National Guidelines for Water, Sanitation, and Hygiene (WASH) in Healthcare Facilities in Nigeria

NATIONAL GUIDELINES for WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA FEDERAL MINISTRY OF HEALTH, 2022 This publication is the property of Federal Ministry of Health, funded by United Nations Children's Funds and supported by the World Health Organization. Published in Nigeria by the Federal Ministry of Health, Nigeria. All rights reserved. No part of this publication may be produced, stored in retrieval system or transmitted in any form or any means; electronic, mechanical, photocopying, recording and / or otherwise, without prior written permission of the Federal Ministry of Health, Nigeria. You must not circulate this book in any other form and you must impose this same condition on any acquirer: For all enquiries or comments, write to: The Honourable Minister Federal Ministry of Health New Federal Secretariat Complex, Phase III Ahmadu Bello Way, Central Business District Abuja, FCT Nigeria http://www.health.gov.ng/ for every child NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA FEDERAL MINISTRY OF HEALTH 2022 v vi vii viii ix ix 1 1 2 2 3 3 4 4 4 4 5 5 6 6 6 6 6 6 7 7 7 8 8 9 9 9 9 9 9 9 9 10 10 10 11 11 12 12 TABLE OF CONTENTS NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIAii FOREWORD PREFACE ACKNOWLEDGEMENTS ABBREVIATIONS AND ACRONYMS LIST OF TABLES LIST OF FIGURES 1.0 SECTION ONE: INTRODUCTION 1.1 Background 1.2 Overview of WASH in Healthcare Facili�es 1.2.1 Global and Regional Context 1.2.2. Nigeria Perspec�ve 1.2.3 Gaps in WASH facili�es in Healthcare Facili�es 1.3 Ra�onale for Developing the Guidelines 1.4 Scope of the Guidelines 1.5 Overall goal of the Guidelines 1.5.1 Specific objec�ve 2.0 SECTION TWO: STRATEGIC PLANS FOR IMPLEMENTING WASH IN HEALTHCARE FACILITIES 2.1 Implementa�on of Na�onal Guidelines 2.2. Planning and Budge�ng for WASH in Healthcare Facili�es 2.2.1 Planning Process 2.2.2 Funds Alloca�on Criteria 2.2.3 Major considera�ons in planning and designing of WASH interven�ons 2.2.3.1 WASH facili�es for people with special needs 2.2.4 Sustainability Plans 3.0 SECTION THREE: ESTABLISHMENT OF WASH TEAMS IN HEALTHCARE FACILITIES 3.1 Composi�on of the WASH Team / Focal point 3.2 Roles of the WASH team / Focal point 4.0 SECTION FOUR: WATER SUPPLY IN HEALTHCARE FACILITIES 4.1 Water Needs, Quality and Standards in healthcare facili�es 4.2 Water Sources 4.2.1 Types of Water Sources 4.2.2 Basic considera�on in selec�ng appropriate water sources for HCFs 4.3 Recommended Water Services for Healthcare Facili�es in Nigeria 4.3.1 Recommended Water Supply Methods/Sources 4.4. Accessibility and Availability 4.5 Protec�on of water sources 4.5.1 Considera�ons for Construc�on of Water sources 4.5.1.1Tube well/Borehole 4.5.1.2 Dug wells 4.5.1.3 Rainwater 4.6 Opera�on, Maintenance and Protec�on of Water Supply System 4.7 Water Storage 4.8 Major Considera�on in the Distribu�on of Water in Healthcare Facili�es 4.9 Monitoring Indicators for Water Services in HCFs 5.0 SECTION FIVE: SANITATION IN HEALTHCARE FACILITIES 5.1 Introduc�on 5.2 Criteria for Sanita�on facili�es in HCFs 5.2.1 Safety 5.2.2 Reliability 5.2.3 Accessibility 5.2.4 User convenience 5.3 Design and construc�on of sanita�on facili�es 5.3.1 General considera�ons 5.3.2 Maintenance and hygiene of pour flush / water closet toilets 5.3.3 Maintenance and hygiene of Ven�lated Improved Pit Toilets 5.3.4 Toilet Facility for people with special needs 5.4 Opera�ons and Maintenance of Sanita�on facili�es 5.5 Monitoring Indicators for Sanita�on Services in HCFs 6.0 SECTION SIX: HYGIENE IN HEALTHCARE FACILITIES 6.1 Hand Hygiene 6.1.1 Promo�on of hand hygiene prac�ces in healthcare facili�es 6.1.2 Awareness on transmission of pathogens by hands 6.1.3 General considera�ons for hand hygiene for non-healthcare workers in Healthcare Facili�es 6.1.4 Hand hygiene in pa�ent handling for Health Workers 6.2 Hand-washing Techniques 6.2.1 General Hand-washing Technique 6.2.2 Hand-washing Techniques prior to surgical opera�ons (Scrubbing) 6. 2.3 Hand Hygiene using Alcohol Based Hand Rub (ABHR) 6.3 Basic Hygiene Services/Facili�es 6.3.1 Hand Hygiene Facili�es 6.4 Quality assurance for hand hygiene compliance and sustainability in HCFs 6.5 Monitoring Hand Hygiene prac�ces in HCFs 7.0 SECTION SEVEN: HEALTHCARE WASTE MANAGEMENT (HCWM) IN HEALTHCARE FACILITIES 7.1 Impact of poor healthcare waste management 7.2 Types of waste 7.3 Healthcare Waste Management Services 7.3.1 Healthcare waste segrega�on 7.3.2 Colour Code 7.3.3 Treatment and disposal 7.3.4 Accessibility of bins 7.3.5 Management of Wastewater 7.3.6 Monitoring Indicators for Healthcare Waste Management Services in HCFs 8.0 SECTION EIGHT: ENVIRONMENTAL CLEANING IN HEALTHCARE FACILITIES 8.1 Environmental Cleaning and Disinfec�on 8.2 Environmental Cleaning Services for Healthcare facili�es 8.2.1 Environmental Cleaning Protocol 8.2. 2 Standard Opera�ng Procedures (SOP) 8.2.3 Cleaning Staff and Capacity Building 8.2.4 Environmental Cleaning Supplies and Equipment 8.3 Monitoring of Healthcare Environmental Cleaning Services in HCFs 8.3.1: Monitoring Indicators for Environmental Cleaning Services in HCFs 13 13 13 13 13 13 13 14 14 14 14 14 14 15 17 17 17 17 17 18 19 19 21 21 22 22 22 22 24 24 24 26 26 26 27 27 28 28 29 29 29 29 29 29 29 30 30 iii NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 9.0 SECTION NINE: MONITORING OF WASH IN HEALTHCARE FACILITIES 9.1 Co-ordina�on and Monitoring Procedure 9.2 Repor�ng Procedure 31 31 31 REFERENCES APENDIX 1: LEGAL AND INSTITUTIONAL FRAMEWORK FOR WASH IN HEALTHCARE F ACILITIES IN NIGERIA. These include; 1. Related Na�onal Legisla�ons i. Na�onal Health Act 2014. ii. Nigeria Centre for Disease Control Act (NCDC Act 2018) iii. Na�onal Primary Healthcare Development Agency Act (NPHCDA 1992) iv. Na�onal Environmental Standards and Regula�ons Enforcement Agency (NESREA), Act 2009 v. Na�onal Environmental (sanita�on and Waste Control) Regula�on 2009. vi. Na�onal Environmental Health Prac�ces Regula�ons, 2016 vii. Environmental Health Officers Registra�on Council of Nigeria (EHORECON) ACT, 2002 2. Related Sectoral Na�onal Policies i. Na�onal Health Policy 2016. ii. Na�onal Rural Water Supply and Sanita�on Policy 2000 iii. Na�onal Healthcare Waste Management Policy 2013. iv. Na�onal Environmental Sanita�on Policy 2005 v. Na�onal Water Resources policy and strategy 2016 vi. Na�onal Health Promo�on Policy 2019 3. Related Na�onal Strategies i. Na�onal Health Strategic Development Plan II (NHSDP II) -2018-2022 ii. Partnership for Expanded Water Sanita�on and Hygiene (PEWASH) 2016. iii. Clean Nigeria Campaign Proposal iv. Na�onal Environnemental Sanita�on Ac�on Plan - FMENV v. Clean and Green Programme – FMENV vi. Na�onal hygiene promo�on strategy- Nigeria vii. Na�onal water resources road map 2016 viii. Protocol for verifica�on and cer�fica�on of ODF and Total Sanita�on Communi�es and Rural markets in Nigeria. 2017 ix. Strategies for scaling up Rural Sanita�on and Hygiene in Nigeria 2007 x. Water Sanita�on and Hygiene - Na�onal Outcome Rou�ne Mapping (WASH-NORM) survey 2019. CONTRIBUTORS 32 34 37 iv NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA v Dr. (Senator) Adeleke Olorunnimbe Mamora Honourable Minister of State for Health, Federal Ministry of Health Abuja, Nigeria. 2022 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA FOREWORD In Nigeria, there is no comprehensive Na�onal document on Water, Sanita�on and Hygiene (WASH) in Healthcare Facili�es (HCFs) to direct and harmonize the ac�vi�es in WASH services and the assignment of roles and responsibili�es in HCFs. This comprehensive Na�onal Guidelines on Water, Sanita�on and Hygiene in Healthcare Facili�es in Nigeria is aimed at guiding, standardizing and strengthening the provision of WASH services by different stakeholders at all levels towards addressing the prevailing WASH related problems in HCFs in Nigeria. Safe drinking-water, Sanita�on and Hygiene are crucial to human health and well-being. Safe WASH is not only a prerequisite to health, but contributes to livelihoods, school a�endance and dignity and helps to create resilient communi�es living in healthy environments. The role of Water, Sanita�on and Hygiene are (WASH) facili�es in preven�ng the spread of infec�ons and promo�ng good health in the Healthcare facili�es is the focal point of this document. Development of func�onal Water, Sanita�on and Hygiene (WASH) facility/system has been recognized as an effec�ve strategy for the preven�on and control of diseases most especially epidemic prone diseases. An effec�ve and efficient WASH facility/system provides a break in the chain of disease transmission that will lead to reduc�on of morbidity and mortality that may result from the epidemics of these infec�ous diseases. In the light of COVID-19 and other emerging Viral Hemorraghic Fevers (VHDF’s), WASH services are essen�al and familiar func�ons of local, state and federal public health agencies. It is mandatory component of Infec�on Preven�on and Control (IPC) for healthcare providers and the general public. WASH services as a strategy reduces the burden of case management for infec�ous diseases and help public health managers and decision-makers to effec�vely prevent, contain and manage disease outbreaks. Without access to adequate Water, Sanita�on and Hygiene (WASH) facili�es, healthcare centers in Nigeria would be ill equipped to manage even the COVID-19 crisis and other Health associated infec�ons HAIs, while the poorest and most vulnerable people in the country would be le� to face the pandemic alone with not even the most basic defense-clean water and a bar soap. Despite handwashing with soap being one of the cri�cal first lines of defense against the spread of the highly contagious and deadly coronavirus disease, a good number of healthcare centres in Nigeria are at risk of becoming epicenters of the disease because of lack of access to combined Water, Sanita�on and Hygiene (WASH) services, pu�ng the lives of doctors, nurses, midwives and pa�ents at risk. There is need for these Guidelines to be widely circulated and disseminated to ensure a harmonized approach to WASH services and guaranty accessibility of health professionals at all levels for effec�ve u�liza�on and assurance of the benefits of WASH in Infec�on, Preven�ons and Control (IPC) of diseases in HCFs in Nigeria. A periodic review of this document to ensure con�nued relevance is not only desirable but inevitable. vi Pharm. (Mrs.) Olubunmi Aribeana Director, Food and Drug Services Department Federal Ministry of Health Abuja, Nigeria. 2022 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA PREFACE This comprehensive Na�onal Guidelines document has been designed to address the gaps associated with Water, Sanita�on and Hygiene (WASH) services in Healthcare Facili�es (HCFs) in Nigeria through the technical inputs of the Technical Commi�ee, Technical Review Team and Na�onal Stakeholders mee�ngs. The document has been categorized into nine sec�ons and the annex. While Sec�ons One, Two and Three look at the Introduc�on, Strategic Plans for Implemen�ng WASH in Healthcare Facili�es and Establishment of WASH Teams in Healthcare Facili�es respec�vely. Sec�on Four, Five and Six dealt with the Water Supply in Healthcare Facili�es, Sanita�on in Healthcare Facili�es and Hygiene in Healthcare Facili�es. These are focal areas of WASH and were handled to close the gaps and provide the desired approach in WASH services in HCFs. Sec�on Seven and Eight also treated Healthcare Waste Management (HCWM) in Healthcare Facili�es and Environmental Cleaning in Healthcare Facilities. These were treated separately from Sanita�on for emphasis and be�er understanding. Sec�on Nine is the Monitoring of WASH in Healthcare Facili�es. This looks at the coordiana�on, monitoring and Repor�ng procedure. The Overall inten�on of this document is the harmoniza�on, strengthening and standardiza�on of provision of WASH services in the Healthcare Facili�es in Nigeria for Infec�on, Preven�on and Control of disease for the well being of Nigeria people. vii M. Mamman Permanent Secretary, Federal Ministry of Health Abuja, Nigeria. 