What we are learning
Insights from the HCF-WISE project
Data collection is complete at several sites and analysis is underway. Full findings will be published in peer-reviewed papers and in site reports returned to participating facilities. Three patterns are already clear.
Pattern one
Service availability is not the same as service adequacy
Patients and staff at health care facilities classified as having basic WASH services can still go without.
Qualitative work established this; the HCF-WISE data now show it quantitatively, revealing how often these problems occur and who is most affected. At several sites where WASH infrastructure was available, patients and staff still reported substantial difficulty reaching the facilities or found that the services were not of adequate quality and functionality to reliably meet their needs.
The practical consequence is that supply-side indicators alone can make a health care facility look adequately served while the people inside it are not. Experiential data complement those indicators: they bring these difficulties into view and support the work of making sure people’s WASH needs are met.
Pattern two
WASH disparities exist within and across facilities
Because the scales collect individual-level data rather than a single facility rating, they can show disparities by age, gender, disability, and position at the health care facility.
This makes it possible to identify disparities across groups and to reveal where there is a mismatch between the WASH services a health care facility has and what people experience when they try to use them.
Across several sites, for example, we see differences between patients and staff, although not always in the same direction. Sometimes staff have access to better services; sometimes they hold higher expectations of those services and are more likely to report problems that affect their wellbeing and their ability to do their work. See patient and staff results by site.
Pattern three
Challenges across all domains
Difficulties are not confined to one domain.
Across sites, patients and staff report problems with water, sanitation, hygiene, environmental cleaning, and waste management, and which domain is most burdensome differs from facility to facility. Handwashing infrastructure, for example, is often present; soap at the moment of need often is not: at all three sites with data so far, more patients and more staff reported not having enough soap to wash their hands than reported not having enough water.
Among the most common challenges across health care facilities is managing menstruation, which is not currently captured as a standalone service level in global monitoring. Asking patients and staff who menstruate about their own experience is among the best ways to identify where provision falls short.
Explore the data
Below you can explore every HCF-WISE item asked at each site. Pick a site and a domain; the grey bar is the difference between the percentage of patients and the percentage of staff who reported it.
Water
Sanitation
Hygiene
Environmental cleaning
Waste management
Menstrual healthAsked of patients and staff who menstruate
See the numbers for this site as a table
| Item | Patients % | Patients answering | Staff % | Staff answering |
|---|---|---|---|---|
| Water | ||||
| Felt thirsty but had no safe water to drink | 56.0 | 275 | 58.4 | 209 |
| Worried water problems could make them or others sick | 23.5 | 272 | 31.1 | 209 |
| Drinking water tasted, looked, or smelled bad (staff only) | – | – | 39.7 | 199 |
| Worried there would not be enough water (staff only) | – | – | 62.7 | 209 |
| Water supply at the facility was interrupted (staff only) | – | – | 53.5 | 200 |
| Could not concentrate on duties because of thirst (staff only) | – | – | 46.4 | 209 |
| Water problems affected their ability to provide care (staff only) | – | – | 42.3 | 175 |
| Water problems affected their ability to clean the facility (staff only) | – | – | 36.7 | 30 |
| Performed or assisted a procedure without enough water (staff only) | – | – | 41.6 | 173 |
| Patients were asked to bring or fetch their own water (staff only) | – | – | 36.6 | 175 |
| Flooding or heavy rains disrupted activities (past 12 months) (staff only) | – | – | 61.7 | 206 |
| Sanitation | ||||
| Unable to use a toilet when needed | 76.3 | 266 | 48.8 | 207 |
