the results of the assessment from Tool 2A and must take note of all the indicators that were scored with 1 and 0.
• 2. Identify and record specific hazards (problems) and associated risks. For every indicator that was scored with 1 and 0, the team must define the hazards and list all the risks associated with each hazard.

Considerations in identifying potential hazard/problems

• ●Problems can be related to infrastructure, operations and maintenance, to a shortage of manpower or inadequate budget.
• ●Problems could be one-off occurrences or long-term issues.
• ●Problems may also be from the constraints of the facility in addressing issues arising from emerging pathogens and infectious diseases, pandemics, AMR, effects of climate change, and increased burden of healthcare waste disposal during disasters and the like.

For every potential hazard or problem, the team must also identify all the potential risks of the hazard to the hf staff, patients, visitors, and the community. The team needs to identify as many associated risks corresponding to the specific hazard as may be determined because it will aid in evaluating the degree of seriousness of the problem.

The team must record the detailed description of the identified hazard including its corresponding WASH indicator number (as listed in Tool 2A) and the risks associated with it using Tool 3.

Tool 3 provides a table that will be used for this task. This tool can be used to record the identified hazards and risks of each WASH indicator. It also contains the grid box that will be used in categorizing the hazards and risks in terms of level of risk versus feasibility of addressing the problem. The team must also record in this tool the actions that will be undertaken to minimize the risks of the hazards.

3. Conduct hazard and risk assessment. The hazards and risks will be categorized according to the seriousness of the risk associated with the hazard/problem and on the degree of difficulty in addressing the problem. This type of categorization involves the use of a grid master or "window-type" box in which problems are plotted according to the difficulty to address the problem versus the level of risk under each quadrant. This will provide a visual way to help the team prioritize the actions to be taken.

Determine the seriousness of the hazard and risk. The risks will be classified (i.e., as high, medium, low, and unknown risk) based on the degree of its effect on the exposed public. The team may create their own risk classification and its

Risk	Definition
High Risk	The hazard/problem very likely results in injuries, acute and/or chronic illness, infection, or an inability to provide essential services. Immediate actions need to be taken to minimize the risk.
Medium Risk	The hazard/problem likely results in moderate health effects, discomfort, or unsatisfactory services, for example, unpleasant odors, unsatisfactory working conditions, minor injuries. Once the high risks issues are addressed, actions should be taken to minimize medium level risks.
Low Risk	No major health effects anticipated. These risks should be addressed as resources become available and should be revisited in the future as part of the review process.
Unknown Risk	Further information is needed to categorize the risk. Some action should be taken to reduce the risk while more information is gathered.

Assessing the level of risk for each problem is context-specific and there is no right or wrong answer. The risk assessment should be undertaken by several individuals within the team to increase the validity of the risk assessment. The team members should share their conclusions on the levels of risk so that an overall risk rating can be arrived at.

Hazard and Risk Categorization using Window-type box

Using the "window type" box below, plot each hazard identified in terms of levels of risk vs. feasibility of addressing the problem. The corresponding indicator number can be used to represent the hazard when plotting in the grid.

Top Left Quadrant - represents problems that are low risk, difficult to address. Top Right Quadrant - represents problems that are high risk, difficult to address. Bottom Left Quadrant - represents problems that are low risk, easier to address. Bottom Right Quadrant- represents problems that are high risk, easier to address.

a. Evaluate the level of difficulty to address the problem/risk. The team must weigh the level or seriousness of the problems/risks in relation to how easy or difficult it will be to act on it. Some hazards may be easier to address than others depending on the resources currently available and/or the time it will take to fix a problem. The facility users should also be considered in the evaluation since risks to public health will vary depending on how often an issue or problem would arise and the severity of the consequences when they materialize.

4. Develop actions to be undertaken. The team must determine and agree on the improvement actions that need to be undertaken to resolve or limit the risks of the identified hazard or problem. The team must ensure that the action plans are aimed towards eliminating or reducing the specific hazard or problem. The agreed actions can be undertaken either locally or at the district/regional level (see Tool 3)

WASH improvement actions that may be considered

• Improving management method
• Building of new infrastructure or repairing existing infrastructure
• Provision of training to staff; building capacities of staff
• Developing standard operating procedures or enhancing existing operational procedures to improve personnel behaviors and/or facility effectiveness and efficiency
• Undertaking community consultation programs
• Research and development
• Developing incident protocols
• Better communication and reporting

Example 1: Sample Hazard and Risk Assessment

Hazard	Hazards (problems)	Risks	Level of risk Actions
Ref No.				Facility/Community	Local/National
WATER
W1	1.1 Birthing room has no piped water supply as a means to wash patients and rely on water supply from refilling stations that have not been regularly tested for water quality.	High	The hazard/problem very likely results in acute and/or chronic illness, infection. Immediate actions need to be taken to minimize the risk.	Install piped water supply from a local water supplier.	The LGU will assist in facilitating the application from the local water district.
W2	1.1 The water supply source for cleaning and washing is affected by turbidity problems especially when it rains.	Medium	The hazard/problem likely results in moderate health effects, discomfort, or unsatisfactory services.	The facility will have an appropriate budget for a piped water supply.
W3	1.2 The bathroom has no sufficient water supply, and is available less than 24 hours.	Low Risk	No major health effects anticipated. These risks should be addressed as resources become available.	Will be addressed once piped water is provided to the facility.

assessment
Hazard	Hazards (problems)	Risks	Level of risk	Actions
Ref No.				Facility/Community	Local/National
	SANITATION
S1	2.9 There is no proper drainage system to prevent ponding of water in the vicinity of the facility during heavy rain.	Medium	The hazard/problem likely results in moderate health effects especially in the neighboring community, discomfort, and unsatisfactory working conditions, minor injuries.	Appropriate budget for the repair and installation of a proper drainage system in the vicinity.
S2	2.3 There is only one common toilet for men and women in the facility	Unknown Risk	Further information is needed to categorize the risk.	Proposal and design for separate toilets
HEALTH CARE WASTE
HM1	2.11 Lack of staff training: The staff assigned to collect and dispose of the healthcare waste has not been trained on how to properly handle, dispose, and disinfect as required.	High	The hazard/problem very likely results in acute or chronic disease due to infections from exposure to harmful HCW. The staff may also inadvertently cause the spread of contaminants within the facility.	Implement regular training of staff on HCW management and infection prevention and control.
HM2	2.17 The healthcare wastes are placed in temporary storage but has not been properly	High	The hazard/problem will likely result in injuries, acute or chronic illness for waste disposable staff	Re-design the temporary storage to allow separation of HCW by categories

assessment
	Hazard Hazards (problems) Risks Level of risk		Actions
Ref No.				Facility/Community	Local/National
	separated by categories.		due to exposure to improperly stored hazardous wastes
HAND HYGIENE
HH1	3.3 There are no hand hygiene stations within the facility to help visitors, staff, and patients sanitize or wash their hands.	High	The hazard/problem will likely result in acute or chronic illness due to cross and nosocomial infections.	Installation of handwash/hygiene stations in all important areas
HH2	3.19P Some essential personnel in the facility were unable to demonstrate proper handwashing techniques	High	The hazard/problem will likely result in acute or chronic illness as personnel may help spread cross and nosocomial infections thru contaminated hands.	Training of staff on proper handwashing technique and IPC
HH3	3.5 Hand hygiene promotion materials and instructions were not visible in important areas.	Low	No major health effects are anticipated but may result in a lack of information to prevent the spread of infection.	Putting up instructional materials in prominent locations within the facility.

Hazard	Hazards (problems)	Risks	Level of risk	Actions
Ref No.				Facility/Community	Local/National
	ENVIRONMENTAL CLEANING
EC1	3.9 There is an insufficient supply of cleaning and disinfection chemicals which results in occasional failure to perform proper disinfection.	High	The hazard/problem very likely results in infection from contaminated surfaces causing acute or chronic infections. Contaminated surfaces may also render the facility unable to deliver the essential services.	Propose an additional budget for WASH materials and chemicals.
MANAGEMENT
M1	4.1 Absence of HCW Management Plan. There is no strict practice in healthcare waste management as used vials from vaccines were disposed of with the general wastebasket.	High	The hazard/problem very likely results in contamination and injuries to staff and municipal waste disposal personnel collecting general waste.	Develop and implement a Healthcare Waste Management Plan
M2	4.4 There is no regular cleaning schedule for the toilets due to lack of available staff	Medium	The hazard/problem likely results in moderate health effects, discomfort, or unsatisfactory services due to unpleasant odors and working conditions.	Hiring of additional cleaning personnel	Approve budget request for more staff

2.9.Task 4: Develop an Improvement Plan

Considering the hazards identified and levels of risks being faced, the team must decide what improvement actions must be prioritized when formulating the improvement plan.

The team must be able to recommend a detailed action plan outlining what improvements will be made within a given timeframe, who will be responsible, and the proper allocation of resources.

Typical Challenges:

Ensuring the WASH FIT is up to date Ensuring the availability of resources to carry out the action plan within the given timeframe.