2022 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA ACKNOWLEDGEMENT Federal Ministry of Health wishes to acknowledge the contribu�ons of all the people and organisa�ons that assisted during the development of these comprehensive Na�onal Guidelines for Water, Sanita�on and Hygiene (WASH) in the Healthcare Facili�es in Nigeria. Our profound apprecia�on to the United Na�ons CHildrens’ fund (UNICEF) for their Financial and Technical support for the finaliza�on and prin�ng of this document. Our special thanks also to the Technical Commi�ee and the 6-Man Technical Team for their technical exper�se, and �me in the development process of this document. ABBREVIATIONS AND ACRONYMS CBO CDC CRPD DHQP E.coli ENT ESCWA FBO FMEnv FMOH FMWR WASH WASHCOM WASH NORM WHO HAI HCF HCWs HCWM HIV JMP LGA MDG MDP MHM NHMIS NGO ODF O & M OPD PHC PPE RCH RUWASSA RWH SARS SDG SON SOP THC UNICEF UN USAID VIP WUI viii NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA Community Based Organiza�on Centre for Disease Control Conven�on on the Rights of Persons with Disabili�es Division of Health Quality Promo�on Escherichia coli Ears, Nose and Throat Economic and Social Commission for Western Asia Faith Based Organiza�on Federal Ministry of Environment Federal Ministry of Health Federal Ministry of Water Resources Water, Sanita�on and Hygiene Water, Sanita�on and Hygiene Commi�ee Water, Sanita�on and Hygiene National OutCome Routine Mapping World Health Organiza�on Healthcare Associated Infec�on Healthcare Facility Healthcare Workers Healthcare Waste Management Human Immunodeficiency Virus Joint Monitoring Programme Local Government Area Millennium Development Goals Municipal Development Partnership Menstrual Hygiene Management Na�onal Health Management Informa�on System Non-Governmental Organiza�on Open Defeca�on Free Opera�on and Maintenance Outpa�ent Department Primary Healthcare Personal Protec�ve Equipment Reproduc�ve Child and Health Rural Water, Sanita�on and Surveillance Agency Rain Water Harves�ng Severe Acute Respiratory Syndrome Sustainable Development Goals Standards Organiza�on of Nigeria Standard Opera�ng Procedure Ter�ary Healthcare United Na�ons Children's Fund United Na�on United State Aid Ven�lated Improved Pit Latrine Water Use Intensity LIST OF TABLES TABLE 1: WHO Standards on Water, Sanita�on and Hygiene in Healthcare Facili�es (WHO, 2008) TABLE 2: Minimum Water Required in Healthcare Se�ngs TABLE 3: Monitoring Indicators for Basic Water Services in HCFs TABLE 4: Monitoring Indicators for Basic Sanita�on Services in HCFs TABLE 5: Monitoring Indicators for Basic Hygiene Services in HCFs TABLE 6: Monitoring Indicators for Basic Healthcare Waste Management Services in HCFs TABLE 7: The five global basic service indicators that provide a valuable star�ng point for global monitoring of WASH services in healthcare facili�es TABLE 8: Monitoring Indicators for Basic Environmental Cleaning Services in HCFs TABLE 9A: Monitoring of Healthcare Environmental Cleaning Services in HCFs TABLE 9B: Indicators Providing Valuable Star�ng Point for Monitoring of Environmental Cleaning Services in HCFs LIST OF FIGURES FIGURE 1: Methods of Rainwater Collec�on FIGURE 2: WHO Moments of Hand Hygiene Figure 3: Hand Hygiene Technique with soap and water 8 11 12 16 23 25 27 28 30 30 11 18 20 ix NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA SECTION ONE: INTRODUCTION 1.1 Background The role of Water, Sanita�on and Hygiene (WASH) services in preven�ng the spread of infec�ons and promo�ng good health in the healthcare facili�es (HCFs) cannot be over emphasized. It has been established that poor WASH services in HCFs is responsible for the spread of some infec�ous diseases, especially among the children under 5years of age. In a joint report by WHO and UNICEF, 2019 �tled; 'Water, sanita�on, and hygiene in health care facili�es: Prac�cal steps to achieve universal access for quality care,¹ it was noted that globally, more than one million deaths each year are associated with births in unhygienic environment; infec�ons account for 26% of neonatal deaths and 11% of maternal mortality.² WASH facili�es and services in HCFs requires a standardized approach that will guide its provision, to ensure quality and safe care for staff, pa�ents, carers and visitors. The poor sanitary condi�on in our HCFs promotes the spread of infec�ous diseases. Though improved WASH in HCFs is a necessary condi�on for comprehensive healthcare services and crucial to improving health outcomes, access to such services in healthcare se�ngs especially in the low and middle income cluster countries like Nigeria is generally poor. This situa�on is linked, among other things, with: (i) Limited financial and human resources for effec�ve and efficient implementa�on of WASH services; and (ii) Lack of clear approach of standardizing and strengthening monitoring mechanisms of WASH interven�ons in HCFs³ (WHO/UNICEF, 2015). These factors are partly responsible for the inability of Nigeria to meet the Millennium Development Goals (MDGs) targets on Water and Sanita�on in 2015, hence the need for a pragma�c approach to meet the targets of the Sustainable Development Goals (SDGs) 3 and 6 on good health and WASH access respec�vely by 2030. 11 ¹WHO and UNICEF report, 2019; 'Water, sanita�on, and hygiene in health care facili�es: Prac�cal steps to achieve universal access for quality care ²WHO and UNICEF report, 2019; 'Water, sanita�on, and hygiene in health care facili�es: Prac�cal steps to achieve universal access for quality care ³WHO/UNICEF, 2015: Good prac�ces in the provision of accessible and inclusive WASH services – (UNICEF Accessible Inclusive WASH Mapping 2015 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA1 ⁴World Bank, WHO, UNICEF, JICA and UHC 2030 Interna�onal Health Partnership (2017). Tokyo Declara�on on Universal Health Coverage. December 2017. h�p:// www.who.int/universal health coverage/tokyo declera�on-uhc.pdf?ua=1 ⁵WHO/UNICEF (2015). Water, sanita�on and hygiene in health care facili�es: Urgent needs and ac�ons. Mee�ng report. h�p://www.who.int/en�ty/water sanita�on health/facili�es/wash-in-hcf geneva.pdf?ua= ⁶WHO. Health care associated infec�ons. Fact sheet. h�p://www.who.int/gpsc/country work/gpsc ccisc fact sheet en.pdf?ua=1 For more informa�on on the global ac�on plan, visit www.washinhcf.org 2 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 1.2 Overview of WASH in Healthcare Facili�es 1. 2.1 Global and Regional Context World leaders recently declared that Universal Health Coverage (UHC) and access to high quality, integrated “people centred” health services, are essen�al to health for all and to human security.⁴ Yet, efforts to accelerate UHC and quality of care will be undermined because fundamental infrastructure and hygiene in health facili�es are not in place. A WHO/UNICEF 2015 global review reported that nearly 40% of facili�es lack water supplies, 19% are without sanita�on and 35% do not have any hand hygiene materials.⁵ Indeed, UHC may be an empty promise without adequate a�en�on to quality, and quality ini�a�ves will fail without adequate a�en�on to water, sanita�on and hygiene (WASH). The lack of WASH services compromises the ability to provide safe and quality care, places both health care providers and those seeking care at substan�al risk of infec�on-related morbidity and mortality, and pose significant economic and social burden. Pregnant women, who are increasingly giving birth in HCFs, and their new-borns, are especially vulnerable to the consequences of poor WASH services. Among hospital-born babies in developing countries, healthcare associated infec�ons are responsible for between 4% and 56% of all causes of death in the new-born period, 75% of which occur in South-East Asia and sub-Saharan Africa.⁶ To address this major gap in services, in 2015, WHO and UNICEF (along with health and WASH partners from across the globe)commi�ed to the vision, that by 2030, every health care facility, in every se�ng, should have safely managed, reliable water, sanita�on and hygiene facili�es and prac�ces that meet staff and pa�ent needs. One output from this commitment has been the development of Water, Sanita�on, Hygiene Facility Improvement Tool (WASHFIT). WASH FIT is a risk-based approach for improving and sustaining water, sanita�on and hygiene and healthcare waste management infrastructure and services in health care facili�es in low- and middle-income countries (LMIC). WASH FIT is an improvement tool to be used on a con�nuous and regular basis, to first and foremost help health care facility staff and administrators priori�ze and improve services, and, second, to inform broader district, regional and na�onal efforts to improve quality health care. The WASH FIT guide contains prac�cal step by-step direc�ons and tools for assessing and improving services. It is adapted from the Water Safety Plan (WSP) approach recommended in the WHO Guidelines for drinking-water quality (WHO, 2011) and goes beyond water safety to include sanita�on and hygiene, health care waste, management and staff empowerment. During the 72nd World Health Assembly held in May 2019, the Resolu�on on WASH in health facili�es was approved. It was highlighted that WASH in health facili�es play a fundamental role in achieving universal health coverage, improving quality of care and preven�ng spread of an�microbial resistance. WHO Member States commi�ed to developing na�onal roadmaps, se�ng and monitoring targets, increasing investments in infrastructure and human resources and strengthening systems to improve and sustain Water, Sanita�on and Hygiene (WASH) services in healthcare facili�es. According to World Health Organiza�on (WHO), there are eight (8) prac�cal steps countries can take to improve WASH in healthcare facili�es which may take place at the na�onal, sub-na�onal level or both. The steps are: conduct a situa�on analysis and assessment; set targets and define a na�onal roadmap; establish na�onal standards and accountability mechanisms; improve and maintain infrastructure; monitor progress and review data; develop the health workforce; engage communi�es; and conduct opera�onal research and share learning. These steps can be achieved based on country priori�es and context, of which Nigeria has already declared a state of Emergency in the WASH sector by President Muhammadu Buhari in November, 2018. Hence, the need to begin the implementa�on of these steps in our Health Facili�es. 1.2.2 Nigeria Perspec�ve The overall status of the WASH sector in Nigeria is poor. Only 9% of the popula�on has access to complete basic water, sanita�on and hygiene services. Specific to WASH in Healthcare facili�es,26% of health facili�es do not have toilets/latrines on premises, only 20% of health facili�es have basic hand hygiene services and only 4% of health facili�es have combined basic water supply, sanita�on, and hygiene services. Furthermore, only 32% of health facili�es have hand hygiene sta�ons with soap and water at points of care, while 28% keep a dedicated budget for cleaning and maintaining the WASH facili�es and 33% safely separate their garbage and waste into at least three labelled bins in consulta�on areas and safely dispose of garbage/waste.⁷ Despite hand-washing with soap being one of the cri�cal first lines of defence against the spread of the highly contagious and deadly corona virus disease, 95% of all healthcare centres in Nigeria are at risk of becoming epicentres of the disease because of lack of access to combined water, sanita�on and hygiene (WASH) services, pu�ng the lives of healthcare workers, pa�ents, visitors and carers at risk. Worse s�ll, about 150 million people (79%) in Nigeria do not have access to hand-washing t facili�es including soap and water.