Water, sanitation and infection control practices in rural health facilities of Jodhpur District, India: an intervention through supportive supervision

Abstract

Background

Inadequate water, sanitation, and hygiene (WASH) infrastructure in rural healthcare facilities in India, poses significant challenges to effective infection control, contributing to the prevalence of healthcare-associated infections (HAIs) and poor patient outcomes. Despite ongoing global efforts to enhance WASH standards, these facilities often lack the necessary resources and management systems to sustain improvements. Supportive supervision has emerged as a potential strategy to address these gaps. This study aimed to improve the water, sanitation, and infection control practices in Rural health facilities of Jodhpur District through supportive supervision.

Methods

This study presents the findings of an intervention study conducted in Luni Block of the Jodhpur district. All the healthcare facilities (6 PHCs and 5 CHCs) in that block were included and baseline assessment was done. The intervention was provided through supportive supervision covering various domains of Water and Sanitation for Health Facility Improvement Tool (WASH FIT). After three months, a follow-up assessment was done in all the Health Care Facilities (HCFs). Endline assessment was done after three months of the follow-up assessment using the same tool. Water and swab samples from the labour room were collected from the facilities for microbiological surveillance during the baseline and endline assessments.

Results

During the baseline, none of the facilities included in this study had a more than 60% bed occupancy rate. Average OPD attendance in CHCs was 57, and in PHCs it was 22. None of the facilities had adequate human resources as per IPHS 2012. The significant issues in water-related practices were quality, accessibility, safe storage, periodic testing of chlorine residue, and sanitation inspection risk score. Unable to meet menstrual hygiene-related needs, improper cleaning records, and inadequate usage of PPE for waste disposal were significant gaps in sanitation-related practices. The unavailability of functional hand hygiene stations, non-adherence to hand hygiene compliance activities, and inadequate knowledge regarding the correct concentration of cleaning solution were identified as potential lacunae related to hygiene. All the facilities had shown statistically significant improvement in WASH FIT scores across all four domains post-intervention.

Conclusions

Practices related to water, sanitation, hygiene, and infection control in health care facilities of rural Jodhpur were not satisfactory. There were specific gaps in all these domains. The intervention in the form of capacity building of healthcare workers, formation of an Infection Control Committee, and continuous supportive supervision was found effective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-12689-7.

Background

Healthcare facilities (HCFs) play a crucial role in ensuring the health and well-being of populations, especially in rural and resource-limited settings. However, the availability of safe water, sanitation, and hygiene (WASH) services in healthcare facilities is often inadequate, particularly in low- and middle-income countries (LMICs), leading to poor health outcomes and increased incidence of healthcare-associated infections (HAIs) [1, 2]. Inadequate WASH infrastructure directly impacts the quality of healthcare services, making it essential to address the gaps in these services to improve overall patient safety and reduce nosocomial infections [3]. Proper WASH services in HCFs are necessary to prevent infections and ensure patient safety by creating a hygienic environment for both healthcare providers and patients [4]. Without these essential services, healthcare systems in LMICs are at a higher risk of facing challenges in controlling infection spread and ensuring effective healthcare delivery.

Water, sanitation, and hygiene (WASH) are fundamental public health interventions required to maintain safe and hygienic healthcare environments. These services are integral to infection prevention and control (IPC) practices, ensuring that healthcare workers (HCWs) and patients are protected from the risks of infections, including highly preventable diseases such as sepsis, diarrheal diseases, and respiratory infections [5]. Poor WASH services in healthcare facilities contribute to the spread of infections, increase the burden on already strained healthcare systems, and affect maternal and neonatal outcomes [6]. For example, studies have shown a strong causal relationship between inadequate hand hygiene among birth attendants and maternal infections, highlighting the importance of WASH in improving birth outcomes [7]. This study aims to evaluate the impact of supportive supervision on improving WASH and infection control practices in rural health facilities in the Jodhpur District of India.

Importance of WASH in healthcare facilities

WASH services are essential in all healthcare settings for the prevention of HAIs and the promotion of overall health. Key components of WASH in healthcare facilities include access to safe and sufficient water, adequate sanitation services, proper management of excreta and healthcare waste, and hygiene practices such as handwashing and environmental cleaning. The availability of these services ensures a safer environment for both patients and healthcare providers, which directly improves healthcare quality. Water of suitable quality and quantity, facilities for securely handling excreta and healthcare waste, and the implementation of hygienic practices such as hand hygiene and environmental cleaning are necessary for any healthcare facility (HCF) [8, 9]. These factors form the foundation of infection control measures and are essential for reducing the risk of disease transmission within healthcare environments [10].