Availability of funds Lack of human resources including technical experts to implement some upgrades

2.9.1. Steps in the development and implementation of improvement plans

• 1. Review the actions agreed in Task 3 and decide what actions are to be implemented. From the agreed improvement actions in Tool 3, the team must determine what actions are feasible to be implemented at a specific given time and available resources. The following may be considered in deciding what actions may be implemented:
  • the level of difficulty or ease with which the improvements can be made
  • availability and technical capability of personnel responsible to implement the improvement actions
  • financing and capital works
  • effectiveness of the proposed action in eliminating or reducing the hazard
  • consider short-, medium- and long-term plans of the facility
• 2. Develop an improvement plan. Using Tool 4, the team must develop the improvement plan of the hf. The recommended improvement actions must be clear, specific, and realistically achievable. The improvement plan must also include the following:
  • person/s or group/s responsible for implementing the actions
  • the activities and resources required to accomplish the plan
  • expected date of completing the action
  • actual date of completion of the action

Tool 4 shall be used to record the improvement plan of the facility. It shall include (1) the specific WASH improvement actions to be taken to eliminate or reduce the hazards, (2) the persons or groups who will be responsible in implementing each action, (3) the resources (e.g., staff, technical, or financial) needed to implement the action, (4) the deadline or expected date for completing the actions, (5) the budget needed and (6) the source of funds. Once the activity has been completed, the team must also record the actual date of completion in the tool.

The improvement plan can be used to seek additional help or support from external donors that is why it is important for the plan to be detailed and complete.

3. Finalize and have the improvement plan approved by the person/s or group/s in authority. The improvement plan should be approved by the head of the hf or the group in authority. The improvement plan must be supported by the top management to ensure that the required resources will be provided.

Example 2: Sample Improvement Plan

Hazard Ref No.	Improvement Action/s	Responsible group/person	Resources needed	Budget	Source of Funds	Target date of completio n	Actual date of completion
W1/W2/W3	Install piped water supply from a local water supplier	COH / Head, Maintenance Div.	Application fee Pipe materials (GI or PE)	Application fee @php 4,500 Pipe materials (GI/PE) lump sum @ Php 20,000	Part of annual budget	3 rd quarter of 2021
HM1	Implement regular training of staff on HCW management and infection prevention and control.	HRD/ COH/ WASH FIT Team	Training materials / Trainor's fee/ venue	Php 1,200/staff @ 50 participants Php 60,000	Annual training budget	2 nd quarter of 2021
HM2	Re-design the temporary storage to allow separation of HCW by categories	Head, Maintenance Div.	Marine plywood / others/ carpentry materials	Marine plywood @php 1,800/board x 8pcs Php 14,400 Other support woods php 4,000	Special fund request from General Services Div.	nd 2 week of September 2020
HH1	Installation of handwash/hygie	Head, Maintenance Div.	Portable sink with fixtures/ Liquid soap/	Portable sink with fixtures @ php 3,500/set x 5 areas	CAPEX for IPC	th quarter 4 of 2020

plan

Hazard Ref No.	Improvement Action/s	Responsible group/person	Resources needed	Budget	Source of Funds	Target date of completio n	Actual date of completion
	ne stations in all important areas.		Disinfectant dispenser/ Alcohol 70%	Php 17,500 Disinfectant dispenser @php 1,200/pc x 10 stations Php 12,000 70% Alcohol @ php 500/gal.x 10 Php 5,000
M1	Develop and implement a Healthcare Waste Management Plan	COH /IPC/WASH FIT Team	NA	NA	NA	st 1 quarter of 2021

2.10. Task 5: Monitor progress of improvement plans

The progress of the improvement plan towards reaching the target indicators for each WASH domain must be continually monitored by the team. The monitoring activities can be incorporated into the regular tasks of the team members.

The team must be able to set standards in monitoring using quantitative and/or qualitative methods and the frequency of performing such in

Typical Challenges:

Lack of sufficient human resources to carry out monitoring Inadequate or absent evaluation of data Changing the attitude of staff members with regards to monitoring and review of action plans

Ensuring new hazards/problems are introduced in the improvement plan

assessing the extent of accomplishments of improvement plans. The team may make changes to the plan as necessary to keep progress on track.

2.10.1. Steps in Monitoring and Revising of Improvement Plans

1. During the regular meetings scheduled by the team in Task 1, the team must review the improvement plans and determine how far the actions are from completion.

Questions to consider in reviewing WASH FIT Improvement Plans

• Are there any new team members since WASH FIT began?
• Do existing team members need a refresher or more detailed technical training?
• Is additional support from other partners required?
• Is the information in the assessment up to date?
• Has the facility changed in any significant way since the last assessment was conducted?
• What has hindered progress and why?
• Are there new hazards and associated risks?
• What improvement actions have already been completed?
• What targets have been reached?
• What have been some of the greatest successes? What remains challenging?
• Should other improvements be prioritized?
• 2. The results of monitoring activities (e.g., observations) must be discussed at each team meeting to allow the team members to provide feedback on the different responsibility areas. If little or no progress has been observed, the team should review the plan and brainstorm ideas to address any problems and determine what further steps are needed to ensure that planned actions are completed within the estimated timeframe.

Using Tool 4, the team must record any revisions made to the plan and what additional efforts are needed to improve the implementation of the action.

3. If monitoring reveals that new problems have arisen, the team should conduct a risk assessment for the new problems, put them into context with the existing problems being addressed, and re-prioritize all problems, as necessary. The team should also revisit the improvement plans and revise, as necessary.

3. WASH FIT Web Application

WATER AND SANITATION FOR FACILITY IMPROVEMENT TOOL DEPARTMENT OF HEALTH

WASH FIT Web Application

The UNICEF Philippines develops the WASH FIT Application. The portal can be access in web browser through this link: https://ona.io/login.

The UNICEF will be providing guidance for the WASH FIT Web Application guideline as a for the portal.

Figure. 5: Sample of WASH Fit Portal

4. References

• Civil Service Commission Memorandum Circular (MC) No. 33, s.1997

• DENR Administrative Order (DAO) No. 2013-22: Revised Procedures and Standards for the Management of Hazardous Wastes

• Department Health Administrative Order No. 2012-012: Rules and Regulation Governing the New Classification of Hospitals and Other Health Facilities in the Philippines

• Department of Environment and Natural Resources Administrative Order No. 2005- 10: Implementing Rules and Regulations of The Philippine Clean Water Act

• Department of Environment and Natural Resources Administrative Order No. 2016- 08: Water Quality Guidelines and General Effluent Standards of 2016

• Department of Health Administrative Order No. 2010-0021: Sustainable Sanitation as a National Policy and a National Priority Program of the DOH

• Department of Health Administrative Order No. 2014-027: National Policy of Water Safety Plan (WSP) for All Drinking-Water Service Providers

• Department of Health Administrative Order No. 2016-002: National Policy on Infection Prevention and Control in Healthcare Facilities

• Department of Health Circular No. 2016-042: Guidelines in the Application for Department of Health Permit to Construct

• Department of Health Circular No. 2018-0103: Revised Licensing Assessment Tools for Hospitals

• Department of Health Department Circular No. 2019-0059: Green Certification of Government health facility Projects

• DOH Administrative Order No. 2017-0010: Philippine National Standards for Drinking Water (PNSDW) of 2017

• DOH AO No. 2017-007: Guidelines in the Provision of the Essential Health Service Packages in Emergencies and Disasters

• Implementing Rules and Regulations of PD 856 Chapter 17: Sewage Collection and Disposal, Excreta Disposal and Drainage (1995)

• Implementing Rules and Regulations of PD 856 Chapter 18: Refuse Disposal (1998)

• Implementing Rules and Regulations of PD 856Chapter 20: Pollution of the Environment (1998)

• Joint DENR-DOH Administrative Order No. 2005-02: Policies and Guidelines on Effective and Proper Handling, Collection, Transport, Treatment, Storage and Disposal of Health Care Wastes

• Philippine Green Building Code

• Presidential Decree No. 856: Code on Sanitation of the Philippines

• Republic Act No. 7160: Local Government Code of 1991

• Republic Act No. 11223: Universal Health Act

• Republic Act No. 4226: Hospital Licensure Act

• Republic Act No. 6969: Toxic Substances and Hazardous and Nuclear Wastes Control Act of 1990

• Republic Act No. 9275: The Philippine Clean Water Act of 2004

• Water and Sanitation for Health Facility Improvement Tool (WASH FIT). Geneva: World Health Organization; 2017.

• Water, sanitation and hygiene in health facility: practical steps to achieve universal access. Geneva: World Health Organization; 2019.

• World Health Organization and the United Nations Children's Fund, WASH in health facility: Global Baseline Report 2019, WHO and UNICEF, Geneva, 2019.

