World Health Organization · 2024 · 31 pages
Regional assessment of WASH infrastructure, challenges, and decision-making factors for health facilities across Pacific, South-East Asia, and Northern Asia
- Issuer
- World Health Organization
- Edition
- 2024
- Audience
- Health facility planners, ministries of health, WASH programme managers, international donors, and development partners working on health infrastructure in low- and middle-income countries
- Evidence
- Compiled from secondary data analysis and semi-structured interviews with key stakeholders (WHO technical officers, ministry of health representatives) in three countries; descriptive assessment rather than graded recommendations
- Reviewed
- 16 Oct 2026 · GMJ
What this guideline says
GMJ summary
This document provides a contextual overview of water, sanitation, and hygiene (WASH) infrastructure in health-care facilities across the WHO Western Pacific Region, focusing on eight priority low- and middle-income countries that have yet to achieve 80% basic WASH coverage: American Samoa, Cambodia, Kiribati, Lao People’s Democratic Republic, Mongolia, Papua New Guinea, Solomon Islands, and Vanuatu. Through stakeholder interviews in Mongolia, Vanuatu, and Lao PDR, the report identifies current technologies, regulatory frameworks, and decision-making processes.
The Region exhibits extreme diversity in climate, hydrology, and infrastructure capacity. Northern Asia relies on centralized piped systems with groundwater backup; Pacific islands depend heavily on rainwater harvesting; South-East Asia uses mixed on-site systems dominated by septic tanks. Key barriers to adequate WASH services include limited budgets, insufficient skilled personnel, lack of technical standards for health-care-specific requirements, and inadequate enforcement of wastewater treatment regulations. Human resource constraints and operation/maintenance expertise were consistently cited as critical gaps across all three countries studied.
The document identifies crucial decision-making factors including: availability of centralized infrastructure, expertise for operation and maintenance, budget for construction and recurrent costs, water source characteristics, enforcement of technical standards, and climate resilience considerations (currently under-emphasized). This assessment supports the development of a companion decision-support framework to guide technology selection for WASH improvements in health-care facilities across priority countries in the Region.
Key points
For clinicians — doses and thresholds as stated in the guideline
- 60% of countries in the Western Pacific Region with data have not reached 80% coverage of basic water services in health-care facilities; 85% have not reached 80% for sanitation services
- Eight priority LMICs identified for WASH improvement: American Samoa, Cambodia, Kiribati, Lao PDR, Mongolia, Papua New Guinea, Solomon Islands, and Vanuatu
- Mongolia relies on centralized piped water and sewerage systems where available, with on-site groundwater pumping or truck delivery as backup; wastewater co-treatment in sewers is mandated by Mongolian National Standard MNS 6392
- Pacific island health facilities depend primarily on rainwater harvesting with average precipitation of 2723.3 mm/year, though drought poses increasing challenges; septic tanks are standard for wastewater with limited sludge management capacity
- Lao PDR health facilities use mixed water supply (piped water in urban areas, groundwater in rural districts); all wastewater is treated on-site using septic tanks as the country has no centralized wastewater treatment systems
- Weekly chlorination and cleaning of water storage tanks is reported in more than 90% of Mongolian health facilities; 87% have water storage tanks to ensure continuous supply
- Critical barriers include: insufficient skilled staff (particularly engineers), limited budgets for operation and maintenance, lack of health-care-specific technical standards, and weak enforcement of wastewater regulations
- Climate resilience and planning for water freezing, drought, sea-level rise, and extreme weather events identified as currently under-emphasized factors requiring greater attention in decision-making processes
Priority countries for each WHO Western Pacific subregion and their performance against the 2025 target
Table extracted from the guideline
| Subregion | Priority countries and areas | ≥80% coverage for basic water service | ≥80% coverage for sanitation service | World Bank income classification |
|---|---|---|---|---|
| Northern Asia | Mongolia | Y | N | Lower-middle-income |
| Pacific islands | Vanuatu | Y | N | Lower-middle-income |
| Pacific islands | Papua New Guinea | N | N | Lower-middle-income |
| Pacific islands | Kiribati | N | N | Lower-middle-income |
| Pacific islands | American Samoa | Y | N | Lower-middle-income |
| Pacific islands | Solomon Islands | N | N | Lower-middle-income |
| South-East Asia | Lao People's Democratic Republic | Y | N | Lower-middle-income |
| South-East Asia | Cambodia | N | N | Lower-middle-income |
Source: World Health Organization, Water and Sanitation Technologies for Health-care Facilities: Current Status and Context in the Western Pacific Region. Reproduced in summary form.
From the guideline
Verbatim
“Expertise and budget availability for the design, construction, operation and maintenance of such systems were invariably crucial.”
