Dissecting WASH Assessment Tools and Recommending a Comprehensive Tool for Indian Healthcare Facilities

Figures & data

Table 1 Summary of Tools Included in the Review

Tool	Publication Year	Developed by	Aim
Service Provision Assessment (SPA) tool	1991 Revised on 2022	ICF International, USAID	Demographic Health Survey
Service Availability and Readiness Assessment (SARA) tool,	2011 Revised on 2015	WHO, USAID, and other global partners	Service readiness of specific program services
Kayakalp	2015 Revised on 2021	Ministry of Health and Family Welfare, GOI,	Promote cleanliness and enhance the quality of public health facilities
TOOL BOX-II	2016	IIPHG (advanced version of the WASH & CLEAN Toolkit)	Assessment of WASH beyond the labour room
WASH FIT 2	2018, revised in 2022	UNICEF & WHO	A practical guide for improving the QoC through WASH in HCFs
FACET (WASH Facility Evaluation Tool), 2018	2018	Terre des hommes, Eawag and CartONG (support from the UNICEF/WHO JMP for WASH	WASH in schools and healthcare facilities
Centres for Disease Control and Prevention (CDC)	Revised in 2019	CDC	Evaluate WASH in primary healthcare facilities

Abbreviations: UNICEF, United Nations International Children’s Emergency Fund; WHO, World Health Organization; JMP, Joint Monitoring Programme; USAID, United States Agency for International Development; HCFs, Healthcare Facilities; GoI, Government of India.

Table 2 Summary of Methodology and Components of WASH Assessment Tools

Components	WASH FIT 2	SPA	KAYAKALP	CDC	FACET	TOOL BOX-II	SARA
Methodology	O, R, RR	O, R	O, SI, PI, RR	O, R	O, R	O, R, RR	O, R
Assessor	Internal	External	External Internal	External	External	External Internal	External
Specific for WASH	√	×	×	×	√	√	×
Scoring	Meets (2), Partially meets (1), Does not meet (0)	Yes/No	Full (2), Partial (1), Non-compliance (0)	Yes/No	Basic, Limited, No Service	Yes/No	Yes/No
Visual Cleanliness	×	×	√	√	√	√	×
Microbiological assessment	×	×	√	×	×	√	×
Water quality testing (E-Coli, Chlorination)	√	×	×	√	√	×	×
Individual and system determinants	×	×	×	√	×	×	×
Patient Satisfaction	×	√	×	√	×	×	×
Staff satisfaction	×	×	×	√	×	×	×
Photo documentation	×	×	×	√	×	√	×
KAP survey	×	×	√	√	×	×	×
Hand hygiene observation	×	×	×	√	×	×	×
Digital Tool	√	×	×	√	√	×	×

Abbreviations: O, Observed; R, reported; RR, record review; PI, Patient interview; SI, Staff Interview; SPA, Service Provision Assessment; CDC, Centres for Disease Control and Prevention; SARA, Service Availability and Readiness Assessment; KAP, Knowlegde, Attitude and Practice

Table 3 Mode of Documentation and Presence of Water Indicators Among the Selected Seven WASH Assessment Tools

Indicators	WASH FIT 2	SPA	KAYAKALP	CDC	FACET	TOOL BOX-II	SARA
Source of water	No	Yes^R	No	Yes^O, R	Yes^R	Yes^R	Yes^R
Accessibility	Yes	Yes^R	No	Yes^R	Yes^R	Yes^R	Yes^R
Available at survey time	Yes	Yes^O	Yes^O, R, PI	Yes^O	Yes^O	Yes^O	Yes^O
Functionality	Yes	No	No	No	No	Yes^O, R	No
Quantity	Yes	No	Yes^R, PI, RR	Yes ^R	Yes^O, R	No	No
Storage	Yes	No	Yes^RR	Yes^R	Yes ^O	No	No
Water interruption	Yes	No	No	Yes^R	No	Yes^R	No
Alternate mechanism	Yes	No	No	Yes^R	Yes ^OR	Yes^R	No
Drinking water	Yes	No	Yes^O	Yes^O	No	Yes^O	No
Visual cleanliness of drinking water	No	No	No	No	No	Yes^O	No
Water quality	Yes	No	Yes^RR	Yes^SC	Yes^R	No	No
Water quality (e-coli)	Yes	No	No	Yes^SC	Yes^R, RR	No	No
Water treatment	Yes	No	No	Yes^R	Yes^R, O	No	No
Rainwater harvesting	Yes	No	Yes^O, R	No	No	No	No
Water reduction	Yes	No	Yes^O, R	No	No	No	No
Water Conservation	No	No	Yes^O,R, RR	No	No	No	No
Arsenic testing	No	No	No	No	Yes^R, RR	No	No

