Final Report

Assessment of Water Supply, Sanitation and Hygiene (WASH) Systems, Including Climate
Resilience and Greening Practices in Selected Health Care Facilities in Region XI

1. Background. The KOICA-funded project (2015-2018) entitled Accelerating Convergence Efforts

Through Systems Strengthening for Maternal and Newborn Health (AcCESS for MNH) is a project
of the World Health Organization Sub National Initiative (WHO SNI) in partnership with the
Department of Health Regional Office XI (DOH RO XI) is on its last year of implementation. To
determine if the health care facilities are compliant to the requirements of DOH and PhilHealth
for the Basic Emergency Obstetric and Newborne Care (BEMONC), including the availability and
quality of WASH and greening component, an assessment will be conducted in selected project
areas of Davao Occidental, Davao Oriental, Davao del Norte and Compostela Valley (Table 1).

2. Objectives. The assessment has the following specific objectives:

 assess the quality of drinking water services if complying to the Philippine National
Standards for Drinking Water (PNSDW) of 2017;
 inspect sanitation facilities if complying to the Sanitation Code of the Philippines;
 determine water and sanitation practices in health care facilities for maintaining safe water
quality and safe environment; identify potential risks that could threaten safety of drinking
water, such as health care wastes, among others, and recommend risk management
strategies that can control identified risks; and
 determine “greening” practices of health care facilities and recommend how to be a climate
resilient facility.

3. Team Composition. The team who conducted the assessment were composed of the following
members:

 Engr Bonifacio Magtibay – Technical Officer, WHO Country Office in the Philippines
 Engr Luis Cruz – Supervising Health Program Officer, DOH Central Office
 Engr Gloria Raut – Regional Engineer, DOH Region 11
 Ms Emielyn Relopez- Project Assistant, WHO/Davao

4. Schedule and Place of Visits

 10-13 July 2018 – Davao Occidental
 17-20 July 2018 – Davao del Norte
 7-9 August 2018 – Davao Oriental
 14-16 August 2018 – Compostela Valley

Table 1: Number of visited HCFs per province, Davao Region, 2018

Province RHU SBF BHS Total

Davao Norte 2 3 3 8
Compostela Valley 2 2 6 10
Davao Occidental 3 3 3 9
Davao Oriental 2 2 5 9
Total 9 10 17 36

Note: RHU – Rural health Unit; SBF – Safe birthing facility; BHS- Barangay health station

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5. Assessment Methodology

5.1 Drinking Water Quality Assessment. The field test kits provided by WHO to DOH during the
Haiyan Response in 2014 were used, such as potable incubator for water samples, multi-
parameter test kits, chlorine residual test kits, and Global Positioning System gadget. Engr
Cruz of DOH took the water samples following the guidelines of the Philippine National
Standards for Drinking Water of 2017 assisted by other members of the team. Parameters
measured include E. Coli, residual chlorine, pH, temperature, conductivity, Total Dissolved
Solids (TDS) and location coordinates.

5.2 Sanitary survey and risk assessment. Engr Magtibay of WHO developed an assessment tool
in the form of a questionnaire and checklist derived from the WHO Water and Sanitation for
Health Facility Improvement Tool (WASH FIT) and WHO/PAHO guidelines for SMART
hospitals. The tool examines the WASH systems and practices in the HCF (Annex 1 and 2).

6. Findings and Analysis

6.1 Water supply systems. All RHUs have water supply served by LGU-managed water supply
systems while most BHSs are relying on community-managed water supply systems.
Majority of the water sources are deep wells with electric pumps and springs that distribute
water by gravity. Most BHSs are experiencing problems on their water supply due to the
occasional malfunctioning of their water supply systems. When BHS water systems are
becoming out of order, they resort to fetching water from a nearby well or just buying water
from peddlers.

6.2 Water quality analysis. E. Coli as the key parameter for drinking-water safety was
determined in all HCFs visited (Annex 7). Findings show that almost 25% of the samples are
contaminated (Table 2). Davao Oriental has the highest level of contamination both for total
coliform (77%) and E. Coli (39%). Total coliform findings mean there are entry points for any
type of contamination while E. Coli results connote the entrance of fecal contamination
which suggests presence of health risks which should be addressed immediately. Engr Cruz
of DOH immediately informed the Sanitary Inspectors of the concerned municipalities to
disinfect their water supply systems and improve the cleaning and maintenance of the
facilities.

