metadata: authors: 0: author: Joseph,George
1: author: Alam,Bushra Binte
2: author: Shrestha,Anne
3: author: Islam,Khairul
4: author: Lahiri,Santanu
5: author: Ayling,Sophie Charlotte Emi
count: Bangladesh
docna: 0: docna: An Assessment of Water, Sanitation and
            Hygiene Access in Bangladesh's Community Health Clinics
docty: Policy Research Working Paper
subtopic: Hydrology,Health Care Services Industry,Inequality,Town Water Supply and Sanitation,Water Supply and Sanitation Economics,Sanitation and Sewerage,Engineering,Sanitary Environmental Engineering,Water and Human Health,Health and Sanitation,Environmental Engineering,Small Private Water Supply Providers,Early Child and Children's Health,Nutrition,Reproductive Health
teratopic: Industry,Science and Technology Development,Water Resources,Environment,Health, Nutrition and Population,Poverty Reduction,Water Supply and Sanitation
abstracts: cdata!: Adequate water, sanitation and hygiene
            (WASH) in health care facilities plays a critical role in
            ensuring improved health care utilization and reducing
            disease burden due to reinfection. WASH in health facilities
            is now gaining momentum with the new SDG targets that
            governments have vowed to meet. This goal calls for a
            baseline examination of existing WASH conditions in health
            facilities. Using data collected through a census of all
            community health clinics in Bangladesh, this paper presents
            an analysis of the state of WASH in Bangladesh's rural,
            public health facilities highlighting that the lack of
            functionality of WASH facilities is a widespread problem
            across the country. The paper also identifies priority areas
            for action when considering the prevalence of poverty and
            chronic undernutrition at the upazilla level.
geo_reg_key: 517198,517191,517212
repnme: repnme: An Assessment of Water, Sanitation and
            Hygiene Access in Bangladesh's Community Health Clinics
display_title: An Assessment of Water, Sanitation
            and Hygiene Access in Bangladesh's Community Health Clinics
listing_relative_url: /research/2019/06/31207394/assessment-water-sanitation-hygiene-access-bangladeshs-community-health-clinics
topicv3: Sanitation m1326453 2000,Water m1326522 137,Poverty m1326687 695,Stunting m1327504 1445,Health m1504661 3480
publishtoextweb_dt: 2019-06-27T00:00:00Z
historic_topic: Industry,Science and Technology Development,Water Resources,Environment,Health, Nutrition and Population,Poverty Reduction,Water Supply and Sanitation
no_of_pages: 20
author_keys: 0: author_key: 912994
1: author_key: 1059224
2: author_key: 1595186
3: author_key: 125490
4: author_key: 1404724
model_extractions: Policy Research Working Paper 8924

# An Assessment of Water, Sanitation and Hygiene Access in Bangladesh’s Community Health Clinics

_George Joseph Bushra Binte Alam Anne Shrestha Khairul Islam Santanu Lahiri Sophie Ayling_ Water Global Practice June 2019
Policy Research Working Paper 8924

# **Abstract**

Adequate water, sanitation and hygiene (WASH) in health care facilities plays a critical role in ensuring improved health care utilization and reducing disease burden due to reinfection. WASH in health facilities is now gaining momentum with the new SDG targets that governments have vowed to meet. This goal calls for a baseline examination of existing WASH conditions in health facilities. Using data collected through a census of all community health clinics in Bangladesh, this paper presents an analysis of the state of WASH in Bangladesh’s rural, public health facilities highlighting that the lack of functionality of WASH facilities is a widespread problem across the country. The paper also identifies priority areas for action when considering the prevalence of poverty and chronic undernutrition at the upazilla level.

This paper is a product of the Water Global Practice. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://www.worldbank.org/prwp. The authors may be contacted at gjoseph@worldbank.org.

