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All slides available at www.washinhcf.org/resources and search “COVID-19”

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WPRO Region WHO Virtual Training 15 April 2020

Maggie Montgomery (montgomerym@who.int)

Water, sanitation, hygiene and waste management for preventing COVID-19

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Latest figures

Total global cases: 1.8 million Total global deaths: 117,000

WASH important to Global COVID-19 response

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Pillar 1: Country-level coordination, planning, and monitoring Pillar 2: Risk communication and community engagement Pillar 3: Surveillance, rapid response teams, and case investigation Pillar 4: Points of entry Pillar 5: National laboratories Pillar 6: Infection prevention and control Pillar 7: Case management Pillar 8: Operational support and logistics

UN-Wide plan WHO Response

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Hand hygiene: Frequent and effective hand hygiene - one of the most important prevention

• measures. Hand hygiene at the right time.

Water and sanitation: Existing WHO guidance on the safe management of drinking-water and sanitation services applies to the COVID-19

• utbreak.

Co-benefits: Many will be realized through good WASH, including preventing millions of deaths each year caused by other infectious diseases. WASH investments: Should be fundamental to all country preparedness and response plans. Environmental hygiene: Effective inactivation on surfaces can be achieved within 1 minute using common disinfectants

Takeaways

1. 2. 3. 4. 5.

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COVID-19 virus

• Enveloped virus, surrounded by weak lipid

membrane

• Relatively fragile in the environment and will

become inactivated much faster than non-enveloped human enteric viruses (e.g. norovirus, rotavirus, hepatitis A virus)

• Current evidence suggests infectious COVID-19 virus may be

excreted in faeces, regardless of diarrhoea or signs of intestinal infection. Only one study has cultured COVID-19 virus from a single stool specimen

• Approximately 2−27% of those with confirmed COVID-19 have

diarrhoea and several studies have detected viral RNA fragments in faecal matter of COVID-19 cases

• Risk of transmission of COVID-19 virus from the faeces of an

infected person appears to be low

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Survival of human coronaviruses

Media Temp (OC) Time Removal Reference Dechlorinated tap water 20 2 days None surviving

Wang et al, J Virol Methods, 2005

Dechlorinated tap water 23 8-12 days 99.9%

Gundy et al Food Environ Virol, 2009

Hospital wastewater 20 2 days None surviving

Wang et al, J Virol Methods, 2005

Settled sewage 25 14 days 99.9%

Casanova, et al, Water Research, 2009

Wastewater 23 2-4 days 99.9 %

Gundy et al Food Environ Virol, 2009

Baby faeces 20 3 hours* None surviving

Lai, et al., Clinical Infectious Disease, 2005

Adult faeces 20 1 day None surviving

Lai, et al., Clinical Infectious Disease, 2005

Cotton gown 20 5 min- 24 hours** None surviving

Lai, et al., Clinical Infectious Disease, 2005

Various surfaces (review of 22 studies + one study on SARS-CoV-2) Average 20 2 hours-9 days None surviving

Kampf, et al., Journal of Hospital Infection, 2020; Dorelman, et al., NEJM, 2020

*Quicker die off attributed to lower pH in baby feces (pH 6-7). **Quicker die off when there is a lower initial concentration of the virus.

Safely managed water supply

Guidelines Health care facilities Water treatment performance

KEY CONSIDERATIONS

• Use water safety plan approach (protection

from source to consumer)

• Residual chlorine of ≥0.5 mg/l after at least 30

minute of contact time and at pH < 8.0

• Point of use treatment where safe, piped

supplies are not available

Water safety planning

E.g. boiling, high performing ultra or nano filters, solar, UV, or appropriately dosed chlorine

Safely managed sanitation

WHO (2018) Guidelines on Sanitation and Health https://www.who.int/water_sanitation_health/publications/guidelines-on-sanitation-and-health/en/

• Safe management at every point of the sanitation chain;

system should be able to meet an increase in demand

• Important to check safety plumbing (e.g. sealed bathroom

drains, backflow valves on bathroom sprayers and faucets)

• Staff and patients should have separate toilets; where

possible COVID-19 patients should have their own toilets

• Regular cleaning and disinfection of bathrooms and

anyone with risk of exposure to excreta should wear PPE

• Practical, simple wastewater treatment technologies exist

(e.g. septic tank + leach field; waste stabilization pond, burying and covering sludge)

• Use multi-modal approach (systems change, training, evaluation and feedback,

reminders, and “safety” culture)

• Critical actions:
• Procurement of adequate quantities of hand hygiene supplies for staff,

patients and visitors

• Refreshers of hand hygiene training
• Refreshers of reminders/communications about its importance to prevent the

spread of the COVID-19 virus.