The importance of WASH services has been highlighted by international organizations such as the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), which have made significant efforts to promote WASH services in healthcare facilities worldwide. WHO and UNICEF co-lead the implementation of global initiatives aimed at improving WASH services in healthcare settings, particularly in LMICs, where such services are often insufficient or absent [11, 12]. These organizations have launched a global call to action on WASH in healthcare facilities, with a focus on improving access to safe water and sanitation, which are critical components for achieving the Sustainable Development Goals (SDGs), particularly targets 6.1, 6.2, and 3.8 [13, 14]. These targets aim to provide universal access to safe drinking water, sanitation, and hygiene by 2030, and ensure that all people have access to quality essential healthcare services.

Despite the global efforts, the coverage of WASH services in healthcare facilities remains inadequate, especially in LMICs. According to the SDG baseline statistics released in 2019, one in four healthcare facilities lacked basic water services, while one in five lacked sanitation services, affecting over two billion and 1.5 billion people, respectively [8]. These deficiencies also extend to the lack of proper waste management systems, hand hygiene stations, and other crucial components necessary for infection control [9]. In high-income countries, it is estimated that between 10% and 70% of healthcare-associated infections (HCAIs) could be prevented through adequate WASH and infection control practices, highlighting the potential impact of improving these services [10, 12]. Inadequate environmental hygiene in healthcare settings has been identified as a major determinant of maternal and neonatal morbidity and mortality, particularly in resource-limited settings [11, 13].

WASH and antimicrobial resistance

Poor WASH practices in healthcare facilities also contribute to the rise of antimicrobial resistance (AMR), which is a growing global public health threat. Infections caused by pathogens resistant to antibiotics can spread rapidly in healthcare environments, particularly when basic infection control measures are not implemented effectively. Inadequate WASH in healthcare facilities increases the reliance on antibiotics, particularly in childbirth, where improper hygiene practices increase the risk of maternal and neonatal sepsis [14]. Each year, approximately 670,000 infant deaths are attributed to sepsis, many of which are associated with antimicrobial-resistant pathogens [15]. Furthermore, the improper disposal of healthcare waste, including untreated wastewater, contributes to the spread of antimicrobial-resistant bacteria in the environment, exacerbating the AMR crisis [16].

Given the critical importance of WASH in healthcare settings, it is essential to implement effective strategies to address the gaps in service provision. In low-resource healthcare facilities, the provision of WASH-related services should be considered a non-negotiable essential service. This responsibility extends beyond healthcare workers to include non-clinical staff and even patients and visitors to healthcare facilities. Leadership, supervision, and continuous monitoring are critical components of ensuring that WASH services are consistently maintained and improved in healthcare settings [17].

Supportive supervision as an intervention

Supportive supervision is recognized as an effective strategy for improving WASH services in healthcare facilities. Unlike traditional supervisory approaches that focus primarily on identifying deficiencies, supportive supervision is collaborative and aims to facilitate problem-solving through two-way communication between supervisors and healthcare staff. This approach helps build the capacity of healthcare workers, strengthens team-based problem-solving, and fosters accountability and ownership of healthcare improvements [18]. Supportive supervision also promotes continuous learning and skill development, which is essential for sustaining improvements in WASH services over time [19, 20].

Despite the known importance of WASH in healthcare settings and the global efforts to improve these services, significant gaps remain, particularly in rural healthcare facilities in India [21]. Inadequate WASH services in these settings contribute to poor infection control practices and increase the risk of nosocomial infections, maternal and neonatal mortality, and the spread of antimicrobial-resistant pathogens [22]. Given these challenges, this study was designed to evaluate the impact of supportive supervision as an intervention to improve water, sanitation, and infection control practices in rural healthcare facilities in Jodhpur District, India.

Therefore, this study was planned with the objectives to assess and improve the water, sanitation, and infection control practices in rural health facilities of the Jodhpur district, through supportive supervision.

Methods

Study design and sampling

This facility-based pre- and post-interventional study was conducted in rural healthcare facilities of the Jodhpur district from March 2021 to December 2022. Out of ten rural Community Development Blocks (CDB), one CDB was selected by simple random sampling. All the CHCs and PHCs of the selected block were visited, and all the available healthcare workers in those facilities were enrolled in the study. The healthcare facilities were enrolled in the study after obtaining permission from the Chief Medical Health Officer (CMHO) of Jodhpur district. Consent was obtained from the Medical Officer and healthcare workers in the respective healthcare facilities during data collection. It includes medical officers, nurses, pharmacists, lab technicians, paramedical staff, housekeeping staff, and other staff in the HCFs. The facility and healthcare workers were not bound to compulsion and were free to withdraw during the study.

