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 Health Care Facility WASH Insecurity Experiences (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) services are essential for health care facilities to deliver safe, quality care and to protect the dignity of patients and staff. Accurate measurement is the first step to ensuring their needs are met.
A fuller picture
What traditional supply-side measures capture
Is a service available at the time of survey?
Facility-based indicators measure availability well, and accessibility in part, at a single point in time.
What HCF-WISE helps fill in
Does the service reliably meet the needs of the people who use it?
Patients and staff report on accessibility, usability and sufficiency, and reliability over time, across all six domains.
The value of measuring experiences
Eight of the ten health care facilities sampled in Uganda as part of the HCF-WISE project had basic water services based on WHO/UNICEF criteria, yet a quarter of their patients still went thirsty.
Data like these help reveal whether services are falling short for the people who use them, and inform what to do about it, whether through service upgrades or other changes. In Uganda, they are helping local decision-makers work out how to better meet the needs of patients and staff.
By WHO/UNICEF JMP criteria
Water service
- Basic serviceWater from an improved source, available on the premises8 of 10 facilities
- Limited serviceAn improved source within 500 metres of the premises
- No serviceAn unimproved source, one over 500 metres away, or none
Water and hygiene challenges experienced by patients and staff at facilities with basic water services
| Problem | Patients (235) | Facility staff (99) |
|---|---|---|
| Thirsty, no safe water to drink | 26 | 21 |
| Not enough water to wash hands | 30 | 23 |
| Not enough soap to wash hands | 43 | 32 |
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.
-
Water
WHO/UNICEF basic service
Water available from an improved source on the premises
Example HCF-WISE question“In the past 4 weeks, how often did you perform or assist with medical procedures without sufficient water?”
From the staff survey
-
Sanitation
WHO/UNICEF basic service
Usable improved toilets, including one for staff, one sex-separated with menstrual hygiene facilities, and one accessible for people with limited mobility
Example HCF-WISE question“During your time at the healthcare facility, how often did you think it was unsafe for you to go to the place for urinating or defecating?”
From the patient survey
-
Hygiene
WHO/UNICEF basic service
Functional hand hygiene facilities at points of care and within five metres of toilets
Example HCF-WISE question“During your time at the healthcare facility, how often was there not enough soap to wash your hands?”
From the patient survey
-
Environmental cleaning
WHO/UNICEF basic service
Cleaning protocols available, and all staff with cleaning responsibilities trained
Example HCF-WISE question“In the past 4 weeks, how often did you use your own money to purchase cleaning supplies for the facility?”
From the staff survey
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 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 cleaning and maintenance staff, and by gender and disability status, giving a clearer picture of how to design efforts to 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.
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.
How the scales are builtWater
Availability, perceived safety, and accessibility of water for drinking, for clinical care, and for cleaning and hygiene at the facility.
Sanitation
Accessibility, privacy, safety, and adequacy of sanitation facilities for the people who need them.
Hygiene
Accessibility and adequacy of hygiene facilities for washing hands as desired.
Environmental cleaning
Adequacy of cleaning in wards, treatment rooms, and other care spaces, and of the supplies and equipment needed to carry it out.
Waste management
Adequacy of waste management for maintaining clean care spaces and reducing the risk of contamination.
Menstrual health
Ability to manage menstrual needs safely, privately, and with dignity while at the health care facility.
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.
Data collection complete
In preparation
Ghana
Data collection completeVolta and Central Regions
PATH
Site lead: Adam Drolet, Senior Program Officer
Get involved
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.
Stay informed
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.
We use your details only to send project updates. We do not share them with anyone else.