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Improving hand hygiene in health care facilities

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Safe health care waste management

Non-infectious and recycling containers (lined) Yellow container (lined) Sharps box

• Follow regular safe

management of waste practices (e.g. segregation, treatment, safe disposal)

• Use PPE while handling

waste (boots, apron, long- sleeved gown, thick gloves, mask and goggles or face shield)

• Waste generated during

home care: put in bin and bagged but not labeled “infectious”

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Cleaning

• Follow existing recommendations (e.g.

trained staff, SOPs on cleaning technique and materials, cleaning frequency based on risks)

• Existing disinfectants are effective (e.g. 70%

ethyl alcohol and 0.1% sodium hypochlorite for surfaces and 0.5% sodium hypochlorite for blood/spills)

• Studies from Singapore and China indicate

recommended cleaning techniques effective for killing COVID-19 virus

• Soiled linens should be machine washed

(60-90 C) with detergent OR soaked in warm water and detergent followed by 0.5% chlorine

WHO Hand Hygiene Campaign and global recommendations

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• High level advocacy on hand hygiene (HH)
• Currently huge gaps in access:
• 2 in 5 health care facilities globally lack hand

hygiene at point of care

• 3 billion individuals, globally, without basic hand

hygiene facilities at home

• Only half of schools globally have hand washing

facilities with soap and water

• WHO recommends obligatory HH in front of

all public buildings, transit hubs, etc. under leadership of public health authorities

• Maintenance and use should be supported by

building manager/transport provider, civil society/NGO or private sector

ABHR at grocery store in Geneva Public handwashing station in Indonesia

Hand hygiene facility options

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• Ideal materials (in order of effectiveness)

Water and soap or ABHR Ash or mud Water alone

• Water does not need to be drinking-water quality
• Water quantity: 0.5-2 l/person
• Local breweries, pharmacies, etc. encouraged

to make ABHR (examples from Switzlerand, US)

• Design considerations:

Tap can be turned off with arm or foot Size and quantity appropriate for type & number of users Grey water should be captured and emptied Easy to repair and parts can be sourcedlocally

• Hygiene promoters should be considered «essential service providers»

given free movement and neccessary protection

Soapy water HH station in Cox’s Bazaar

What you can do?

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• Advocate for inclusion of WASH in country COVID-19

plans (WASH in HCF, WASH in schools, hand hygiene in public settings, WASH service providers as «essential»

• Make rapid WASH improvements in health care facilities,

especially where COVID-19 patients are/will be treated

• Strengthen support to water and sanitation workers and

hygiene promoters (protective gear, training, hand hygiene at work and home)

• Install hand hygiene facilities and make use obligatory
• Ensure water and sanitation providers have back-up supplies

and contingency plans for disinfection chemicals, fecal indicator and chlorine testing equipment

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Key resources

Download the WASH and COVID-19 technical brief at: https://www.who.int/publications- detail/water-sanitation-hygiene-and-waste-management-for-covid-19 Obligatory hand hygiene recommendations: https://www.who.int/who-documents-detail/interim- recommendations-on-obligatory-hand-hygiene-against-transmission-of-covid-19

CDC, 2019. Best practices for environmental cleaning in health care facilities: in resource limited settings. US Centers for Disease

• Control. USA. https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-508.pdf

WHO, 2020. Infection prevention and control during health when novel coronavirus (nCoV) infection is suspected. https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection- is-suspected-20200125 WHO, 2008. Essential environmental health standards in health care. World Health Organization, Geneva. http://www.who.int/water_sanitation_health/hygiene/settings/ehs_hc/en/ WHO, 2011. Guidelines for drinking-water quality, 4th edition. World Health Organization, Geneva. http://www.who.int/water_sanitation_health/publications/2011/dwq_chapters/en/index.html WHO, 2019. Results of Round II of WHO International Scheme to Evaluate Household Water Treatment Technologies. https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-508.pdf WHO, 2018. Guidelines on sanitation and health. World Health Organization, Geneva. https://www.who.int/water_sanitation_health/publications/guidelines-on-sanitation-and-health/en/ WHO, 2014. Safe management of wastes from health-care activities. World Health Organization, Geneva. http://www.who.int/water_sanitation_health/medicalwaste/wastemanag/en/ WHO, 2019. Overview of technologies for the treatment of infectious and sharp waste from health care facilities. https://www.who.int/water_sanitation_health/publications/technologies-for-the-treatment-of-infectious-and-sharp-waste/en/