Study tools

Physical status and service availability in the health care facilities were assessed as per Indian Public Health Standards (IPHS) 2012 PHC and CHC. For assessing WASH in healthcare facilities, the questionnaire had three sections: Essential indicators, Advanced indicators, and Additional indicators. Essential and Advanced indicators were adopted from the WASH FIT tool (the Water and Sanitation for Health Facility Improvement Tool) [15] covering water, sanitation, health waste disposal, hygiene, and management. Additional indicators were taken from the Kayakalp implementation tool [16].

Study framework

Baseline assessment of the facilities, Intervention training, Supportive supervision, including formulation of an infection control committee, follow up after 3 months assessment of training, Continued supportive supervision and Endline assessment of facilities (Figs. 1 and 2).

Fig. 1.

Supportive supervision, including formulation of an infection control committee

Fig. 2.

Flow diagram of the study

All the PHCs and CHCs in the selected block were visited, and baseline assessment was done using predefined tools. Interviews were conducted with the healthcare workers. Water sample was collected by trained staff from the main drinking water source (piped water supplied by the government) in each of the facility using sterilized containers and transported in insulated vaccine carriers to prevent contamination, in line with WHO guidelines (WHO, 2011) within 2 to 3 h. The Physical, Chemical, and Microbiological aspect of drinking water were assessed using WHO water quality standards. Physical and chemical parameters were tested using the HI3817 water quality test kit in the Environmental laboratory of the Department of CMFM, AIIMS Jodhpur. Microbiological parameters were tested using the Multiple tube method in the Hospital infection control laboratory of the Department of Microbiology, AIIMS Jodhpur. Six Swab samples were taken from the facilities with a functional labour room in each of the facilities. Swabs were taken from six sites from the labour room, namely spotlight, gauze drum, delivery tray, fetoscope, rubber sheet and episiotomy scissors using the surface swabbing technique. The surface swabbing is done using a nutrient agar plate and incubated at 37℃ for 24 h in the Hospital infection control laboratory of the Department of Microbiology, AIIMS Jodhpur.

Intervention training of HCWs

Considering various domains assessed using WASH FIT [15] and Kayakalp tool [16] (Supplementary file S1), the intervention module was developed to incorporate all of them through different channels of communication such as an information booklet, Power Point (PPT) presentations, demonstrations, posters, and checklist.

The capacity-building workshop was conducted offline through PowerPoint presentations, posters, and live demonstrations for 2 h by experts in WASH. The initial 10 min were utilized for introduction and orientation to the importance of WASH in HCF, 45 min were used for the following domains viz. Water, Sanitation, Infection control practice including hand hygiene and Biomedical waste Management, next 45 min were utilized for demonstration and enaction, and last 20 min were used for distributing posters, checklists and clearing queries of HCWs. Following workshop, all the available healthcare workers, including medical officers, nursing officers, lab technicians, paramedical staff, and housekeeping staff, were given training related to all the domains of WASH in Health care facilities individually by the author using poster and pamphlets.

Supportive supervision, including formulation of an infection control committee were done. The committee comprised of Medical officers, nursing officer, community health workers, pharmacist, paramedical workers, housekeeping staffs under the supervision of block medical officer. The supervisory visit was uninformed to capture the relevant information. During the supervisory visit, information was collected by the investigator using a checklist, and if any deficiencies were observed, onsite training was also given following data collection. The checklist and intervention material were displayed to facilitate continuous reinforcement of WASH-related practices in HCFs.

Following that, follow up assessment and endline assessment was done in all the health care facilities. Activities were ensured by reporting the findings to the Infection Control Committee in the healthcare facilities. All the health care workers were informed about the importance of supervision.

Data collection

After getting clearance from the Institutional Ethical Committee, baseline data collection commenced by the author. The intervention was delivered through training of HCWs and supportive supervision of the health facilities following the baseline assessment. After maintaining a gap of 3 months, a follow-up assessment was done. During this period, supportive supervision was provided to the healthcare facilities. After maintaining a gap of 3 months, the endline data collection was started. Data entry was done parallel to data collection.

Data analysis

The data were analyzed using Microsoft Excel 2016 and Statistical Package for Social Sciences ver. 23.0. (IBM SPSS, Inc., Chicago, IL). Descriptive analysis, including frequency distribution, proportion, and mean, was performed to summarize the characteristics of the healthcare facilities. Cumulative scores were calculated for each component, and the total score was calculated by adding those cumulative scores. Cumulative scores of individual facilities were analyzed using the Friedmann test after checking normality using the Shapiro-Wilk test. Changes in the mean scores were analyzed using repeated measures ANOVA.