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 Georgia continues strengthening its Universal Health Coverage programme, this Western Pacific assessment offers a practical framework for our own health facility infrastructure gaps. Like Mongolia and Lao PDR, Georgia has good coverage of piped water in urban hospitals but faces challenges in rural primary care facilities, where maintenance expertise and recurrent budgets for water systems are chronically insufficient. The finding that climate resilience receives inadequate attention resonates strongly—our recent droughts in Kakheti and flash flooding in mountainous regions have exposed vulnerabilities in facility water supplies that emergency planning rarely addresses. I would urge our Ministry of Health to conduct a similar technology mapping exercise across all polyclinics and rural ambulatories, focusing not just on whether taps exist but whether operation, maintenance, and backup systems are actually functional and staffed, then develop costed standards specific to medical activities rather than relying solely on general municipal water regulations.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 16 Oct 2026
Applicability
Georgia and the South Caucasus
While this document focuses on the Western Pacific Region, its framework for assessing WASH infrastructure challenges is directly relevant for Georgia and neighbouring South Caucasus countries. Georgia’s health system faces similar constraints: limited budgets for health facility infrastructure, shortages of specialized technical personnel for water system operation and maintenance, variable access to centralized water and sewerage networks (particularly in rural areas), and the need for climate-resilient solutions given increasing drought and extreme weather events. National programmes would need to conduct similar facility-level assessments to map existing water sources (municipal supply, wells, springs), wastewater systems (sewerage connections versus septic tanks), and operation/maintenance capacity, then develop costed implementation plans with technical standards specific to health-care requirements rather than relying solely on general drinking-water regulations.
Questions this guideline answers
Quick answers
What water and sanitation coverage levels are considered adequate for health-care facilities?
WHO has set a target of 80% coverage of basic water and sanitation services in health-care facilities by 2025. Basic water service means an improved water source on premises available at all times. Basic sanitation service means improved sanitation facilities that are usable (functional, private, with at least one toilet for staff, one for patients segregated by sex, and one accessible for people with limited mobility). In the Western Pacific Region, 60% of countries with data have not reached the 80% target for water and 85% have not reached it for sanitation.
What are the main barriers to adequate WASH in health facilities across the Region?
The most consistently reported barriers are: (1) human resource constraints, particularly lack of skilled engineers and dedicated water/sanitation staff for operation and maintenance; (2) limited budgets for both capital expenditure and recurrent costs (electricity, chemicals, monitoring); (3) absence of health-care-specific technical standards and guidelines for appropriate technologies; (4) weak enforcement of wastewater treatment regulations with minimal penalties for non-compliance; and (5) inadequate consideration of climate resilience in planning, despite vulnerability to droughts, flooding, and extreme weather events.
What water supply technologies are most commonly used in different parts of the Region?
This varies by subregion: Northern Asia (Mongolia) prioritizes centralized piped water systems where available, with groundwater pumping or truck delivery as backup in rural areas. Pacific islands rely heavily on rainwater harvesting due to high rainfall (average 2723 mm/year) and limited groundwater, though drought is increasingly problematic. South-East Asia uses mixed systems: piped chlorinated water in urban central hospitals, groundwater from boreholes in rural district facilities, and gravity-fed systems in mountainous northern areas. Water storage tanks (elevated or underground) are common across all regions to manage supply interruptions.
How is wastewater managed in health facilities where centralized sewerage is unavailable?
On-site systems dominate where sewerage is absent. Septic tanks are the most common technology across all three subregions, though proper sludge management (regular emptying, treatment, safe disposal) is often lacking due to limited budgets and unclear responsibilities. In Mongolia, regulation mandates disinfection before disposal; in Lao PDR, some central hospitals segregate wastewater streams (blackwater to septic tanks, greywater/laboratory waste to activated sludge treatment), though operational challenges limit effectiveness. Vanuatu's Port Vila hospital has a dedicated treatment plant (primary sedimentation, trickling filters, chlorination) but maintenance issues have caused contamination of receiving waters. Rural facilities often use pour-flush toilets with pits or direct environmental disposal.
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- Issuer
- World Health Organization
- Type
- Guidance (normative)
- Edition
- 2024
- Status
- Current
- Published
- 2025-05-08
- Languages
- English
- Scope
- Regional assessment covering 37 countries and areas in WHO Western Pacific Region with detailed case studies from Mongolia, Vanuatu, and Lao People's Democratic Republic
- Audience
- Health facility planners, ministries of health, WASH programme managers, international donors, and development partners working on health infrastructure in low- and middle-income countries
- Pages
- 31
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 9789290620648
- Evidence
- Compiled from secondary data analysis and semi-structured interviews with key stakeholders (WHO technical officers, ministry of health representatives) in three countries; descriptive assessment rather than graded recommendations
- Record history
- Created 16 Oct 2026 · updated 16 Oct 2026 · next check Apr 2027
World Health Organization Regional Office for the Western Pacific. Water and sanitation technologies for health-care facilities: current status and context in the Western Pacific Region. Manila: WHO Regional Office for the Western Pacific; 2024. Licence: CC BY-NC-SA 3.0 IGO.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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