Abbreviations: O, Observed, R, reported, RR, record review, PI, Patient interview; SPA, Service Provision Assessment; CDC, Centres for Disease Control and Prevention; SARA, Service Availability and Readiness Assessment.

Table 4 Comparison of the Sanitation Indicators of Selected Tools

Indicators	WASH FIT 2	SPA	KAYAKALP	CDC	FACET	TOOL BOX-II	SARA
Availability of toilets	Yes	Yes^O, R	No	Yes^R	Yes^O, R	Yes^O, R	Yes^O
Type of toilets	Yes	Yes^O	Yes^O	Yes^O	No	Yes^O	Yes^O
Functional	Yes	Yes^O, R	Yes^O	Yes^O	Yes^O	Yes^O, R	Yes^O
Accessibility	No	No	No	No	Yes^O	No	No
Separate for people with limited mobility	Yes	Yes^O	Yes^O	Yes^O	Yes^O	Yes^R	No
Separate for male and female	Yes	Yes^O	No	Yes^R	Yes^O	Yes^R	No
Separate for staff	Yes	Yes^O	No	Yes^O	Yes^O	Yes^R	No
Toilet for menstrual Hygiene	Yes	Yes^O	No	Yes^O	No	No	No
Toilets with adequate drainage	Yes	No	No	Yes^O R	No^O	Yes^O	No
Toilets with hand washing	Yes	Yes^O	No	Yes^O	Yes^O	Yes^O, R	No
Clean toilet hand washing facility	No	No	No	No	No	Yes^O	No
Visual cleanliness	No	No	Yes^O	Yes^O	Yes^O	Yes^O	No
Availability & functionality showers	Yes	No	No	Yes^R	No	No	No
Cleaning frequency	Yes^R, RR	No	Yes^R, RR	No	Yes^R	Yes^R, RR	No
The material used for cleaning	No	No	No	No	Yes^R	No	No
IEC on toilets	No	No	Yes^O	No	No	No	No
Faecal sludge, storm, and waste management	Yes	No	No	No	Yes^O, R	No	No
Grey water management	Yes	No	Yes^O, R	No	No	No	No
Open defecation around HCF	No	No	No	Yes^O	Yes^O	No	No

Abbreviations: O, Observed; R, reported; RR, record review;; SPA, Service Provision Assessment; CDC, Centres for Disease Control and Prevention; SARA, Service Availability and Readiness Assessment.

Table 5 Comparison of the Hygiene Indicators of Selected Tools

Indicators	WASH FIT 2	SPA	KAYAKALP	CDC	FACET	TOOL BOX-II	SARA
Availability of PPE	Yes	Yes^O, R	Yes^O, R, RR	No	No	Yes^O, R	Yes^O, R
Availability and accessibility of alcohol rub	Yes	Yes^O,R	Yes	Yes^R	Yes^O	Yes^R	Yes^O,R
Usage of washable surgical and nursing clothing after proper sterilization	No	No	Yes^O, R	No	No	Yes^R	No
Functional apparatus available	No	Yes^O, R	No	No	Yes^O,R	Yes^R	Yes^O, R
Use of signal locks for sterilization	No	No	Yes^O, R	No	No	Yes^RR	No
Sterility of autoclaved pack maintained during storage	No	No	Yes^O, R	No	No	No	No

Abbreviations: O, Observed; R, reported; RR, record review; PI, Patient interview; SPA, Service Provision Assessment; CDC, Centres for Disease Control and Prevention; SARA, Service Availability and Readiness Assessment; PPE, Personal Protective Equipment.