⁸ Healthcare services are provided in facili�es operated by both public and private sectors which are hierarchically categorized into three levels: i. Primary Healthcare (PHC), which is a grassroots management approach in providing healthcare services to communi�es comprising of health posts, PHC centres and Primary Health clinic. ii. Secondary Healthcare (SHC). This level is an intermediary between the PHC and THC usually having a State management approach. It comprises General and Private Hospitals. iii. Ter�ary Healthcare (THC). This level of healthcare system is known as specialized consulta�ve healthcare usually for inpa�ents and on referral from primary and secondary healthcare for advanced medical inves�ga�on and treatment. The main providers of ter�ary care are University Teaching Hospitals (Federal and State), Federal Medical Centres, Specialized Hospitals and Na�onal Hospital. Generally, the healthcare system is characterized by a marked discrepancy in the availability and quality of WASH services between private and public facili�es and between urban and rural areas. Also, the ter�ary and general hospitals tend to be overcrowded because the primary healthcare centres are func�oning below expecta�on. 1.2.3 Gaps in WASH facili�es in Healthcare Facili�es Despite the availability of exis�ng laws, policies and regula�ons suppor�ng WASH ac�vi�es in Nigeria (refer appendix 1, for list of exis�ng laws, policies and regula�ons in Nigeria), there are gaps rela�ng to WASH access, financing, inclusion and gender, monitoring and repor�ng. ⁷WASH Na�onal Outcome Rou�ne Mapping (WASH NORM) report 2019 ⁸The scandal of 95% of healthcare centres in Nigeria and 150 million Nigerians without access to water and hygiene facili�es in the face of the COVID-19 pandemic, WaterAid, May 2020 3 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA ii. Provide benchmark for monitoring of WASH services in HCFs iii. Opera�onalize the WASH component of the Na�onal Strategic Health Development Plan II (NSHDP II) 2018-2022 and beyond. iv. Improve sanita�on and hygiene prac�ces in HCFs v. Define standard protocols for WASH prac�ces in HCFs by health workers, pa�ents, caregivers and visitors. ⁹WASH Na�onal Outcome Rou�ne Mapping (WASH NORM) report 2019 ¹⁰Water and sanita�on for health facility improvement tool (WASH FIT) 2018; A prac�cal guide for improving quality of care through water, sanita�on and hygiene in healthcare facili�es 4 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA Whereas, water, sanita�on, hygiene, waste disposal and environmental cleaning services play cri�cal roles in the con�nuum of healthcare, access to WASH services in Nigeria remains alarmingly poor. According to the 2019 WASH Na�onal Outcome Rou�ne Mapping (NORM) report, only 4% of HCFs have comprehensive access to water, sanita�on and hygiene services, 5% have access to only sanita�on and hygiene services, while 14% have access to only water and hygiene services.⁹ It is important to note that with a poten�al increase in pa�ent influx, the demand for water and sanita�on services might be higher than the available resources; it will be essen�al to close the gap to avoid disrup�on of health services. 1.3 Ra�onale for Developing the Guidelines Whereas there are exis�ng policies, guidelines and frameworks with components of WASH in healthcare facili�es, however, there are no comprehensive na�onal guidelines for the provision of WASH services in HCFs. This could lead to lack of standardiza�on in planning and budge�ng, technical designing and construc�on, opera�on and maintenance with respect to quality of care in different healthcare se�ngs such as emergencies, intensive care unit (ICU), burns unit, isola�on centres etc. Availability of na�onal guidelines will ensure effec�ve monitoring and integra�on of WASH services in HCFs into na�onal strategies thereby contribu�ng to the achievement of the Sustainable Development Goals (SDGs) 3 and 6 targets in Nigeria by 2030. 1.4 Scope of the Guidelines These guidelines are developed for use by all stakeholders in the health sector including those involved in architectural and design works of the healthcare facili�es. These guidelines will focus on the promo�on of WASH services at all levels of healthcare facili�es in line with the domains of UNICEF/WHO WASH Facility Improvement Tool (WASH-FIT),¹⁰ which comprises of Water (quan�ty and quality), Sanita�on (Faecal waste, storm water and healthcare waste), Hygiene (Hand Hygiene and Environmental disinfec�on) and Management (Planning, budge�ng, monitoring and repor�ng). 1.5 Overall goal of the Guideline To ins�tu�onalize WASH in all HCFs as part measures to improve quality healthcare services in Nigeria. 1.5.1 Specific objec�ves The guidelines are to: i. Offer prac�cal guidance for effec�ve and efficient provision of standardized WASH services in both public and private healthcare facili�es for improved quality of healthcare delivery in Nigeria SECTION TWO: STRATEGIC PLANS FOR IMPLEMENTING WASH IN HEALTHCARE FACILITIES 2.1 Implementa�on of Na�onal Guidelines These guidelines will be implemented by all relevant stakeholders by adop�ng the following strategies: i. Integrate implementa�on of WASH services into regular health sector planning, budge�ng and programming to deliver quality services including Covid-19 response and recovery efforts ii. Develop facility-based costed ac�on plans for addressing sustainable WASH services that includes elements of IPC, healthcare management and hygiene behaviour change programmes amongst others. iii. Conduct advocacy to poli�cal, tradi�onal and private sector leaders including policy makers at all levels for ownership and support. iv. Ensure effec�ve collabora�on with stakeholders from relevant MDAs, development partners, NGOs, Media, CSOs, CBOs, FBOs, Disability support organisa�ons, women and youth groups, Pa�ent Support Groups etc. v. Capacity building of all healthcare workers to achieve a culture of adherence to standardized IPC prac�ces in all HCFs. vi. Implement WASH guidelines in line with exis�ng IPC programma�c structure at every HCF as recommended by WHO's minimum requirements for establishment of, and core components of IPC programmes.¹¹ vii. Provide dedicated budget lines (life circle budge�ng) to improve and maintain WASH services in healthcare facili�es. viii. Cons�tute a dedicated WASH Team in every HCF who will be part of the IPC commi�ee to support con�nuous improvement, planning and implementa�on of WASH services. WASH focal person can be appointed where there are inadequate staff members to form a team and work with the IPC focal person in such facility. ix. Build and maintain a data base for WASH services in HCF at all levels x. Conduct regular risk and hazard assessments of HCFs. Using iden�fied findings, develop, implement and monitor improvement plan to prevent the spread of infec�ous diseases. xi. Explore new technologies and current innova�ons to improve infrastructural facility, reduce cost and enhance service delivery. 22 ¹¹Wh�ps://www.who.int/teams/integrated-health-services/infec�on-preven�on-control/core component-8 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA5 ¹²h�ps://apps.who.int/iris/bitstream/handle/10665/254910/9789241511698-eng.pdf ¹³World Health Organiza�on and United Na�ons Children's Fund (2019), WASH in health care facili�es: Prac�cal steps to achieve universal access to quality care, h�ps://www.who.int/water sanita�on health/publica�ons/washin-health-care-facili�es/en/ 6 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 2.2. Planning and Budge�ng for WASH in Healthcare Facili�es Planning and budge�ng is necessary for the economic u�liza�on of materials, manpower, and financial resources. It entails deciding in advance what to do, who to do, when to do, how to do and with what resources in order to achieve the desired result. 2.2.1 Planning Process The following steps should be adopted while planning to improve WASH in HCFs. Step 1 Conduct situa�onal analysis/needs assessment for WASH services in healthcare facili�es using the WASHFIT¹² or other applicable standardized tools. Step 2 Scru�nize WASH plans Step 3 Establish costs for each iden�fied WASH needs Step 4 Priori�ze WASH needs Step 5 Explore different sources of funding for WASH interven�ons Step 6 Resources priori�za�on for new WASH interven�ons or improvements.¹³ 2.2.2 Funds alloca�on criteria Alloca�on of resources to different WASH services should be based on the following aspects: I. The list of priori�zed WASH needs based on findings from the situa�onal analysis/ needs assessment including personnel demands. Repair, maintenance and upgrade of ac�vi�es WASH services in HCFs that are of great demand to vulnerable groups e.g. pregnant women, children under-five years of age, people with special needs etc. 2.2.3 Major considera�ons in planning and designing of WASH interven�ons Facili�es should be planned and designed in a manner that they are safe, user-friendly, and people-centred and provide equitable services with due community engagement. 2.2.3.1 WASH facili�es for people with special needs Special considera�on should be given to the following; i. People with disabili�es, such as those with limited mobility, visually impaired etc. ii. People seeking care as a result of disease of public health emergencies such as Lassa fever, cholera, COVID-19 etc. requiring isola�on and standard precau�onary interven�ons. iii. Other people with special needs such as; children, older persons (geriatrics), menstrua�ng, pregnant and perinatal women. 2.2.4 Sustainability Plans In implemen�ng these guidelines, there shall be sustainability plans which should include the following: i. Enabling Environment (suppor�ve leadership, alignment with exis�ng WASH related policies/frameworks and guidelines on One-Health, IPC, AMR programmes, health security, Ins�tu�onal capacity strengthening, Opera�on and Maintenance). ii. Sustainable funding of WASH services through domes�c budgetary alloca�on at all levels of care and donor support. iii. Comprehensive inclusion of relevant stakeholders in planning and implementa�on of the guidelines iv. Monitoring and Evalua�on Plan etc. SECTION THREE: ESTABLISHMENT OF WASH TEAMS IN HEALTHCARE FACILITIES 33 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA7 Each HCF irrespec�ve of the category (Primary, Secondary or Ter�ary) shall establish a WASH Team/ Focal point which shall be responsible for leading the assessment, planning, budge�ng, implemen�ng, monitoring and repor�ng of WASH related services in the facility. 3.1 Composi�on of the WASH Team / Focal point The WASH team shall comprise of relevant mul�-disciplinary professionals within the HCF and preferably led by a licensed Environmental Health Officer (EHOs). Where an EHO is unavailable, any Health Staff with adequate training in WASH and especially infec�on prevention and control shall suffice. 3.2 Roles of the WASH team / Focal point The WASH team, working as part of the IPC commi�ee/team shall be responsible for the implementa�on of the WASH component of the IPC programme (refer WHO core component 8 of IPC programme). They shall; i. Lead the periodic assessment and repor�ng of the WASH and IPC situa�on in the HCF ii. Develop plans and budget to address the iden�fied gaps in the WASH services and IPC in HCFs iii. Coordinate, monitor and report on the overall WASH services in the facility, including availability of materials for Water, Sanita�on and Hygiene Services. iv. Undertake Opera�on and Maintenance (O & M) func�ons to ensure op�mum performance and func�onality of the WASH equipment and facili�es. v. Develop and implement Standard Opera�ng Procedures (SOP) and Protocols for all WASH services such as water quality, cleaning, waste management etc. vi. Train all staff engaged for delivery of WASH services in HCFs. vii. Where necessary, facilitate engagement of facility leadership with relevant stakeholders such as Community leaders, NGOs, CBOs, FBOs, and Donors etc. Hold regular mee�ngs and submit reports through appropriate channels to the facility leadership. SECTION FOUR: WATER SUPPLY IN HEALTHCARE FACILITIES 44 ITEMS RECOMMENDATIONS EXPLANATIONS Water quan�ty 5–400 litres/person/day. Outpa�ent services require less water, while opera�ng theatres and delivery rooms require more water. The upper limit is for viral hemorrhagic fever (e.g. Ebola) isola�on centres. Water access On site supplies. Water should be available within all treatment wards and in wai�ng areas. Water quality Drinking-water should comply with (NSDWQ: NIS-554-2015) Standard for Drinking water Quality for microbial, chemical and physical aspects. Facili�es should adopt a risk management approach to ensure drinking water is safe. ¹⁴WHO Standards for Water, Sanita�on and Hygiene in Healthcare Facili�es (WHO, 2008) NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA8 Less than 1 Escherichia coli/ thermo tolerant / total coliforms per 100 ml. Presence of residual disinfectant. Water safety plans in place. 