Annex 1: Other Technical Guides on WASH in HF

Guideline	Links
Water
WHO Water Safety Plan, 2009	https://www.who.int/water_sanitation_health/publications/publication_9789241562638/en/
WHO Climate-resilient Water Safety	https://www.who.int/water_sanitation_health/publications/climate-resilient-water-safety
Plan, 2017	plans/en/
Sanitation
WHO Sanitation Safety Plan	https://www.who.int/water_sanitation_health/publications/ssp-manual/en/
Health Care Waste Management
WHO Safe Management of Wastes	https://www.who.int/water_sanitation_health/publications/safe-management-of-wastes-from
from Health-care Activities (2nd edition),	healthcare-activities/en/
2014
WHO Essential Environmental Health	https://www.who.int/water_sanitation_health/publications/ehs_hc/en/
Standards in Health Care, 2008
WHO Guidelines on Sanitation and	https://www.who.int/water_sanitation_health/publications/guidelines-on-sanitation-and
Health, 2018	health/en/
WHO/WED Technical Notes for WASH	https://www.who.int/water_sanitation_health/publications/technotes/en/
in Emergencies, 2013
Climate Change Adaptation/Greening in hf
UN Initiative on Greening Procurement	https://www.who.int/phe/publications/greening-procurement-in-the-health-sector/en/
in the Health Sector for Products to
Services, 2013
WHO Climate Change and Health: A	https://www.who.int/phe/publications/greening-procurement-in-the-health-sector/en/
Tool to Estimate Health and Adaptation
Costs, 2013
PAHO/WHO LED Lighting in Hospitals,	https://www.paho.org/en/documents/smart-hospitals-led-lighting-hospitals
2020

Guideline	Links
PAHO/WHO Rainwater Harvesting for	https://www.paho.org/en/documents/smart-hospitals-rainwater-harvesting-smart-health-care
Smart Healthcare Facilities, 2020	facilities
PAHO/WHO Smart Hospitals Toolkit,	https://www.who.int/publications/i/item/smart-hospitals-toolkit
2017
Pandemic Response/Emerging Disease
WHO Water, Sanitation, Hygiene and	https://www.who.int/publications/i/item/water-sanitation-hygiene-and-waste-management-for
Waste Management for the COVID 19	the-covid-19-virus-interim-guidance
Virus: Interim Guidance, 2020
Infection Prevention and Control for	https://www.who.int/publications/i/item/infection-prevention-and-control-for-long-term-care
Long Term Care Facilities in the	facilities-in-the-context-of-covid-19
Context of COVID-19, 2020
Cleaning and Disinfection of	https://www.who.int/publications/i/item/cleaning-and-disinfection-of-environmental-surfaces
Environmental Surfaces in the Context	inthe-context-of-covid-19
of COVID-19, 2020

Annex 2: WASH FIT Tools Template (Tool 1A WASH FIT Team)

TEAM LIST
Date:

NAME	ORGANIZATION	JOB TITLE	ROLE IN THE WASH FIT	RESPONSIBILITI ES	CONTACT DETAILS

		Date of Meeting:
		Time:
Name of Team	Key Issues	Decisions/Outcomes/Actions	Responsible	Timeline
Members Participating	Discussed

WASH FIT Operations Guidelines and Standards Annexes

Tool 2A.1 WASH Assessment Link: https://bit.ly/WASHFITexcel

WASH FIT INDICATO R reference	INDICATOR (WASH FIT)	Score = 2 Meets minimum standard	Score =1 Partially meets minimum standards	Score = 0 Does not meet minimum standards	SCORE Please put NA if indicator is not applicable	Remarks/Note s
			WATER
1.15P	Improved DRINKING water supply piped into facility or on premises	Improved water supply within facility and available	Improved water supply on premises (or outside of facility building) and available	No improved water source within facility grounds, or improved supply in place but not available
1.1	Improved water supply piped into facility or on premises, with no leaks	Improved water supply within facility and available, with no leaks	Improved water supply on premises (outside of facility building) and available, with no leaks	No improved water source within facility grounds, or improved supply in place but not available
1.2	Water services available at all times and of sufficient quantity	Water services available every day and of sufficient quantity	Water services available more than 5 days per week or every day but not sufficient quantity	Water services available fewer than 5 days per week

1.3	Reliable drinking water	A reliable drinking	A reliable drinking	A reliable drinking
	station available	water station is	water station is	water station is not
		present at all times	present sometimes,	available
		and locations and	or only in some
		accessible to all	places or not
			available for all users
1.4	Drinking water safe	Yes, all available	Some of the available	Drinking water points
	storage and has no E.	drinking water is	drinking water points	are not safely stored or
	Coli	safely stored with	are safely stored.	no drinking water
		cover and tap, and is		available.
		free of E. Coli
1.8	Water storage is	Yes, water storage is	Water storage meets	Water storage meets
	sufficient	sufficient to meet the	more than 75% of the	less than 75% of the
		needs of the facility	needs of the facility	needs of the facility for
		for 3 days	for 3 days	3 days
1.10	Water supply has	Yes, water supply has	Water supply has	Water supply is not
	appropriate disinfectant	appropriate chlorine	chlorine residual, but	treated/do not know
	residual	residual	is less than 0.3mg/l	residual/do not have
			for a normal setting	capacity to test
			or less than 0.5mg/l	residual/ no drinking
			for an emergency	water available/ no
			period	chlorine residual
				expected in our
				drinking water source
1.12	Sufficient energy for	Yes, sufficient energy	Yes, sufficient energy	No, sufficient energy is
	water	is always available for	is sometimes	never available for
		pumping and boiling	available for pumping	pumping and boiling
		water	and boiling water	water

	WASH FIT Operations Guidelines and Standards				Annexes
1.13	Shower and bathing areas accessible and functioning	Yes, shower or bathing area is available, functioning, accessible and following minimum number appropriate for our facility	Showers are available but not meeting minimum number of showers	No showers are available; or there are showers available but are not functional and needs repair
			SANITATION
2.1	Sufficient number of functional toilets or latrines available	Meets minimum number of toilets or latrines per type of health facility as indicated in the guidance notes and, all are functional	Sufficient number of usable toilets or latrines present but not all functioning; or insufficient in number	Less than 50% of required number of usable toilets or latrines available and functioning
2.2	Toilets or latrines separated for staff, patients, and visitors	Yes, toilets or latrines are clearly separated for staff and patients and visitors	Some separate toilet or latrines but not for all three categories (staff, patients and visitors)	No separate toilet or latrines; or, no space to add another toilet
2.3	Toilets or latrines separated for male and female	Yes, toilets or latrines clearly separated for male and female	N/A	No indication of gender separation for toilets or latrines
2.4	Menstrual hygiene management	Yes, all toilets or improved latrines for female use provide the means to manage menstrual hygiene needs	Yes, at least one toilet or improved latrine provides the means to manage menstrual hygiene needs	None of the toilets or latrines provide the means to manage menstrual hygiene needs

		Meets minimum	Yes, there are toilets	No toilets for users
		number of toilets for	for people with	with reduced mobility;
2.5		people with reduced	reduced mobility but	or there are available
2.5	Toilet meeting the	mobility as indicated	not all are functional	toilets for them but all
	needs of people with	in the guidance notes		are not functional
	reduced mobility	and, all are functional
		Yes, functioning hand	Hand washing	Hand washing stations
		washing stations	stations are present	are not present within
2.6		within five meters of	within five meters of	five meters of toilets or
2.0	Functioning hand	toilets or latrines	toilets or latrines but,	latrines; or are not
	hygiene stations at latrines or toilets		not all have soap	functioning or no water
	Wastewater (both	Yes, using a	Wastewater is	On-site treatment of
	greywater and black	functioning on-site	discharged to a	wastewater is not
2.8	water) is safely	wastewater treatment	septic tank followed	present; or it is present
2.0	managed	facility with a	by drainage pit or	but not functioning;
		discharge permit	sent to a functioning
			sewer system.
	Greywater drainage	Yes, greywater	Greywater drainage	Greywater drainage
	system is safely	drainage system is	system is in place but	1
	managed	safely managed	not functioning and	present
2.9			obvious pools of
			water
	Toilets and latrines are	Yes, toilets or latrines	Toilets or Latrines	Toilets or Latrines are
2.10	adequately lit	are adequately lit,	have a lighting	not adequately lit or
2.10		including at night	infrastructure, but not	have no lighting
		including at might	functioning	infrastructure

	HEALTH CARE WASTE
2.11	Trained person responsible for health care waste	Yes, a trained person responsible for health care waste is present and adequately trained	A person is responsible for health care waste but not trained	No one is appointed for health care waste management
2.12	Functional collection containers for each type of health care waste	Yes, functional collection containers for each type of health care waste is in close proximity to all waste generation points	Separate bins present; but only two bins (instead of three); or present at some but not all waste generation	No bins or separate sharps disposal
2.13	Waste correctly segregated at all generation points	Yes, waste is correctly segregated at all waste generation points	Some sorting of waste but not all correctly or not practiced throughout the facility	No sorting of waste

2.15	Safe disposal of	Yes, there is a	Thermal processing	No thermal processing
	hazardous waste	functional and of a	or alternative	or alternative treatment
		sufficient capacity for	treatment for safe	technology for safe
		thermal processing or	disposal of	disposal of hazardous
		alternative treatment	hazardous waste is	waste or it is present
		technology for the	present but not of	but not functional
		treatment and safe	sufficient capacity
		disposal of hazardous	(e.g., if using
		waste	concrete vault)
2.17	Hazardous and non	Yes, separated	Separated hazardous	No separate
	hazardous waste are	hazardous and non	and non-hazardous	hazardous and non
	stored separately	hazardous waste	waste storage areas	hazardous waste
		storage areas are	are available but with	storage areas
		available	insufficient capacity	available
			or overfilled
2.18	Infectious waste stored	All infectious waste is	Infectious waste is in	Infectious waste is
	in protected area and	stored in a protected	a protected area that	stored longer than
	treated within safe time	area before	is not refrigerated	prescribed period, or
	period	treatment, for no	and stored for longer	stored not in a
		longer than the	than 48 hours and	protected area; and/or
		default and safe time	only treated	not treated at all
		as stated in the	thereafter
		guidance note

