World Health Organization · 2nd edition, 2022 · 128 pages
A facility-level risk assessment and improvement tool for water, sanitation, hygiene, waste management and environmental services in health care settings
- Issuer
- World Health Organization
- Edition
- 2nd edition, 2022
- Audience
- Health facility managers, quality improvement teams, infection prevention and control focal points, district health officers, WASH engineers, national policy-makers, NGOs and implementing partners
- Evidence
- Expert consensus and synthesis of existing WHO/UNICEF normative guidance; based on field implementation in >40 countries since first edition (2017)
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
WASH FIT (Water and Sanitation for Health Facility Improvement Tool) is a WHO/UNICEF risk-based management framework for health care facilities to systematically assess, prioritize and improve water, sanitation, hygiene (hand hygiene and environmental cleaning), health care waste management, and energy/environment services. The tool uses a continuous five-step improvement cycle: (1) establish and train a multidisciplinary team; (2) conduct a comprehensive facility assessment across seven domains using >90 indicators; (3) perform risk assessment to prioritize gaps; (4) develop and implement an incremental improvement plan; and (5) monitor, review and adapt.
The second edition (2022) strengthens guidance on climate resilience, gender equality and disability inclusion (GEDSI), integration with infection prevention and control (IPC) programmes, and emergency preparedness including COVID-19 response. The tool is designed for facilities of all levels, from primary health care centres to district hospitals, and can be adapted to national contexts. It directly supports the 2019 World Health Assembly resolution 72.7 calling on all 194 Member States to ensure universal access to WASH in health care facilities.
Globally, one-third of health care facilities lack hand hygiene facilities at points of care, one in four lack basic water services, and one in ten have no sanitation services. In the 47 least developed countries, half of facilities lack basic water. WASH FIT provides a structured, low-cost approach to incremental improvement using existing resources, with emphasis on quick wins alongside longer-term infrastructure investment. Successful implementation requires senior management commitment, regular supportive supervision, integration with quality improvement programmes, and sustainable financing for both capital costs and ongoing operation and maintenance.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Assessment covers 7 domains with >90 indicators scored 0 (does not meet target), 1 (partially meets) or 2 (fully meets target); facilities scoring <67% require major improvements, 67–75% need additional efforts, >75% are performing well with ongoing maintenance needed
- Hand hygiene: all patient care areas require functioning handwashing stations or alcohol-based hand rub within 5 metres of points of care; maternity/delivery rooms must have dedicated functional handwashing stations with soap
- Water: facilities must have an improved water source on premises, available 24/7, with free residual chlorine ≥0.2 mg/L and ≤0.5 mg/L (or alternative disinfection), and sufficient quantity to meet all needs (minimum 40 litres per patient per day for inpatient facilities)
- Sanitation: at least one functional toilet per 20 users for outpatients and one per 40 inpatient beds, gender-separated, with disability access, functioning locks, lighting, and facilities for menstrual hygiene management; liquid effluent safely managed through sewerage or septic tank with no leaks
- Health care waste: infectious waste, sharps and pharmaceutical waste segregated at all generation points into clearly labelled bins, with safe treatment (autoclave, incinerator or centralized non-burn technology) and disposal within safe time limits (<48 hours for infectious waste)
- Environmental cleaning: dedicated cleaning staff with written cleaning schedules, appropriate supplies (mops, detergents, personal protective equipment), and cleaning performed at defined frequency (at least daily for patient areas, more frequently for high-touch surfaces)
- Energy: reliable electricity supply 24/7 with functional backup source for essential areas; all patient care areas, toilets and delivery rooms have adequate lighting
- Risk assessment scores each gap 0–10 for severity (health/dignity/environmental consequences) and 0–10 for likelihood, with total scores 15–20 classified as high risk requiring immediate action, 8–14 medium risk, 0–7 low risk
Summary of per-facility capital and recurrent costs to meet basic WASH and waste service standards in least developed countries (2020 US$)
Table extracted from the guideline
| Service area | Facility type or technology | Capital IQR | Capital N | Recurrent IQR | Recurrent N |
|---|---|---|---|---|---|
| Water | Piped | 2,000–23,750 | 38 | 500–5,289 | 33 |
| Water | On-site | 5,000–28,726 | 38 | 500–4,500 | 25 |
| Sanitation | Sewerage | 5,000–24,000 | 25 | 150–2,006 | 21 |
| Sanitation | On-site, septic | 6,000–30,000 | 40 | 350–3,500 | 30 |
| Hygiene | Non-hospital | 463–3,500 | 38 | 200–950 | 34 |
| Hygiene | Hospital | 1,107–6,690 | 34 | 403–3,000 | 29 |
| Waste management | Non-hospital | 3,000–15,000 | 38 | 500–3,918 | 30 |
| Waste management | Hospital | 15,000–50,000 | 34 | 1,500–10,500 | 28 |
Source: World Health Organization, WASH FIT: A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities, Second edition. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Added comprehensive guidance on climate resilience and adaptation to extreme weather events across all domains
- Strengthened gender equality, disability and social inclusion (GEDSI) indicators and guidance throughout assessment
- Expanded integration with infection prevention and control (IPC) core components and emergency preparedness
- Added Technical Fact Sheets on climate resilience, GEDSI, water safety planning, health care waste sustainability, and hand hygiene multimodal improvement strategy
- Enhanced guidance on national-level roll-out, data management, supportive supervision and sustainable financing
- Updated to reflect COVID-19 pandemic lessons on basic services for outbreak response
From the guideline
Verbatim