4.1 Water needs, Quality and Standards in healthcare facili�es HCFs known for its high-Water Use Intensity (WUI) shall always have unhindered access to adequate water supply in terms of quality, quan�ty, reliability and accessibility in order to maintain pa�ents' care services and other opera�ons. Water should be treated to meet the Na�onal and Interna�onal Standards approved for its intended use e.g. Nigerian Standard for Drinking Water Quality (NSDWQ: NIS-554-2015 (Table 1). Table 1: WHO Standards for Water, Sanita�on and Hygiene in Healthcare Facili�es (WHO, 2008)¹⁴ ¹⁵h�ps://www.who.int/water sanita�on health/dwq/sheet4.pdf ¹⁶h�ps://www.water.wa.gov.au/ data/assets/pdf file/0009/4014/104027.pdf 9 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 4.2 Water Sources 4.2.1 Types of Water Sources Healthcare Facili�es may access water through any of the following three main sources found in Nigeria: i. Ground water: These are sources whereby water is obtained from beneath the surface in rock and soil, and accumulates underground in aquifers e.g. Boreholes, Wells etc. ii. Surface water: These are sources whereby water is collected on the surface of the earth. They include lakes, rivers, dams, ponds or wetlands iii. Rain water: This is an alterna�ve source that can ensure availability of water in HCFs through Rainwater Harves�ng System (RHS), especially in areas with water scarcity or intermi�ent water supply. 4.2.2 Basic considera�on in selec�ng appropriate water sources for HCFs a) Water Quan�ty b) Water Quality c) Protec�on of Water Sources d) Accessibility e) Affordability f) Feasibility g) Opera�on and Maintenance 4.3 Recommended Water Services for Healthcare Facili�es in Nigeria 4.3.1 Recommended Water Supply Methods/Sources Recommended water supply to HCFs shall be from any of the following methods/sources: i. Piped supply inside the building ii. Piped supply outside the building. iii. Tube well / Borehole iv. Protected dug well v. Protected spring vi. Rain water harves�ng 4.4. Accessibility and Availability The source of the water must be located within the premises, from an improved source and water should always be made available. 4.5 Protec�on of water sources All water sources shall be adequately protected from pollu�on and contamina�on especially water from, tube well / borehole, protected dug well and rain water.¹⁵ ¹⁶ 4.5.1 Considera�ons for Construc�on of Water sources Healthcare Facili�es should take into considera�on the following during construc�on water sources to ensure they are protected. 10 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 4.5.1.1 Tube well/Borehole Tube wells should be sited in a suitable environment free from any form of waste disposal. i. Toilets should be sited downhill of tube wells and boreholes to avoid possible contamina�on. ii. The top of the tube well/borehole should be completely covered by making a concrete plinth to prevent any surface or spilt water from entering the well. iii. A hand-pump should be securely fixed on a concrete plinth for tube wells. iv. The plinth should be surrounded by a sloppy apron and a drainage channel built to allow spilt water to flow away from the wellhead to a soak-away for tube wells. v. There should be regular inspec�on and monitoring for water quality sampling and tes�ng to ensure safe and adequate water supply. 4.5.1.2 Dug wells i. Dug wells should be sited in a suitable environment free from any form of waste disposal. ii. Toilets should be sited downhill of ground water such as hand dug well, borehole, etc. to avoid possible contamina�on. iii. New sep�c tanks or other sewage treatment methods to be installed at least 50 feet from a well. iv. Wells should be covered with a hard surface v. Wells should be lined with concrete rings to avoid washed sediment into the body of the water. 4.5.1.3 Rainwater Water from this source can be collected using the Rainwater Harves�ng System (RHS).The RHS collects water from house's roof into a storage tank. (surface or underground). The following are recommenda�ons for protec�on of rainwater from RHS; a) Roofing: Roofs suitable for the collec�on of water in Healthcare Facili�es is the one which does not interfere with the quality and safety of the collected water. E.g. coated aluminium, stainless steel, aluminium sheet and concrete or terra co�a �les. b) Drainage: it is important to bring together all downpipes into one pipe for entry into the tank. c) Storage Tank Installa�on: i. In most cases a flat, shallow tank is preferable. ii. The tank should have an inflow and an overflow. The overflow needs to go to a soak-away or surface water drain. iii. Back filling around tank should be done with concrete or compactable gravel, depending on the tank. d) Installing the pump: A pump needs to be installed in the tank to send the water to the property. e) Internal plumbing: The internal pipe-work must be a dedicated feed to the toilets and washing areas. f) Filtra�on: Leaf filters are mostly built into the tanks and filters are also installed on the pump to stop par�cles coming through. g) Main backup system: To ensure there is an uninterrupted water supply to the building RAIN BARREL DRY SYSTEM WET SYSTEM FIGURE 1: Diagram for Different Method to Collect Rainwater 4.6 Opera�on, Maintenance and Protec�on of Water Supply System An effec�ve and efficient Opera�on and Maintenance management system should be put in place to ensure constant availability of water in the Healthcare Facility. (Table 2). TABLE 2: Minimum Water Required in Healthcare Se�ngs 4.7 Water Storage i. Water should be stored in containers made of material that will not compromise the quality of the stored water. ii. Storage container must be of adequate capacity to meet the water demand for the HCF iii. Regular maintenance of the water storage facili�es such as cleaning, disinfec�on etc. should be maintained. iv. Rou�ne cleaning, disinfec�on, and policies should be implemented and periodically reviewed. HEALTHCARE SETTINGS MINIMUM WATER QUALITY REQUIREMENT Outpa�ents 5 liters per consulta�on Inpa�ents 40-60 liters/pa�ent/day Inpa�ent Therapeu�c Feeding Centre 60 liters/pa�ent/day Cholera Treatment Centers 60 liters/pa�ent/day Opera�ng Theatre/Maternity Unit 100 liters/interven�on Viral Hemorrhagic Fever Isola�on Center SOURCE: World Health Organiza�on, Essen�al Environmental Health Standards in Healthcare, WHO, Geneva, 2008, <www.who.int/water sanita�on health/publica�ons/ehs hc/en>. Severe Acute Respiratory Syndrome Isola�on Center 100liters/isola�on 300-400 liters/isola�on 11 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 4.8 Major Considera�on in the Distribu�on of Water in Healthcare Facili�es The following aspects should be taken into considera�on while installing water points in Healthcare Facili�es: i. Suitable drinking-water points should be available for staff, pa�ent and carers at all �mes. ii. Where piped water is available, it should be re�culated to cri�cal points within the Healthcare Facility, e.g. wards, isola�on areas, emergency units, consul�ng rooms, laboratory, laundry, toilets, steriliza�on units and opera�ng theatres etc. Alterna�vely, running water should be available at all cri�cal points using other methods e.g. buckets with taps (Veronica buckets). iii. Water should be made available at all �mes at hand washing points 4.9 Monitoring Indicators for Water Services in HCFs Monitoring water services for HCFs should be based on the indicators provided by WHO/UNICEF as contained table 3 below: TABLE 3: Monitoring Indicators for Water Services in HCFs ELEMENT MONITORING DEFINITION Improved Unimproved Unimproved sources include unprotected dug wells or springs and surface water (e.g. lake, river, stream, pond, canals, irriga�on ditches). On premises Water is accessed within buildings, or within the facility grounds. Available Accessibility The source of the water must be located within the premises and water should be available at all the �me Ownership Facility owned or outsourced 12 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA Improved water sources are those which, by nature of their design and construc�on, have the poten�al to deliver safe water. Improved sources include piped water, boreholes or tube wells, protected dug wells, protected springs, rainwater, and packaged or delivered water. Water from the main water source is available always and on the day of the survey or ques�onnaire SECTION FIVE: SANITATION IN HEALTHCARE FACILITIES 5.1 Introduc�on Sanitary management of excreta in healthcare facility is important to ensure fecal pathogens do not contaminate the environment. 5.2 Criteria for Sanita�on facili�es in HCFs The following minimum criteria should be considered when planning for sanita�on management in HCFs: 5.2.1 Safety Sanita�on facili�es including toilets should be safe to avoid the spread of harmful agents like microbes, physical and chemical contaminants, or disease harbouring vectors / vermin to prevent the transmission of infec�ous diseases. Measures should be put in place to control flies and breeding ground for mosquitoes, furthermore, floors should be dry to avoid falling. 5.2.2 Reliability Toilets should be func�onal, clean and in good state of use at all �mes with provision of consumable (water, toilet-paper, soap, etc.) 5.2.3 Accessibility Toilets must be accessible to intended users, located not more than 30 meters from users and should always be opened with the lock inside. Also accessible to Nurses sta�on in case of falls or other emergencies. 5.2.4 User convenience i. There should be separate toilets for women, men, young children, and people with disabi l ity, people who are immobile, cri�cally ill or in isola�on, older persons, immune-compromised persons, pregnant, menstrual and perinatal women ii. Toilet for women/girls should have a mirror on the internal part of the door to enable effec�ve changing of used menstrual material and self-cleaning bin with a lid for the disposal of used material and water and soap for menstrual hygiene and washing. iii. Mobility aids should be provided such as ramps, support grips and rails for people with visual impairments. iv. Signage indica�ng the loca�on/direc�on of toilets as well as differen�a�ng male and female toilets should always be in place. v. Provision of a bin with a lid on it with water and soap available in a private space for washing. vi. Lockable doors for privacy and clear pathways with ligh�ngs for proper accessibility. 55 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA13 14 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA viii. Dedicated separate toilet facili�es for staff us 5.3 Design and construc�on of sanita�on facili�es 5.3.1 General considera�ons Sanita�on facili�es for Healthcare se�ngs should fall in any of the following categories: i. Pour flush ii. Water closet iii. Ven�lated improved pit (VIP) toilets 5.3.2 Maintenance and hygiene of pour flush / water closet toilets For maintenance and hygiene purposes the following prac�ces are recommended: (I) Users of flush toilets should be reminded through a visibly displayed poster that they must flush and leave the toilet clean a�er use. (ii) Flush toilets should be cleaned using standard cleaning materials such as toilet brushes, detergents and approved disinfectants (iii) There should be a cleaning schedule that shows the frequency and dura�on along with a supervisor's verifica�on column for monitoring and supervisory purposes. (iv) Periodic checks on effec�ve func�oning of the flush toilets in the HCF should be carried out to iden�fy any mechanical faults especially the blockage of pipes and faulty cistern mechanism. (v) Since in many cases, flush toilets are located within the buildings, rec�fica�on of faults should be done immediately to avoid flies within the premises and eliminate odour from blocked toilets. 5.3.3 Maintenance and hygiene of Ven�lated Improved Pit Toilets i. Users should of VIP toilets should be reminded to always cover the pits to avoid flies' infesta�on. ii. Anal cleansing using water is recommended, however, where not available, anal cleansing materials such as toilet paper should be provided along with a bin for sanitary disposal. iii. Users of VIP toilets should be reminded to sweep out spills a�er anal cleansing with water. iv. VIP toilets should be cleaned using standard cleaning materials such as detergents and approved disinfectants. v. There should be a cleaning schedule that shows the frequency and dura�on along with a supervisor's verifica�on column for monitoring and supervisory purposes. vi. Periodic checks on effec�ve func�oning of the vent and lid should be carried out to iden�fy and rec�fy faults. vii. As many VIP toilets are located outside the building, adequate ligh�ng and clearing of pathways to prevent exposure of users to hazards. 