2.19	Disposal of anatomical	Yes, anatomical	Pit is present for	No pit is present for
	pathological waste	pathological waste is	anatomical	anatomical
		put in a dedicated	pathological waste	pathological waste; or,
		pathological	but not used or	it is present but not
		waste/placenta pit,	overfilled or not	functional
		burnt in a	fenced and locked
		crematorium or buried
		in a cemetery
2.20	Disposal of ash or	Yes, a dedicated ash	A dedicated ash pit is	No dedicated ash pit is
	residue from facilities	pit is available for	present for disposal	present for disposal of
	using a thermal	disposal of ash or	of ash or residue but	ash or residue; or it is
	process or other	residue or collected	it is overfilled or not	present but not
	alternative treatment	by DENR-accredited	fenced and locked	functional
	methods	TSD facility operators
2.21	Protocol or Standard	Yes, protocol or SOP	Protocol or SOP	No protocol or SOP
	Operating Procedure in	(Standard Operating	(Standard Operating	(Standard Operating
	place for health care	Procedure) for safe	Procedure) for safe	Procedure) for safe
	waste	management of	management of	management of health
		health care waste is	health care waste is	care waste is in place
		clearly visible and	written but not visible
		implemented	or implemented
2.22	Appropriate protective	Yes, all staff in	Some protective	No protective
	equipment for waste	charge of waste	equipment	equipment appropriate
	treatment and disposal	treatment and	appropriate for waste	for waste treatment
		disposal have	treatment and	and disposal is
		appropriate protective	disposal is available,	available
		equipment	but not for all staff or
			available but
			damaged

			HAND HYGIENE
3.1	Functioning hand	Yes, functioning hand	Hand hygiene	Not present; or hand
	hygiene	hygiene stations are	stations present, but	washing stations
	stations are available at	available in all points	no soap or 70%	present but no water
	all	of care areas; and	alcohol hand rub	available
	points of care	following the	solution available; ; or
		minimum number	there is insufficient
		required.	number of hand
			hygiene stations
3.2	Hand hygiene	Yes, hand hygiene	Hand hygiene	No hand hygiene
	promotion materials	promotion materials	promotion materials	promotion materials
		are clearly visible and	are clearly visible and	are clearly visible and
		understandable at	understandable at	understandable
		key places.	some places but not
			all

3.3	Functioning hand	Yes, functioning hand	Functioning hand	No functioning hand
	hygiene stations	hygiene stations are	hygiene stations are	hygiene stations are
	available in-service	available in-service	present but no soap	present; or
	areas	areas; and following	or 70% alcohol-based	handwashing stations
		the minimum number	hand rub solution	present but no water
		required.	available; or there is	available
			insufficient number of
			hand hygiene
			stations
3.4	Functioning hand	Yes, functioning hand	Functioning hand	No functioning hand
	hygiene stations	hygiene stations are	hygiene stations are	hygiene stations are
	available in waste	available in waste	present in waste	present or present but
	disposal area	disposal area	disposal area but no	no water available
			soap; or 70% alcohol
			based hand rub
			solution available; or
			there is insufficient
			number of hand
			hygiene stations
3.5	Hand hygiene	Yes, hand hygiene	Hand hygiene	Hand hygiene
	compliance undertaken	compliance are	compliance are not	compliance at critical
	regularly	undertaken regularly	carried out with any	moments not followed
			regularity	at all

3.19P	Staff can demonstrate correct procedures for hand washing	Yes, all staff can demonstrate correct procedures for handwashing	Some staff can demonstrate correct procedures for handwashing	None of the staff can demonstrate correct procedures for handwashing
			ENVIRONMENTAL CLEANING
3.8	A clear and detailed facility (or ward) cleaning policy or protocol is clearly displayed, which is implemented and monitored	Yes, cleaning policy or protocol exists, is implemented and monitored	Cleaning policy or protocol exists but is not implemented or monitored	No cleaning policy or protocol exists
3.9	Appropriate and well maintained materials for cleaning available	Yes, appropriate and well-maintained materials for cleaning available	Appropriate materials for cleaning available but not well maintained	No materials for cleaning available
3.10	Personal protective equipment available to all cleaning staff	Yes, personal protective equipment available to all cleaning and waste disposal staff	Personal protective equipment is available but in poor condition; OR not all have PPEs	No personal protective equipment is available

3.11	All staff responsible	Yes, all responsible	At least half of the	No staff received
	have received training	staff received training	responsible staff	training and can
	on environmental	and can demonstrate	received training and	demonstrate correct
	cleaning	correct procedures for	can demonstrate	procedures for
		environmental	correct procedures	environmental cleaning
		cleaning	for environmental
			cleaning
3.12	Beds have insecticide	Yes, all beds have	Insecticide-treated	No beds have
	treated nets	insecticide-treated	nets are available on	insecticide-treated nets
		nets	some but not all
			beds, or available but
			with rips and/or holes
3.13	Mechanism exists to	Yes, a mechanism	A mechanism exists	No mechanism exists
	track supply of IPC	exists to track supply	to track supply of	to track supply of IPC
	related materials	of IPC-related	IPC-related materials	related materials
		materials	but is not enforced
3.14	Record of cleaning	Yes, a record of	A record of cleaning	No record of floors and
	visible and signed by	cleaning visible and	exists, but is not	surfaces being cleaned
	the cleaners each day	signed by the	completed daily or is	exists
		cleaners each day	outdated
3.15	Laundry facilities are	Yes, laundry facilities	Laundry facilities	No laundry facilities
	available	are available or	exist, but are not
		outsourced	working or not being
			used; or outsourced
			laundry services not
			able to follow
			standard IPC

			measures
	MANAGEMENT
3.16	Facility has sufficient natural ventilation	Yes, facility has sufficient ventilation and regularly checked/ maintained by facility engineer	Facility has some ventilation but is not well maintained or is insufficient to produce ventilation, or not regularly checked.	The facility does not have sufficient ventilation
3.17P	Vermin / vector control program implemented	Yes, vermin or vector control program is implemented	N/A	No, vermin or vector control program is not implemented
3.18	Beds adequately separated from each other	Yes, all beds are adequately separated from each other (at least 1.5 meters apart)	Some but not all beds are adequately separated from each other	No beds are adequately separated from each other
4.1	WASH FIT and other quality improvement/ management plan (i.e., HCWM, SSP, WSP)	Yes, WASH FIT and other quality improvement/ management plan (HWCM, SSP and WSP) for the facility is in place, implemented and regularly monitored	WASH FIT and other quality improvement/ management plan (HCWM, SSP and WSP) for the facility is complete but has not been implemented and/or monitored or is incomplete	No WASH FIT or other quality improvement/ management plan (HCWM, SSP and WSP) for the facility is in place

4.2	Adequate budget for	Yes, the annual	An annual planned	Annual planned budget
	WASH infrastructure	planned budget for	budget for the facility	for the facility is not
	and operations are	the facility is available	is available but	available or not utilized
	utilized	and fully utilized	budget is insufficient
			or not fully utilized
4.4	Adequate cleaners and	Yes, adequate	Some cleaners and	No cleaners and
	WASH maintenance	cleaners and WASH	WASH maintenance	WASH maintenance
	staff	maintenance staff are	staff are available,	staff are available
		available	but not adequate
4.7	New personnel receive	Yes, new personnel	Not all new personnel	No new personnel
	(Infection, Prevention	receive IPC training	receive IPC training	receive IPC training, or
	and Control) IPC	before deployment	before deployment	IPC training provided
	training before			but only after
	deployment			deployment
4.9	Presence of Infection	Yes, facility has an	Yes, facility has an	No, the facility does
	Control Committee	ICC or ICT or a	ICC or ICT or a	not have an ICC or ICT
	(ICC) or Infection	designated health	designated health	or a designated health
	Control Team (ICT) or	worker for IPC	worker for IPC but	worker for IPC
	designated health care		focal point does not
	worker for IPC		have sufficient time,
			resources or
			motivation to carry
			out duties

Tool 2A.2 Summary of Results

Domain	Total Number of Indicators Assessed	Total Score	Percentage Rating	Number of Indicators that needs improveme nt (Score=0)	Number of Indicators that partially meets minimum standards (Score=1)	Number of Indicators that meets minimum standards (Score=2)
Water	9	0	0%	0	0	0
Sanitation	9	0	0%	0	0	0
Health Care Waste	10	0	0%	0	0	0
Hand Hygiene	6	0	0%	0	0	0
Environmental
Cleaning	8	0	0%	0	0	0
Management	8	0	0%	0	0	0
Total	50	0	0%	0	0	0

Over-All WASH FIT Rating

RATING	DESCRIPTION	What does your rating mean?	When is the next assessment?
NO STAR	At least one of the national indicators are not meeting the minimum standards	Critical changes needed immediately	Do another assessment after 3 months
ONE STAR	50% of the national indicators are at least partially meeting minimum standards With at least one advanced (global) indicator partially meeting minimum standards	Continue making improvements	Do another assessment after 6 months
TWO STAR	100% of national indicators are fully meeting minimum standards With at least 31% of advanced (global) indicators fully meeting minimum standards	Minimum WASH standards met! Continue making improvements.	Do another assessment after 12 months
THREE STAR	100% of national indicators are fully meeting minimum standards With at least 75% of advanced (global) indicators fully meeting minimum standards	Congratulations! Maintain this rating.	Do another assessment after 12 months

Tool 2A.3 Score Sheet - WASH FIT

FACILITY NAME LOCATION
DATE OF ASSESSMENT
	INDICATO RS		NATIONA L	GLOBAL	SCORE	Total - NATL	Total - GBL
WATER	1.15p	drinking water source
WATER	1.1	water supply
WATER	1.2	water available and sufficient qty
WATER	1.3	drinking water stn available
WATER	1.4	drinking water safe storage
WATER	1.8	sufficient water storage
WATER	1.10	drinking water FRC
WATER	1.12	energy for water
WATER	1.13	shower and bathing available and separate