“Fully functioning water, sanitation, hygiene (WASH) and health care waste management services are a critical aspect of infection prevention and control (IPC) practices, and ensuring patient safety and quality of care.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has worked with WHO on health systems strengthening across the South Caucasus, I see WASH FIT as an overdue practical tool for a foundational problem. Georgia's health facilities, especially in rural Kakheti, Samtskhe-Javakheti and mountainous regions, often struggle with intermittent water supply, inadequate sanitation and rudimentary waste management – issues I have observed during accreditation site visits. The risk-based approach is well suited to our context: it allows facilities to make immediate low-cost improvements (fixing leaks, installing hand hygiene reminders, segregating waste) while planning for larger infrastructure investments. I would particularly emphasize to Georgian colleagues the integration of WASH into existing infection control committees and quality improvement structures, rather than creating parallel systems, and the importance of climate adaptation given our increasingly severe summer droughts and winter flooding. The practical challenge will be sustained financing: while initial assessment and training costs are modest, ongoing operation and maintenance – particularly for waste treatment technologies and water quality monitoring – require reliable budget allocations that are often the first to be cut. District health offices and the National Centre for Disease Control must provide regular supportive supervision, as experience in Lao PDR and Liberia shows this is critical for momentum beyond the first assessment cycle.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia and South Caucasus countries face WASH infrastructure challenges in health facilities, particularly in rural and remote areas. National health systems implementing universal health coverage programmes (Georgia since 2013, Armenia’s Basic Benefit Package) require functional WASH as a foundation for quality care and patient safety. The tool is directly applicable to Georgia’s ongoing health system strengthening, hospital accreditation efforts, and primary health care reforms. Countries should adapt the assessment to national infection control standards, climate risks (water scarcity in summer, flooding risks, earthquake resilience for infrastructure), and ensure indicators reflect local regulations. Integration with existing quality improvement programmes, such as maternal and child health initiatives and IPC committees, will be essential for sustainability. National-level commitment, district health office engagement for supportive supervision, and allocation of budget for both capital improvements and ongoing operation and maintenance (estimated 4–6% of recurrent health spending) are prerequisites for successful implementation.
Questions this guideline answers
Quick answers
How often should a facility conduct a full WASH FIT assessment?
A comprehensive facility assessment should be conducted every 6–12 months depending on facility size. In addition, weekly or monthly spot checks are needed for high-priority areas such as toilet cleanliness and functionality, hand hygiene station supplies, and waste segregation at generation points. Newly implementing facilities may need more frequent meetings initially until the process is well established.
What is the minimum water quantity required for a health facility?
For inpatient facilities, a minimum of 40 litres per patient per day is required. The water must be from an improved source on premises, available 24 hours a day, 7 days a week, with free residual chlorine between 0.2 and 0.5 mg/L (or equivalent disinfection). For outpatient facilities, functional handwashing stations with running water and soap must be within 5 metres of all patient care areas.
How many toilets does a health facility need?
At least one functional toilet per 20 users for outpatient areas and one functional toilet per 40 inpatient beds. Toilets must be gender-separated, clearly labelled, have functioning locks and lighting, be accessible to people with disabilities, and include facilities for menstrual hygiene management. Delivery rooms should have dedicated showers for women who have given birth.
Can WASH FIT be used during disease outbreaks or emergencies?
Yes. The assessment can be simplified to focus on priority issues most relevant to the outbreak (e.g., hand hygiene, environmental cleaning, waste management for COVID-19), or additional outbreak-specific indicators can be added. In Mali, indicators from the national COVID-19 taskforce were successfully integrated into the WASH FIT assessment. The tool helps facilities rapidly identify and address gaps that compromise outbreak response capacity.
Related on GMJ
Interconnected resources
Dictionary of Public Health
GMJ News coverage
ASF accreditation standards
Other guidelines on this topic
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- Sustainable management of radiotherapy facilities and equipment
- Implementation toolkit for accessible telehealth services
- Infection prevention and control and water, sanitation and hygiene measures for home care and isolation for mpox in resource-limited settings: interim operational guide
- Safe, climate-resilient and environmentally sustainable health care facilities: an overview
- Issuer
- World Health Organization
- Type
- Technical document
- Edition
- 2nd edition, 2022
- Replaces
- WASH FIT: A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities, 2017
- Status
- Current
- Published
- 2022-04-12
- Languages
- English (French, Spanish, Portuguese, Russian, Arabic translations available separately)
- Scope
- All levels of health care facilities: primary health care centres, health posts, clinics, maternity units, district hospitals, referral hospitals
- Audience
- Health facility managers, quality improvement teams, infection prevention and control focal points, district health officers, WASH engineers, national policy-makers, NGOs and implementing partners
- Pages
- 128
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-004323-7
- Evidence
- Expert consensus and synthesis of existing WHO/UNICEF normative guidance; based on field implementation in >40 countries since first edition (2017)
- Next review
- Not stated
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
World Health Organization, UNICEF. Water and Sanitation for Health Facility Improvement Tool (WASH FIT): a practical guide for improving quality of care through water, sanitation and hygiene in health care facilities, second edition. Geneva: World Health Organization; 2022. 128 p. ISBN 978-92-4-004323-7.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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