Department of Health Health Facility Development Bureau 2025

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Department of Health San Lazaro Compound Rizal Avenue, Sta. Cruz, Manila 1003 PHILIPPINES

PRODUCTION CREDITS

Project Leader/s: Dr. Ma. Bituin S. Reyes Engr. June Philip O. Ruiz

Copy Editor: Mr. Glenn A. Cruz

Ms. Georgina Mae R. Zulueta

Acknowledgement: World Health Organization UNICEF

Development of the 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, 1406

Email Address: hfdb@doh.gov.ph or gshfp@doh.gov.ph

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

Table	of	Contents

1. Introduction	1-2
1.1. Comparison of WASH FIT, WSP, and SSP	2-4
2. Proposed Integration of WASH FIT, WSP, and SSP	5
2.1. Preparation	5-6
2.2. Facility Assessment and Development of Schematic Diagram	6-12
2.3. Hazard and Risk Assessment	12-13
2.4. Evaluation Plan	13-14
2.5. Development of Integrated Improvement and Monitoring Plan	15-28
List of Tables Table 1: Comparison of WASH FIT, WSP, and SSP Table 2: WASH FIT Rating Table 3: Additional Guidance Notes Table 4: Risk assessment and Control Measure template Table 5: Improvement and Monitoring Plan template Table 6: Evaluation Plan template	3-4 7 8-11 13 13 14
List of Figures
Figure 1: WASH FIT and Safety Plan Process	6
Figure 2: Sample Integrated Water Supply and Sanitation Systems Schematic Diagram	12

1. Introduction

The development of green health facilities is an integral part of the health sector's response to climate change and the country's journey to achieving universal health care. The Green and Safe Health Facilities Manual integrates measures on climate change adaptation and mitigation as relevant in aspects of health facility operations and service delivery. These are aligned with Section 15 of the DOH Special Provisions in the Republic Act (R.A.) No. 12116, the General Appropriations Act (GAA). Attached herewith is the summary of special and general provisions under the FY 2025 GAA that address aspects of green, safe, and climate-resilient health facilities for your reference. The minimum green and safe standard for all hospitals and other health facilities was established through the DOH's issuance of Department Circular No. 2021-0437, Dissemination of the Green and Safe Health Facilities Manual, First Edition, or referred as green manual that contains the following performance standards and guidelines from sections 10 to 17: governance, energy eciency, water eciency, sanitation and hygiene, health care waste management, environmentally resilient health facility, site sustainability, materials sustainability and indoor environmental quality.

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 a 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.

The Health Facility Development Bureau (HFDB) of the Department of Health (DOH) released the localized Water and Sanitation for Health Facility Improvement Tool (WASH FIT) Manual of the Philippines on April 18, 2023 , through DOH Department Circular No. 2023-0185. Recognizing Water, Sanitation, and Hygiene as performance standards of Green and Safe Health Facilities, the WASH FIT guidelines were simplified to allow the straightforward application of the tool and the prompt development of improvement plans. The said guidelines are designed to contribute to the attainment of the country's goals towards sustainable development, climate action, and universal health care through this link: https://bit.ly/WASHFITguide.

To provide a more comprehensive and holistic approach to managing and ensuring safely managed water and sanitation systems, the DOH intends to integrate the Water Safety Plan (WSP) and Sanitation Safety Plan (SSP) into the WASH FIT for hospitals. This report details the recommendations on how to integrate the WSP and SSP into the WASH FIT process. The development of WSP for healthcare facilities is a milestone in consistently addressing the need for safe access to drinking water. Thus, this guideline provides a step-by-step process on the formulation of WSP tailored fit in hospital settings, which will also serve as a model for other health facility on the formulation of their WSPs. The guidelines for Guidelines for Water Safety Plan Development of Health Facilities can be accessed at https://bit.ly/PLANwater.

SSP is a guide to facilitate the drafting and implementation of health risk assessment and management plans along the sanitation chain to meet 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 assure the authorities and the general public of the safety of euents for discharge or re-use. The guide to developing the Sanitation Safety Plan for Health facilities can be accessed at https://bit.ly/SSPplanHF.

1.1. Comparison of WASH FIT, WSP, and SSP

The frameworks of WASH FIT, WSP, and SSP share the same principles of facility assessment, risk management, continuous improvement, and monitoring, but each focuses on different components of WASH. WASH FIT provides a broad framework for WASH improvements, while WSP and SSP offer targeted, risk-focused plans for water and sanitation safety.