WASH FIT Operations Guidelines and Standards						Annexes
SAN	2.1	toilet quantity
SAN	2.2	toilet separate for staff, px, vis
SAN	2.3	toilet single sex
SAN	2.4	mhm
SAN	2.5	toilet pwd
SAN	2.6	toilet hand washing station
SAN	2.8	wastewater
SAN	2.9	grey water drainage
SAN	2.10	toilet lighting
HCW	2.11	HCWM trained person
HCW	2.12	HCW collection containers
HCW	2.13	HCW segregation
HCW	2.15	Infectious and sharps waste disposal
HCW	2.17	separate storage Non-HZ and HZ waste
HCW	2.18	storage infectious waste
HCW	2.19	disposal anatomical / pathological
HCW	2.20	disposal ash or waste residue

HCW 2.21 SOP for HCWM

WASH FIT Operations Guidelines and Standards	Annexes
----------------------------------------------	---------

HCW	2.22	PPE for HCW staff
HH	3.1	HH stn - points of care
HH	3.2	HH promotion materials
HH	3.3	HH stn - service areas
HH	3.4	HH stn - waste disposal area
HH	3.5	HH compliance
HH	3.19p	Demo - HH steps
ENV CLN	3.8	clean disinfected surface
ENV CLN	3.9	well maintained cleaning matls
ENV CLN	3.10	PPE to cleaning staff
ENV CLN	3.11	Demo - cleaning and disinfection steps
ENV CLN	3.13	Tracking IPC supplies
ENV CLN	3.14	Cleaning record visible
MGT	3.15	Laundry facility available
MGT	3.16	ventilation
MGT	3.12	ITN
MGT	3.17p	vermin control pgm
MGT	3.18	distance of beds

		WASH FIT Operations Guidelines and Standards					Annexes
MGT	4.1	WASH facility improvement plan
MGT	4.2p	WASH budget available and utilized
MGT	4.4	adequate staff
MGT	4.7	IPC training pre-deployment
MGT	4.9	IPC team / staff
			Number of indicators -		NOT APPLICABLE
				Number of indicators -		OTHERS
			Total Number of indicators not counted (NA, OTH)
				Count of answered indicators
					Denominator
					Percentage Score
			3-STAR	2-STAR	1- STAR	NO STAR
		Has a 100% score for national indicators?
		Has a score of at least 50% for national indicators?

WASH FIT Operations Guidelines and Standards	Annexes
Has at least a 75% score for global indicators?
Has at least 31% score for global indicators?
Has at least over 0% score for global indicators
Has zero score for global indicators?

Tool 2A.4 Guidance Notes Water

WASH FIT INDICATOR INDICATOR reference number		GUIDANCE NOTE
WATER
1.15P	Improved DRINKING WATER supply piped into	Improved drinking water sources are as follows: Piped water into health facility or yard/ plot; Public tap or standpipe; Tube Well or borehole or protected well; improved spring; Rainwater from a cistern or tank; Packaged water – bottled water; Water from water refilling stations
	facility or on premises	Unimproved drinking water sources are unprotected well/ spring and surface water, water provided through tanker truck
		This refers to the water supply for general purposes, including washing and cleaning.
1.1	Improved water supply piped into facility or on	Improved water sources are as follows: Piped water into health facility or yard/ plot; Public tap or standpipe; Tube Well or borehole; or protected well; improved spring; Rainwater from a cistern or tank; Packaged water – bottled water; Water from water refilling stations
	premises, with no leaks	Unimproved water sources are unprotected well/ spring and surface water, water provided through tanker truck
		For hospitals: Water piped inside the facility to all high-risk wards (maternity, operating room/OR, intensive care/ICU) (note a and b)
	Water services available at	Source: Essential Environment Health Standards in Health Care (WHO, 2008);
1.2	all times and of sufficient quantity	To calculate the facility's water requirements, add up the following applicable national standards:

WASH FIT Operations Guidelines and Standards Annexes
		+ Outpatients: 5 L/consultation
		+ Inpatients: 40–60 L/patient/day
		+ Operating theater or maternity unit: 100 L/intervention
		+ Dry supplementary feeding center: 0.5–5 L/ consultation depending on waiting time
		+ Wet supplementary feeding center: 15 L/ consultation
		+ Cholera treatment center:60 L/patient/day
		+ Severe acute respiratory diseases/isolation center: 100 liters/patient/day
		+ Viral hemorrhagic fever isolation center: 300–400 liters/patient/day
1.3	Reliable drinking water station available	This refers to water station or water dispenser or water containers available at all times and accessible to all
1.4	Drinking water safe storage and has no E. Coli	This refers to water dispenser or water containers with cover and tap
1.8	Water storage is sufficient	Source: Essential Environment Health Standards in Health Care (WHO, 2008); DOH DM 2020-0123 Interim guidelines on the management of surge capacity through the conversion of public spaces
		To calculate the facility's water requirement for a day, add up the following applicable national standards:
		+ Outpatients: 5 L/consultation
		+ Inpatients: 40–60 L/patient/day
		+ Operating theatre or maternity unit: 100 L/intervention

	WASH FIT Operations Guidelines and Standards	Annexes
		+ Dry supplementary feeding center: 0.5–5 L/ consultation depending on waiting time
		+ Wet supplementary feeding center: 15 L/ consultation
		+ Cholera treatment center:60 L/patient/day
		+ Severe acute respiratory diseases/isolation center: 100 liters/patient/day
		+ Viral hemorrhagic fever isolation center: 300–400 liters/patient/day
		Multiply by three the daily water volume to get the total 3-day storage requirement. Then, assess if your facility is able to meet the volume required for water storage.
		In addition to the 3-day water reserve, rainwater harvester can be installed with a minimum capacity of one (1) day reserve.
	Water supply has chlorine residual	During an emergency period, a free residual chlorine (FRC) of 0.5mg/L min is required, as a general preventive measure for patient's safety.
1.1		In normal settings, bulk water supply shall maintain a free residual chlorine (FRC) level of 0.3 mg/L to a maximum of 1.5 mg/L at the point of delivery. (DOH PNSDW 2017)
1.12	Sufficient energy for water	Source: DOH DM 2020-0123 Interim guidelines on the management of surge capacity through the conversion of public spaces
		For temporary treatment and monitoring facilities, a backup supply of electricity and free flowing water for at least 72 hours must be ensured, in case of water and power interruption.
		For other facilities, provide on-site renewable energy generation or backup electricity generation that can power the facility's emergency power needs.

	WASH FIT Operations Guidelines and Standards	Annexes
	Shower and bathing areas accessible and functioning	Source: Manual of Primary Care Facilities (DOH, 2020); DOH AO 2016-0042; Essential Environment Health Standards in Health Care (WHO, 2008); DOH DM 2020-123
		For TTMF, one shower for every eight (8) persons.
1.13		For BHS or RHU or UHC, with birthing facilities, at least 1 bathroom inside the labor room or ward.
		For residential DATRC, at least 1 bathroom for every ten (10) patients.
		For other settings, at least one bathing area or shower available for 40 users in inpatient settings (users include patients, staff and carers staying in the health-care setting).
		[THIS IS NOT ASKED FOR FACILITIES NOT ACCEPTING IN-PATIENTS]

Tool 2A.5 Guidance Notes Sanitation

WASH FIT INDICATOR reference number	INDICATOR	GUIDANCE NOTE
SANITATION
2.1	Sufficient number of functional toilets or latrines available	Source: Manual of Primary Care Facilities (DOH, 2020); DOH AO 2016-0042; DOH DM 2020- 0123; DOH DM 2020-0072
		A toilet is defined as having a flush toilet following the standard septic tank design under the Code on Sanitation of the Philippines and DOH AO 2019-0047 (National Standard on the Design, Construction, Operation and Maintenance of Septic Tank System). It is also recommended that toilets be provided with a bidet. A latrine refers to pour flush systems that follow standard septic tank design. A functioning or usable toilet or latrine should have water available at all times.
		Use the guide below to assess if you are meeting the required minimum number of toilets regardless of PWD-accessibility and sex segregation.
		For non-health facilities that are used as COVID-19 isolation or quarantine unit facility or TTMFs, one water closet or toilet per 25 males and one toilet per 20 females. There should also be one urinal per 10-50 males, adding one fixture for each additional 50 males.
		Other health facilities not listed below: one toilet per 20 users
		Barangay Health Station (BHS): One PWD toilet with urinal and sink
		BHS w/ birthing: 2 toilets (PWD and inside labor room or ward)

	Rural Health Unit (RHU) or Urban Health Centers (UHC): 6 toilets
	-One PWD toilet with 1 sink
	-Male toilet with 1 cubicle, 1 urinal and sink
	-Female toilet with 2 cubicles and 2 sinks
	-Two public toilets each with 1 urinal and 1 sink near the waiting room
	RHU / UHC with attached birthing facility: 8 toilets
	-One PWD toilet with sink
	-Male toilet with 1 cubicle, 1 urinal and 1 sink
	-Female toilet with 2 cubicles and 2 sinks
	-Two public toilets with urinal and sink near the waiting room
	-One toilet with sink inside labor room
	-One toilet with sink inside OB ward/Family room
	-One toilet with sink and bath inside Supervisor's area
	RHU / UHC with birthing facility and TB-DOTS area: 8 toilets
	-Staff toilet with 1 urinal and 1 sink
	-Male toilet with 1 urinal and 1 sink
	-Female toilet with 1 sink and 2 cubicles (one of the cubicles is for PWD)

	WASH FIT Operations Guidelines and Standards	Annexes
		-One public toilet with 1 urinal and 1 sink near the TB-DOTS area
		-One toilet with sink inside the prenatal room
		-One toilet with sink and bath inside the OB ward/Family Room
		-One toilet with sink and bath inside Supervisor's area
		2 Storey RHU / UHC with birthing facility and TB-DOTS area: 10 toilets
		Birthing Home (detached) – 1 toilet for every 6 beds
		For all hospitals, observe a ratio of one (1) toilet for every eight (8) patients or personnel. There should be toilets with handwashing stations in the following areas: Admin Service area or lobby, Dietary, Emergency Room, Out-Patient Department, Surgical and Obstetric Service, Labor room, Patient Room, Isolation Room, Clinical laboratory, X-ray Room
		For Level 2 hospitals, in addition to above, the following areas should have toilets with handwashing stations: in all nurses' stations, intensive care unit (ICU), and nursing service unit.
		For Level 3 hospitals, in addition to above, the following areas should have toilets with handwashing stations: in all nurses' stations, intensive care unit (ICU), nursing service unit, dialysis clinic and rehabilitation room.
2.2	Toilets or latrines separated for staff, patients, and visitors	Source: Manual of Primary Care Facilities (DOH, 2020); DOH AO 2016-0042; DOH DM 2020- 0072
		For primary care facilities, separate toilets for staff and patients are required for Rural Health Units or Urban Health Centers, with or without birthing facilities or TB-DOTS.
		No separate toilets for staff, patients and visitors are required in Barangay Health Stations, except in BHS with birthing facilities.