Ethical approval and consent to participate

Ethical approval was obtained from AIIMS Jodhpur, Institutional Ethics Committee vide reference No. AIIMS/IEC/2021/3348, dated– 12/03/2021. All the healthcare workers were informed about the objective of the study and the benefits of participating in the study. Written and informed consent was obtained from all the health care workers included in this study. After inclusion in the study, written consent was taken from the Chief Medical Health Officer, Jodhpur district, the Medical Officer in Charge, and the staff of the facilities included in this study. A participant information sheet was given to all the participants, and their role in the study was correctly explained before administering the tool. Data confidentiality was assured to the participants, and they were given the option of withdrawing from the study at any point if they desired to do so. Privacy was maintained during the interviews by ensuring that they were conducted in a separate room.

Results

Overview of healthcare facilities and population coverage

The study included 11 healthcare facilities in the Luni Block of Jodhpur District, comprising 6 Primary Health Centres (PHCs) and 5 Community Health Centres (CHCs). These facilities catered to populations ranging from 13,450 to 30,840 for PHCs and 27,832 to 58,830 for CHCs. All facilities provided Outpatient Department (OPD) services, while CHCs also offered 24/7 emergency services. The average number of beds was 27 in CHCs and 5 in PHCs, reflecting their respective capacities. The Bed Occupancy Rate (BOR) at CHCs reached a maximum of 50%, while PHCs had a BOR of 15%, suggesting a lower demand for inpatient services. Average OPD attendance was 57 patients at CHCs and 22 patients at PHCs (Supplementary table S2).

A key challenge identified was the shortage of manpower across all facilities. According to the Indian Public Health Standards (IPHS), each CHC requires 46 staff members, and each PHC needs 13. However, none of the facilities met these standards, with CHCs having an average of 18.4 staff members and PHCs having 10, highlighting a significant staffing gap. All healthcare facilities had electricity, although none had backup generators, potentially affecting services during power outages. Laboratory services were available in all facilities, and labour rooms were functional in all CHCs and four PHCs. Additionally, minor operation theatres were available in four CHCs and five PHCs (Supplementary table S3).

Water related indicators

The assessment of water supply focused on essential, advanced, and additional indicators, following the WASH FIT tool. At baseline, all facilities had improved water supply piped into the premises, and this status remained consistent throughout the study period. However, challenges always arose with the availability of water.

At baseline, none of the facilities fully met the requirement for constant water availability. By the follow-up, 2 facilities (18.2%) fully met this standard, increasing to 4 facilities (36.4%) at endline, indicating gradual improvement in continuous water supply. Reliable drinking water stations were another key indicator. At baseline, 3 facilities (27.3%) fully met this requirement, while 8 facilities (72.7%) partially met it. By the endline, 7 facilities (63.6%) fully met the indicator, showing substantial progress. However, the need for safe storage of drinking water remained a concern throughout the study. At baseline, 2 facilities (18.2%) fully met the requirement for storing water in clean, covered containers, improving to 5 facilities (45.4%) by endline (Table 1).

Table 1.

Assessment of water in health care facilities as per WASH FIT tool - Essential indicator (n = 11)

Indicators	Baseline, n (%)			Follow up after 3 months, n (%)			Endline, n (%)
	FM	PM	NM	FM	PM	NM	FM	PM	NM
Improved water supply piped into the facility or on-premises and available	11 (100)	-	-	11 (100)	-	-	11 (100)	-	-
Water services are available at all times and of sufficient quantity for all uses	-	11 (100)	-	2 (18.2)	9 (81.8)	-	4 (36.4)	7 (63.6)	-
A reliable drinking water station is present and accessible for staff, patients, and carers at all times and in all locations/wards	3 (27.3)	8 (72.7)	-	3 (27.3)	8 (72.7)	-	7 (63.6)	4 (36.4)	-
Drinking water is safely stored in a clean bucket/tank with a cover and tap	2 (18.2)	5 (45.4)	4 (36.4)	4 (36.4)	5 (45.4)	2 (18.2)	5 (45.4)	6(54.5)	-

Among the advanced indicators for the assessment of water in healthcare facilities. During the baseline assessment, the sanitation inspection risk score revealed a low risk in three facilities. At the endline, nine facilities had low risk. Drinking water was treated and collected in two facilities using WHO-approved technology during baseline and four facilities during endline. At baseline, three facilities had functional and accessible bathing areas per 40 patients. This increased to six facilities post-intervention scores in indicators related to water in health care facilities across baseline, midline and endline assessment which were fully met, partially met and not met (Supplementary table S4, S5).

Parameters for assessment of the Physical & Chemical quality of drinking water is used as per Bureau of Indian Standards. Presumptive coliform count per 100 ml was satisfactory in three facilities during baseline and improved to five facilities during endline. All the facilities had acceptable pH, Nitrate, and odour in the baseline. The intervention couldn’t improve chlorine, and the hardness of water compared to the baseline (Supplementary table S12).