| Thought the toilets were dirty or smelled bad | 80.1 | 267 | 73.2 | 209 |
| Thought it was unsafe to go to the toilet | 65.0 | 266 | 39.4 | 208 |
| Worried they could be seen while using the toilet | 29.7 | 266 | 29.7 | 209 |
| Not enough materials to clean themselves afterwards | 81.0 | 268 | 72.6 | 208 |
| Ate or drank less to avoid using the toilets (staff only) | – | – | 37.8 | 209 |
| Waited until they got home to use a toilet (staff only) | – | – | 66.5 | 209 |
| Felt ashamed or embarrassed to use the toilets (staff only) | – | – | 40.7 | 209 |
| Could not concentrate on duties because they needed a toilet (staff only) | – | – | 40.7 | 209 |
| Hygiene | ||||
| Not enough water to wash hands | 57.9 | 273 | 54.5 | 209 |
| Not enough soap to wash hands | 82.1 | 273 | 69.1 | 207 |
| Unable to get their hands as clean as they wanted | 67.2 | 274 | 65.2 | 207 |
| Felt annoyed by the handwashing options available (staff only) | – | – | 49.3 | 207 |
| Environmental cleaning | ||||
| Thought the areas where care was given were dirty | 35.7 | 277 | 50.2 | 209 |
| Thought other parts of the facility were dirty | 41.9 | 277 | 49.3 | 209 |
| Worried uncleanliness could make them or others sick | 31.4 | 277 | 39.7 | 209 |
| Thought surfaces were not properly cleaned (staff only) | – | – | 47.8 | 209 |
| Thought medical equipment was not properly cleaned (staff only) | – | – | 33.9 | 174 |
| Not enough soap, detergent, or disinfectant for cleaning (staff only) | – | – | 73.3 | 30 |
| Used less cleaning product to avoid running out (staff only) | – | – | 76.7 | 30 |
| Limited in cleaning by problems with the cleaning tools (staff only) | – | – | 76.7 | 30 |
| Used their own money to buy cleaning supplies (staff only) | – | – | 28.2 | 209 |
| Not enough protective equipment to work safely (staff only) | – | – | 58.2 | 184 |
| Reused disposable protective equipment because supply ran short (staff only) | – | – | 42.4 | 184 |
| Waste management | ||||
| Thought waste was not properly disposed of | 35.6 | 270 | 33.2 | 208 |
| Worried waste could make them or others sick | 33.6 | 277 | 34.0 | 209 |
| Waste containers were overfilled (staff only) | – | – | 32.9 | 207 |
| Could not manage waste adequately or safely (staff only) | – | – | 50.0 | 30 |
| Menstrual health | ||||
| No clean, safe place to change menstrual materials | 84.7 | 144 | 36.4 | 110 |
| Difficult to dispose of menstrual materials privately | 91.0 | 144 | 43.6 | 110 |
| Unable to wash after changing menstrual materials | 90.3 | 144 | 54.5 | 110 |
| Felt nervous or embarrassed about coming to work (staff only) | – | – | 22.0 | 109 |
| Missed work because of their period (staff only) | – | – | 6.4 | 110 |
| Worried materials would not be available in an emergency (staff only) | – | – | 43.6 | 110 |
| Did not have materials to absorb their period (staff only) | – | – | 38.2 | 110 |
How to read this. Each dot is the share of respondents who said they had experienced the item (answering “sometimes” or “many times” rather than “never”), out of those who answered it. The grey bar shows the gap between patients and facility staff.
Item wording was adapted for each site and is shortened here; hover over a dot for the percentage and the number of respondents behind it. Menstrual health items were asked only of patients and staff who menstruate. Values based on fewer than 30 respondents are not shown.
Patients answered about their time at the facility and staff about the past four weeks. In Uganda staff were asked about both the current and the opposite season; the current-season answer is the one shown.
These are preliminary descriptive results from the scale-development phase. They describe the participating health care facilities only, are not representative of the country, and have not yet been peer reviewed.
Water
Sanitation
Hygiene
Environmental cleaning
Waste management
Menstrual healthAsked of patients and staff who menstruate
See the numbers for this site as a table
| Item | Patients % | Patients answering | Staff % | Staff answering |
|---|---|---|---|---|
| Water | ||||
| Felt thirsty but had no safe water to drink | 5.0 | 302 | 9.0 | 111 |
| Worried water problems could make them or others sick | 9.3 | 364 | 21.6 | 111 |
| Drinking water tasted, looked, or smelled bad (staff only) | – | – | 9.0 | 111 |