Table 6 Comparison of the Environmental Cleaning Indicators of Selected Tools

Indicators	WASH FIT 2	SPA	KAYAKALP	CDC	FACET	TOOL BOX-II	SARA
Hospital cleaning policy and protocols	Yes	No	Yes^SI/RR	Yes^R, RR	No	Yes^R, RR	No
Cleaning records available signed by cleaners	Yes	No	Yes^O/ RR	No	No	No	No
Monitoring of adequacy of cleaning material used	No	No	Yes^R, RR	No	No	No	No
Cleaning frequency of all departments	No	No	Yes^R, RR	No	Yes^R	Yes^R	No
Cleanliness of all departments	No	No	Yes^O	Yes^O	Yes^O	Yes^O	No
Bed sheets and linen are changed daily	No	No	Yes^O, R,PI	Yes^R	No	Yes^O	No
Personnel: Required number of cleaning staff available	Yes	No	No	Yes	No	Yes	No
Dedicated person for monitoring housekeeping	No	No	Yes^R,RR	Yes^R	No	No	No
Training on cleaning	Yes	Yes^R	No	Yes^R	Yes^R	Yes^R, RR	No
Awareness & demonstration of cleaning procedures	No	No	Yes^O	No	No	No	No
Extra staff and additional cleaning supplies are available for high load	Yes	No	No	No	No	No	No
Cleaning materials available (eg detergent, mops, buckets)	Yes	No	Yes^O, R, RR	No	Yes^O	Yes^O	No
Availability of detergent and disinfectant solution	No	Yes^O, R	Yes^O, R, RR	No	Yes^O	Yes^O	Yes^O, R
Availability of eco-friendly biodegradable buckets and carts for mopping	No	No	Yes^R, RR	No	No	No	No
Supply for mopping separate mops/three-bucket system	No	No	Yes^SI/O	No	No	Yes^O, R	No
Mopping direction, disinfection of mops	No	No	Yes^SI/O	No	No	No	No
Storage and cleanliness of mops & buckets	No	No	No	No	No	Yes^O	No
Types of mops, laundered properly	No	No	No	No	No	Yes^O	No
All beds/mattresses have waterproof covers available and free from damage	Yes	No	Yes^O, RR, PI	No	No	Yes^O	No
Availability of garbage Storage area, mercury and spill management kit	No	No	Yes^O	No	No	No	No
Dedicated area for storing cleaning materials	Yes	No	No	No	No	Yes^O	No
Clean and well-maintained laundry facilities	Yes	No	Yes^O	No	No	Yes^O	No
Laundry services with hot water to reprocess cloths	Yes	No	No	No	No	No	No
Food is safely prepared and handled	Yes	No	No	No	No	No	No
Protection of Kitchen stores from flies, other insects and rats	Yes	No	Yes^O	No	No	No	No

Abbreviations: O, Observed; R, reported; RR, record review; PI, Patient interview; SI, Staff Interview; SPA, Service Provision Assessment; CDC, Centres for Disease Control and Prevention; SARA, Service Availability and Readiness Assessment.