Sanitation indicators

The sanitation assessment revealed significant gaps, especially in toilet availability, menstrual hygiene management, and facilities for people with reduced mobility. At baseline, no facility fully met the requirement for the availability of usable toilets for patients. Six facilities (54.5%) partially met this standard, but by the endline, only 1 facility (9.1%) fully met it. The separation of toilets for staff and patients was another area that saw modest improvement. At baseline, 3 facilities (27.3%) fully met the requirement, increasing to 5 facilities (45.4%) at endline. Similarly, the number of facilities with gender-separated toilets improved from 3 facilities (27.3%) at baseline to 7 facilities (63.6%) at endline (Table 2).

Table 2.

Assessment of sanitation in health care facilities as per WASH FIT tool -Essential indicator (n = 11)

Indicators	Baseline, n (%)			Follow up after 3 months, n (%)			Endline, n (%)
	FM	PM	NM	FM	PM	NM	FM	PM	NM
Number of available and usable toilets or improved latrines for patients	-	6(54.5)	5 (45.4)	-	7 (63.6)	4 (36.4)	1 (9.1)	5 (45.4)	5 (45.4)
Toilets or improved latrines clearly separated for staff and patients	3 (27.3)	6(54.5)	2 (18.2)	3 (27.3)	6(54.5)	2 (18.2)	5 (45.4)	4 (36.4)	2 (18.2)
Toilets or improved latrines clearly separated for male and female	3 (27.3)	4 (36.4)	4 (36.4)	5 (45.4)	2 (18.2)	4 (36.4)	7 (63.6)	-	4 (36.4)
At least one toilet or improved latrine provides the means to manage menstrual hygiene needs	-	2 (18.2)	9 (81.8)	2 (18.2)	5 (45.4)	4 (36.4)	4 (36.4)	4 (36.4)	3 (27.3)
At least one toilet meets the needs of people with reduced mobility	-	3 (27.3)	8 (72.7)	-	3 (27.3)	8 (72.7)	-	3 (27.3)	8 (72.7)
Functioning hand hygiene stations within 5 m of latrines	2 (18.2)	9 (81.8)	-	4 (36.4)	7 (63.6)	-	7 (63.6)	4 (36.4)	-
Health care waste
A trained person is responsible for the management of healthcare waste in the health care facility	-	2 (18.2)	9 (81.8)	5 (45.4)	5 (45.4)	1 (9.1)	6(54.5)	5 (45.4)	-
Functional waste collection containers near all waste generation point for: non-infectious waste, infectious waste, sharps waste	-	8 (72.7)	3 (27.3)	2 (18.2)	9 (81.8)	-	6(54.5)	5 (45.4)	-
Waste is correctly segregated at all waste generation points	2 (18.2)	4 (36.4)	5 (45.4)	2 (18.2)	9 (81.8)	-	3 (27.3)	8 (72.7)	-
Functional burial pit/fenced waste dump or municipal pick-up available for disposal of non-infectious (non-hazardous/general waste)	-	8 (72.7)	3 (27.3)	3 (27.3)	5 (45.4)	3 (27.3)	5 (45.4)	3 (27.3)	3 (27.3)
Incinerator or alternative technology for the treatment of infectious and sharp waste is functional and of a sufficient capacity	-	5 (45.4)	6(54.5)	-	6(54.5)	5 (45.4)	-	6(54.5)	5 (45.4)
Sufficient energy available for incineration or alternative treatment technologies	-	5 (45.4)	6(54.5)	-	5 (45.4)	6(54.5)	-	5 (45.4)	6(54.5)

Menstrual hygiene management (MHM) posed a significant challenge. At baseline, none of the facilities fully met the requirement for providing means to manage menstrual hygiene. By the follow-up and endline, however, 4 facilities (36.4%) fully met this indicator, highlighting progress in addressing the needs of menstruating individuals. For people with reduced mobility, the availability of at least one accessible toilet was inadequate throughout the study. At baseline, 3 facilities (27.3%) partially met this requirement, and this remained unchanged by the endline, demonstrating no significant progress in this critical area of sanitation (Table 2).

Advanced indicators for the assessment of sanitation in healthcare facilities depicted during baseline, none of the facilities had displayed the checklist for cleaning toilets. Following the intervention, it was displayed in ten facilities. During baseline, only three facilities had latrines adequately lit at night. Following the intervention, it improved to five facilities (Supplementary table S6, S7).