WASH FIT: a practical tool for improving quality of care

• QI methodology
• Feedback from >30 countries
• Assessment form revised
• Simplified and advanced service levels
• Simplified version for COVID-19 response
• Simplified risk prioritization
• Updates: climate resilience, gender & inclusivity,

emergencies

• Updated training package:

www.washinhcf.org/resources “search WASH FIT”

• Revised guide: July 2020
• Share your experiences - get in touch!

washinhcf@who.int

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WPRO Cambodia, Laos, the Philippines and Viet Nam. AFRO Ghana, Guinea, Guinea-Bissau, Chad, Comoros, DRC, Ethiopia (modified version integrated with an existing national programme – CASH), Kenya, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, South Sudan, Tanzania, Togo and Zambia. EURO Tajikistan SEARO Bangladesh (Cox’s Bazaar), Bhutan, India, Indonesia, Maldives, Myanmar and Nepal. EMRO Iraq PAHO Nicaragua

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Countries with WASH FIT implementation (33 countries)

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MINISTRY OF HEALTH VIET NAM HEALTH ENVIRONMENT MANAGEMENT ANGENCY

HEATHCARE WASTE MANAGEMENT FOR THE COVID-19 IN VIET NAM

Regional Training Webinar , 15 April 2020

• Dr. Nguyen Thi Lien Huong,

Director General of Health Environment Management Agency

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LOGO

Contents

• 1. Status of COVID-19 pandemic and control

policies

• 2. Existing regulation and current practice on

healthcare waste management

• 3. Experience in managing healthcare waste for

COVID-19 prevention

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LOGO

SECTION I. STATUS OF COVID-19 PANDEMIC AND CONTROL POLICIES

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LOGO

Status of COVID-19 pandemic and control policies

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• 1. Status breakdown of COVID-19 cases as of April 13, 2020

Infections 262 Active cases 118 Recovered 144 Deaths

• 2. Quarantine policy:
• Quarantine in appointed facilities/hotels operated by Army:

All people come to Vietnam from other countries will be quarantined for 14 days since the first arrived day.

• Quarantine at hospitals: F0: confirmed cases (positive SARS-

COV-2 testing); F1: suspected cases (have COVID-19 symptoms) and cases having close contact with F0.

• Quarantine at home or residences for workers: Cases have

close contact with F1.

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Status of COVID-19 pandemic and control policies

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• 2. Laboratories can provide SARS-CoV-2 testing: 110 labs.
• 3. Hospitals provide COVID-19 treatment: 294 hospitals

registered to MOH as of 14th April.

• 4. Since April 1st: Vietnam has gone into 15 days of

nationwide social distancing and self-isolation. As a consequence:

• Number of health examination at healthcare facilities

decreased by 32.11% comparing to the number in the same period in 2019. The amount of healthcare waste may decrease accordingly

LOGO

Status of COVID-19 pandemic and control policies

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• 5. Vietnam developed a plan to deal with COVID-19 with 5

levels:

• Level 1: There are confirmed cases invased from outside

country.

• Level 2: Secondary infection in the community happened.
• Level 3: There are more than 20 confirmed cases in the

country.

• Level 4: The disease spreads in the communities with 1,000 to

3,000 confirmed cases.

• Level 5: The disease spreads widely in the communities with

3,000 to 30,000 and more than 30,000 confirmed cases

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SECTION II. EXISTING REGULATION AND CURRENT PRACTICE ON HEALTHCARE W ASTE MANAGEMENT

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LOGO

Status on waste generated and treated

• About 13.664 health facilities (HFs)
• Healthcare solid waste:

+ 450 tons/day, of which 47 tons of hazardous medical waste + Meet the standards: 94.2% of central hospitals; 78.3% of provincial hospitals; 79.4%

• f

district hospitals; 24.9%

• f

commune health centers.