		For hospitals, separate toilets for patients and staff are required
		[THIS IS NOT ASKED FOR BHS WITHOUT BIRTHING FACILITY]
2.3	Toilets or latrines separated for male and female	For Rural Health Units or Urban Health Centers, with or without birthing facility or TB-DOTS, there should be at least 1 set of separate public toilets for males and females. In Barangay Health Stations, no separate public toilets for males and females are required.
		For hospitals, there should be separate toilets for male and female patients and personnel.
		[THIS IS NOT ASKED FOR BHS WITHOUT BIRTHING FACILITY]
2.4	Menstrual hygiene management	Toilets should have a bin for disposal of waste and an area for washing, with water available.
		Ensure that facilities for disposal of menstrual hygiene products are available (Provide menstrual hygiene bins), hygienic place and that disposal systems are functional.
2.5	Toilet meeting the needs of people with reduced mobility	For primary care facilities, at least one PWD toilet is required for BHS (with or without birthing facility), and RHU / UHC (with or without birthing facility or TB-DOTS).
		For hospitals, a minimum of one (1) toilet on each floor accessible to PWD patients.
2.6	Functioning hand hygiene stations at latrines or toilets	A functional hand hygiene station should have a sink or bucket with tap and water with soap. In settings where this is not possible, water "flowing" from a pre-filled container with a tap is preferable to still-standing water in a basin.
		Alcohol-based handrub is not suitable for use at latrines or toilets.
2.8	Wastewater is safely managed	Wastewater is safely managed through use of an on-site treatment facility that has been provided with a discharge permit by DENR;or, through use of a septic tank followed by a drainage pit or sent to a functioning sewer system.

	WASH FIT Operations Guidelines and Standards	Annexes

2.9	Greywater drainage system is safely managed	Grey water (i.e. rainwater or wash water) drainage system is in place that diverts water away from the facility (i.e. no standing water) and also protects nearby households
2.1	Toilets and latrines are adequately lit	Toilet and latrines shall have an efficient and functional lightning at all times

Annex 2: WASH FIT Tools Template (Tool 2A WASH FIT Indicators Assessment Form) Tool 2A.6 Guidance Notes HCWM

WASH FIT INDICATOR reference number	INDICATOR	GUIDANCE NOTE
HEALTH CARE WASTE MGT
2.11	Trained person responsible for health care waste	Ensure training conducted to HCWM committee and other healthcare workers involved with HCWM
		Source: DOH Manual of PFC 2020, Health Care Waste Manual 4th Ed (DOH, 2020); DOH DM 2020-0178
2.12	Functional collection containers for each type of health care waste	Pedal-operated waste collection bins with liners should be available at all waste generation points. In absence of pedal-operated waste bins, bins with swinging lids can be opted as the alternative. Otherwise, open waste containers are better than those which require touching the lid of the garbage container.
	Waste correctly segregated at all generation points	Source: DOH Health Care Waste Management Manual, 4th edition; DOH DM 2020- 170
2.13		Garbage container and plastic liners should follow the color-coded for various healthcare waste based on the latest HCWM Manual
		Black container or black bag liner for non-infectious or general waste.
		Green container or green bag liner for non-infectious or wet / biodegradable waste

	WASH FIT Operations Guidelines and Standards	Annexes
		Yellow container or yellow bag liner for infectious waste
		Puncture-proof container for sharps waste
		Source: Overview of technologies for the treatment of infectious and sharp waste from health facility (WHO, 2019); Clean Air Act Implementing Rules and Regulations; Health Care Waste Management Manual, 4th edition (DOH, 2020); DOH DM 2020- 170
		Health Care Waste Treatment Technology Options
	Safe disposal of hazardous waste	• Low-heat thermal-based process: autoclaves, vacuum autoclaves (with integrated shredder), microwave-based technologies, frictional heat treatment; pyrolysis (in which residue is disposed at the landfill)
2.15		• Chemical-based process: Sodium hypochlorite treatment systems; or use of hydrogen peroxide, peroxyacetic acid, and heated alkali.
		• High-heat thermal-based process: Dual chamber incineration with flue gas treatment
		• Biological process using enzyme mixture, or composting or vermin culture; recommended for biodegradable waste
		• Encapsulation for disposal of sharps by adding immobilizing material and sealing the container
		• Inertization through mixing waste with cement or other substances before disposal; appropriate for sharps, pharmaceutical residues and chemicals (solid form)

	WASH FIT Operations Guidelines and Standards	Annexes
		• Use of concrete vault to dispose infectious waste
		Any healthcare waste treatment facility using a thermal process should have undergone emission testing and have passed the standards set forth in the National Emission Standards for Source Specific Air Pollutants (NESSAP), under the IRR of Clean Air Act.
		Waste may be treated offsite, but there should be a means to confirm if waste is treated safely once removed from the facility premises.
2.17	Hazardous and non-hazardous waste are stored separately	Source: Manual of Primary Care Facilities (DOH, 2020); Health Care Waste Management Manual, 4th edition (DOH, 2020)
		For primary care facilities, there should be waste holding area located outside the building but within the site or premises.
		For hospitals and other health facility, there should be separate storage areas for:
		a) General wastes;
		b) Recyclable materials;
		c) Hazardous waste (other than phased-out mercury devices); and
		d) Phased-out mercury devices.
		Storage areas must be located away from the dietary section, patient rooms, laboratories, hospital function/operation rooms or any public access areas.

	WASH FIT Operations Guidelines and Standards	Annexes
		If there is an area available for composting of biodegradable wastes, a storage area is not necessary. It must be disposed of directly in the composting site.
2.18	Infectious waste stored in protected area and treated within safe time period	Source: DOH DM 2020-0170; Health Care Waste Management Manual, 4th edition (DOH, 2020)
		Unless a refrigerated storage room (at 3 to 8 degree Celsius) is available, storage times for infectious waste (e.g. the time between generation and treatment) should not exceed the following periods:
		• 48 hours during the cold season
		• 24 hours during the hot season
		Storage areas should be fenced (or lockable) and protected from flooding and the rain.
		If waste is removed and taken off site, both the site and the holding area should comply with the above requirements.
2.19	Disposal of anatomical pathological waste	Source: Manual of PCF (DOH, 2020); Health Care Waste Management Manual, 4th edition (DOH, 2020)
		In primary care facilities, placenta pit should be provided if birthing services are being offered in the facility.
		Placenta pits: lined or unlined depending on the geology, with slab, with ventilation pipe; and should be more than 30m from water source.
		SKIP THIS FOR Primary Care Facilities without inpatient beds

2.20	Disposal of ash or residue from facilities using a thermal process or other alternative treatment methods	Ash pits: lined or unlined depending on the geology but must prevent leaching to the environment, with slab, bottom of pit at least 1.5 m away from groundwater table. If water gets into the ash pit, it can leach pollutants into the soil.
2.21	Protocol or Standard Operating Procedure in place for health care waste
2.22	Appropriate protective equipment for waste treatment and disposal	Protective equipment for people handling waste includes: gloves, apron, mask, heavy duty rubber boots.

Tool 2A.7 Guidance Notes Hand Hygiene

WASH FIT INDICATOR reference number	INDICATOR	GUIDANCE NOTE
HAND HYGIENE
	Functioning hand hygiene stations are available at all	Source: Essential Environment Health Standards in Health Care (WHO, 2008); DOH DM 2020-123
	points of care	Point of care is where three elements come together: the patient; the health care workers; and care or treatment involving contact with the patient or their surroundings. This may include consultation rooms, operating rooms, delivery rooms and laboratories.
3.1		Hand hygiene stations should have a sink or bucket with tap, water and soap; or 70% alcohol-based handrub. In settings where tap water is not possible, water "flowing" from a pre-filled container with a tap is preferable to still-standing water in a basin.
		Preferably, hand hygiene stations should be designed as hands-free, or that the tap can be turned on or off by using one's arm, elbow, or foot; or using a motion sensor.
		There should be at least two hand hygiene stations in a ward with more than 20 beds.
		For TTMFs, one hand washing station is required for every 10 males and one for every 10 females.

