inadequate nutrition. Together, in the short term, this puts pressure on resources of the poor and in the long term, has the potential to compromise capabilities that push them back into to the cycle of poverty. Most often, this is manifested in chronic undernutrition. Chronic undernutrition is where a child’s ability to grow to their full physical and cognitive potential is stunted, due to chronic deprivation of essential nutrients through inadequate dietary intake and/or disease (UNICEF, 1990). There is growing evidence that inadequate WASH adds to the disease causal pathway of stunting through increased burden of diarrheal diseases and environmental enteric dysfunction (EED) (Humphrey, 2009; Ngure et al., 2014; Prüss–Ustün et al. 2014). Since about 35 percent of all children under five in Bangladesh are stunted, it is important to prioritize WASH in community clinics when we consider the far‐reaching impacts it can have on human development.

Another factor that invites a closer look at community clinics in Bangladesh is its decentralized institutional framework for primary health care provision. Theoretically, a decentralized system can be more efficient and have greater accountability. However, in countries with high regional disparities in income, decentralization often reduces the redistributive powers of the central government and limits the level of transfers from richer to poorer jurisdictions, worsening equity (Akin et al.,2005). In Bangladesh, this means that the Union Parishads (UPs) are responsible for allocating resources towards CCs. The poorer the UPs, the less likely they are to have sufficient resources to allocate towards WASH in CCs in the face of competing budget demands. Therefore, without an intervention that enables such resource allocation towards WASH in HCFs, CCs in poorer UPs may not have the means to improve their conditions.

Thus, while this analysis presents a snapshot of the status of WASH in CCs at the upazila (sub‐district) level in Bangladesh, it also seeks to understand the extent of the problem in relation to the incidence of poverty and stunting. Specifically, it identifies regions with elevated levels of poverty, high stunting and low WASH in CCs, which are those where the UPs may not be able to improve outcomes on their own and prioritized interventions are called for.

The remaining sections of this brief describe the data used for this analysis and method used to create a WASH index, the status of WASH in upazilas and concludes with a discussion on the way forward.

# Data Sources

This analysis uses three main sources of data to combine upazila level HCF WASH data, poverty data and stunting data for children under five.

For the WASH indicators, data from a 2017 rapid assessment survey of WASH by the Community Based Health Care (CBHC), Directorate General of Health Services (DGHS) and the Ministry of Health and Family Welfare (MoH&FW) was used. The survey covers 63 zilas (districts) and 469 upazilas out of 492 upazilas. As of June 2016, DGHS registry<sup>1</sup> showed that 13, 394 CCs were in operation. The rapid assessment was designed for scale rather than depth. It only contains six questions on the type of water, sanitation and hand‐washing facility and the state of their functionality that the CCs self‐reported online.<sup>2</sup> The questions on functionality highlights the value‐added of this survey as this information is not usually captured in surveys. To verify the reliability of this data, CBHC used a validation survey (WaterAid Bangladesh, 2018)<sup>3</sup> , the results of which we compare herein.

> 1 http://facilityregistry.dghs.gov.bd/index.php

> 2 For details, see Annex‐Table 1

> 3 Two CCs from each upazila were randomly selected

3