_The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent._ Produced by the Research Support Team
# An Assessment of Water, Sanitation & Hygiene Access in Bangladesh’s Community Health Clinics

George Joseph, Bushra Binte Alam, Anne Shrestha , Khairul Islam, Santanu Lahiri, Sophie Ayling

## JEL: I15; I18, Q01

Key Words: SDG, Health Clinics, Health Centers, WASH access, Water Supply, Sanitation, Bangladesh Corresponding author: George Joseph (Water Global Practice, The World Bank, Washington DC, USA 20433, <u>gjoseph@worldbank.org); Anne Shrestha (Water Global Practice, The World Bank, Washington DC, USA 20433, ashrestha7@worldbank.org); Bushra Binto Alam( Health Nutrition and Population Global Practice, The World Bank, Dhaka,</u> Bangladesh; balam@worldbank.org; Khairul Islam, Water Aid Bangladesh, Dhaka , Bangladesh,khairulislam@wateraid.org; Santanu Lahiri, Water Global Practice, The World Bank, Dhaka, Bangladesh, <u>slahiri@worldbank.org); Sophie Ayling (sophie2@ayling.com, InterAmerican Development Bank, Washington DC, USA 20577</u> This paper is a product of an assignment conducted for the FAO and World Bank using data collected by Community Based Health Care (CBHC) with support from World Bank and WaterAid Bangladesh. This was made possible by the Swedish International Development Cooperation Agency and benefited from funding from the Government of Japan through the Japan Trust Fund for Scaling Up Nutrition. We would like to thank the valuable contributions of Prof. Dr. Md. Abul Hashem Khan, Dr. Ashish Kumar Saha, Er. Md. Ziaul Haque, Dr. Barendra Nath Mandal, Dr. Farzana Munmun, Ms. Soma Ghosh Moulik, Mr. Arif Ahamed, Ms. Rokeya Ahmed, Mr. Abu Ahmed Mansoor Kabir, Mr. Mohammed Abu Hamid, Mr. SM Rezaul Islam, Mr. Mohammed Abu Hamid, Mr. Bakhtiar Sohag, Mr. Sahil Deo, Ms. Sanjana Krishnan, Mr. Akramul Haque and Mr. Tareq Mahamud.

The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of FAO or The World Bank, its Board of Executive Directors, or the governments they represent. FAO or The World Bank does not guarantee the accuracy of the data included in this paper.
Advanced service To be defined at national level Basic service Water is available from an improved source” located on premises.

Limited service An improved water source is within 500 meters of the facility, but not all requirements for basic service are met.

Advanced service Advanced service To be defined at To be defined at national level national level Basic service Basic service Improved sanitation Functional hand facilities"® are usable hygiene facilities with at least one (with water and toilet dedicated for soap and/or alcohol staff, at least one based hand rub) are sex-separated toilet available at points with menstrual of care, and within hygiene facilities, 5 meters of toilets. and at least one toilet accessible for people with limited mobility.

Limited service Limited service At least one Functional hand improved sanitation hygiene facilities facility, but not all are available at requirements for either points of care basic service are or toilets, but not met. both.
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
|_Table 1:_<br>_Tier_|_WASH Tiers_<br>_Water_|_Sanitation_|_Handwashing_|
|---|---|---|---|
|0|<sup>No supply/ Not</sup><br>functional|<br>No latrine/ Not<br>functional|No facility|
|1|Functional<br>hand‐pump|One functional<br>latrine|Facility with<br>water|
|2|Functional<br>piped water|Two functional<br>latrines|Facility<sup>1</sup>with<br>water and soap|
|3|‐<br>|Three functional<br>latrines|<br>‐|
|4|‐|Four functional<br>latrines|‐|

The poverty figures at the upazila level are derived from the predicted poverty estimates from Steele et al. (2017).<sup>4</sup> It uses overlapping data from i) traditional household surveys (DHS, HIES, 2010 and Census 2011); ii) remote sensing data such as night‐time lights, distance to roads, distance to closest urban settlements, climate variables; and iii) call detail records at varying spatial resolutions to estimate poverty rates using Bayesian geostatistical models (BGMs) (See Annex‐Figure 1 for a upazila level map with poverty estimates). The only other poverty estimate available to us at the time of analysis were the national estimates from Census 2011, which we deemed outdated to use alongside 2017 WASH data.