Table 7 Comparison of the Healthcare Waste Indicators of Selected Tools

Indicators	WASH FIT 2	SPA	KAYAKALP	FACET	TOOL BOX-II	CDC	SARA
Available and functional waste collection container	Yes	Yes ^O,R	No	Yes^O	Yes^O, R	Yes^O	Yes^O,R
Bags with liners	No	Yes^OR	No	No	Yes^O, R	Yes^O	Yes^OR
Cutting of syringes before disposal	No	No	Yes^O, R	No	Yes^O	No	No
Availability of hub cutter	No	No	Yes^O, R	No	Yes^O, R	No	No
Sharp waste is stored in a puncture-proof container	Yes	Yes^R, O	Yes^O, R	Yes	Yes^O, R	Yes^O	Yes^O, R
Kit for collection and transporting of waste	No	No	No	Yes^O	No	No	No
PPE for waste handlers	Yes	No	No	Yes^O	No	Yes^R	No
Resources for hand hygiene	Yes	No	Yes^O	No	No	No	No
Dedicated waste storage area	Yes	No	Yes^O	Yes^R	Yes^R	Yes^O	No
Correct waste segregation	Yes	No	Yes^O, R	Yes^O	Yes^O	Yes^O	No
Waste treatment technology for infectious waste	Yes	Yes^R	No	Yes^R	Yes^R	Yes^R, O	Yes^R
Waste treatment technology for sharp waste	Yes	Yes^R	No	Yes^R	Yes^R	Yes, ^R, O	Yes^R
Availability & functionality of incinerator	Yes	Yes^R	No	Yes^(O)	No	No	Yes^R
Sufficient energy available for incineration	Yes	Yes^R	No	No	No	No	Yes^R
Ash pit for an incinerator	Yes	No	No	No	No	No	No
Functional burial pit	Yes	No	Yes^O, RR	No	No	No	No
Burial pit with stand flooding	Yes	No	No	No	No	No	No
Storage duration of Infectious waste in the facility	Yes	No	Yes^R, RR	No	Yes^R	No	No
Recyclable waste management (segregated and sent)	Yes	No	Yes^O, R, RR	No	Yes, ^O, RR	No	No
Correct disposal of anatomical waste	Yes	No	No	No	No	No	No
Correct disposal of pharmaceutical waste	Yes	No	Yes^O, R, RR	No	No	No	No
Buckets are full	No	No	No	No	Yes^O	Yes^O	No
IEC for waste management	Yes	No	Yes^O	No	Yes^R	Yes^R, O	No
Training on waste management and carry out duty correctly	Yes	No	Yes^R, RR	No	No	No	No
Reminders & training for rational use of PPE	Yes	No	No	No	No	No	No
Strategy to reduce the quantity of waste	Yes	No	No	No	No	No	No
Strategies to deal with additional waste	Yes	No	No	No	No	No	No
Waste disposal and storage systems (barcodes, committees)	No	No	Yes^R, RR	No	No	No	No
Education of patients and visitors on the disposal of recyclable and biodegradable waste	No	No	Yes^R, RR	No	No	No	No
Awareness of needle stick injury/ spill management)	No	No	Yes^R	No	No	No	No
Disposal of the radiographic developer, disinfectant and waste of infectious diseases like COVID	No	No	Yes^R, RR	No	No	No	No

Abbreviations: O, Observed; R, reported; RR, record review; SPA, Service Provision Assessment; CDC, Centres for Disease Control and Prevention; SARA, Service Availability and Readiness Assessment; IEC, Information Education and Communication; PPE, Personal Protective Equipment.

Table 8 Comparison of the Infrastructure Indicators of Selected Tools

Indicators	WASH FIT 2	SPA	KAYAKALP	CDC	FACET	TOOL BOX-II	SARA
Functional electricity	Yes	Yes^R	No	Yes^R	No	Yes^R	Yes^R
Sufficient energy available	Yes	Yes^R	No	No	No	No	No
Sufficient energy for pumping water and heating	Yes	No	No	No	No	No	No
A functional backup source of energy	Yes	Yes^R	No	Yes^R	No	Yes^R	Yes^R
Energy-efficient lighting is used	Yes	No	Yes^O	No	No	No	No
Adequate lighting in the delivery room, including at night	Yes	No	Yes^O	No	No	No	No
Adequate lighting in the shower(s) and latrines, including at night	Yes	No	No	No	Yes^O	No	No
Adequate illumination indoors, in front of hospital and roads, auxiliary areas	No	No	Yes^O	No	No	No	No
Sufficient functioning environmental ventilation	Yes	No	Yes^O	No	No	No	No
Beds have insecticide-treated nets	Yes	Yes^O, R	Yes^O, R, PI	No	Yes^O	No	No
Mosquito netting on doors and windows	No	No	No	No	Yes^O	No	No
Sustainable procurement is applied throughout the facility	Yes	No	No	No	No	No	No
General waste bins are available in all public areas, and efforts to maintain the aesthetic appearance of the facility	Yes	No	Yes^O	No	No	No	No

Abbreviations: O, Observed; R, reported; RR, record review; PI, Patient interview; SPA, Service Provision Assessment; CDC, Centres for Disease Control and Prevention; SARA, Service Availability and Readiness Assessment.