• Healthcare wastewater:

+ Healthcare facilities: 125.000 m3/day and night + Meet the standards: 43,5% of central hospitals; 64,1% of provincial hospitals; 66,5% of district hospitals; 13,7% of health centers.

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LOGO

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National Assembly’s laws Government’s decrees MONRE Circular MONRE & MOH Joint Circular MOST Circular

Environmental Protection Management of waste and discarded materials

• Hazardous waste management
• National Technical Regulations
• n waste mangament

Regulatory framework on HCWM

Healthcare waste management Management of radioactive wastes and used radioactive sources

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Solid waste management at HF

COVID-19 Waste

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Classification and collection at sources Department/ward waste storage area Transportation to centralized treatment facilities Hospital storage area of HCW

Medical solid waste management

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Hazardous solid medical waste treatment

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• 1. Waste transportation and treatment
• Off-site transportation of waste to centralized treatment

facilities licensed by MONRE.

• Off-site transportation of waste to a HF within a cluster of

nearby HFs for treatment.

• On-site treatment (discouraged, new on-site incinerators are not

invested).

• 2. Treatment technologies
• Non-incineration and eco-friendly technologies (priority)
• Centalized incineration technologies

LOGO

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Wastewater collection from departments, wards, toilets

Wastewater treatment plant/system

Comply with National standard No 28:2010/BTNMT

Medical wastewater treatment

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MOH CENTRAL LOCAL MONRE VIHEMA VEA

PROVINCIAL PEOPLE’S COMMITTEE

HEALTH FACILITIES DOH DONRE

Organizational structure of HCWM and monitoring

INFECTIOUS CONTROL UNIT

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7 training sets for 7 types of audience:

Training on HCWM

• Trainers on HCWM
• HF’s department head/managers
• Key staffs on HCWM at DOH &

HFs

• Healthcare professionals

(doctors, nurses, mid-wives, technicians)

• Waste collectors, transporters
• Waste treatment plant operators
• Environmental monitoring
• fficers

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SECTION III. EXPERIENCE IN MANAGING HEALTHCARE W ASTE FOR COVID-19 PREVENTION

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LOGO

Issuing documents and instructions

• n time

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• Guidelines
• n

healthcare waste management in treatment and quarantine for the COVID 19 patient

• Guidelines
• n

disinfection and environmental treatment of areas where COVID-19 patients live

• Closely supervise the collection, storage and transfer
• f medical waste, especially used medical masks,

personal protective equipment to avoid reuse

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Classify infectious waste for management

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Highly infectious waste

• Waste generated from SARS-CoV 2 laboratories

(NIHE, Hospital, CDC province…)

• Be preliminarily treated by autoclave or
• ther

sterilizing equipment (at laboratories)

• After preliminary treatment, waste is collected and

further treated like infectious waste

LOGO

Classify infectious waste for management

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Infectious waste Source:

• Waste from COVID- 19 treatment area (hospital)
• Mask, nose and mouth wipes of risk case (quarantine facilities)
• Waste generated from disinfecting confirmed case area
• PPE of person who contacted with suspected or confirmed cases
• r their waste

Management:

• Be segregated in bin with yellow lining bags
• When collecting, tie the first bag tightly and put in the second

bag which is labeled “COVID-19 waste”

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Priority to collection and treatment of infectious waste

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• Everyone involve in manage COVID-19 waste must

wear PPE

• Collect COVID-19 waste:
• > 2 times/day
• Use bins have lids and “COVID-19 waste” label
• Transportation & treatment: daily
• Preferably on-site treatment

LOGO

Some results

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• Infectious waste be collected and treated on time

and meet requirement, not overload in HCFs

• No reported cases of SARS-CoV-2 infection related

to COVID-19 waste management activities

• Area where COVID-19 cases live is disinfected on

time to reduce the spread of SARS-CoV-2 in communities

LOGO

Some results

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• Building a system of inspection and supervision in all

level

• Collaborate

with

• ther

Ministry to inspection, punishment

• The ability of healthcare waste treatment currently

meets 3 level of the COVID-19 pandemic

• The MOH is coordinating with the MONRE to

develop a plan to respond to any situation of pandemic

LOGO

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WASH FIT:

SHARING EXPERIENCES AND LESSONS LEARNT

Dr Panom, Deputy Director, DHHP, MOH Dr Oyuntogos Lkhasuren, WHO Representative office for the Lao PDR

MOH has established regulatory framework for WASH in HCF last 3 years:

1.