WASH FIT is a comprehensive tool that encompasses six domains for health facilities namely,

a. Water
b. Sanitation
c. Hygiene
d. health care wastes
e. environmental cleaning
f. management practices.

It aims to improve the overall quality of WASH services by assessing current conditions, identifying gaps, and providing a structured approach to enhance these services. The WASH FIT process consists of six tasks as shown in Table 1.

On the other hand, WSP focuses primarily on the safety of the water supply by managing risks from the source to the point of use and includes ten modules. SSP, with six modules, aims to protect public health and the environment from the risks of the sanitation chain, ensuring that wastewater generated is safely managed from collection to disposal or reuse. The modules of WSP and SSP are shown in Table 1

Table 1: Comparison of WASH FIT, WSP and SSP

	WASH FIT	WSP	SSP
Coverage	Covers six domains namely, water, sanitation, hygiene, health care wastes, environmental cleaning, and management	Water supply system, from point of entry/source to point of use.	Sanitation chain, from wastewater generation to point of disposal or reuse
Process/ Steps	Consists of five (5) tasks:	Consists of ten (10) modules :	Consists of six (6) modules:
	Task 1: Assemble the WASH FIT team Task 2: Assess	Module 1: Assemble the WSP team Module 2: Describe the Water Supply	Module 1: Prepare for Sanitation Safety Plan
	the existing WASH facilities and practices Task 3:	System Module 3: Identify the Hazards and Hazardous Events	Module 2: Describe the Sanitation System
	Undertake hazard and risk assessment Task 4: Develop an	Module 4: Determine and Validate Control Measures and Assess the Risks.	Module 3: Identify hazardous events, assess existing control measures and exposure risks
	Improvement Plan Task 5: Monitor the progress of improvement plans	Module 5: Develop, Implement, and Maintain an Improvement/ Upgrade Plan	Module 4: Develop and implement an incremental improvement plan Module 5:
		Module 6: Define the Monitoring of the Control Measures	Monitor control measures and verify performance
		Module 7: Verify the Effectiveness of the WSP	Module 6: Develop supporting programs and review

	Module 8: Prepare Management Procedures	plans
	Module 9: Develop Supporting Programs
	Module 10: Review and Update WSP

2. Proposed Integration of WASH FIT, WSP and SSP

To streamline the safe management of WASH facilities in hospitals, the WSP and SSP modules will be integrated into the five tasks of WASH FIT (see Figure 1). This approach allows for a unified framework where water and sanitation risk management is incorporated within WASH FIT's structured tasks. This provides a more holistic approach to managing water and sanitation systems in the hospital.

Moreover, it is highly encouraged the use new and emerging technologies in WASH infrastructure that promote sustainability, such as decentralized wastewater treatment, biogas generation from organic waste, and water-ecient sanitation solutions. Conduct thorough assessments of different technologies, including their cost, feasibility, and long-term operational savings, to guide healthcare facilities in selecting the most suitable solutions.

The proposed activities per task are discussed in the succeeding subsections.

2.1 Preparation

From the WASH FIT Team or Green and Safe Health Committee of the hospital, a point person for WSP and for SSP should be designated. These point persons will be responsible for the collection of information needed to assess the systems, do walkthroughs and conduct risk assessments. They will also be responsible for the assessment of the Water and Sanitation indicators for WASH FIT.

Refer to Module 1 of the Guidelines for the Development of WSP in Hospitals and Guidelines for the Development of SSP in Hospitals for further details on the responsibilities of the point persons.

Figure 1: WASH FIT and Safety Plan Process

2.2. Facility Assessment and Development of Schematic Diagram

To facilitate the conduct of WSP and SSP, data gathering and facility walkthrough will be done by the point persons as part of Task 2 of WASH FIT.

The information to be collected about the hospital's water supply and sanitation systems are listed under the General Information tab of the proposed revised WASH FIT and Safety Plan Tool. For more comprehensive guidance, refer to Module 2 of the Guidelines for the Development of WSP in Hospitals and Guidelines for the Development of SSP in Hospitals.

The point persons should also conduct a walkthrough of the entire water supply and sanitation systems of the hospital, assessing both physical and operational conditions to determine if there are any potential risks. This assessment will be conducted concurrently with the evaluation of WASH FIT indicators related to water and sanitation, ensuring a comprehensive review of system performance.