Hygiene indicators

The assessment of hygiene focused on hand hygiene stations, promotion materials, and cleaning supplies. Initially, none of the facilities had functioning hand hygiene stations at all points of care. By endline, 7 facilities (63.6%) fully met this standard, indicating notable improvement in the provision of hand hygiene facilities. Hand hygiene promotion materials were also evaluated. At baseline, 6 facilities (54.5%) partially met this requirement, with 8 facilities (72.7%) fully meeting the standard by the endline. This suggests increased efforts to promote hygiene among staff and patients. Facility cleanliness was another focus area. At baseline, 8 facilities (72.7%) had clean exteriors, and this increased to 9 facilities (81.8%) at follow-up, though it dropped to 7 facilities (63.6%) at endline. In terms of cleaning supplies, all 11 facilities had appropriate cleaning materials, such as mops, buckets, and detergent, at baseline, and by the endline, 7 facilities (63.6%) fully met the requirement for maintaining cleaning supplies (Table 3).

Table 3.

Assessment of hygiene, facility environment, cleanliness, and disinfection in health care facilities as per WASH FIT tool-Essential indicator (n = 11)

Indicators	Baseline, n (%)			Follow up after 3 months n (%)			Endline, n (%)
	FM	PM	NM	FM	PM	NM	FM	PM	NM
Functioning hand hygiene stations are available at all points of care	-	11 (100)	-	2 (18.2)	9 (81.8)	-	7 (63.6)	4 (36.4)	-
Hand hygiene promotion materials visible and understandable at key places	-	6(54.5)	5 (45.4)	4 (36.4)	7 (63.6)	-	8 (72.7)	3 (27.3)	-
The exterior of the facility is well-fenced, kept generally clean	-	8 (72.7)	3 (27.3)	2 (18.2)	9 (81.8)	-	4(36.36)	7 (63.6)	-
General lighting sufficiently powered and adequate to ensure safe provision of health care including at night	4(36.36)	7 (63.6)	-	7 (63.6)	4 (36.4)	-	8 (72.7)	3 (27.3)	-
Floors and horizontal surfaces appear clean	-	6(54.5)	5 (45.4)	2 (18.2)	9 (81.8)	-	3 (27.3)	8 (72.7)	-
Appropriate and well-maintained materials for cleaning (i.e., detergent, mops, buckets, etc.) are available	-	11 (100)	-	3 (27.3)	8 (72.7)	-	4 (36.4)	7 (63.6)	-
At least two pairs of household cleaning gloves and one pair of overalls or apron and boots in a good state, for each cleaning and waste disposal staff member	-	2 (18.2)	9 (81.8)	3 (27.3)	4 (36.4)	4 (36.4)	-	11 (100)	-
At least one member of staff can demonstrate the correct procedures for cleaning and disinfection and apply them as required to maintain clean and safe rooms	-	3 (27.3)	8 (72.7)	2 (18.2)	8 (72.7)	1 (9.1)	5 (45.4)	6(54.5)	-
Beds have insecticide treated nets to protect patients from mosquito-borne diseases	-	-	11 (100)	-	-	11 (100)	-	-	11 (100)

Advanced indicators also included the capacity of staff to manage cleaning and disinfection procedures. At baseline, only 3 facilities (27.3%) had a staff member who could demonstrate the correct cleaning procedures, but by endline, this increased to 5 facilities (45.4%). This improvement highlights the importance of training and capacity-building to ensure proper hygiene and sanitation practices within healthcare settings (Supplementary file S8, 9).

Infection control and waste management indicators

Infection control was assessed by evaluating waste management practices, which showed marked improvement during the study period. At baseline, no facility had a trained person responsible for healthcare waste management, and 9 facilities (81.8%) did not meet this requirement. By endline, 6 facilities (54.5%) fully met the standard, and the remaining 5 facilities partially met it, reflecting progress in waste management.

The availability of waste collection containers improved significantly. At baseline, 8 facilities (72.7%) partially met the requirement, and by the endline, 6 facilities (54.5%) fully met it. Waste segregation practices also improved, with only 2 facilities (18.2%) fully meeting the standard at baseline, increasing to 3 facilities (27.3%) by endline. The availability of a functional incinerator or alternative technology for treating infectious and sharp waste improved over time. At baseline, none of the facilities fully met this requirement, with 5 facilities (45.4%) not meeting it. By endline, 6 facilities (54.5%) fully met this requirement, highlighting a strong improvement in infection control infrastructure (Table 3).

Advanced indicators during baseline, demonstrated that only one facility had a dedicated pit for the disposal of anatomical waste. Post-intervention, it improved to three facilities. None of the facilities displayed protocol for the safe management of healthcare waste during baseline. During the endline, five facilities have displayed the protocol in the facility. During baseline, none of the facilities used personal protective equipment for waste disposal. Following the intervention, personal protective equipment was used in one facility (Supplementary table S10).

Management indicators

Essential indicators for assessment of management in health care facilities displayed that during baseline, WASH FIT or other quality improvement plan for the facility was in place only in two facilities. Following the intervention, during the endline, it was available in all facilities. Only three facilities had adequate cleaners and WASH maintenance staff available during baseline. Following the intervention, it was made available in six facilities during the endline (Table 4).