The upazilas level stunting estimates for children under five were taken from the _Small‐Area Estimation of Child Undernutrition in Bangladesh_ report by Haslett et al. (2014), Bangladesh Bureau of Statistics (BBS) and the World Food Programme (WFP). The estimates combine survey data from the Child and Mother Nutrition Survey of Bangladesh 2012 (CMNS) and the Health and Morbidity Status Survey 2011 (HMSS) which some additional data from the BBS Census 2011.

|_Table 2: HCFs at ea_<br>_Water_|_ch WASH Tie_<br>_Freq._|_r, by category_<br>_%_|
|---|---|---|
|0|7,690|64.67|
|1|3,692|31.05|
|2|509|4.28|
|_Total_|_11,891_|_100_|
|_Sanitation_|Freq.|Percent|
|0|3,539|30.03|
|1|6,402|54.33|
|2|1,586|13.46|
|3|183|1.55|
|4|74|0.63|
|_Total_|_11,891_|_100_|
|_Handwashing_|Freq.|Percent|
|0|1,697|14.27|
|1|4|0.03|
|2|10,190|85.7|
|_Total_|_11,891_|_100_|

# Method

In addition to descriptive statistics, the primary objective of this analysis is to have a upazila level spatial snapshot of the state of WASH in CCs. To this end, we first create tiers for each category of WASH using the available survey data. The questions in the survey are not comprehensive enough to create the complete JMP tiers. However, we follow the JMP guidelines to the extent possible with the available data. Specifically, each of the three category tiers are coded as shown in Table 1.<sup>5</sup> Table 2 shows the number and proportion of CCs that fall under each tier.

Each of the three tiers are then scaled into an index between 0 and 1. The WASH score for each HCF is the aggregate of the three indices combined. And the WASH index is the mean of the HCF WASH scores at the upazila level, scaled between 0 and 1. The upazilas with WASH index below 0.5 are categorized as ranking “low” in WASH, whereas those with a score above 0.5

> 4 Mean probability of households being below $2.50/day using the Progress Out of Poverty Index (PPI) computed using survey data.

> 5 The survey includes whether there was arsenic testing done at the HCF, however, no further information on water treatment or quality was solicited. The survey also includes a question on when the pit latrine was last emptied. However, this information is not complete enough to make a proper assessment of the state of sanitary facilities beyond functionality. Therefore, we leave those out in constructing our index. See Annex‐Table 1 for questionnaire.

4
are categorized as ranking “high” in WASH. **However, it is important to note that a perfect score of 1 indicates relatively better WASH but not necessarily adequate WASH based on JMP standards. Therefore, it is most useful to read these results to compare across upazilas keeping in mind that bad scores indicate very poor WASH in CCs but good scores do not necessarily reflect adequate WASH.** Similarly, the upazila level poverty probabilities and stunting estimates are also rescaled to range between 0 and 1, and then categorized into “low” or “high” poverty/stunting based on the 0.5 score cut‐ off. Again, “low” and “high” should be read in relative terms only.

Using the WASH, poverty and stunting indices, we identify and map upazilas in Bangladesh that rank high in poverty and in stunting in relation to their WASH status. The base maps for the upazilas are from the Global Administrative Areas database.

The Status of WASH in Community Clinics: A Snapshot

**The community clinics in Bangladesh still have a long way to go to achieve adequate WASH facilities that are critical to providing safe, hygienic environments that help promote proper treatment and well‐ being of patients.** Overall, the rapid assessment data shows that adequate handwashing facilities at CCs are becoming near universal, whereas adequate water and sanitation are far from adequate.