After collecting the necessary information, an integrated schematic diagram of the water supply and sanitation system will be developed. This diagram will visually represent the system's components, flow paths, and interactions, facilitating a better understanding of the infrastructure and identifying potential areas for improvement.

Table 2: WASH FIT Rating

Rating	Description	What does your rating mean?	When is the next assessment?
No Star	At least one of the national indicators is not meeting the minimum standards	Critical changes are needed immediately.	Do another assessment after 12 months
One Star	50% of national indicators are at least partially meeting the minimum standards with at least one advanced (global) indicator partially meeting minimum standards	Continue making improvements	Do another assessment after 12 months
Two Stars	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 24 months
Three Stars	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 36 months

Moreover, using the WASH FIT shall provide health facilities risk-based assessment of water and sanitation concerns. Additional guidance notes are proposed for selected indicators of Water, Sanitation, and Environmental Cleaning, to provide a more detailed assessment of water and sanitation-related risks. The proposed additional guidance notes are presented in Table 3.

Table 3: Proposed Additional Guidance Notes

Water
Indicat or No.	WASH FIT Indicator	Relevant Water Supply Component	Proposed Additional Guidance Note
1.15P	Improved DRINKING water supply piped into the facility or on premises	Point-of-Entry (POE)/Water source Distribution Water treatment	Improved drinking water sources should have a low risk based on WSP risk assessment. Water is treated and regulated with safe water management by a service provider or water is regularly treated on-site to meet the required quality (PNSDW, dialysis). Piped water: All taps are connected to an available and functioning water supply, with no leaks in pipes, Water pipes should be inspected regularly, and a system in place to fix leaks as soon as they are found. If there are breakdowns in the water supply, it should be repaired within 48 hours. Rainwater: Gutters and roofs used for rainwater catchment and storage tanks should be regularly cleaned at least monthly or as needed during heavy storms and rainfall. The system should also use a first flush device which is designed to divert the first portion of contaminated rainwater so it does not enter the storage tank and a filter box.

Water
1.1	Improved water supply	Point-of-Entry (POE)/Water source	Improved drinking water sources should have a low risk based on WSP risk assessment.
	piped into the facility or on premises, with no leaks?	Distribution	Water is treated and regulated with safe water management by a service provider or water is regularly treated on-site to meet the required quality (PNSDW, dialysis).
			Piped water:
			All taps are connected to an available and functioning water supply, with no leaks in pipes, Water pipes should be inspected regularly, and a system in place to fix leaks as soon as they are found. If there are breakdowns in the water supply, it should be repaired within 48 hours.
			Rainwater:
			Gutters and roofs used for rainwater catchment and storage tanks should be regularly cleaned at least monthly or as needed during heavy storms and rainfall. The system should also use a first flush device which is designed to divert the first portion of contaminated rainwater so it does not enter the storage tank and a filter box.
1.3	Reliable drinking water station available	Point-of-Use	Water in the drinking water station should be safe.
			Refer to WSP risk assessment. The risk associated with the point of use should be low.
1.4	Drinking water-safe storage and has no E. Coli	Water Storage	Including other water storage tanks.
			Water storage tank/s are protected (e.g. from climate-related extreme weather events, from ingress of contaminants) and

Water
			adequately managed (e.g. inspected, cleaned/disinfected regularly, structural integrity) Refer to WSP risk assessment. Risks associated with water storage should be low.
1.10	The water supply has appropriat e disinfectant residual	Point-of-Use	The residual chlorine in all water supplies (primary, backup, and supplemental supplies) is routinely tested according to PNSDW.

Sanitation
Indicato r No.	WASH FIT Indicator	Relevant Sanitation System Component	Proposed Additional Guidance Notes
2.1	Sucient number of functional toilets or latrines available	Wastewater generation (Toilet)	A functioning or usable toilet or latrine should be maintained in a clean condition
2.8	Wastewater (both greywater and black water) is safely managed	Wastewater generation (Toilet and other wastewater sources) Containment/C onveyance (septic tank, sewer line) Wastewater treatment	Toilets and other wastewater sources are connected to a sanitary plumbing system without leaks and any cross-connection with the drinking water supply. The sewer conveys excreta and wastewater with no leaks/overflows to treatment If STP, operated by trained personnel with appropriate personal protective equipment Treated euent from WWTP should be compliant with DENR General Euent Standards (GES) If septic tanks, fecal sludge from the septic tank is periodically emptied without spills (within the last 5 years) by trained personnel with

