Implementation and adaptation of WASH FIT in healthcare facilities: A systematic scoping review

• Adaptation in WASH FIT programs is common but not always evidence-based • Some programs initiate WASH FIT assessments but never implement improvements • Some programs complete one round of improvements but never iterate the WASH FIT cycle • Low-quality evidence impedes research to identify WASH FIT’s theory of change • WASH FIT may drive change through national advocacy and peer pressure to unlock funding Environmental health services are important for patient safety and strong health systems, yet access in many countries is poor. To address this, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) developed the Water and Sanitation for Health Facility Improvement Tool (WASH FIT) to drive improvements. While widely used, there is no systematic documentation of how WASH FIT has been adapted across contexts and the implications of these adaptations. We conducted a systematic scoping review to assess WASH FIT implementation contexts and processes, adaptations, and good practices for implementation. We included peer reviewed and grey literature that described the implementation and/or adaptation of WASH FIT in at least one healthcare facility in a low- or middle-income country. Our search yielded 20 studies; few reported details on healthcare facility contexts. Adaptation was widespread, with nearly all studies deviating from the five-step WASH FIT cycle as designed in the WHO/UNICEF manual. Many studies conducted only one facility assessment and one or no rounds of improvement. Good practices for implementation included adequate resourcing, government leadership, and providing WASH FIT teams with sufficient training and autonomy. Low-quality reporting and a high degree of adaptation make it challenging to determine how and why WASH FIT achieves change. We hypothesize that healthcare facility-level action by WASH FIT teams to assess conditions and implement improvements has some effect. However, advocacy that uses WASH FIT indicators to highlight deficiencies and promotion of WASH FIT by WHO and UNICEF to pressure government action may be equally or more powerful drivers of change. More rigorous evidence to understand how and why WASH FIT works is essential to improve its performance and inform scale-up.