5.3.4 Toilet Facility for people with special needs An accessible toilet should be designed to accommodate people with physical disabili�es. Designs of sanita�on facili�es should essen�ally take into account the following categories of disabili�es: (i) People with visual impairments should be provided with mobility aids such as ramps, support grips and rails including proper ligh�ng of the pathways. (ii) The design of a toilet should include wider doors, and special grips or foldable seats for people who are non-ambulatory and on wheelchairs, crutches etc iii) Bed pans should be provided to people that are bedridden 5.4 Opera�ons and Maintenance of Sanita�on facili�es Sanita�on infrastructure and facili�es requires careful organiza�on and ac�ons to ensure smooth opera�ons and provision of maintenance services in case of structural or func�onal changes. Rou�ne and periodic maintenance services are prerequisite for sustaining sanita�on facili�es in healthcare facili�es. (i) There should be a clear descrip�on of staff roles on management of sanita�on infrastructure and services. Depending on the facility level, there should be a commi�ee with assigned responsibili�es in rela�on to maintaining sanita�on infrastructure. (ii) Toilets should be cleaned whenever they are dirty, and at least thrice a day with a disinfectant used on all exposed surfaces and a brush to remove visible soiling. Strong disinfectants are unnecessary and should not be used in large quan��es.¹⁷ (iii) There should be weekly and daily cleaning schedule that specify when sanita�on facili�es should be cleaned and supplied with cleaning and hygiene agents. Cleaning schedule should iden�fy persons or groups responsible for undertaking the cleaning tasks and their supervisors. The schedules should be displayed for easy access and be shared among responsible officers. (iv) Orienta�on, training, and educa�on of users is an important aspect of opera�ons that must be implemented. Orienta�on materials, personnel and �me should be dedicated to help new comers, regular visitors, and staff members. (v) Opera�on and maintenance plan must be put in place to cover for the running and repairs of sanita�on infrastructure and services. This should include regular or incidental repairs and scheduled maintenance ac�vi�es. (vii) Faecal sludge should be emp�ed when the sep�c tank is ¾ full. (viii) Cleaning and maintenance inspec�on ac�vi�es should be documented and reported in weekly mee�ngs. 5.5 Monitoring Indicators for Sanita�on Services in HCFs Monitoring sanita�on services for HCFs should be based on the indicators provided by WHO/UNICEF as contained table 4 below. ¹⁷Essen�al Environmental Health Standards in HCF, 2008 15 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA TABLE 4: Monitoring Indicators for Sanita�on Services in HCFs ELEMENT MONITORING DEFINITION Improved Improved sanita�on facili�es are those designed to hygienically separate excreta from human contact. Improved facili�es include: pour flush, sep�c tanks or pit latrines; ven�lated improved pit latrines, compos�ng toilets or pit latrines with slabs. Unimproved Unimproved facili�es include pit latrines without a slab or pla�orm, hanging latrines, and bucket latrines. For the purpose of this document “toilets” is taken to mean any of these improved facili�es. Usable Toilets are available, func�onal, and private: Available to pa�ents and staff (toilets are on premises; doors are unlocked or a key is available at all �mes) Func�onal (the toilet is not broken, the toilet hole is not blocked, there should be no cracks or leaks in the toilet structure and water is available for flush/pour-flush toilets), and Private (there are closable doors that can be locked from the inside and no large gaps or holes in the structure) on the day of the survey or ques�onnaire. Dedicated for staff There are separate toilet facili�es dedicated for pa�ent and staff use. Gender separated with menstrual hygiene facili�es Accessible for users with limited mobility Toilets are considered accessible if they meet relevant na�onal or local standards. In the absence of such standards, toilets should be accessible without stairs or steps, have ramps, handrails for support a�ached either to the floor or sidewalls, a door which is at least 80cm wide, and the door handle and seat within reach of people using wheelchairs or crutches/s�cks. ¹⁸h�ps://www.who.int/water sanita�on health/hygiene/se�ngs/ehs health care.pdf.pdf 16 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA At least one toilet is separated for use by women / girls and has a bin with a lid on it and/or water and soap available in a private space for washing The recommended ra�o of one toilet is 1/20 people and should be used as a planning guideline. Users include pa�ents, staff and carers. Actual numbers required for inpa�ent se�ngs will depend on a number of factors, including the average propor�on of pa�ents using bedpans instead of toilets.18 SECTION SIX: HYGIENE IN HEALTHCARE FACILITIES 66 ¹⁹h�ps://www.healio.com/news/infec�ous disease/20140422/10 3928 1081 597x 20140101 00 1340650 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA17 6.1 Hand Hygiene Prac�cing hand hygiene is a simple yet effec�ve way to prevent infec�ons. Cleaning hands can prevent the spread of germs, including those that are resistant to an�bio�cs and are becoming difficult, if not impossible, to treat. Hand hygiene is the single most effec�ve means of reducing the risk of Healthcare Associated Infec�ons (HAIs).¹⁹ Failure to observe hand hygiene at cri�cal �mes could increase the risk of spreading HAIs. 6.1.1 Promo�on of hand hygiene prac�ces in healthcare facili�es Effec�ve hand hygiene in healthcare facili�es has been the cornerstone of infec�on preven�on and control. Health care workers and visitors to HCFs can spread pathogens through their hands. It is important that healthcare facili�es provide adequate informa�on and enlightenment on hand hygiene prac�ces in addi�on to provision of hand -washing facili�es with soap and water at all designated loca�ons within the HCF used by health care workers, pa�ents as well as visitors. 6.1.2 Awareness on transmission of pathogens by hands Disease can spread when: i. Eyes, nose and mouth are touched with unclean hands. ii. Foods are prepared or eaten with unclean hands. iii. Hands are contaminated with respiratory droplets through coughing or sneezing and spread through handshakes, touching of surfaces and objects 6.1.3 General considera�ons for hand hygiene for non-healthcare workers in Healthcare Facili�es I. Before and a�er caring for the sick in any form. ii. Before, during and a�er preparing, ea�ng food and feeding a baby iii. A�er changing diapers or cleaning up a child who has used the toilet iv. A�er using the toilet v. Before and A�er using your face mask vi. A�er blowing nose, coughing or sneezing vii. A�er touching and disposing waste viii. A�er being in the public places and touched items or surfaces that may be frequently touched by other people, like doors, tables, gas pumps, shopping carts, or electronic cashier register / screen etc. 6.1.4 Hand hygiene in pa�ent handling for Health Workers WHO recommends five moments of hand hygiene to track hand hygiene performance of healthcare workers. The five cri�cal moments of hand hygiene that should be performed to ensure the health and safety of pa�ents and staff include: i. Before touching pa�ents ii. Before performing clean or asep�c procedure iii. A�er a procedure with the risk of exposure to body fluids iv. A�er touching pa�ents' directly and v. A�er touching pa�ents' surroundings 20 Figure 2: WHO moments of hand hygiene ²⁰h�ps://www.hygiene-in-prac�ce.com/media/your-5-moments-for-hand-hygiene/ 18 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 6.2 Handwashing Techniques 6.2.1 General Hand-washing Technique i. Dura�on of the en�re procedure should be 40-60 seconds ii. Remove all hand jewellery including rings and watches iii. Wet hands with water iv. Apply enough soap to cover all hand surfaces v. Rub hands palm to palm vi. Right palm over le� dorsum with interlaced fingers and vice versa vii. Palm to palm with fingers interlaced. viii. Backs of fingers to opposing palms with fingers interlocked and rota�onal rubbing backwards and forwards ix. Rota�onal rubbing of the le� thumb clasped in right palm and vice versa x. Rota�onal rubbing of the finger�ps of the right hand on the palm of the le� hand and vice versa xi. Rota�onal rubbing of the le� wrist with the right hand and vice versa. xii. Rinse hands with water and dry hands thoroughly with a single use towel or air dry your hands if towel is not available xiii. Use towel to turn off faucet or your elbow if single use towel is not available xiv. Throw the paper towel in the waste bin 19 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA Figure 3: Hand Hygiene Technique with Soap and water²¹ ²¹ 20 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 6.2.2 Hand-washing Techniques prior to surgical opera�ons (Scrubbing) i. Remove all jewellery and trim the nails ii. Use soap, a brush (on the nails and finger �ps) and running water to clean thoroughly around and underneath the nails iii. Scrub your hands and arms up to the elbows iv. A�er scrubbing, hold up your arms to allow water to drip off your elbows v. Turn off the tap with your elbow. vi. Dry hands with a sterile towel and make sure the towel does not become contaminated. vii. Hold your hands and forearms away from your body and higher than your elbows un�l you put on a sterile gown and sterile gloves. viii. Always wash your hands a�er removing your gloves 6. 2.3 Hand Hygiene using Alcohol Based Hand Rub (ABHR) 21 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA ²²h�ps://www.ncbi.nlm.nih.gov/books/NBK144032/ ²³WHO Hand hygiene assessment framework-h�ps://cdn.who.int/media/docs/default-source/integrated health-services-(ihs)/hand-hygiene/monitoring/hhsa-framework-october-2010.pdf?sfvrsn=41ba0450 6 22 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 6.3 Basic Hygiene Services/Facili�es 6.3.1 Hand Hygiene Facili�es A hand hygiene facility is any device that enables staff and pa�ents to clean their hands effec�vely under running water such as, a sink with tap, water tank with tap, bucket with tap (Veronica bucket) or other similar device. Alcohol based hand rub dispensers are also hand hygiene facili�es, whether they are fixed or portable. To provide basic hygiene services in HCFs the following condi�ons must be sa�sfied: i. All the hygiene facili�es must be func�onal. ii. Points of Care: There must be func�onal hand hygiene facili�es at points of care (e.g consulta�on/examina�on rooms) with soap and water or either alcohol based hand rub however, when alcohol-based hand rub is used, healthcare staff may carry a dispenser around between points of care. iii. Accessibility: There must be func�onal hand hygiene facili�es in toilets or (5meters of toilets and must have soap and water available always. Alcohol-based rub is not considered adequate for hand hygiene at toilet as it does not remove faecal ma�er from hands. iv. Hand hygiene facili�es should be located at every strategic point in the facility e.g. entrance gate, recep�on, walkways, etc. v. The five (5) steps implementa�on strategy of WHO mul�modal hand hygiene implementa�on strategy should be prac�ced in HCFs.