World Health Organization · 2024 · 56 pages
Decision-support framework and technology factsheets for selecting suitable water supply and wastewater treatment systems in health-care facilities in low- and middle-income settings.
- Issuer
- World Health Organization
- Edition
- 2024
- Audience
- Health sector staff, HCF administrators, ministries responsible for HCFs, water and sanitation experts
- Evidence
- Literature review of >100 sources; stakeholder engagement in Lao PDR, Mongolia, Vanuatu; expert consensus framework
- Reviewed
- 16 Oct 2026 · GMJ
What this guideline says
GMJ summary
This WHO guidance document provides a systematic framework for selecting appropriate water and sanitation technologies for health-care facilities (HCFs) in the Western Pacific Region and similar contexts. It addresses the critical gap in safe water supply and wastewater treatment in HCFs in low- and middle-income countries and areas (LMICs), where approximately 60% and 85% of countries respectively have not attained the 80% coverage goal for basic water and sanitation services.
The document presents a decision-support framework organized around three groups of factors: site and environmental factors (HCF characteristics, surrounding human environment, and natural environment), institutional factors (standards, public sector capacity, private sector expertise), and technological factors (treatment performance, construction and O&M requirements, energy use, climate resilience). This framework is accompanied by factsheets on nine water supply technologies (ranging from centralized piped water to desalination and point-of-use treatment) and twelve sanitation technologies (from pit latrines to advanced oxidation processes).
The guidance emphasizes that HCFs have unique requirements: higher water consumption demanding continuous supply, elevated water quality standards including ultra-pure water for specific medical activities, and wastewater containing 4–150 times higher concentrations of emerging pollutants (pharmaceuticals, antibiotic-resistant bacteria) than municipal wastewater. Technology selection must consider not only technical performance but also long-term sustainability, operation and maintenance capacity, climate resilience, and management practices including wastewater source control, segregation, tailored treatment, and reuse.
Key points
For clinicians — doses and thresholds as stated in the guideline
- HCFs should implement on-site water storage providing a minimum of 48 hours' supply as a rule-of-thumb to mitigate risks from intermittent supply
- Hospital wastewater contains 4–150 times higher concentrations of emerging pollutants (pharmaceuticals, ARB) than municipal wastewater and requires advanced treatment before disposal
- Point-of-use treatment (tap filtration or boiling at >77°C) is recommended to provide sterile water for specific medical and clinical activities requiring microbe-free water
- Pre-treatment of HCF effluents (co-treatment) is needed before discharge to municipal sewers to avoid overwhelming centralized treatment plants not designed to remove emerging contaminants
- Constructed wetlands can achieve significant removal of organic matter and nutrients but require additional tertiary disinfection for ARB removal
- Activated carbon adsorption (PAC or GAC) effectively removes persistent pharmaceuticals and should be used as add-on treatment after conventional processes
- Climate resilience requires assessing water source vulnerability to droughts and flooding, and incorporating design features such as backup systems, renewable energy, and rapid-recovery components
- Wastewater segregation (separating blackwater, greywater, and chemical-laden streams) facilitates tailored treatment and can reduce overall treatment requirements
Water supply technology summary
Table extracted from the guideline
| Water source and treatment technology | Cost | Scale | O&M | Energy use | End-use | Considerations |
|---|---|---|---|---|---|---|
| 1. Piped water (with storage/disinfection) | $—$$ | All | L—M | L | Drinking-water | May require additional technologies for intermittent supply or contamination |
| 2. Groundwater pumping + [treatment] | $$—$$$ | M—La | M—H | M—H | Drinking-water | Source water quality monitoring essential; pumping energy-intensive |
| 3. Groundwater handpump | $ | S—M | H | M—H | Non-drinking-water | Considerable manpower; highly uncertain water quality |
| 4. Rainwater harvesting + treatment | $—$$ | S—La | L—M | L | Drinking-water | Requires sufficient storage; seasonal variability |
| 5. Desalination (RO/nanofiltration) | $$$ | S—M | M—La | H | Drinking-water | High costs and technical expertise; economies of scale required |
| 6. Granular media filters | $$—$$$ | M—La | L—M | M—H | Drinking-water | Expert personnel needed; requires ample space |
| 7. Membrane systems | $$$ | M—La | M—H | M—H | Drinking-water | Compact; materials may not be locally available |
| 8. Point-of-use (sterilization) | $—$$ | S | L | L—H | Medical/clinical | On-demand for specific activities; boiling >77°C |
| 9. Point-of-use (high purity) | $—$$ | S | L | L—H | Clinical activities | Laboratory-grade water; various methods available |
Source: World Health Organization, Water and Sanitation Technologies for Health-care Facilities: Selecting Options for Adoption and Scale-up in the Western Pacific Region. Reproduced in summary form.
From the guideline
Verbatim
“Globally, one in five HCFs lacks basic water services, and one in 10 does not have access to sanitation services. Hence 1.7 billion people attend HCFs without proper water services and 800 million people utilize HCFs without toilet facilities.”