Table 4.

Assessment of management in health care facilities as per WASH FIT tool -Advanced indicator (n = 11)

Indicators	Baseline, n (%)			Midline, n (%)			Endline, n (%)
	FM	PM	NM	FM	PM	NM	FM	PM	NM
WASH FIT or other quality improvements/management plan for the facility is in place, implemented and regularly monitored	-	2 (18.2)	9 (81.8)	1 (9.1)	10 (90.9)	-	-	11 (100)	-
An annual planned budget for the facility is available and includes funding for WASH infrastructure, services, personnel, and the continuous procurement of WASH items (hand hygiene products, minor supplies to repair pipes, toilets) which is sufficient to meet the needs of the facility	5 (45.4)	6(54.5)	-	5 (45.4)	6(54.5)	-	6(54.5)	5 (45.4)	-
An up-to-date diagram of the facility management structure is clearly visible and legible	-	-	11 (100)	-	-	11(100)	-	-	11(100)
Adequate cleaners and WASH maintenance staff are available	3 (27.3)	8 (72.7)	-	5 (45.4)	6(54.5)	-	6(54.5)	5 (45.4)	-

Advanced indicators for assessment of management in health care facilities showed that during baseline, regular ward-based audits were undertaken only in two facilities. During the endline, it improved to nine facilities during endline. None of the facilities had a dedicated WASH or IPC focal person during baseline. During the endline, dedicated staff was available in three facilities following the intervention. During baseline, highly performing staff are recognized and rewarded in none of the facilities. Following the intervention, it was done in three facilities during the endline (Supplementary table S11).

Table 5 showcases the cumulative scores for all healthcare facilities depicting the status of WASH. From baseline to endline, the mean score of the water, sanitation, hygiene, and management components shows significant improvement in all components following the intervention. The WASHFIT tool had indicators classified into fully met, partially met and not met based on certain criteria. Using that scores were calculated for all the four domains across baseline, midline and endline (Fig. 3).

Table 5.

Status of WASH in health care facilities

Health care facility	Baseline (Mean ± SD)	Midline (Mean ± SD)	Endline (Mean ± SD)	P-value*
Water (15–45)	31.272.49	33.093.05	35.554.01	< 0.001
Sanitation (22–66)	35.09 ± 5.99	41.456.76	44.097.62	< 0.001
Hygiene (18–54)	27.45 ± 3.62	34.554.8	37.734.73	< 0.001
Management (11–33)	15.732.61	19.092.63	20.183.12	< 0.001

Fig. 3.

Cumulative score of all four WASH domains across baseline, midline and endline. (*p value calculated using repeated measures ANOVA)

The results of the study show a significant improvement in water, sanitation, hygiene, and waste management (WASH) infrastructure and practices in the healthcare facilities, particularly in the implementation of management plans and waste management systems. However, critical gaps remain in areas such as constant water availability, sanitation facilities, menstrual hygiene management, and accessible facilities for individuals with reduced mobility. The shortage of manpower remains a major challenge, as none of the facilities met the IPHS standards for essential human resources.

Overall, the findings underscore the need for sustained support and investment in WASH infrastructure, human resources, and continuous monitoring to achieve full compliance with national standards. The positive trends in essential, advanced, and additional indicators reflect the impact of supportive supervision and the potential for further improvements in healthcare service delivery.

Discussion

This facility-based intervention study in rural Jodhpur assessed water, sanitation, and infection control practices in healthcare facilities (HCFs) using the WASH FIT and Kayakalp tools. The study implemented supportive supervision to enhance these practices [23, 24]. Results support the effectiveness of this multi-modal intervention through supportive supervision. The evaluation covered various aspects of WASH, using different indices.

This study demonstrates that targeted interventions—namely structured training, supportive supervision, and governance through Infection Control Committees (ICC)—can significantly improve water, sanitation, hygiene, and infection control practices in healthcare facilities (HCFs) in resource-limited rural settings. The improvement across all WASH domains reflects the utility of comprehensive frameworks like WASH FIT and Kayakalp guidelines in enhancing environmental health standards within healthcare systems [23, 24].

Improved water, sanitation, and hygiene practices

Results showed significant improvement in water, sanitation, and hygiene (WASH) indicators from baseline to endline assessments, which supports findings from similar studies in low- and middle-income countries (LMICs) where structured interventions yielded substantial improvements in WASH compliance [25–28]. For example, midline and endline data indicate notable increases in water quality scores, meeting international water quality standards as advocated by WHO guidelines [29]. The results align with literature demonstrating that training on safe water handling, alongside infrastructure upgrades, can improve water quality and reduce health risks in HCFs [30–32].