²² The steps are; 1. Facility preparedness (readiness for ac�on) 2. Baseline evalua�on-establishing the current situa�on 3. Implementa�on (introducing the improvement ac�vi�es) 4. Follow-up evalua�on (evalua�ng the implementa�on impact) 5. Ac�on planning (review cycle-developing a plan for the next 5 years) 6.4 Quality assurance for hand hygiene compliance and sustainability in HCFs i. The IPC commi�ee/WASH team/Focal person shall ensure adherence and compliance to hand hygiene prac�ces by all staff, pa�ents, carers and visitors in all areas of the HCFs where healthcare and related services are provided. ii. The HCF shall ensure regular capacity building of the IPC Commi�ee/WASH team/Focal Person. Relevant tools for monitoring of hand hygiene compliance (eg WHO hand hygiene self-assessment framework²³) should be provided. iii. In addi�on, the IPC commi�ee/WASH team/Focal person shall see to the development of opera�onal plans and ensure that all relevant materials, supplies and tools for implemen�ng hand hygiene guidelines are put in place. iv. Each HCF according to its working environment, should adopt a behaviour change and communica�on model that will contribute towards improving hand hygiene prac�ces by all. 6.5 Monitoring Hand Hygiene prac�ces in HCFs Monitoring hand hygiene prac�ces in HCFs should be based on the indicators provided by WHO/UNICEF as contained table 5 below TABLE 5: Monitoring Indicators for Hand Hygiene Services in HCFs ELEMENT MONITORING DEFINITION Hand hygiene facili�es A hand hygiene facility is any device that enables staff and pa�ents to clean their hands effec�vely, such as a sink with tap, water tank with tap, bucket with tap or other similar device. Alcohol based hand rub dispensers are also hand hygiene facili�es, whether they are fixed or portable. Func�onal Points of care Points of care are any loca�on in the healthcare facility where care or treatment is delivered (e.g. consulta�on/examina�on rooms). Within 5 meters of toilets Hand hygiene facili�es at toilets must be located not more than 5 metres from the toilets. 23 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA To be considered func�onal, hand hygiene facili�es at points of care must have either alcohol based hand rub, or soap and water. If alcohol-based hand rub is used, healthcare staff may carry a dispenser around between points of care. To be considered func�onal, hand hygiene facili�es at toilets must have soap and water available within 5m of toilets. Alcohol-based rub is not considered adequate for hand hygiene at toilet as it does not remove faecal ma�er from hands. SECTION SEVEN: HEALTHCARE WASTE MANAGEMENT (HCWM) IN HEALTHCARE FACILITIES 7.1 Impact of poor healthcare waste management Improper treatment and disposal of healthcare waste may pose health risks indirectly through the release of pathogens and toxic pollutants into the environment as enumerated below: i. The disposal of untreated healthcare wastes in landfills can lead to the contamina�on of drinking, surface, and ground waters if those landfills are not properly constructed. ii. The treatment of healthcare wastes with chemical disinfectants can result in the release of chemical substances into the environment if those substances are not handled, stored and disposed in an environmentally sound manner. iii. Incinera�on of waste has been widely prac�ced, but inadequate incinera�on or the incinera�on of unsuitable materials results in the release of pollutants into the air and in the genera�on of ash residue. Incinerated materials containing or treated with chlorine can generate dioxins and furans, which are human carcinogens and have been associated with a range of adverse health effects. Incinera�on of heavy metals or materials with high metal content (in par�cular lead, mercury and cadmium) can lead to the spread of toxic metals in the environment. iv. Poor management of healthcare waste poten�ally exposes healthcare workers, waste handlers, pa�ents and the community at large to infec�on, toxic effects and injuries, and risks pollu�ng the environment. Other poten�al infec�ous risks may include the spread of drug-resistant micro organisms from healthcare establishments into the environment. 7.2 Types of waste Out of the total amount of waste generated by healthcare ac�vi�es, about 85% is general, non-hazardous waste comparable to domes�c waste. The remaining 15% is considered hazardous material that may be infec�ous, chemical or radioac�ve.²⁴ Waste and by-products cover a diverse range of materials, as follows: i. Infec�ous waste: waste contaminated with blood and other body fluids (e.g. from discarded diagnos�c samples), cultures and stocks of infec�ous agents from laboratory work (e.g. waste from autopsies and infected animals from laboratories), or waste from pa�ents with infec�ons (e.g. swabs, bandages and disposable medical devices) 77 ²⁴WHO 2018, Healthcare waste. World Health Organiza�on, Geneva NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA24 ii. Sharps waste: syringes, needles, disposable scalpels and blades, etc.; iii. Chemical waste: for example, solvents and reagents used for laboratory prepara�ons, disinfectants and heavy metals contained in medical devices (e.g. mercury in broken thermometers) and ba�eries; iv. Pharmaceu�cal waste: expired, unused and contaminated drugs and vaccines; v. Cytotoxic waste: waste containing substances with genotoxic proper�es (i.e. highly hazardous substances that are mutagenic, teratogenic or carcinogenic), such as cytotoxic drugs used in cancer treatment and their metabolites; vi. Radioac�ve waste: such as products contaminated by radionuclide including radioac�ve diagnos�c material or radio therapeu�c materials. vii. Non-hazardous or general waste: waste that does not pose any par�cular biological, chemical, radioac�ve or physical hazard CLASSIFICATION AND DESCRIPTION EXAMPLES NON-HAZARDOUS Class 1: NON-RISK GENERAL WASTE Similar to normal household municipal waste and can be managed by the municipal waste services. Paper, cardboard, plas�c, kitchen waste, ash, sawdust, pieces of wood segregated from hazardous waste at the point of genera�on HAZARDOUS Class 2: INFECTIOUS WASTE Generated by both inpa�ents/out -pa�ents or animals, this waste is known or likely to contain pathogenic micro organisms and can be dangerous or infec�ous to both pa�ents, healthcare workers and the public. It therefore requires special management both inside and outside the hospital. Laboratory waste, materials poten�ally infected blood, swabs, materials that have been in used in surgery or been in contact with pa�ents. Internal body organs, amputated limbs, placentas, foetus. Also includes urine and blood products. Class 5: CHEMICAL, PHARMACEUTICAL, GENOTOXIC WASTE Wastes, including expired products, generated from the pharmacy, radiology and from chemotherapy. Vials, connec�ng tubing, drugs, vaccines, pharmaceu�cal products, disinfec�on solu�ons. HIGHLY HAZARDOUS Class 3: SHARPS These are sharp-edged wastes that can cause cuts or puncture wounds (e.g. needle s�ck injuries). They are hazardous whether or not they are contaminated with blood. They must be segregated, packaged, and handled with specific procedures within the health facility. Needles, syringes, surgical blades, scalpels, test tubes, ampoules, glass instruments, pipe�es. Table 6: Classifica�on, descrip�on, and examples of healthcare waste classes 25 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA Class 4: PATHOLOGICAL / ANATOMICAL Includes amputa�ons and other body �ssues resul�ng from surgical opera�ons, autopsy (post -mortem), or delivery. Requires special treatment for ethical and aesthe�c reasons. Sputum cultures of TB laboratories, contaminated blood clots and glassware, highly concentrated microbiological cultures carried out in medical analysis laboratories. Class 7: RADIOACTIVE WASTE Any solid, liquid, or pathological waste contaminated with radioac�ve isotopes of any kind Radioac�ve papers, gloves, co�on swabs, needles (sharps), liquid-pa�ent excre�on, spent radia�on sources radium needles. 7.3 Healthcare Waste Management Services To provide Healthcare Waste Management Services in HCFs the following condi�ons must be sa�sfied. 7.3.1 Healthcare waste segrega�on i. At least three clearly labelled and colour-coded bins should be in place to separate 1: Non-infec�ous / general waste (Black) 2: infec�ous waste (Yellow) and 3:highly infec�ous waste (Red).For other categories of waste e.g. pharmaceu�cal, radioac�ve, other chemical waste, an addi�onal colour coded bin (brown) with relevant signage is recommended. ii. Bins should not contain waste other than that corresponding to its label, and should not be more than three quarters (75%) full before disposal. iii. Bins should be appropriate to the type of waste they are to contain; sharps containers should be puncture-proof and others should be leak-proof. Bins for all waste should have �ght fi�ng lids and corresponding bin liners. 7.3.2 Colour Code Healthcare waste is put in plas�c bags (bin liners), metal containers, and hard plas�c barrels and bins which should be colour coded. For efficiency purposes, all waste containers in the same stream should be the same colour. If there are small bins in examina�on rooms for infec�ous waste and those bins are red, then the larger containers for infec�ous waste should also be red, and the drums or boxes in the storage area for infec�ous waste should also be red. If you use black for non-hazardous waste, use black in all such containers throughout the facility. 26 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA Class6: HIGHLY INFECTIOUS These highly infec�ous wastes required immediate treatment by chemical disinfectants or autoclaving before joining the hazardous HCW stream. Table 7: Classifica�on and colour-coding of Healthcare Wastes 7.3.3 Treatment and disposal Appropriate Infec�on, Preven�on and Control (IPC) measures should be observed in the collec�on, transporta�on and treatment of healthcare waste within and outside the HCF. Waste should be safely treated and disposed appropriately using any of the following approved methods: i. Incinera�on: municipal solid waste, hazardous waste, and medical waste ii. Autoclaving: Used medical sharps and sharps containers, Bloody bandages or gauze. Masks or gowns (worn by doctors or pa�ents) iii. Burial in a lined, protected pit: Contaminated biomaterials iv. Collected and transported off-site for medical waste treatment: By incinera�on and Land disposal off site NOTE: Healthcare Wastes should not be treated in any of the following ways: i. Open dumping ii. Open burning and iii. Any other way that can impact nega�vely on the environment 7.3.4 Accessibility of bins Waste bins should be properly located at every point of care, hand-washing sta�ons, toilets and where other services are rendered in the HCFs 27 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 7.3.5 Management of Wastewater Managing wastewater and faecal sludge in HCF the following guidelines should be followed: (i) Treat wastewater from HCFs before final disposal. The treatment should be either onsite by using sep�c tanks and soak way pit or offsite by using waste water treatment systems (ii) Pour flush toilets should be connected to inspec�on chambers, sep�c tanks and soak way pit. ²⁵WHO/UNICEF JMP 2019 ELEMENT MONITORING DEFINITION Safely segregated in consulta�on area At least three clearly labelled or colour coded bins should be in place to separate (i) sharps waste, (ii) infec�ous waste, and (iii) non-infec�ous general waste. Bins should be no more than three quarters (75%) full, and each bin should not contain waste other than that corresponding to its label. Bins should be appropriate to the type of waste they are to contain; sharps containers should be puncture-proof and others should be leak-proof. Bins for sharps waste and infec�ous waste should have lids. Consulta�on areas are rooms or areas within the healthcare facility where care or treatment is delivered. Treated and disposed of safely Safe treatment and disposal methods include incinera�on, autoclaving, and burial in a lined, protected pit. Wastes may also be collected and transported off-site for medical waste treatment and disposal. Fence off of areas if treatment and disposal is happening on site Transporta�on and handling of healthcare waste Appropriate Infec�on, Preven�on and Control measures (IPC) should be observed in the collec�on, transporta�on, treatment and disposal of medical waste in and outside the HCFs. Provide appropriate PPE for those handling waste 28 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA (iii) For HCFs where the wastewater treatment plant is not available, contaminated liquids should be disinfected with chlorine before final disposal. (iv) Drainage systems should be installed for management of ablu�on waste for all Healthcare delivery points, lavatories, sluice rooms, laundry, and at any other points where grey water is produced. (v) Ablu�on waste drains should be centralized or detached depending on the complexity of the facility infrastructure and the health and safety risks involved. (vi) Wastewater from hand washing points should be disposed in simple ground seepage systems. (vii) The wastewater from delivery rooms, dressing rooms, and other places where invasive procedures should be channelled to appropriate soak-away pits / sewage treatment systems. (viii) For HCFs located in urban areas, the most appropriate op�on for wastewater disposal is connec�on to the exis�ng sewer systems. (ix) Provide proper faecal sludge emptying methods for HCFs with on-site sanitary facili�es 7.3.6 Monitoring Indicators for Healthcare Waste Management Services in HCFs Monitoring healthcare waste management should be based on the indicators provided by WHO/UNICEF as contained in table 8 below.