Table 2. Bacteriological Examination Results per province, Davao Region, 2018

Number Results
Summary of Total
Samples Coliform % E Coli %
Davao Norte 11 5 45.45 2 18.18
Davao Occidental 13 9 69.23 1 7.692
Davao Oriental 13 10 76.92 5 38.46
Compostela Valley 15 4 26.67 5 33.33
Total 52 28 53.85 13 24.14

6.3 Sanitation and wastewater systems. All HCFs have toilet facilities. Most of the BHSs have at
least one toilet while RHUs have a minimum of three toilets designated for male, female and
persons with disability. Some RHUs can call desludgers when septic tanks are full but all

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 BHSs have no desludging systems. Most of the HCFs have inadequate drainage systems
making them prone to flooding.

6.4 Handwashing facilities. All HCFs have handwashing facilities which are located either inside
the toilets via lavatory or outside of the toilets through the sinks. All RHUs have soaps,
running water, and posters on handwashing displayed in front of the sinks or lavatories.
However, due to lack of WASH funds for BHSs, soaps are not always available. Some of them
are bringing their own soap to be used for handwashing.

6.5 Health care waste management practices. RHUs have better health care waste management
practices such as segregation, disposal of sharps to septic vault, disposal of placenta to
placenta vault, and collection of general wastes by the municipal LGUs than the barangay
health stations (BHS). BHSs have safety boxes for sharps but have no point person for health
care waste management and would need orientation or guidelines on segregation of wastes
and its proper disposal. Safety boxes for sharps are then forwarded to RHUs for them to
manage the disposal.

6.6 General cleanliness and housekeeping. At BHS level, cleaning is done by BHWs whoever is on
duty. In some cases, cleaning materials are not always available due to lack of LGU budget
allocation. BHWs are sparing their personal money or relying on some donations to buy soap
or detergents. RHUs are better off due to available LGU budget that can support utility
workers and cleaning materials. Considering housekeeping, it was noticed that there is a
need to include a store room in both RHUs and BHSs as the supplied medicines and other
materials are clogging the hallways and offices. Moreover, standard operation procedures
(SOP) for cleaning and housekeeping have to be developed by DOH to guide responsible
persons on appropriate steps. In some BHSs, there are Barangay Sanitary Inspectors (BSI)
who are volunteer workers of the barangays for sanitation activities.

6.7 Greening practices

Since green health care practices are new approaches, it is understandable that most of the
HCFs are not yet familiar on greening and climate resilient approaches. Although some of
them are practicing these items (water conservation, phase out of mercury in HCF
instruments, handling infectious wastes, and promotion of smoke free-environment) these
are not yet regarded as part of green health care practices. Other green health care
practices that need improvements are pest control, use of renewable energy, food safety,
rainwater harvesting, drainage system, and infection control.

7. Conclusion and Recommendations. It is apparent that there are issues on WASH and greening of
HCFs which affect patients and staff in the areas visited. RHUs have adequate support on WASH
from LGUs but BHSs need more assistance. To address these concerns, the following items are
being recommended for various levels of governance:

7.1 DOH National

7.1.1 Review the DOH standard design for RHUs and BHSs (including Philhealth
requirements) on WASH and consider improvement in the design of water quantity,
water pressure, minimum number of toilets, desludging systems, required storage
rooms, training for health care waste management and infection control.
7.1.2 Develop SOPs, guidelines, and training materials for cleanliness and housekeeping,
drinking-water quality surveillance, water/sanitation safety planning for HCFs,
desludging, drainage management, and greening of HCFs.

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 7.1.3 Finalize the development of green health care standards and make these applicable to
RHUs and BHSs.
7.1.4 Update the health care waste management manual and make it applicable to RHUs
and BHSs.
7.1.5 Develop national/regional/provincial trainors on WASH and greening for HCFs.
7.1.6 Develop policies and guidelines for recruiting and capacitating BSIs.

7.2 DOH Region

7.2.1 Provide technical assistance to the province/city, RHUs and BHS in terms of training on
healthcare waste management, water quality surveillance, water/sanitation safety
planning, cleanliness and housekeeping, infection control, and greening of HCF.
7.2.2 Advocate to LGU councils on providing adequate funds for WASH for BHSs.

7.3 Municipal level

7.3.1 Monitor, assess, and assist HCFs in terms of compliance to WASH and green standards.
7.3.2 Allocate funds for WASH for cleaning, housekeeping, desludging, drainage, and
greening of HCFs.
7.3.3 Support the recruitment and training of BSIs.

7.4 Barangay level

7.4.1 Support the BHWs or BSIs in participating to training to be organized by DOH
7.4.2 Support the municipal LGUs in complying with the WASH and green standards of DOH

Annexes

Annex 1 – WASH Assessment Tool

Annex 2 – Green Assessment Tool
Annex 3 –Findings in Davao Occidental
Annex 4 – Findings in Davao Oriental
Annex 5 – Findings in Davao del Norte
Annex 6 – Findings in Compostela Valley
Annex 7 – Results of Total Coliform and E.Coli per Health Care Facility in Four Provinces of Region 11