| Worried there would not be enough water (staff only) | – | – | 17.3 | 110 |
| Water supply at the facility was interrupted (staff only) | – | – | 20.7 | 111 |
| Could not concentrate on duties because of thirst (staff only) | – | – | 2.7 | 111 |
| Water problems affected their ability to provide care (staff only) | – | – | 0.0 | 31 |
| Water problems affected their ability to clean the facility (staff only) | – | – | 2.9 | 35 |
| Performed or assisted a procedure without enough water (staff only) | – | – | 3.2 | 31 |
| Patients were asked to bring or fetch their own water (staff only) | – | – | 3.2 | 31 |
| Flooding or heavy rains disrupted activities (past 12 months) (staff only) | – | – | 35.1 | 111 |
| Sanitation | ||||
| Unable to use a toilet when needed | – | – | 15.3 | 111 |
| Thought the toilets were dirty or smelled bad | 29.6 | 216 | 34.2 | 111 |
| Thought it was unsafe to go to the toilet | 11.1 | 216 | 14.4 | 111 |
| Worried they could be seen while using the toilet | 6.0 | 216 | 5.5 | 109 |
| Not enough materials to clean themselves afterwards | 8.8 | 215 | 11.7 | 111 |
| Ate or drank less to avoid using the toilets (staff only) | – | – | 3.6 | 110 |
| Waited until they got home to use a toilet (staff only) | – | – | 8.1 | 111 |
| Hygiene | ||||
| Not enough water to wash hands | 6.5 | 324 | 15.3 | 111 |
| Not enough soap to wash hands | 16.1 | 322 | 16.2 | 111 |
| Unable to get their hands as clean as they wanted | 8.4 | 322 | 9.0 | 111 |
| Felt annoyed by the handwashing options available (staff only) | – | – | 36.4 | 110 |
| Environmental cleaning | ||||
| Thought the areas where care was given were dirty | 3.0 | 363 | 9.7 | 31 |
| Thought other parts of the facility were dirty | 15.5 | 362 | 29.0 | 31 |
| Worried uncleanliness could make them or others sick | 7.2 | 359 | 27.9 | 111 |
| Thought surfaces were not properly cleaned (staff only) | – | – | 35.1 | 111 |
| Thought medical equipment was not properly cleaned (staff only) | – | – | 27.5 | 40 |
| Not enough soap, detergent, or disinfectant for cleaning (staff only) | – | – | 25.7 | 35 |
| Used less cleaning product to avoid running out (staff only) | – | – | 22.9 | 35 |
| Limited in cleaning by problems with the cleaning tools (staff only) | – | – | 28.6 | 35 |
| Used their own money to buy cleaning supplies (staff only) | – | – | 15.3 | 111 |
| Not enough protective equipment to work safely (staff only) | – | – | 34.7 | 49 |
| Reused disposable protective equipment because supply ran short (staff only) | – | – | 10.0 | 50 |
| Waste management | ||||
| Thought waste was not properly disposed of | 13.6 | 360 | 26.1 | 111 |
| Worried waste could make them or others sick | 10.9 | 357 | 24.3 | 111 |
| Waste containers were overfilled (staff only) | – | – | 43.2 | 111 |
| Could not manage waste adequately or safely (staff only) | – | – | 17.2 | 64 |
| Menstrual health | ||||
| No clean, safe place to change menstrual materials | 6.2 | 32 | 19.2 | 73 |
| Difficult to dispose of menstrual materials privately | 12.5 | 32 | 23.3 | 73 |
| Unable to wash after changing menstrual materials | 9.4 | 32 | 6.8 | 73 |
| Felt nervous or embarrassed about coming to work (staff only) | – | – | 19.2 | 73 |
| Missed work because of their period (staff only) | – | – | 4.1 | 73 |
| Worried materials would not be available in an emergency (staff only) | – | – | 74.0 | 73 |
How to read this. Each dot is the share of respondents who said they had experienced the item (answering “sometimes” or “many times” rather than “never”), out of those who answered it. The grey bar shows the gap between patients and facility staff.
Item wording was adapted for each site and is shortened here; hover over a dot for the percentage and the number of respondents behind it. Menstrual health items were asked only of patients and staff who menstruate. Values based on fewer than 30 respondents are not shown.
Patients answered about their time at the facility and staff about the past four weeks. In Uganda staff were asked about both the current and the opposite season; the current-season answer is the one shown.
These are preliminary descriptive results from the scale-development phase. They describe the participating health care facilities only, are not representative of the country, and have not yet been peer reviewed.