3.2	Hand hygiene promotion materials	Key places include at points of care areas, the waiting room, at the facility's entrance and within 5 meters of latrines or toilets.
	Functioning hand hygiene 3.3 stations available in service areas	Source: Essential Environment Health Standards in Health Care (WHO, 2008); DOH DM 2020-268
		Sink or bucket with tap, water and soap or 70% alcohol-based handrub should be available 24/7.
		Preferably, hand hygiene stations should be designed as hands-free, or that the tap can be turned on or off by using one's arm, elbow, or foot; or using a motion sensor.
		Service areas include sterilization, laboratory, kitchen, laundry, showers, waste zone, mortuary, including strategic areas such as walkways, entrances and exits, information desk, and waiting areas.
	Functioning hand hygiene stations available in waste disposal area	Sink or bucket with tap and water with soap.
3.4		Preferably, hand hygiene stations should be designed as hands-free, or that the tap can be turned on or off by using one's arm, elbow, or foot; or using a motion sensor.
	Hand hygiene compliance 3.5 undertaken regularly	Hand hygiene compliance refers to the practice of hand hygiene during five critical moments, as shown below, including during donning and removal of PPEs:
		1- before touching a patient
		2- before doing a clean / aseptic procedure
		3- after touching body fluid / exposure risk
		4- after touching a patient

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		5- after touching patient surroundings
3.19P	Staff can demonstrate correct procedures for hand washing	Training to staff and protocol on hand hygiene technique being followed.

Tool 2A.8 Guidance Notes Environmental Cleaning

WASH FIT INDICATO R reference number	INDICATOR	GUIDANCE NOTE
ENVIRONMENTAL CLEANING
	A clear and detailed facility (or ward) cleaning policy or protocol is clearly displayed, which is implemented and monitored	Source: Essential Environment Health Standards in Health Care (WHO, 2008); DOH DM 2020-178
3.8		Environmental surfaces or objects contaminated with blood, other body fluids, secretions or excretions are cleaned and disinfected as soon as possible using standard hospital disinfectants. Floors shall be made of materials that are non-slip, easy to clean, and resistant to chipping. A clean surface is noted by absence of waste, visible dirt, excreta, body fluid spills and insects.
		Source: DOH DM 2020-157
3.9	Appropriate and well maintained materials for cleaning available	There should be a designated physical space for storage, preparation, and care of cleaning supplies and equipment.
		Cleaning materials include:
		· Detergent or soap
		· Disinfectants, liquid bleach or chlorine granules or powder

	WASH FIT Operations Guidelines and Standards	Annexes
		· Portable containers (e.g., bottles, pump dispenser, small buckets)
		· Surface cleaning cloths
		· Mops or floor cloths, with buckets/wringers
		· Pedal-operated (or swing lid) trash bins
		Store chlorine (liquid or powder) in air-tight non-metallic containers, away from heat, light and humidity in a ventilated area. Carefully close disinfectant containers after use. Never place in contact with water, acid, fuel, detergents, organic or inflammable materials (e.g. food, paper or cigarettes).
		Mops and cleaning cloths should be laundered or rinsed in a clean disinfectant solution, then thoroughly dried before reuse.
3.10	Personal protective equipment available to all cleaning staff	Protective equipment for people cleaning the facility or handling waste includes gloves, mask, heavy duty rubber boots, goggles (if there is risk for splash); and, water-proof apron or cover-all.
3.11	All staff responsible have received training on environmental cleaning	Demonstrate proper procedure in cleaning and disinfection of toilets, patients' rooms and high touch surfaces.

	Beds have insecticide-treated nets	Source: Essential Environment Health Standards in Health Care (WHO, 2008)
3.12		In malaria endemic areas or with reported incidence, it is important not to expose patients as this may make them more vulnerable to COVID-19.
		[THIS IS ASKED FOR FACILITIES IN MALARIA ENDEMIC AREAS ONLY]
3.13	Mechanism exists to track supply of IPC related materials	IPC-related materials include PPEs, materials and supplies used for cleaning and disinfection and for hand hygiene.
3.14	Record of cleaning visible and signed by the cleaners each day	Have a record for environmental cleaning and updated, checked and signed being visible to auspicious areas.
3.15	Laundry facilities are available	If laundry services are outsourced, there must be a means to confirm that they follow standard IPC measures.

Tool 2A.9 Guidance Notes Management

WASH FIT INDICATOR reference number	INDICATOR	GUIDANCE NOTE
MANAGEMENT
3.16	Facility has sufficient ventilation	Source: Clinical care for severe acute respiratory infection: toolkit. COVID-19 adaptation (WHO, 2020); DOH DM 2020-028; Green and Safe health facility Manual (DOH); DOH DM 2020-268
		Natural ventilation is the use of natural forces to introduce and distribute outdoor air into or out of a building. Increase passage of natural ventilation in all parts of the facilities
		Use a dilution ventilation system for patient rooms and wards (e.g.
		use of unidirectional electric fans to direct airflow).
		In COVID-19 single isolation rooms and ICU, where aerosol-generating procedures are performed, it should be adequately ventilated, meaning negative pressure rooms with a minimum of 12 air changes per hour; or at least 160 L/ second/ patient in facilities with natural ventilation.
		In the buffer zone of the Triage Area, Emergency Department and COVID-19 isolation wards, there should be negative pressure ventilation to ensure that the air flows from clean to the contaminated area. If this is not feasible, a dilution ventilation must be utilized, with air exhausted to an air space with no people.

3.17P	Vermin / vector control program implemented	Have a record for either physical, chemical or biological environmental pest control being implemented in health facilities
		Source: DOH AO 2016-0042
3.18	Beds adequately separated from each other	For residential DARTC, the bed shall be placed at least one (1) meter apart. Or, if a double-decked bed is utilized, this shall have at least one-meter space from the ceiling and again between the upper and lower beds. (DOH AO 2016-0042)
4.1	WASH FIT and other quality improvement/ management plan (i.e., HCWM, SSP, WSP)	Quality improvement plans include health care waste management plan, sanitation safety plan and water safety plan. These quality improvement plans should have clearly identified the facility management structure responsible to carry out the daily operation, maintenance and required improvement in the facility related to water, sanitation, health care waste and hygiene.
4.2	Adequate budget for WASH infrastructure and operations are utilized	The budget refers to that used for capital and operational costs. It could be from the community and/or the government.
4.4	Adequate cleaners and WASH maintenance staff	In the absence of a standard ratio, an adequate number of cleaners is defined as being able to fulfill all cleaning and disinfection tasks required in a day, without having to work overtime.
4.7	New personnel receive IPC training	To have appropriate training design for new personnel that IPC training.

	WASH FIT Operations Guidelines and Standards	Annexes
	Presence of Infection Control
4.9	Committee or Infection Control	IPC Committee or Team or designee in the health facilities to ensure WASH is being
	Team or designated health care	implemented in health facilities
	worker for IPC

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Annex 2: WASH FIT Tools Template (Tool 2B Sanitary Inspection Forms)

INSPECTION FORMS
TOOL 2B: SANITARY

A. Dug Well with Hand Pump

• I. General information
  • a. Name of facility:
  • b. Location and/or name of dug well:
  • c. Date of inspection:
  • d. Weather conditions during inspection:

Note. If there is more than one dug well in your community, or if the community uses other water sources (such as springs or boreholes), carry out sanitary inspections for these sources too.

______________________________________________________________________________________________

_________________________________________________________________________________________________

________________________________________________________________________________

_____________________________________________________________________________

• II. Specific questions for assessment
  • 1. Is the source located at an unsafe distance from unsealed latrine (i.e. latrine nearby is uphill or at a location where the groundwater gradient would flow from the latrine to water source)? Y/N
  • 2. Is the fence absent, inadequate, or faulty? Y/N

3. Can animals have access within 30 meters (100feet) of the well? Y/N

4. Is there any other source of pollution within 30 meters (100feet) of the well (such as animal breeding, cultivation, roads, health care waste, domestic garbage)? Y/N

WASH FIT Operations Guidelines and Standards	Annexes
Is there stagnant water within 3 meters of the well? 5.	Y/N
Is the drainage channel absent or cracked, broken, or in need of cleaning? 6.	Y/N
Is the cement floor or slab less than 2 meters in diameter around the top of the well? 7.	Y/N
Are there cracks in the cement floor or slab? 8.	Y/N
Is the hand pump loose at the point of attachment or, for rope-washer pumps, 9. is the pump cover missing or damaged?	Y/N
Is the well cover absent, cracked, or unsanitary? 10.	Y/N

III. Results and comments

Sanitary inspection risk score (tick appropriate box):

Very high risk (risk score: 9–10)	High risk (risk score: 6–8)	Medium risk (risk score: 3–5)	Low risk (risk score: 0–2)

Important points of risk noted and reported on the reverse of this form:

● List according to question numbers 1–10

● Additional comments.

IV. Names and signatures of assessors:

FORMS TOOL

2B: SANITARY INSPECTION

NOTES FOR SI FORM: PUBLIC/YARD TAPS AND PIPED DISTRIBUTION

1. Does the tap leak?

If taps are leaking or damaged then cracks may provide a route for contaminants to enter the pipes, particularly if the distribution system is operating intermittently. Leaking taps also contribute to water wastage. During the inspection, you will need to differentiate between water from leaking taps and spilt water. If you observe leaks or damage at taps, answer "Yes".

2. Is the tap or are attachments (such as hoses) insanitary?

If the tap is contaminated, or if any attachments to the tap (such as hoses) are insanitary, collected water may be contaminated and contamination can be introduced to the distribution system. If the tap is unsanitary, answer "Yes".

3. Does spilt water accumulate around the tap stand?

Any spilt water may be contaminated by runoff, especially if animals have access to the collection area. Containers may be contaminated by the spilt water during collection. Also, if cracks are present in the collection area, they may provide a route for contaminants to enter the distribution pipes, particularly if the distribution system operates intermittently. If you observe the accumulation of spilt water, answer "Yes".

