The cycle of policy and practice: improving WASH in healthcare facilities in Tanzania

on
13 May 2019
WaterAid/ James Kiyimba

As Health Ministers prepare to meet at the World Health Assembly in a week’s time, Twaha Mubarak, Senior Programme Manager, and Priya Sippy, Communications and Campaigns Officer from WaterAid Tanzania, discuss the importance of a multi-stakeholder approach to improving access to water, sanitation and hygiene (WASH) in healthcare facilities (HCFs). 

In July 2018, WaterAid Tanzania, and a small delegation from Canada, visited Geita region to see our WASH in HCFs project being implemented in two districts. As we walked towards Kakora Dispensary, we heard singing and chanting, and the sight of colourful khangas as the community prepared to welcome us. 

Just a few months prior to this visit, the dispensary, primary school and community had no access to clean water, forcing community members to walk long distances to fetch water from shallow wells. Kakora is just 1 of 12 villages in Geita where we have been implementing WASH in HCFs, supported by the Government of Canada through Global Affairs Canada.

Influencing Tanzania’s development agenda

Since 2014, WaterAid Tanzania has been working to improve WASH in HCFs, as part of WaterAid’s global advocacy priority – Healthy Start. Over the past few years we have gone through a steady cycle of policy and practice for WASH in HCFs, undertaking research and changes in policy, alongside real change on the ground. 

This work has contributed to WASH in HCFs moving higher up Tanzania's national development agenda, led by the Ministry of Health, Gender, Community Development, Elderly and Children (MoHGCDEC), and embedded in the Water Sector Development Programme, under the Ministry of Water. In fact, the Government recently committed to ensuring 1,000 HCFs have WASH by 2021, a pledge we have strongly welcomed. 

Jonathan M. Mhogota, 65, Nyamalimbe Village Chairman in meeting with village health team members, Nyamalimbe Village, Geita District, Tanzania, June 2018.
WaterAid/ James Kiyimba
Jonathan M. Mhogota, 65, Nyamalimbe Village Chairman in meeting with village health team members, Nyamalimbe Village, Geita District, Tanzania, June 2018.

Using research to inform solutions

Every journey must first begin with research, to understand the real situation on the ground. Back in 2014, we teamed up with Soapbox Collaborative and SHARE to carry out research on Improving Maternal Health in Zanzibar through Improved WASH. The findings revealed poor access to clean water and sanitation and a gap in hygiene practices among frontline healthcare workers. 

Through lobbying and engagement, the Ministry of Health developed a training manual for WASH in HCFs targeting frontline health workers. This manual focuses on hygiene best practices, healthcare waste management and general environmental cleanliness to reduce Hospital Acquired Infections, and subsequently has been rolled out across Zanzibar.

Meanwhile, in mainland Tanzania back in 2015, WaterAid started working on the practice side of things, with local NGOs SEMA and AMREF Health Africa, to implement a WASH in HCFs project in Singida, which involved work in 21 facilities. 

This project combined three major components:

  • Improving Reproductive Maternal and Child Health (RMNCH)
  • Water Sanitation and Hygiene (WASH)
  • Sexual Reproductive and Health Rights (SRHR). 

The WASH in HCFs training manual for frontline healthcare workers in Zanzibar was piloted in this area, before it launched in December 2016.

During the construction phase in Singida, we identified a gap in a policy document that specifies the minimum standards for design, operation and maintenance, and for budgeting etc. for WASH in HCFs in the country. Subsequently, WaterAid Tanzania, in collaboration with UNICEF and the Ministry of Health, Community Development, Gender, Elderly and Children began a national consultation process to put such guidelines together. At the end of 2017, the Ministry of Health endorsed and officially launched the National WASH in HCFs guidelines.

Although this is an important first step, we must now turn our attention back to practice – and this means ensuring the rolling out and implementation of the guidelines in the construction of any new HCFs, as well as upgrading the existing facilities to comply with the guidelines.

So far, we have been utilising the guidelines in our own project in Geita, as mentioned above, funded by Global Affairs Canada. Following the guidelines, we have used different technologies, such as solar power, and rainwater harvesting to ensure a clean and sustainable supply of water.

Health workers at Kashishi Health Centre inspecting a raised water tank under installation, Kashishi Health Centre, Geita District, Tanzania, June 2018.
WaterAid/ James Kiyimba
Health workers at Kashishi Health Centre inspecting a raised water tank under installation, Kashishi Health Centre, Geita District, Tanzania, June 2018.

What have we learnt from our WASH in HCFs journey so far?

For effective policy and practice work, we need to gather evidence and engage government at all levels

To influence national policy, you need to work closely with government while documenting the evidence, such as institutional pitfalls, best practices and other enabling environments. For us, that meant working directly with the Ministry of Health, Community Development, Gender, Elderly and Children who lead the process in creating the national WASH in healthcare guidelines in Tanzania mainland and the Ministry of Health Zanzibar in forming the training manual for frontline healthcare workers. The buy-in from government helps to ensure it becomes a key priority for the country and becomes a common focus for regional and local governments.

Similarly, to ensure this informed best practice is implemented and sustained, you need the buy-in of local government. At WaterAid we use the District Wide Approach, where we begin working at district level, and aim to scale the work up and apply it across remaining parts of the district and other districts. Ensuring local government is on board can also provide more resources for the project, and helps to maintain and sustain the project after WaterAid has left.

Coordination among stakeholders for national impact is needed

Currently, there are multiple stakeholders carrying out various small-scale WASH in HCFs projects. What is lacking is a national programme, which aims to implement the guidelines on a large scale. To really make change, and to make it quickly we need a country-wide intervention for WASH in HCFs, which involves all key stakeholders.

The journey is really just beginning for Tanzania, with the Ministry of Health citing that we have more than 6,000 healthcare facilities in the country, 50% of which have access to WASH. However, the two sets of guidelines are an important first step, and we must continue the cycle of policy and practice to make long lasting and sustainable change.

The Government of Tanzania is one of several member states leading global discussions on WASH in HCFs at the upcoming World Health Assembly, including putting forward a proposed formal resolution. WaterAid urges all member states, from across every region and income level, to back this resolution as the beginning of a step-change in investment and action.