Six steps towards clean healthcare settings in Cambodia

7 min read
Image: WaterAid/Tom Greenwood

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. 

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:

  1. What is the basic WASH situation in healthcare facilities?
  2. What are the training needs for healthcare staff on WASH within infection prevention control procedures?
  3. 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:  

  1. Basic water supply facilities 
  2. Basic sanitation facilities 
  3. Basic hand hygiene facilities 
  4. Cleaning routines 
  5. 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 tweets as @channasam

1This tool (previously named WASH Safety Plan), is based on the Water Safety and Sanitation Safety Approaches. It provides a range of ready-to-use tools to help identify risks and prioritise improvements for water, sanitation and hygiene (WASH) services, and related safety aspects, in small healthcare facilities in low-income settings. WASH FIT is in drafting stage. For more detail see