²⁵ TABLE 8: Monitoring Indicators for Basic Healthcare Waste Management Services in HCFs SECTION EIGHT: ENVIRONMENTAL CLEANING IN HEALTHCARE FACILITIES 88 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA29 8.1 Environmental Cleaning and Disinfec�on Environmental cleaning refers to the cleaning and disinfec�on of environmental surfaces (for example, bed rails, call bu�ons, chairs), floors, bathrooms and the management of spills of blood and body fluids, and surfaces of non-cri�cal pa�ent care equipment (for example, IV poles, stethoscopes). This prac�ce plays a cri�cal role in preven�ng the transmission of Healthcare Associated Infec�ons (HAI) because, some of the pathogens linked with HAI can survive for months on surfaces. 8.2 Environmental Cleaning Services for Healthcare facili�es To provide Environmental Cleaning services in HCFs, the following condi�ons must be sa�sfied: 8.2.1 Environmental Cleaning Protocol Each HCF should establish environmental cleaning protocol that describe the required type and frequency of cleaning for different purposes, who is responsible for doing the cleaning, and how cleaning should be performed and recorded. 8.2. 2 Standard Opera�ng Procedures (SOP) Each HCF should develop wri�en protocols that specify the tools and materials that should be used for each type of cleaning and provide step-by-step instruc�ons on the process. SOPs should also describe preparatory steps, including the use of personal protec�ve equipment. 8.2.3 Cleaning Staff and Capacity Building Each HCF should engage adequate number of cleaning staff and put in place regular structured training plans or programs for the staff. Emphasis to be placed on appropriate cleaning methods, standard dilu�on methods of cleaning agents, use of dedicated colour-coded equipment, based on risk stra�fica�on of healthcare areas to be cleaned with effec�ve suppor�ve supervision. 8.2.4 Environmental Cleaning Supplies and Equipment The selec�on, care, safe storage and appropriate use of supplies and equipment is cri�cal for effec�ve environmental cleaning. These should include but not limited to: I. Cleaning and disinfec�on products (for example, detergents, disinfectants) II. Reusable/disposable supplies and equipment III. Personal Protec�ve Equipment (PPE) for the cleaning staff IV. Access to sufficient quan��es of clean / safe water SERVICE ELEMENT BASIC INDICATORS EXAMPLE OF INDICATORS Availability Accessibility Acceptability Quality Others Environm ental Cleaning i. Availabili ty: Protocol in place. ii. Quality : Staff trained. loca�on and number of cleaning sta�on presence of cleaning supplies, including disinfectant Yes/No Yes/No cleaning frequency observed cleanliness cleaning methods SOURCE: (WHO /UNICEF JMP 2018) ELEMENT MONITORING DEFINITION Protocols for cleaning Protocols should include: · Step-by-step techniques for specific tasks, such as cleaning a floor, cleaning a sink, cleaning a spillage of blood or body fluids. · A cleaning roster or schedule specifying the frequency at which cleaning tasks should be performed Staff with cleaning responsibili�es Includes non-health care providers, such as cleaners, whose tasks include cleaning, as well as health care providers who, in addi�on to their clinical and pa�ent care du�es, are responsible for cleaning Training 30 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 8.3 Monitoring of Healthcare Environmental Cleaning Services in HCFs Monitoring environmental cleaning services in HCFs should be based on the indicators provided by WHO/UNICEF as contained table 9a below Table 9a: Monitoring of Healthcare Environmental Cleaning Services in HCFs Training refers to structured training plans or programs led by a trainer or appropriately qualified supervisor. SOURCE: WHO/UNICEF JMP, 2019 8.3.1: Monitoring Indicators for Environmental Cleaning Services in HCFs Valuable star�ng point for monitoring environmental cleaning in HCFs should be based on the indicators provided by WHO/UNICEF as contained table 9b below TABLE 9b: Indicators providing valuable star�ng point for monitoring of Environmental Cleaning services in HCFs SECTION NINE: MONITORING OF WASH IN HEALTHCARE FACILITIES 99 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA31 The aim of monitoring WASH services in HCFs is to measure the extent to which recommended standards by the Guidelines are complied with and iden�fy gaps for necessary interven�on. Effec�ve monitoring, documenta�on and repor�ng will provide needed informa�on to measure the Country's progress towards achieving the targets of SDGs on WASH by 2030. 9.1 Co-ordina�on and Monitoring Procedure To achieve the intended purpose of developing this guideline, Standard Monitoring processes are hereby provided for and shall be put in place at various levels of the Government (Federal, State and Local). i. FMOH, shall Co-ordinate, and in collabora�on with other relevant MDAs, Development partners, NGOs, develop standard monitoring tools in line with the WHO/UNICEF Standards for monitoring WASH services in HCFs and deployed to the States and LGAs WASH departments as well as WASH units in the HCFs. ii. WASH department in the State Ministry of Health will be advised to use the monitoring tools for periodic monitoring/assessment of the HCFs under the States and the LGAs. iii. LGAs WASH departments/units (where they exist and as applicable in respec�ve states) and the Primary healthcare departments will use the tools to periodically monitor the primary HCFs in their jurisdic�on. iv. WASH team shall be the Focal Point at the facility level and will conduct monitoring of WASH services and facili�es on rou�ne basis. v. FMOH, in collabora�on with other relevant MDAs, shall use the Standard tool to conduct periodic monitoring of WASH services in the HCFs across the country. 9.2 Repor�ng Procedure Repor�ng shall be a bo�om-up format with verifica�on mechanism in place. i. The WASH team in the HCFs shall report to the Head of the facility, through the IPC team/commi�ee, in line with the na�onal IPC policy. ii. Following exis�ng repor�ng pla�orm for healthcare services at LGA, state and federal levels, the head of the facility shall provide periodic report as required. . iii. The states shall verify the report and forward to the Federal Ministry of Health (FMOH) iv. The FMOH will verify the report and send to Na�onal Health Management Informa�on System (NHMIS) and any other relevant informa�on pla�orm and stakeholders. v. There shall be annual report of WASH services in HCFs from the generated data REFERENCES 1. Water, Sanita�on and Hygiene in Healthcare Facili�es: Global baseline report 2019. New York: United Na�ons Children's Fund (UNICEF) and World Health Organiza�on, 2019. 2. Na�onal Outcome Rou�ne Mapping of Water Sanita�on and Hygiene Services in Nigeria, WASH NORM Survey findings May 2019 3. Healthy Villages: A Guide for Communi�es and Community Health Workers 4. Peace Amoatey (Mrs) and Professor Richard Bani, Wastewater Management Department of Agricultural Engineering, Faculty of Engineering Sciences, University of Ghana, Ghana h�ps://www.washcapacity.info/org-capacity 5. Technical notes on drinking-water, sanita�on and hygiene in emergencies W.H.O. WEDC (Water Engineering and Development Centre) 6. Assessment of water quality in selected shallow wells of Keiyo Highlands Kenya, June, 2017 7. Good prac�ces in the provision of accessible and inclusive WASH services – UNICEF (UNICEF Accessible Inclusive WASH Mapping 2015) 8. Food and Agriculture Organiza�on of the United Na�ons – Environmental and Social (E & S) Management Guidelines (FAO, 2015) 9. The Na�onal Guideline for Water, Sanita�on and Hygiene in Healthcare Facili�es, October, 2017 (United Republic of Tanzania) 10. Paul Gormley talks through the process of installing a Rainwater Harves�ng System 11. Health Implica�on of Inadequate Water and Sanita�on Services. CDC and U.S. AID 2009 12. W.H.O. 2008, Essen�al Environmental Health Standards in Healthcare 13. Olabisi, Awonusi and Adebayo (2008), Shallow wells in Abeokuta, Nigeria 14. Water and Sanita�on for Health Facility Improvement Tool (WASH FIT). Geneva: World Health Organiza�on; 2017. Licence: CC BY-NC-SA 3.0 IGO 15. MEASURE Evalua�on. (2019). Implemen�ng Nigeria's Master Facility List: Guidelines. Chapel Hill, NC, USA: MEASURE Evalua�on, University of North Carolina 16. Healthcare: Primary, Secondary and Ter�ary [Brief Descrip�on]August 1, 2016, Posted in Healthcare Technology 17. Makinde, Olusesan, Ayankogbe, Olayinka, Boone, David Distribu�on of health facili�es in Nigeria: Implica�ons and op�ons for Universal Health Coverage Interna�onal Journal of Health Planning and Management August 2018 DOI:10.1002/hpm.2603 32 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 18. Magdalene Ma�hews Ofori-Kuma, UNICEF ESARO, August 2019 WASH in Healthcare Facili�es UNICEF Scoping Study in Eastern and Southern Africa © United Na�ons Children's Fund UNICEF Eastern and Southern Africa Regional Office (ESARO) Nairobi, Kenya 19. Monitoring WASH in Healthcare Facili�es: FINAL Core Indicators and Ques�ons. November 25, 2016 20. Monitoring WASH in healthcare facili�es: 2018 JMP report 21. Center for Disease Control and Preven�on, Handwashing :Clean Hands saves lives 22. WHO guideline on Hand hygiene in healthcare: First Global Pa�ent Safety Challenge Clean Care Is Safer Care. Geneva: World Health Organiza�on; 2009. 1, Defini�on of terms 23. Water, Sanita�on and Hygiene in Health care Facili�es: Global baseline report 2019. New York: United Na�ons Children's Fund (UNICEF) and World Health Organiza�on, 2019 24. WHO 2018, Healthcare waste. World Health Organiza�on, Geneva 25. The scandal of 95% of healthcare centres in Nigeria and 150 million Nigerians without access to water and hygiene facili�es in the face of the COVID-19 pandemic, WaterAid, May 2020 26. Core ques�ons and indicators for monitoring WASH in health care facili�es in the Sustainable Development. World Health Organiza�on and the United Na�ons Children's Fund (UNICEF) 2018 27. WASH in Healthcare Facili�es: UNICEF Scoping Study in Eastern and Southern Africa 2019 28. COVID-19 Emergency Response: WASH and Infec�on Preven�on and Control (IPC) in Healthcare facili�es (HCF) Guidance Note 2020 33 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA APENDIX 1 3.0 SECTION THREE: LEGAL AND INSTITUTIONAL FRAMEWORK FOR WASH IN HEALTH CARE FACILITIES IN NIGERIA This chapter provides insight to policies, programmes, strategies and legisla�ons that corroborate mul� sectoral nature of WASH. 3.1 Related Na�onal Legisla�ons 3.1.1 Na�onal Health Act 2014 This Act provides a framework for the regula�on, development and management of a na�onal health system and set standards for rendering health services in the Federa�on, and other ma�ers connected therewith. 3.1.2 Nigeria Center for Disease Control Act (NCDC Act 2018) This Act was enacted to establish the Nigeria Center for Disease Control and Preven�on, for the preven�on, detec�on, inves�ga�on, monitoring and control of communicable disease in Nigeria and for related ma�ers. 3.1.3 Na�onal Primary Healthcare Development Agency Act (NPHCDA 1992) Na�onal Primary Healthcare Development Agency (NPHCDA) established to provide technical direc�on for development of PHC in Nigeria thereby making PHC services available to all in Nigeria. 3.1.4 Na�onal Environmental Standards and Regula�ons Enforcement Agency (NESREA), Act 2009 charged with responsibility for the protec�on and development of the Environment in Nigeria, and for other Related Ma�ers. 3.1.5 Na�onal Environmental (sanita�on and Waste Control) Regula�on 2009 The regula�ons purpose is to adopt sustainable and environment friendly prac�ces in environmental sanita�on and waste management to minimize pollu�on. 3.1.6 Na�onal Environmental Health Prac�ces Regula�ons, 2016: These regula�ons intend to prevent and abate nuisances, protect and promote physical and social well-being of the public, prevent and control incidences of communicable diseases through environmental health interven�ons, reduces environmental hazards to health, promote the general welfare of the public by regula�ng the sanitary construc�on and sanita�on of all premises, and regulate private and public sector collabora�on for purposes of Maintaining adequate sanita�on and promo�on of public health and safety. 