Table 9 Comparison of the Management of Workforce Indicators of Selected Tools

Indicators	WASH FIT 2	SPA	KAYAKALP	CDC	FACET	TOOL BOX-II	SARA
An up-to-date facility diagram is visible and legible	Yes	No	No	No	No	Yes^RR	No
Clear written Job description of all auxiliary staff and cleaners	Yes	No	Yes^R, RR	No	No	No	No
Induction training on WASH and IPC for auxiliary staff, waste handlers, and cleaners	Yes	No	No	No	No	Yes^R	No
Regular performance appraisal of staff	Yes	No	No	No	No	Yes^RR	No

Abbreviations: R, reported; RR, record review; SPA, Service Provision Assessment; CDC, Centres for Disease Control and Prevention; SARA, Service Availability and Readiness Assessment; IPC, Infection Prevention and Control.

Table 10 Comparison of the Policy & Protocols Indicators of Selected Tools

Indicators	WASH FIT 2	SPA	KAYAKALP	CDC	FACET	TOOL BOX-II	SARA
Functional quality improvement/ IPC committee	Yes	Yes^R	Yes	No	No	Yes^R, RR	No
Representation of all cadres in IPC committee	No	No	Yes	No	No	Yes^R	No
Dedicated person for IPC	Yes	No	No	No	No	Yes^R	No
Training on IPC	Yes	Yes^R	Yes	No	Yes^R	Yes^RR	No
Designated staff for cleaning	No	Yes^R	No	Yes ^R	No	Yes^R	No
Dedicated person for infectious diseases surveillance	No	Yes^R	No	No	No	No	No
Staff vaccination	Yes	No	Yes^R, RR	No	No	Yes^R	No
Extra staff and cleaning supply for high pt. load	Yes	No	No	No	No	No	No
Strategy to deal with additional waste	Yes	No	No	No	No	No	No
Availability of an emergency preparedness and response plan	Yes	Yes^R, RR	No	No	No	No	No
IPC guidelines	No	Yes^R, RR	No	No	No	Yes^RR	Yes^R, RR
Topics covered in the guidelines	No	Yes^R	No	No	No	No	No
Monitoring of IPC/ frequency of monitoring	No	Yes^R	No	No	No	No	No
A cleaning policy or protocol exists	Yes	No	Yes	Yes^RR	No	Yes^RR	No
Protocols for replacement of mops/ buckets	No	No	No	No	No	Yes^RR	No
SOP for biomedical waste	No	No	Yes	No	No	Yes^RR	No
A protocol for infrastructure operation, maintenance and procurement	Yes	No	No	No	No	Yes^RR	No
Availability and implementation of Policies for the occupational safety of cleaners and waste technicians	Yes	No	No	No	No	No	No
Patient safety policy/charter and sustainable environmental policy is written, up-to-date, and operational	Yes	No	No	No	No	No	No
Consultation with Women, disability and indigenous groups, users and staff about WASH needs and technology designs	Yes	No	No	No	No	No	No
Availability of budget to cover the costs of cleaners, training, IPC consumables	Yes	No	No	No	No	Yes^RR	No
An annual budget for environmental cleaning supplies	Yes	No	No	No	No	Yes^RR	No
Regular microbiological surveillance of Critical areas	No	No	Yes	No	No	Yes^RR	No
The facility measures surgical site infection rates	No	No	Yes	No	No	Yes^RR	No
Implementation of antibiotic policy	No	No	Yes	No	No	Yes^RR	No
Protocol for autoclave	No	No	Yes	No	No	Yes^R	No
Provision of the isolation ward	No	Yes^R	Yes	No	No	Yes^R	No
Separation of infectious patients	No	No	Yes	No	No	No	No
Adequate bed-to-bed distance maintained inwards	No	No	Yes	No	No	No	No
Restricted external footwear in critical areas	No	No	Yes	No	No	No	No
Restricted visitors to the isolation area	No	No	Yes	No	No	No	No
Monitoring of infection control practices regularly	No	No	Yes	No	No	No	No
Medical check-ups of food handlers and housekeeping staff regularly	No	No	Yes	No	No	No	No
Measuring of devices related to HAI rates	No	No	Yes	No	No	No	No
Measuring of blood-related and respiratory tract HAI	No	No	Yes	No	No	No	No
Corrective action on the occurrence of HAIs	No	No	Yes	No	No	No	No