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 on health system strengthening and environmental health in the Caucasus region for decades, I find this WHO guidance particularly timely for Georgia and our neighbours. The framework's integration of technological, institutional, and environmental factors mirrors the complexity we face: while Tbilisi hospitals may have piped water, rural HCFs in Racha or Tusheti struggle with intermittent supply and lack on-site treatment—putting infection prevention at risk. The most critical recommendation for our context is the 48-hour water storage rule and the recognition that hospital wastewater, with its high pharmaceutical and antimicrobial-resistant bacteria load, requires pre-treatment before municipal sewer discharge; this is especially relevant as Georgia strengthens its hepatitis C elimination programme and antimicrobial stewardship. However, implementation faces real constraints: the public sector's limited technical capacity to oversee advanced wastewater treatment systems, the cost of membrane bioreactors or activated carbon when budgets are stretched, and the frequent lack of private-sector expertise for operation and maintenance outside major cities. The decision-support framework itself is sound, but successful adoption will require building a cadre of water-sanitation engineers within the Ministry of Health and regional Public Health Centers, and possibly piloting simpler, nature-based solutions like constructed wetlands in rural settings before attempting advanced oxidation processes.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 16 Oct 2026
Applicability
Georgia and the South Caucasus
For Georgia and the South Caucasus, this guidance is highly relevant as the region works toward universal health coverage and health system strengthening. While urban centres may have centralized water and sewerage systems, rural and mountain HCFs face challenges with intermittent supply, water quality, and lack of on-site treatment capacity. The framework’s emphasis on climate resilience is particularly pertinent given increasing droughts, flooding, and landslide risks in the region. National programmes should assess existing HCF water and sanitation infrastructure against the 80% basic service coverage target, develop context-appropriate standards for HCF wastewater (particularly for pharmaceuticals and antimicrobial resistance containment), strengthen public sector technical capacity for oversight of advanced treatment systems, and integrate climate risk assessment into HCF infrastructure planning. The decision-support framework can guide prioritization of investments in HCF WASH, balancing immediate improvements (e.g., adequate storage, basic treatment) with longer-term goals (advanced wastewater treatment, climate adaptation).
Questions this guideline answers
Quick answers
What is the minimum water storage capacity recommended for health-care facilities?
HCFs should provide on-site water storage equivalent to a minimum of 48 hours' supply as a rule-of-thumb. This is particularly important in LMICs where intermittent water supply is common, and helps mitigate risks of water shortages that could compromise patient care and infection prevention and control.
Why do hospitals need different wastewater treatment than municipal systems?
Hospital wastewater contains 4–150 times higher concentrations of emerging pollutants (pharmaceuticals, antibiotic-resistant bacteria, chemicals) compared to municipal wastewater. Municipal treatment plants are not designed to remove these contaminants, so hospitals often require pre-treatment (co-treatment) or on-site advanced treatment before disposal to protect public health and the environment.
What water treatment is needed for surgical and laboratory activities?
Surgical and laboratory activities require ultra-pure or sterile water. Point-of-use treatment methods include: tap filtration to prevent bacterial passage, boiling at >77°C to kill pathogens, distillation, reverse osmosis, or deionization. These are applied at the point of use for specific activities rather than treating all facility water to this level.
How can health-care facilities improve climate resilience of water and sanitation systems?
The ClimateFIRST framework recommends six design strategies: avoiding exposure to hazards (e.g., raising infrastructure above flood levels), withstanding exposure (e.g., oversized storage tanks for drought), enabling operational flexibility (interoperable parts), containing failures (multiple water sources), limiting consequences of failure (safe disposal materials), and facilitating fast recovery (locally available components and repair expertise). Assessment should consider local climate risks such as droughts, flooding, cyclones, and sea-level rise.
Related on GMJ
Interconnected resources
GMJ News coverage
- UK Hospital Superbug Infections Show Mixed Trends in Latest Government DataJun 2026
- Overuse of 'Just in Case' Antibiotics Accelerates Antimicrobial Resistance Crisis, Researchers WarnSep 2026
- WHO Adopts New Decade-Long Strategy to Combat Antimicrobial Resistance Through 2036Aug 2026
- Malaysian Pharmacists Show Critical Gaps in Pharmaceutical Waste ManagementMay 2026
Quality & accreditation
- ASF Hospital — Standard 18 — Sustainable Care
- ASF Hospital — Standard 5 — Safety & Emergency Preparedness
- ASF Medical Transport — Standard 5 — Infection Prevention & Control
- ASF Laboratory — Standard 7 — Examination: Process & Safety
- ASF Hospital — Standard 7 — Governance & Management
- ASF Hospital — Standard 4 — Care & Treatment
Other guidelines on this topic
- Water and Sanitation Technologies for Health-care Facilities: Current Status and Context in the Western Pacific Region
- Water and Sanitation Technologies for Health-care Facilities
- International Code of Conduct on Pesticide Management: Guidance note on addressing illegal trade of pesticides
- Measuring the progress and impact of the UN Decade of Healthy Ageing (2021–2030): framework and indicators recommended by WHO Technical Advisory Group
- International Code of Conduct on Pesticide Management: Guidance on options for reducing risk when phasing out pesticides
- Issuer
- World Health Organization
- Type
- Guidance (normative)
- Edition
- 2024
- Status
- Current
- Published
- 2025-05-08
- Languages
- English
- Scope
- Water supply and wastewater treatment technologies for health-care facilities in Western Pacific Region and similar LMIC contexts
- Audience
- Health sector staff, HCF administrators, ministries responsible for HCFs, water and sanitation experts
- Pages
- 56
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 9789290620655
- Evidence
- Literature review of >100 sources; stakeholder engagement in Lao PDR, Mongolia, Vanuatu; expert consensus framework
- 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: selecting options for adoption and scale-up 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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