Water
Sanitation
Hygiene
Environmental cleaning
Waste management
Menstrual healthAsked of patients and staff who menstruate
See the numbers for this site as a table
| Item | Patients % | Patients answering | Staff % | Staff answering |
|---|---|---|---|---|
| Water | ||||
| Felt thirsty but had no safe water to drink | 25.6 | 250 | 16.9 | 130 |
| Worried water problems could make them or others sick | 14.4 | 250 | 9.3 | 129 |
| Drinking water tasted, looked, or smelled bad (staff only) | – | – | 16.4 | 122 |
| Worried there would not be enough water (staff only) | – | – | 8.5 | 129 |
| Water supply at the facility was interrupted (staff only) | – | – | 29.7 | 128 |
| Could not concentrate on duties because of thirst (staff only) | – | – | 10.8 | 130 |
| Water problems affected their ability to provide care (staff only) | – | – | 8.4 | 83 |
| Water problems affected their ability to clean the facility (staff only) | – | – | 10.8 | 83 |
| Performed or assisted a procedure without enough water (staff only) | – | – | 6.0 | 83 |
| Patients were asked to bring or fetch their own water (staff only) | – | – | 4.8 | 83 |
| Flooding or heavy rains disrupted activities (past 12 months) (staff only) | – | – | 29.2 | 130 |
| Sanitation | ||||
| Unable to use a toilet when needed | – | – | 10.0 | 130 |
| Thought the toilets were dirty or smelled bad | 36.3 | 226 | 26.9 | 130 |
| Thought it was unsafe to go to the toilet | 26.2 | 225 | 17.8 | 129 |
| Worried they could be seen while using the toilet | 21.5 | 228 | 2.3 | 130 |
| Not enough materials to clean themselves afterwards | 49.6 | 228 | 36.2 | 130 |
| Ate or drank less to avoid using the toilets (staff only) | – | – | 1.5 | 130 |
| Waited until they got home to use a toilet (staff only) | – | – | 7.7 | 130 |
| Hygiene | ||||
| Not enough water to wash hands | 28.6 | 241 | 17.8 | 129 |
| Not enough soap to wash hands | 40.9 | 242 | 27.7 | 130 |
| Unable to get their hands as clean as they wanted | 32.6 | 242 | 16.2 | 130 |
| Felt annoyed by the handwashing options available (staff only) | – | – | 20.0 | 130 |
| Environmental cleaning | ||||
| Thought the areas where care was given were dirty | 3.2 | 252 | 13.4 | 82 |
| Thought other parts of the facility were dirty | 6.8 | 251 | – | – |
| Worried uncleanliness could make them or others sick | 2.0 | 250 | 16.2 | 130 |
| Thought surfaces were not properly cleaned (staff only) | – | – | 15.5 | 129 |
| Thought medical equipment was not properly cleaned (staff only) | – | – | 7.0 | 86 |
| Not enough soap, detergent, or disinfectant for cleaning (staff only) | – | – | 17.7 | 79 |
| Used less cleaning product to avoid running out (staff only) | – | – | 15.2 | 79 |
| Limited in cleaning by problems with the cleaning tools (staff only) | – | – | 9.8 | 82 |
| Used their own money to buy cleaning supplies (staff only) | – | – | 4.6 | 130 |
| Not enough protective equipment to work safely (staff only) | – | – | 17.5 | 103 |
| Reused disposable protective equipment because supply ran short (staff only) | – | – | 12.7 | 102 |
| Waste management | ||||
| Thought waste was not properly disposed of | 11.5 | 252 | 16.9 | 130 |
| Worried waste could make them or others sick | 8.8 | 251 | 16.9 | 130 |
| Waste containers were overfilled (staff only) | – | – | 18.5 | 130 |
| Could not manage waste adequately or safely (staff only) | – | – | 9.3 | 54 |
| Menstrual health | ||||
| No clean, safe place to change menstrual materials | not shown | 14 | 9.2 | 65 |
| Difficult to dispose of menstrual materials privately | not shown | 14 | 7.7 | 65 |
| Unable to wash after changing menstrual materials | not shown | 14 | 15.4 | 65 |
| Felt nervous or embarrassed about coming to work (staff only) | – | – | 9.2 | 65 |
| Missed work because of their period (staff only) | – | – | 9.2 | 65 |
| Worried materials would not be available in an emergency (staff only) | – | – | 32.3 | 65 |
How to read this. Each dot is the share of respondents who said they had experienced the item (answering “sometimes” or “many times” rather than “never”), out of those who answered it. The grey bar shows the gap between patients and facility staff.
Item wording was adapted for each site and is shortened here; hover over a dot for the percentage and the number of respondents behind it. Menstrual health items were asked only of patients and staff who menstruate. Values based on fewer than 30 respondents are not shown.
Patients answered about their time at the facility and staff about the past four weeks. In Uganda staff were asked about both the current and the opposite season; the current-season answer is the one shown.
These are preliminary descriptive results from the scale-development phase. They describe the participating health care facilities only, are not representative of the country, and have not yet been peer reviewed.
More analyses ahead
The core purpose of this project is to determine which items work well for assessing WASH insecurity within and across settings. Analyses are currently focused on which items are understood consistently across languages and settings, which items distinguish facilities that differ in ways we can verify, and which items can be dropped without losing information. The final scale will be shorter than the instruments now being implemented.
Findings will be published in peer-reviewed papers and returned to participating health care facilities and ministries as short reports. The site explorer above is a first, preliminary version of the interactive site profiles; it will be updated as more findings emerge.
Follow the work
Papers, presentations, and site reports as they appear
Findings are published as they clear review, and returned to participating facilities as short summary reports. If you would like to talk about the approach or the emerging results, we would be glad to hear from you.