Enhanced sanitation practices, evidenced by increased scores in this study, reflect improvements in waste disposal and environmental cleanliness, which are crucial for infection control. Similar studies have shown that structured sanitation interventions can lead to substantial reductions in environmental contamination, enhancing patient and staff safety [33–35]. Moreover, increases in hygiene scores post-intervention, such as hand hygiene practices, are critical given that handwashing is among the most effective infection control measures [36–38].

Intervention training and healthcare worker engagement

The study’s training module, covering essential WASH domains and infection control, produced marked improvements across facilities, as observed through increased WASH compliance scores. Training sessions were conducted using diverse, accessible materials (e.g., PowerPoint, pamphlets, and posters) tailored to the educational backgrounds of healthcare workers (HCWs). This approach reflects effective educational interventions in LMICs that have successfully used multimedia for HCW training, thereby enhancing knowledge retention and compliance [39–41].

The impact of training is further amplified when coupled with ongoing supportive supervision. Literature shows that supervision helps HCWs adhere to standard practices and identify areas requiring immediate corrective actions, thus promoting sustained improvements [42–44]. Our findings are consistent with those of related studies, which demonstrate that supervisory visits reinforce behavior change and compliance with protocols over time [45].

Infection control committees and supportive supervision

The establishment of Infection Control Committees (ICC) as a part of the intervention has been effective in sustaining WASH improvements in each facility. By involving multidisciplinary teams, ICCs facilitate collective responsibility for maintaining health standards and addressing deficiencies promptly. Studies indicate that the formation of such governance structures improves adherence to infection control practices and fosters a sense of ownership among HCWs [46–48]. Moreover, the decentralized nature of the ICC approach aligns with broader health systems strengthening strategies, where facility-level governance enables responsive, context-specific interventions [49, 50].

Supportive supervision by the ICCs involved unannounced visits and real-time feedback, which literature supports as effective for reinforcing hygiene practices, identifying non-compliance, and providing immediate corrective measures [51, 52]. Regular, supportive supervision has been highlighted as a critical factor in improving compliance with hand hygiene and sanitation protocols across similar resource-constrained settings [53].

Physical and microbiological environmental assessments

The use of microbial testing to assess environmental cleanliness, particularly in labour rooms, further validates the study’s impact on infection control. Our findings echo prior studies which suggest that environmental surface contamination is a significant vector for hospital-acquired infections, especially in critical areas such as delivery rooms [54, 55]. Studies employing microbiological assessments have shown that targeted cleaning and disinfection protocols reduce contamination and lower infection risks among patients and HCWs [56].

Water testing, conducted following WHO standards, identified improvements in physical and microbiological water quality parameters, ensuring safer drinking water. Evidence indicates that regular water quality assessments, combined with facility-based water treatment protocols, are integral to safe water supply in healthcare settings [57]. The study’s approach to periodic water testing and real-time corrective measures reflects practices recommended for improving water safety in HCFs [58].

The statistically significant improvements across all WASH domains underscore the effectiveness of the intervention and align with other studies using similar methods to demonstrate the impact of structured training and supportive supervision on WASH outcomes [18, 59–61]. Such analyses ensure that observed improvements are not merely chance findings but rather the result of systematic intervention.

Limitations and future directions

While the study demonstrates significant improvements, some limitations include a focus on one community development block, which may limit generalizability across other regions. Future studies could expand this model to multiple blocks or districts to evaluate broader applicability. Additionally, long-term assessments could provide further insight into the sustainability of interventions, addressing the need for longitudinal WASH studies in HCFs [62, 63].

Conclusion

This study highlights the effectiveness of structured interventions, supportive supervision, and the establishment of ICCs in improving WASH conditions in healthcare facilities. It offers a replicable model for resource-constrained settings, contributing to literature that advocates for capacity building and systematic supervision to enhance environmental health standards in HCFs.

Authors’ contributions

Sridevi and Manoj Kumar Gupta developed the concept of the study. Sridevi did the data collection. Vidhi Jain was involved in the processing of microbiological samples. Pankaj Bhardwaj, Akhil Goel, and Srikanth contributed equally to designing the study, and data collection. Formal statistical analysis, interpretations of manuscript development, and review were done by Sridevi, Manoj Kumar Gupta, and Vinoth. Pankaja Raghav did a review. All authors read and approved the final manuscript.

Funding

Indian council of Medical Research- MD Thesis grant.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethical approval obtained from Institutional Ethics Committee and all methods were performed in accordance with the relevant guidelines and regulations. Informed and written consent obtained from all the health care workers involved in the study.

Consent for publication

NA.

Competing interests

The authors declare no competing interests.