4. Is the area around the tap stand unsanitary?

Feces, garbage, and other waste increase the risk of water becoming contaminated during collection – for example, by contaminating collection containers. If you observe any of these problems close to the tap, answer "Yes".

5. Is the area around the tap stand unfenced, allowing animals to access the area?

If there is no fence – or if the fence is inappropriate (for example, too low or not equipped with a functioning gate) or damaged – animals (including those used for collecting the water) can access the tap stand area. They may cause damage to the taps and pollute the area or collection containers with excreta. You will need to check whether animals are routinely in the area by asking residents and by personal observation in the area (including seeing any animal excreta at the site). If you observe any of these problems or if the area is unfenced, answer "Yes".

6. Are there any signs of leaks in the inspection area (for example, accumulating water)?

If pipes are damaged or leaking then cracks may provide a route for contaminants to enter the pipes, particularly if the distribution system operates intermittently. Watch out for stagnant water or unexpected flows of water above ground but you will need to differentiate between water from leakage and spilt water. If you observe leaks in the inspection area, answer "Yes".

7. Are any of the pipes exposed above ground in the inspection area?

Exposure of the pipe means that it is more prone to both damages (especially if by/on a road) and contamination from runoff than pipes below ground. You will need to identify the routes of the main pipelines in the inspection area. If the pipelines are exposed, answer "Yes".

8. Do users report any pipe breaks within the last week?

Pipe breaks pose a risk to water quality as contaminants can enter the system through the break, particularly if the distribution system operates intermittently. You will need to ask residents about any pipe breaks. If breaks are reported, answer "Yes".

9. Has there been a discontinuity in the last 10 days?

During discontinuities the distribution pipes become empty and pressure differences may lead to ingress of water and silt from the soil around the pipes. As water and soil may be contaminated this poses a risk to water quality. You will need to ask residents about discontinuities. Also record the frequency and duration, if possible. If there has been a discontinuity, answer "Yes".

10. Is there a sewer or a latrine within 30 meters of the tap stand?

Any leaks from a sewer or infiltration from a latrine could contaminate the piped water, especially if there are any cracks in the distribution system and if the distribution system operates intermittently. Groundwater may flow towards the distribution pipes from the direction of the sewer or latrine. You can observe latrines and cross-check with residents, but you may need to ask relevant professionals

	WASH FIT Operations Guidelines and Standards	Annexes
A.	STORAGE RESERVOIRS
I.	General information
	a. Name of facility:
	b. Location and/or name of storage reservoir:
	c. Date of inspection:
	d. Weather conditions during inspection:
	e. Location and/or name of water source(s) feeding the reservoir:
	Note. If there is more than one storage reservoir used in your facility, use one form for each reservoir.
	Note. If the storage reservoir feeds a piped distribution system, also carry out a sanitary inspection using the form "Public/yard taps and piped distribution".
	Note. If the storage reservoir is equipped with a tap for collecting water, also carry out a sanitary inspection using questions 1–5 of the form "Public/yard taps and piped distribution".
II.	Specific questions for assessment
1.	Is there any point of leakage of the pipe between the source and storage reservoir?	Y/N
2.	Is the physical infrastructure of the storage reservoir cracked or leaking?	Y/N
3.	Is the inspection cover of the storage reservoir absent or open?	Y/N

4. Is the inspection cover faulty, corroded or is the concrete around the cover damaged? Y/N

WASH FIT Operations Guidelines and Standards	Annexes
5. Is the inspection cover insanitary?	Y/N
6. Are screens protecting the air vents on the storage reservoir missing or damaged?		Y/N
7. If there is an overflow pipe, is the screen protecting it missing or damaged?	Y/N
8. Is there any scum or foreign objects in the storage reservoir?	Y/N
9. Is the diversion ditch above the storage reservoir absent or non-functional?	Y/N
10.Is the area around the storage reservoir unfenced or is the fence damaged, allowing animals to access the area? Y/N
11.Is the storage reservoir not regularly cleaned and disinfected?	Y/N

Total score of risk factors as the total number of "YES" answers:

III. Results and comments

Sanitary inspection risk score (tick appropriate box):

Very high risk (risk score: 9–10)	High risk (risk score: 6–8)	Medium risk (risk score: 3–5)	Low risk (risk score: 0–2)

WASH FIT Operations Guidelines and Standards
Important points of risk noted and reported on the reverse of this form:
● List according to question numbers 1–10
● Additional comments.
Names and signatures of assessors: IV.

NOTES FOR SI FORM: STORAGE RESERVOIRS

1. Is there any point of leakage of the pipe between the source and storage reservoir?

If pipes are damaged or leaking, then cracks may provide a route for contaminants to enter the pipes. Watch out for stagnant water or unexpected flows of water above the ground. If you observe leaks, answer "Yes".

2. Is the physical infrastructure of the storage reservoir cracked or leaking?

Cracks allow contaminants to reach the water stored in the tank; leakage also leads to loss of water. If you find deep cracks that penetrate the tank, answer "Yes".

3. Is the inspection cover of the storage reservoir absent or open?

If there is no inspection cover or the cover is not closed at the time of inspection, it allows contaminants (such as bird droppings or other feces from rodents or cats) to reach the water stored in the tank rapidly, especially in wet weather. If you observe either of these problems, answer "Yes".

4. Is the inspection cover faulty, corroded or is the concrete around the cover damaged?

Corroded or damaged covers and cracked concrete surrounds allow contaminants (such as bird droppings or other feces from rodents or cats) to reach the water stored in the tank rapidly, especially in wet weather. If you observe any of these problems, answer "Yes".

5. Is the inspection cover unsanitary?

If the inspection cover is contaminated by feces (for example, from birds or rodents), spider webs, insects, soil, or slime, this poses a risk to water quality. If you observe any of these problems, answer "Yes".

6. Are screens protecting the air vents on the storage reservoir missing or damaged?

If no screens are protecting the air vents, or if they are damaged, this allows insects and other animals (such as birds and rodents) to access the reservoir. This poses a risk to water quality. If you observe either of these problems, answer "Yes".

7. If there is an overflow pipe, is the screen protecting it missing or damaged?

If no screens are protecting the overflow pipe, or if they are damaged, this allows insects and other animals (such as birds and rodents)

to access the reservoir. This poses a risk to water quality. If you observe either of these problems, answer "Yes".

8. Is there any scum or foreign objects in the storage reservoir?

If there is any scum floating on the surface of the water table (for example, insects, foam, or algae), or if there are any other objects on the ground of the reservoir (for example, dead animals or garbage), this poses a risk to water quality. If you observe any of these conditions, answer "Yes".

9. Is the diversion ditch above the storage reservoir absent or non-functional?

The role of the ditch is to protect the reservoir from surface runoff by directing it downhill and away from the reservoir. If the ditch is filled with waste or poorly contoured then runoff can collect and infiltrate near the reservoir, possibly causing damage to the infrastructure or posing a risk to water quality due to ingress into the reservoir. You should look for water or waste collected in the ditch. If the ditch is absent or not functioning correctly, answer "Yes".

10. Is the area around the storage reservoir unfenced or is the fence damaged, allowing animals to access the area?

If there is no fence – or if the fence is inappropriate (for example, too low or not equipped with a functioning gate) or damaged – animals (including those used for collecting the water), can access the reservoir area. They may cause damage to it and pollute the area with excreta. You will need to check whether animals are routinely in the area by asking residents and by personal observation in the area (including seeing any animal excreta at the site). If you observe any of these problems or if the area is unfenced, answer "Yes".

11. Is the storage tank not regularly cleaned and disinfected?

The storage tank should be washed with soap and water, then the whole of the inside wiped using a 0.5% chlorine solution. If this is not done, answer "Yes".

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Annex 2: WASH FIT Tools Template (Tool 3 Hazard and Risk Assessment)

ASSESSMENT
	Date of Assessment:

Hazard Ref No.	Hazards (problems)	Risks	Actions
			Facility/Community	Local/National
WATER
SANITATION
	HEALTHCARE WASTE MANAGEMENT
HAND HYGIENE
ENVIRONMENTAL CLEANING
MANAGEMENT

Risk Definition

WASH FIT Operations Guidelines and Standards	Annexes
High Risk	The hazard/problem very likely results in injuries, acute and/or chronic illness, infection or an inability to provide essential services. Immediate actions need to be taken to minimize the risk.
Medium Risk	The hazard/problem likely results in moderate health effects, discomfort or unsatisfactory services, for example unpleasant odors, unsatisfactory working conditions, minor injuries. Once the high risks issues are addressed, actions should be taken to minimize medium-level risks.
Low Risk	No major health effects anticipated. These risks should be addressed as resources become available and should be revisited in the future as part of the review process.
Unknown Risk	Further information is needed to categorize the risk. Some action should be taken to reduce the risk while more information is gathered.

WASH FIT Operations Guidelines and Standards Annex 2: WASH FIT Tools Template (Tool 4 Improvement Plan)							Annexes
PLAN
Date improvement plan was written:				Date of Review 1:		Date of Review 2:
Hazard Ref. No	SPECIFIC IMPROVEMEN T ACTION	RESPONSIBLE	RESOURC ES NEEDED	BUDGET	SOURCE OF BUDGET	TARGET DATE	COMPLETION DATE	MONITORING What changes are needed?
								Review 1	Review 2
WATER
SANITATION
HEALTHCARE WASTE
HYGIENE
MANAGEMENT