**A large majority of the community clinics had limited WASH facilities only.** Table 3 shows the number of CCs that met individual WASH category criteria. Less than 36 percent of the community clinics had basic water supply, i.e. a functional improved water source. Around 30 percent did not have any functional sanitation facility. Only 16 percent had two functional latrines on premises. According to the 2008 WHO guidelines, HCFs must have at least 4 functional, _Table 3:HCFs with limited/ basic WASH, by category_ improved sanitation facilities on premises.  Less than 2 percent of the community clinics met this WHO _WASH Category_ Freq. % criterion. Eighty‐five percent of the community clinics _Basic Water_ 4,201 35.33 have adequate handwashing facility with soap and _Limited Sanitation ≥ 1 latrines_ 8,352 70.24 water. However, it is unclear to what extent the _Limited Sanitation ≥ latrines_ 1,950 16.4 handwashing facilities were affected by the lack of _Limited Sanitation ≥ 4 latrines_ 181 1.52 functional water supply. _Limited Handwashing_ 10 190 85.7

|_WASH Category_|Freq.|%|
|---|---|---|
|_Basic Water_|4,201|35.33|
|_Limited Sanitation ≥ 1 latrines_|8,352|70.24|
|_Limited Sanitation ≥ latrines_|1,950|16.4|
|_Limited Sanitation ≥ 4 latrines_|181|1.52|
|_Limited Handwashing_|10,190|85.7|

**The CBHC survey revealed that a major challenge is**

**that many community clinics did not have any type of WASH facility within premises;** 2,280 community clinics (19 percent) did not have any functional water, sanitation or hand‐washing facility.<sup>6</sup>

**Of the 11,891 CCs surveyed, 3,660 community clinics reached the ‘limited’ JMP standard detailed in Figure 1.** In other words, only about 31 percent of the community clinics had at least a functional improved water source (handpump or piped), at least one functional latrine (type unknown), and a handwashing station with water and soap. If we set a stricter standard of at least two functioning latrines (one for each gender) as suggested as one of the criterion in the JMP ‘basic’ sanitation tier, the number of community clinics with adequate overall WASH falls to 1,003. These preliminary numbers show that most rural and peri‐urban residents in Bangladesh have less than reliable primary health services in CCs, which are often the first line of care for patients.

> 6 For further details, please refer to Annex‐Table 3 and Annex‐Table 4.

5
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One of the main findings is that the prevalence of non‐functional water and sanitation facilities is a significant issue. More information is necessary to establish what the secondary sources are, and if they are adequate for effective health service delivery. There is also a need for more comprehensive data to be collected not just on where arsenic testing has been carried out, but what the results were and whether proper treatment was administered to mitigate the issue before usage.

In relation to our health indicator for human development, the degree of overlap between upazilas with high levels of stunting and low levels of WASH is remarkably high and calls for a closer look at the determinants of stunting in those regions.

Despite low income levels, the west of Bangladesh had relatively higher levels of WASH in its community clinics. As noted in the above sections, there are two main caveats to keep in mind. One, that the index is a relative measure and a perfect score of 1 is by no means indicative of adequate WASH. Two, it is worth entertaining the possibility that there could have been measurement errors in the collection of data for the rapid assessment. If that is the case, we can expect to see over‐ or under‐estimated rates of WASH at community clinics.

While the lowest income areas are not necessarily the ones where WASH is the poorest, it is worth noting that the Union Parishad’s limited revenues, particularly own resource mobilization, will most probably be a constraint to achieving adequate level of WASH by the SDG standards. Therefore, the local governments who are accountable for the improvement of community clinics need support at the national level through dedicated budget accounts. This pattern where WASH levels are higher in poorer regions could also reflect that more Bangladeshis in poorer regions use community clinics whereas those who live in richer regions bypass community clinics and may prefer to use private health services or hospitals even for the first line of care, causing greater neglect of community clinics in richer regions. If this happens to be the case, then the poorest of the poor in relatively higher income regions are likely to be left out to a greater degree than the poorest of the poor in relatively low‐income regions.

However, this assessment only gives us a partial picture. To understand the depth of the problem, a more extensive analysis would be necessary. The simplicity of the rapid assessment survey affords representativeness at the cost of depth of information. Therefore, while this analysis provides a preliminary account of the state of WASH in community clinics, it does not sufficiently establish a baseline against which progress towards SDGs can be measured. The DGHS an MoHFW will benefit from adopting the core survey components designed to assess SDG indicators detailed in the WHO/UNICEF (2018) guidelines, which can then be adjusted to fit the Bangladeshi context.

10