Sanitation
			appropriate personal protective equipment and treated by a DENR-accredited service provider. Safely managed wastewater systems should have a low risk based on SSP assessment.
2.9	Greywater the drainage system is safely managed	Containment/ Conveyance (drainage)	The drainage system is not overflowing, maintained in good condition by trained personnel with appropriate protective equipment
3.8	A clear and detailed facility (or ward) cleaning policy or protocol is clearly displayed, which is implement ed and monitored	Wastewater generation (Toilet)	Including cleaning of toilets Toilets are cleaned at least once each day, and a record of cleaning is signed by the cleaners and displayed visibly

Management
Indicator No.	WASH FIT Indicator	Proposed Additional Guidance Notes
4.1	WASH FIT and other quality improvement/ management plan (i.e., HCWM, SSP, WSP)	A risk assessment should have been conducted to develop an integrated improvement plan for WASHFIT, WSP,and SSP. A protocol or procedure is in place for normal, incident, and emergency operating conditions of WASH
4.2	Adequate budget for WASH infrastructure and operations are utilized	Including budget for maintenance and repairs

Figure 2: Sample Integrated Water Supply and Sanitation Systems Schematic Diagram

2.3. Hazard and Risk Assessment

As part of Task 3, the hospital will also conduct a risk assessment of the water supply system and sanitation system of the hospital (Task 2b). The hospital will follow Module 3 of the WSP and SSP. The results of the risk assessment will be considered in evaluating the relevant WASH FIT indicators. Design an integrated risk assessment tool that addresses both water and sanitation safety. This will allow the hospital to assess risks to both water supply and wastewater management simultaneously, ensuring that they are treated as interconnected systems.

The hospital shall be developing an integrated water supply and sanitation systems schematic diagram to check whether the water quality or discharge is compliant with the existing rules and regulations.

Table 4: Risk assessment and Control Measure template

	Hazard and Hazardous Event	Risk Assessment	Control Measures
	Water System
I.	Point of Entry (POE)
II.	Water Storage
III.	Water Treatment
IV.	Point of Use (POU)
	Sanitation System
I.	Wastewater Generation
II.	Containment/Conveyance
III.	Stormwater Management
IV.	Wastewater Treatment

2.4. Development of Integrated Improvement and Monitoring Plan

An integrated Improvement Plan and Monitoring Plan will be developed for WASH FIT, WSP, and SSP. With this, the hospitals can monitor all WASH aspects under one system. This integration reduces redundant processes, making it easier to track and manage compliance with standards and safety protocols consistently, and will allow the hospitals to allocate resources more effectively, addressing both general WASH needs and specific water and sanitation safety risks in a coordinated way.

Below is the summary of the Improvement and Monitoring Plan for the Integrated Water Safety Plan and the Sanitation Safety Plan. The improvement plan will ensure that the risk or gap will have its specific responsible unit or personnel, cost or fund source, and target date, while the monitoring plan will monitor the key observation, where or area of the observation, corrective action, and status. Indicators will be based on the actual accomplishment of the health facilities' WASH FIT Safety Plan template.

Table 5: Improvement and Monitoring Plan template

IMPROVEMENT PLAN			MONITORING PLAN
Responsible	Cost/Fund	Target
Unit/Personnel	Source	Date	Observation	Where	Corrective Action	Status

Water Safety

Sanitation Safety

2.5. Evaluation Plan

The team must weigh the level or seriousness of the problems/risks about how easy or dicult 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 arises and the severity of the consequences when they materialize. For the evaluation of the WASH FIT Safety Plan, it shall have compliance monitoring for water quality on internal and external auditing, customer satisfaction, and discharges for the general euent system. Moreover, the evaluation plan matrix will allow for ensuring that verification activity or monitoring parameters are in place, including the description, location of activity, responsible personnel, and recipient of analysis. Thus, action on failing results and third-party recipients of results shall also provide an unbiased evaluation.

Table 6: Evaluation Plan template

EVALUATION PLAN
Verification				Analyst/
Activity/		Location		Person	Recipient	Action on	3rd-Party
Monitoring	Descripti	of	Frequency	Responsib	of Analysis	unusual/	Recipient
Parameter	on	Activity	of activity	le	Result	failing result	of Results
	Compliance Monitoring (Water Quality)
Internal Auditing
	External Auditing
Customer Satisfaction
Discharges