Dirty sinks
used for handwashing and cleaning medical equipment in one health centre in
rural Cambodia.
Channa Sam Ol, WASH and Health Program
Manager for WaterAid Cambodia, describes how the team is working to put water,
sanitation and hygiene (WASH) at the centre of improvements to healthcare
facilities.
Ensuring healthcare facilities have clean
water, accessible toilets and handwashing stations has huge benefits – and is
the key focus of WaterAid's current campaign, Healthy Start. It prevents
infections and the spread of disease; protects staff, patients, care-givers,
pregnant women and newborns; and improves the experience of care. The 2015
World Health Organization (WHO) and UNICEF WASH in healthcare facilities report
stated that just 67% of Cambodian healthcare facilities have water coverage,
with no data reported for sanitation or water and soap coverage for effective
handwashing.
At WaterAid Cambodia, we have been taking
steps to address this urgent issue.
1 Identifying
where there is a need
In 2014, we started work to help Cambodia
meet its target of universal access to clean water and sanitation by 2025. We
undertook a scoping exercise to identify the most strategic ways in which our
expertise could support the country’s health priorities and bring WASH to the
core of its health policies and programmes. We identified WASH in healthcare
facilities as one of the priority areas.
2
Understanding the situation
To build a more detailed understanding of the
status of WASH in healthcare facilities, we partnered with the National
Institute of Public Health to review existing Ministry of Health data and
identify the extent to which WASH in healthcare facilities is monitored
nationally. The findings showed there is no single policy document that
comprehensively explains standards and coverage targets for WASH in healthcare
facilities in Cambodia.
Because of limited national policies,
standards and monitoring, together with WHO we developed an assessment tool to
capture data on WASH access and practices in healthcare facilities. Assessments
were then successfully completed in 12 facilities (health centres and referral
hospitals), collecting information on the main indicators of access to safe
WASH in healthcare. The study highlighted that in most cases an improved water
source was not available all year round. Instead, multiple sources were used, leading
to a lack of drinking water. Typically, toilets were not functioning well, or
were inaccessible to staff or patients with a disability, with limited
mobility, or in the last trimester of pregnancy. None of the toilets had the
features to support menstrual hygiene management.
Being in the maternal and child health field
for more than ten years, I have seen with my own eyes a situation not so
different from what the study found. There are a lot of challenges around the
cleanliness of maternity wards: poor hand hygiene practices and facilities; a
lack of clean water for newborn bathing; poor medical waste management
(especially placenta disposal); and a lack of personal protection for staff.
WaterAid’s studies showed that the status of WASH in healthcare facilities in
Cambodia is not adequately captured in national monitoring mechanisms, and
therefore nobody really knows the actual situation. This motivates me to work
to address these challenges, especially to contribute to improving maternal and
child mortality and morbidity, and to raise the profile of WASH and health
within my country’s health system. In a discussion I had with a colleague from
WHO in my first month at WaterAid, I remember asking, “How should we start?”
3 Identifying
stakeholders and partners
To address the challenges, all stakeholders,
including the government, development partners and local NGOs, need to
understand the situation and take action. Through identifying others working on
WASH in healthcare facilities in Cambodia, we learned that Emory University was
already undertaking work that had similar goals to WaterAid’s. We began a
partnership with Emory University under the project name Safe water: access to
clean water in healthcare facilities. In late 2015, WaterAid Cambodia and key
actors organised an informal consultation meeting to gather all interested
partners to identify the challenges and opportunities and begin developing a
plan for moving forward.
4 Taking
formal steps
In order to make significant and sustainable
improvements to WASH in healthcare facilities, we needed to build a strong
relationship with government partners. We were delighted to secure a formal
meeting with the Secretary of State for the Ministry of Health, His Excellency
Professor Eng Huot. During the meeting, Prof Huot was presented with the clear
message that WASH in healthcare facilities is part of basic quality of care and
a fundamental part of infection prevention control. He not only agreed with its
importance for improving health in Cambodia but reinforced it, stating,
“Without water, the healthcare facilities can’t reach the infection prevention
control standard.” This initial meeting led to an official memorandum of
understanding between WaterAid Cambodia and the Ministry of Health, to
implement a WASH and health project with WASH in healthcare facilities as the
priority starting point.
A midwife washes her hands in a rural health centre in Pusat province.
5 Turning
planning into action
With an official memorandum of understanding
in hand, we began our project with the Ministry of Health’s Department of
Hospital Services, together with WHO and other partners. Jointly, we organised
a second consultation meeting, this time lead by the Department of Hospital
Services and a representative from the Ministry of Rural Development’s Rural
Health Care Department. NGOs who would be implementing the WASH in healthcare
facilities programme also attended. The meeting concluded with three points to
understand:
What is the basic WASH situation in
healthcare facilities?
What are the training needs for healthcare
staff on WASH within infection prevention control procedures?
How can we include sections on WASH in the
existing policies, guidelines and standards related to healthcare facilities?
6
Institutionalising the WASH in healthcare facilities assessment tool
Building on our assessment tool and WHO’s
Essential Environmental Health Standards in Health Care, the National Institute
of Public Health developed a national assessment tool. The tool addresses both
public referral hospitals and health centres. Its main objective is to guide
and harmonise national assessment of WASH in public health facilities in
Cambodia. More specifically, it is to be used to collect data to compute the
five core indicators:
- Basic water supply facilities
- Basic sanitation facilities
- Basic hand hygiene facilities
- Cleaning routines
- Healthcare waste management
What next?
In our team, we are taking an ‘adaptive
planning’ approach, to stop and think what to do next as we learn more and the
situation changes.
The WASH in healthcare facilities programme
is aligned with the Government’s new five-year strategy to improve access to
equitable and quality health services. During a WASH in healthcare facilities
event organised by WaterAid at the 69th World Health Assembly, a senior officer
from the Ministry of Health of Cambodia gave his support to integrate WASH in
healthcare facilities as part of the quality of care agenda. The Ministry of
Health’s influential support clears a pathway for change for WASH in healthcare
facilities. In a recent discussion on localising Sustainable Development Goal 3
‘Ensure healthy lives and promote well-being for all at all ages’, it became
apparent that two indicators on water and sanitation are being included, and we
are working hard to have a third on handwashing added too.
In the coming months, we will assist the
Ministry of Health to administer and institutionalise the national assessment
tool within healthcare facilities. When the Ministry has collected data and
identified healthcare facilities to prioritise, we intend to support provincial
health departments to upgrade behaviours and facilities. We are considering
piloting the WHO Water and Sanitation for Health Facility Improvement Tool
(WASH FIT)1 approach for this.
It’s an exciting time to be working with
healthcare facilities. As part of the decentralisation agenda, facilities are
for the first time receiving grants directly from the Ministry of Economics and
Finance, and there are financial incentives for them to improve their quality
of care. If we can tie improvements to WASH to this agenda we may see real
interest from healthcare facilities staff, and leverage this new funding.
We will continue to raise the profile of WASH
in healthcare facilities through engaging stakeholders, being a supportive
partner and monitoring progress. With our partners, we are helping to catalyse
change and revolutionise rural health care in Cambodia.
Channa Sam Ol
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