Basic environmental health standards in HCFs (2018)

HCWM Regulation, training program developed (2017) 5 Year National Action Plan in rural WASH/HCFs (2019)

Health facility level improvement

• Facility level improvement is equally important to translate the newly

formulated policy, regulation and standards into action at facility.

• WASH FIT introduced aiming at achieving basic environmental health

standards and sound HCWM regulation.

2017

• WASH FIT tool

guide translated

• Mater trainers
• Pilot started
• Capacity

building, central staff training 2018

• Pilot project

completed/evalu ation, design

• National,

Provincial trainers

• The tool

guide/PPT slides updated. 2019

• CC related risks

added

• Scaled up in

HCFs prone to flood and drought in three provinces

• Basic supply, WQ

test, HCWM

Key achievements and good practice

• WASH FIT Pilot successful, tool adopted, capacity building and

expansion in all District hospitals in 2 provinces, 5 HCFs in 1 province

• WASH FIT is considered a good practical tool that enhances staff

capacity and local leadership.

• Leadership role of central, provincial and district health
• Funding support from MOH DHO/PHD, based on the improvement

plans

• O&M, cleaning and functionality improved from 20% to 100%
• Visibility of effectiveness and evidence (before and after

implementation of the plans)

• Enhanced capacity to use the WASH FIT tool
• Technical – mid level staff and cleaning team well engaged and part of

the committee Key success is functional WASH IPC committee (action oriented)

Main challenges:

• WASH infrastructure lacking /poor coverage/O&M is weak
• Climate resilience of WASH systems: flood and drought prone

areas already vulnerable to climate change – for example 37 HCFs damaged and destroyed during flood in 2018.

• HCWM weakest part in most of rural hospitals.
• Facility level training and technical support requires more time

and efforts.

• Expansion slower than expected, as it includes several steps
• Follow up monitoring and technical support: every 2 months –

requires training, time and staff motivation and commitment

WASH FIT: design of implementation

Experience sharing and scale up planning in province TOT Provincial/ district level trainers WASH FITT Facility level training, 5 steps, tools completed WASH FIT IP starts 1st monitoring mentoring A 2 day HCWM training Second monitoring mentoring support

Climate resilient WASH services in health care facilities – WASH FIT

• Many HCFs face

challenges due to floods and droughts

• WASH FIT used in

HCFs affected by flood to make WASH services functional again.

• we appreciate that

the new version of WASH FIT includes a part on CC adaptation/DRR.

WASH FIT expanded in flood prone hospitals (GEF) a) A three day training for trainers of the DHO DHs b) 2 day facility level training is followed: IPC/WASH team formed, improvement/monitoring plan. c) CR WASH interventions designed for upscaling and resource mobilization for GCF, KOICA CNs

WASH FIT - during covid-19 response

• IPC elements
• Hand hygiene station /functionality/any soap/or hand gel
• Environmental cleaning and disinfection
• HCWM
• Needlestick sharp injury
• PPE
• IPC/WASH committees established in hospitals are implementing WASH FIT to

effect rapid assessments of health facility readiness and preparedness

• Training/equipment supply : IPC training on HCWs includes HCWM, hand washing

and environmental surface cleaning and disinfection

• Cleaning and disinfection in Non health settings
• Places for quarantine, central treatment facility and home care
• MOH provides guide/SOPs for cleaning, disinfection and demonstration

training for airports, public transport, hotels, guest houses and food establishments.

• Communications materials and awareness raising messages on these topics

targeting public, all the sectors

Monitoring, partnering and upscaling: ongoing

• Monitoring – WASH FIT assessment results feeds into WASH

monitoring

• MOH – ongoing efforts to integrate it with DHIS2.
• Scale up plan: The implementation of the WASH FIT in all HCFs

well reflected in the Strategy (2018-30) and a 5-year Action Plan (2018-22) for Rural WASH including HCFs.

• More partners
• WHO in collaboration with UNICEF, SNV, SRC and other

partners supports the MOH/Namsaat in 2020 in assessing current situation and defining targets and roadmap towards SDGs.

All slides available at www.washinhcf.org/resources and search “COVID-19”