3.1.7 Environmental Health Officers Registra�on Council of Nigeria (EHORECON) ACT, 2002 Charged with the responsibility of registering and licensing the Environmental Health prac��oners in the country and regulate the prac�ce of Environmental Health in Nigeria. 3.2 Related Sectoral Na�onal Policies 3.2.1 Na�onal Health Policy 2016 The policy spelt out many ac�ons that require inter-sectoral and mul�-sectoral collabora�on to ensure Nigeria health system is significantly strengthened to improve the health status and wellbeing of Nigerians and the achievement of the health-related SDGs and Universal Health Coverage (UHC). One of the objec�ves is to 34 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA promote universal access to safe drinking water and acceptable sanita�on to reduce the disease burden resul�ng from unsafe water and poor sanita�on. 3.2.2 Na�onal Rural Water Supply and Sanita�on Policy 2000 The objec�ve is for all Nigerians to have access to adequate, affordable and sustainable sanita�on through the ac�ve par�cipa�on of Federal, State and Local Governments, NGOs, Development Partners, Private sector, communi�es, households and individuals. (h�ps://cheld.org/wp-content/uploads/2012/04/Na�onal-Water-Sanita�on-Policy.pdf) 3.2.3 Na�onal Healthcare Waste Management Policy 2013 The Policy was developed to address environmental and health problems associated with poor management of healthcare waste and provide roadmap to safe healthcare waste management prac�ces in all Healthcare facili�es in Nigeria. 3.2.4 Na�onal Environmental Sanita�on Policy 2005 The major trust of the Na�onal Environmental Sanita�on Policy is to ensure sound Environmental Sanita�on Prac�ces that shall promote sustainable development, public health and good quality of life. The policy is implemented through its Na�onal Guidelines on Sanitary Inspec�on of premises, Solid Waste Management, Excreta and Sewage Management, Market and Aba�oir Sanita�on; Pest and Vector Control, School Sanita�on, Food Sanita�on and adequate potable water supply. One of the objec�ves of the policy is to prevent sanita�on related diseases, illnesses and injuries thus reduce poverty and increase life expectancy. 3.2.5 Na�onal Water Resources policy and strategy 2016 The main policy objec�ve is to foster the integrated management of water resources for op�mum, sustainable, efficient, and equitable water resources development and management in order to meet the current and future user water demand, conserve the water quality and protect the environment. This is to be done in an integrated manner involving all the stakeholders par�cularly governments at all levels, the communi�es, the private sector and civil society organiza�ons. It is also hoped that the policy will lay the founda�on for Post 2015 Development Agenda from Millennium Development Goals (MDG's) to Sustainable Development Goals (SDG's) where universal coverage for Water and Sanita�on should be achieved by 2030. 3.2.6 Na�onal Health Promo�on Policy 2019 3.3 Related Na�onal Strategies 3.3.1 Na�onal Health Strategic Development Plan II (NHSDP II) -2018-2022 The document was produced to provide blueprint for realiza�on of SDG s health related targets and overall well being of Nigerians. 3.3.2 Partnership for Expanded Water Sanita�on and Hygiene (PEWASH) by FMWR, PEWASH – partnership for expanded water supply sanita�on and hygiene programme strategy 2016. The over-arching goal of the Partnership for Expanded Water Supply, Sanita�on and Hygiene (PEWASH) programme is to contribute to improvements in public health and eradica�on of poverty in Nigeria through equitable and sustainable WASH interven�ons. Water and Sanita�on are cri�cal factors in human development and economic growth, and therefore central to the achievement of the Sustainable Development Goals (SDG). Nigeria is commi�ed to a�aining the SDG-6 targets for water and sanita�on by 2030. The PEWASH programme is specifically aimed at achieving SDG-6.1 and 6.2 targets in the rural areas through a mul�-sectoral partnership while suppor�ng the empowerment of rural dwellers in Nigeria. 3.3.3 Clean Nigeria Campaign Proposal The aim of the hygiene behaviour change “Clean Nigeria: use the toilet” campaign is to get 47 million Nigerians to use the toilet and stop open defeca�on. 35 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA 3.3.4 Na�onal Environnemental Sanita�on Ac�on Plan - FMENV 3.3.5 Clean and Green Programme – FMENV: Launched in 2016 with one of its aims geared towards a clean Nigeria and a target to end open defeca�on by 2025. 3.3.6 Na�onal hygiene promo�on strategy - Nigeria Na�onal strategy for the promo�on of sanita�on and hygienic behaviour among individual, household, communi�es, schools and markets. 3.3.7 Na�onal water resources road map 2016 The Government of Nigeria is commi�ed to end open defeca�on in the country by 2025 which is in line with the revised global target set by the United Na�ons. Towards this end, FMWR requested UNICEF, Nigeria to undertake the development of a road map for making Nigeria open-defeca�on free by 2025. 3.3.8 Protocol for verifica�on and cer�fica�on of ODF and Total Sanita�on Communi�es and Rural markets in Nigeria. 2017 3.3.9 Strategies for scaling up Rural Sanita�on and Hygiene in Nigeria 2007 3.3.10 Water Sanita�on and Hygiene - Na�onal Outcome Rou�ne Mapping (WASH-NORM) survey 2019 3.4 Ins�tu�onal framework Water, Sanita�on and Hygiene (WASH) is a global concept that is implemented by all �ers of government of the federa�on (Federal, State and LGAs) using collabora�ve approach. WASH is mul�-sectoral which involves the collabora�on of several MDAs, NGOs and Development Partners that play concerted roles in the implementa�on of various aspects of WASH Services in Nigeria. These organiza�ons include: Federal Ministry of Health (FMOH), Federal Ministry of Water Resources (FMWR), Federal Ministry of Environment (FMEnv), Federal Ministry of Educa�on, WHO, UNICEF, Water Aid and other Non-Governmental Organiza�ons. FMOH is saddled with the responsibili�es of developing and implemen�ng Policies, Programmes, Strategies, Guidelines etc of which WASH programme is an integral component in the realiza�on of SDG 3 and SDG 6 (Good Health and Wellbeing and Clean Water and Sanita�on) respec�vely. FMWR also play cri�cal roles in the development, implementa�on and coordina�on of various programmes and strategies in the WASH sector. Federal Ministry of Environment also a major stakeholder in WASH saddled with the responsibility of coordina�ng Na�onal Sanita�on with the following objec�ves: i. To achieve a clean and healthy environment ii. Developing, implemen�ng and enforcing Environmental Sanita�on policies, Laws, regula�ons, guidelines and standards. These are implemented through the following: solid Waste Management, Excreta and sewage management, school sanita�on, sanitary inspec�on of premises (EHS), Food Sanita�on and Hygiene, Market and Aba�oir sanita�on, pest and vector control, ensuring availability of potable water, weed and vegeta�on control, environmental sanita�on and hygiene educa�on etc. The collabora�on in the WASH sector is the momentum that drives programmes and ac�vi�es of WASH in the country, bringing all the stakeholders to a common goal and target. The Development Partners, WHO, UNICEF, WaterAid etc. provide technical and financial support giving WASH sector in Nigeria and Interna�onal Standard. 36 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA NAME ORGANISATION / DEPT DESIGNATION / FUNCTION Pharm. M.O. Lawal Fed. Min. of Health/Food and Drug Services Department Director, Food and Drug and Services Department Mr. Fubara Chuku Fed. Min. of Health /Food and Drug Services Department Director, Food and Drug and Services Department Pharm. Olubukola Ajayi Fed. Min. of Health /Food and Drug Services Department Director, Food and Drug and Services Department Pharm. Olubunmi Aribeana Fed. Min. of Health /Food and Drug Services Department Director, Food and Drug and Services Department Pharm. Ologun Taiye Joseph Fed. Min. of Health /Food and Drug Services Department Shaibu B.A. Fed. Min. of Health /Public Health Department Director, Climate Change Engr. Francisca Iwuji Fed. Min. Works & Housing Director, Civil Engineering Services Department Engr. C.S.O Nwufo Fed. Min. Works & Housing Director, Civil Engineering Services Department Celine Onukwo Fed. Min. of Health /Food and Drug Services Department Deputy Director, Drug and Vaccine Development Mr. Atanda O. John Fed. Min. of Health /Food and Drug Services Department Na�onal Coordinator, Food, Chemical, Cosme�cs and Water Safety Management Programme Mr. Baruwa E� .O.O.S Fed. Min. of Health /Food and Drug Services Department Head, Water Safety Management Programme Mr. S. Olanrewaju Fed. Min. of Health /Food and Drug Services Department Head Chemical Safety Management Programme Madu Ezioma Fed. Min. of Health/Family Health Department Assistant Director, Health Promo�on Division Mr. Ajose Adeyemi Fed. Min. Water Resources Assistant Director, Water Quality and Surveillance Mr. Musa Dayemi Fed. Min. Water Resources Chief Scien�fic Officer, Water Quality and Surveillance Dr. Abiodun Ogunniyi Assistant Director/Head, Infec�on , Preven�on and Control Unit Dr. Ejezie Obiefuna Assistant Director, Surveillance Unit, MBBS, FTCE Tahir Mustapha Michael Forson UNICEF WASH Manager Mr. Job Ominyi UNICEF Water, Sanita�on and Hygiene Officer, Hygiene Promo�on and WASH in Ins�tu�ons in Nigeria Mrs. Okea Rita Fed. Min. of Environment Assistant Director, Environmental Health and Sanita�on Aghogho O. B. Gbesere Fed. Min. of Environment Dickson Akoh Silas Fed. Min. of Environment Mr. Francis E. Ibeke Fed. Min. of Health/Hospital Services Department CONTRIBUTORS 37 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA Director, Pharmaceu�cal Services Division Nigeria Centre for Disease Control Nigeria Centre for Disease Control Nigeria Centre for Disease Control Engr. Patrick Ani Fed. Min. Works & Housing Mr. Obasi Chimaroke Fed. Min. of Health /Public Health Department Dr. Edwin Isotu World Health Organisa�on Na�onal Consultant, Public Health and Environment Mr. Kolawole Banwo WaterAid Nigeria Head, Advocacy, Policy and Communica�ons Wandoo Akosu WaterAid Nigeria Bauchi State Lead and Sanita�on Focal Person Dr Iloma U. Richard Rivers State College of Health Science and Management Technology, Port Harcourt Senior Lecturer Mohammed .M. Manga Federal Teaching Hospital Gombe Consultant / Infec�on, Preven�on and Control Abubakar Abiso Moh'd University of Maiduguri Teaching Hospital Maiduguri Consultant / Infec�on, Preven�on and Control Amasiani Rose N. Anambra State Ministry of Health WASH Lead Nwagwu Joy N. Enugu State Ministry of Health WASH Lead Ahmed Mai Bukar Federal Medical Centre Jalingo Infec�on, Preven�on and Control Focal Person Bobga Pavali Taraba State Ministry of Health Infec�on, Preven�on and Control Focal Person Anyakoha Uche Federal Medical Centre Owerri Head Environment Isiyaka Isiyaku Katsina State Primary Healthcare Development Agency Director, WASH Abubakar Umar Maiha Adamawa State Primary Healthcare Development Agency Secretary Aminu Ado Taura Federal Medical Centre Jigawa State Assistant Director, Environmental Health Anyakoha Uche Federal Medical Centre Owerri Head Environment Philomina Nwobosi Fed. Min. of Health /Food and Drug Services Department Mr. Okoye O. Boniface Fed. Min. of Health /Food and Drug Services Department Mr. Magayaki Joshua Fed. Min. of Health /Food and Drug Services Department Mr. Isaac Ibrahim Fed. Min. of Health /Food and Drug Services Department Ms. Biate Azibataram Fed. Min. of Health /Food and Drug Services Department Mr. Kasim Muhammad Fed. Min. of Health /Food and Drug Services Department Ms. Jack E. A. Mirian Fed. Min. of Health /Food and Drug Services Department Bishara Emmanuel Fed. Min. of Health/Hospital Services Department Dr. Chris Elemuwa Na�onal Primary Healthcare Development Agency Ag HOD, Community Health Services Department 38 NATIONAL GUIDELINES FOR WATER, SANITATION AND HYGIENE (WASH) IN HEALTHCARE FACILITIES IN NIGERIA for every child