Abbreviations: R, reported; RR, record review; SPA, Service Provision Assessment; CDC, Centres for Disease Control and Prevention; SARA, Service Availability and Readiness Assessment; IPC, Infection Prevention and Control; HAI, Healthcare Associated Infection.

Table 11 Recommended WASH Assessment Components

SN	Variable	Variable	Variable	Variable	Variable	Variable
Observed
	Water	Sanitation	Hand Hygiene	Environmental Hygiene	Biomedical Waste Management	Additional
1.	Water point availability	Improved toilet available	Basic hand washing facility	Personal protective equipment	Waste bins	IPC committee
2.	Water availability	Functional Toilet	Improved hand-washing facility	Instrument cleanliness	Status of waste bins	Hand hygiene compliance
3.	Drinking Water	Separate toilets for males and females	Hand washing station accessible	Hard and horizontal surfaces of the department	Waste handling	Autoclave protocol
4.	Drinking water area and tap	Separate toilet for staff	Cleanliness of hand washing point	Cleanliness of bed	Sharp containers status	BMW Segregation protocol
5.	–	Cleanliness of hard and horizontal surfaces of the toilet	–	State of bed	Designated area to store BMW until disposal	Hospital cleaning policy and protocols are clearly displayed
6.	–	Hand washing facility (Accessibility)	–	Storage area to keep cleaning material	Disposal method and practice	Monitoring of IPC and cleaning activities
7.	–	Hand washing facility (Usability)	–	Status of daily used mop	Kit for collection and transportation of waste	Procurement document
8.	–	Frequency of toilet cleaning	–	Type of mop	General waste Bins	Vaccination of staff
Observed
	Water	Sanitation	Hand Hygiene	Environmental Hygiene	Biomedical Waste Management	Additional
9.	–	Bathing facility	–	Cleaning of mop	–	Hospital measures Surgical Site Infection/ HAI Rates
10.	–	IEC on use of toilets	–	Storage and drying of mop	–	Antibiotic policy
11.	–	Open defecation around health care facility (observation within 15 meters)	–	Mop Separation	–	The budget is available to cover the costs of cleaners, training, IPC consumables
12.	–	–	–	Bucket cleanliness	–	The hospital takes corrective Action on the occurrence of HAIs
13.	–	–	–	Cleaning frequency	–	Regular microbiological surveillance of Critical areas
14.	–	–	–	Ventilation facility department wise	–
Reported
	Water	Sanitation	Hand Hygiene	Environmental Hygiene	Biomedical Waste Management	Governance
1.	Water point availability	Improved toilet available	The alternative of hand washing	Personal protective equipment	Waste bins	Electricity supply
2.	Water availability	Functional Toilet		Laundry facilities	Storage duration	Electricity backup
3.	Water interruption	Separate toilets for males and females		Contaminated linen cleanliness	Disposal method and practice	Source of water
4.	Alternate source of water	Separate toilets for Staff members		Used linen cleanliness	Kit for collection and transportation of waste	Sufficient water quantity available
5.	Drinking water	Sufficient toilets available		Linen Storage		Water treatment
6.		IEC on use of toilets		Mop change		Availability of sterilization equipment
7.		Greywater management (Wastewater from non-toilet plumbing system)		The material used for floor		Separate toilets for differently able people
Reported
	Water	Sanitation	Hand Hygiene	Environmental Hygiene	Biomedical Waste Management	Governance
8.				Cleaning frequency		Isolation ward
9.				Cleaning material supply		Adequate availability of cleaning staff
10.						Defined Job description for IPC
11.						WASH training

Abbreviations: IPC, Infection Prevention and Control; IEC, Information Education and Communication; HAI, Healthcare Associated Infection; BMW, Bio Medical Waste.