Health Care Facility WASH Insecurity Experiences Scales
Bringing the human voice to WASH in health care
We know whether WASH services are available in health care facilities – but do they meet the needs of patients and staff?
The HCF-WISE Scales are brief surveys that answer that question by capturing whether services are accessible, acceptable, and adequate for the people who depend on them.
Why we are building these tools
Reliable water, sanitation, and hygiene (WASH) is needed for health care facilities to function well and to deliver appropriate care. It underpins infection prevention and control, supports safe childbirth, enables staff to do their work, and protects the dignity of patients.
Despite decades of investment, many facilities do not have adequate WASH systems. Part of the reason is that we may not be measuring what matters most: global monitoring largely counts water points, toilets, and handwashing stations rather than assessing whether those services work reliably and adequately for everyone in the facility.
WHO, UNICEF, and others have called for next-generation indicators that capture whether services deliver their intended benefits. The HCF-WISE Scales are designed to answer that call.
Measuring beyond basic
Global monitoring systems classify water, sanitation, hygiene, waste management, and environmental cleaning services at health care facilities as basic, limited, or no service, based on what is present and whether it is usable at the time of survey. The HCF-WISE Scales complement these supply-side indicators by assessing whether services are accessible, acceptable, and adequate for the diverse needs of the people who use them.
Questions are taken from the patient and staff surveys. Patients are asked about their time at the facility, with response options of never, some of the time, or most of the time; staff are asked about the past four weeks, with response options of never, sometimes, or many times.
Revealing unmet need
Eight of ten facilities in Uganda had a basic water service, yet patients still went thirsty and without sufficient soap.
Across ten health care facilities in Uganda, eight met the WHO/UNICEF standard for a basic drinking-water service. Even so, a quarter of patients reported being thirsty with no safe water to drink, and two in five reported not having enough soap to wash their hands. These data are helping local decision-makers determine how to better meet the needs of patients and staff.
Water and hygiene problems reported at the facility (%)
Ten facilities in Uganda, eight of them with basic drinking-water services based on JMP criteria. Patients report on their time at the facility, staff on the past four weeks.
Apply the scales to advance WASH in health care facilities
Measure what matters
User-centered data reveal whether services are accessible, acceptable, and adequate for diverse needs. These are the conditions that determine whether a service is actually used and whether it supports safe care.
Examine disparities
Conventional health care facility WASH measures describe conditions at the facility level. The individual-level data collected through HCF-WISE surveys reveal disparities between patients, clinical and administrative staff, and the cleaning and maintenance staff who keep a facility running, and by characteristics such as gender and disability status, giving a clearer picture of how to design efforts that equitably improve conditions.
Inform policy and investment
Survey items and the resulting scores are designed to be comparable across settings. They can identify the populations most acutely affected and, paired with other data, point to the drivers of WASH insecurity, direct investment where it is needed, and engage other sectors by demonstrating the wider benefits of investing in WASH.
A comprehensive conceptualization of WASH
The HCF-WISE Scales ask about experiences across six domains: water, sanitation, hygiene, environmental cleaning, waste management, and menstrual health. These align with, and expand upon, the services currently monitored by the WHO/UNICEF JMP.
Availability, perceived safety, and accessibility of water for drinking, for clinical care, and for cleaning and hygiene at the facility.
Accessibility, privacy, safety, and adequacy of sanitation facilities for the people who need them.
Accessibility and adequacy of hygiene facilities for washing hands as desired.
Adequacy of cleaning in wards, treatment rooms, and other care spaces, and of the supplies and equipment needed to carry it out.
Adequacy of waste management for maintaining clean care spaces and reducing the risk of contamination.
Ability to manage menstrual needs safely, privately, and with dignity while at the health care facility.
Alongside the surveys, study teams complete a structured assessment of each facility's WASH infrastructure. Pairing the experiential information with conventional supply-side indicators shows whether service availability consistently translates into better experiences for patients and staff, and where conditions need to improve when it does not.
A growing consortium
The HCF-WISE project is a network of academic institutions, NGOs, and implementing partners. Consortium members implement the surveys through standalone studies or embed them in existing monitoring and evaluation efforts within health care facilities, and contribute the resulting data to a shared, harmonized database.
Facility-based data collection is complete in Ghana, Mozambique, Nepal, and Uganda, with further sites planned or underway. We are actively seeking partners in high-income countries, South America, the Middle East and North Africa, and Asia, where experiential WASH measurement in health care facilities is least developed.
Join the HCF-WISE movement
Use the tools
Add the survey to ongoing or planned work
- The tools are developed, and our team can help with implementation
- The HCF-WISE modules can be embedded in ongoing studies or facility evaluations
Partners who contribute a site to the scale development study receive early access to the tools, training and technical support, results returned for their own sites, and opportunities for co-authorship.
Fund the work
Help the consortium reach new settings
We now have data from several sites, but the scales need to be implemented in more of them before we can judge how well they perform across diverse settings and facility types. We are therefore seeking support for new study sites and for training partner teams. We would welcome a conversation.
Newsletter
The project newsletter carries updates on milestones, new sites, publications, and consortium news. Papers, presentations, and site reports are collected on the Resources page as they become available.
Work in health care facilities? Put the tools to work.
The surveys are developed and ready to pilot, and our team is available to help train staff on using the tools. Partners get early access to the tools, technical support, a place in a global measurement network, and opportunities for co-authorship.
Use the scales