Qualitative assessment of the water and sanitation for health facility improvement tool (WASH FIT) implementation in Zimbabwe

Abstract

Inadequate water, sanitation, and hygiene (WASH) services in healthcare facilities (HCFs) put patients and HCF staff at risk of healthcare-associated infections. To facilitate continuous improvements of WASH services in Zimbabwe, the Water and Sanitation for Health Facility Improvement Tool (WASH FIT) program was implemented in 100 HCFs from August 2021 to May 2023. A qualitative study was conducted to describe the experiences and perceptions of WASH FIT implementation by HCF staff and government officers in four provinces of Zimbabwe through in-depth interviews. The findings revealed that WASH FIT has been recognized as a practical methodology, which can contribute to increasing WASH service availability, patient and staff satisfaction, and health service utilization. Constraints on financial resources, supplies, and personnel time and skills were noted as key implementation challenges. This study also highlighted that training might not have been adequate for HCF staff to fully internalize the methodology and five steps of WASH FIT. By mobilizing continuous and adequate financial resources and conducting adequate training for HCF teams, HCFs may further enhance the ownership and sustainability of WASH FIT implementation.

Introduction

Water, sanitation, and hygiene (WASH) is a key component of infection prevention and control (IPC) efforts in healthcare facilities (HCFs) [1, 2]. The COVID-19 pandemic highlighted the importance of key WASH practices, such as handwashing with soap and use of alcohol-based hand sanitizer [3]. The global coverage of WASH services in HCFs, however, remains low. The WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) revealed that in 2021, 49% of HCFs did not have basic hygiene services worldwide, leaving 3.85 billion people without basic services and at risk of infectious diseases [4]. Approximately 11% of HCFs and 857 million people had no water services, and 10% of HCFs and 780 million people had no sanitation service [4]. In 39% of hospitals and 27% of primary health care facilities, basic health care waste services were not available [4]. The global coverage of environmental cleaning services has not been estimated due to the limited availability of national data in many countries [4].

Inadequate WASH services in HCFs are key risk factors of healthcare-associated infections (HAIs) [5] and antimicrobial resistance [6] with a major disparity by income levels. Available evidence suggests that the pooled prevalence of HAIs ranges from 7.6% in high-income countries to 15.5% in low- and middle-income countries [7, 8]. In resource-constrained countries, HCF staff may also be demoralized by insufficient WASH service availability, which consequently leads to compromised quality of care, negative patient experience and dissatisfaction, and delayed health service seeking behaviors [9].

Global efforts on WASH in HCFs have been accelerated since the World Health Assembly passed a resolution in May 2019. The resolution called on WHO Member States to conduct assessments and take concrete actions to improve WASH and IPC measures in HCFs [10]. A global survey on IPC in HCFs was conducted in 2019 and highlighted that only 15.2% of HCFs met the minimum IPC requirements as per the WHO IPC Assessment Framework (IPCAF) [11]. To equip global communities with a key WASH improvement methodology and monitoring benchmarks, eight practical steps for WASH in HCF improvements were developed [12]. The Water and Sanitation for Health Facility Improvement Tool (WASH FIT) [13] may be used by countries to achieve these steps, from conducting assessments to improving infrastructure and monitoring progress.

WASH FIT is a risk-informed WASH quality improvement tool, which consists of five steps including: (1) team formation and training; (2) assessment of HCFs in water, sanitation, healthcare waste management, hand hygiene, environmental cleaning, energy, and HCF management and personnel domains; (3) risk assessment to prioritize areas for improvement; (4) development of WASH improvement plans and implementation; and (5) monitoring and continuous improvements of WASH services in HCFs [13]. WASH FIT has been implemented in over 50 countries [4], including Togo [14], Ghana [15], Kenya [16], and Zimbabwe [17].

In response to the global call for WASH in HCF actions, Zimbabwe has made progress on the five practical steps and employed WASH FIT as a guiding methodology to improve WASH services in HCFs. In 2020, a WASH FIT assessment was conducted in 50 HCFs with COVID-19 isolation areas to identify and address immediate WASH service gaps to protect patients and HCF staff [17]. Since 2021, UNICEF has supported the Ministry of Health and Child Care (MoHCC) on a WASH in HCF project in 100 HCFs with co-funding from the U.S. Centers for Disease Control and Prevention (CDC) and USAID’s Bureau of Humanitarian Assistance (BHA). The project also included Action Contre la Faim (ACF), Africa AHEAD (AA), and International Medical Corps (IMC) as implementing partners. The project activities consisted of: (1) WASH FIT training; (2) WASH FIT quantitative assessments at three time points, including baseline (August 2021), midline (October and November 2022), and endline (April and May 2023); (3) a WASH FIT qualitative assessment at midline; and (4) WASH IPC training, supply provision and infrastructure upgrades.

To date, few studies have explored people’s experiences and perceptions of the WASH FIT methodology and key barriers to scaling up WASH FIT implementation [14]. In Zimbabwe, evidence regarding the acceptability and practical applicability of WASH FIT has remained limited. To fill this evidence gap, this study was conducted as part of mixed-methods research to describe the experience and perceptions of WASH FIT implementation by HCF staff and government officers in four provinces of Zimbabwe. The results of the quantitative assessment will be described separately.

Methods

Study sites

This study was conducted in two metropolitan provinces (Harare and Bulawayo) and two rural provinces (Manicaland and Matabeleland South) of Zimbabwe. Shona is the main local language in Harare and Manicaland while Ndebele is a more common language in Bulawayo and Matabeleland. These provinces were selected for WASH FIT implementation and evaluation in consultation with MoHCC by considering the risk of COVID-19 and gaps in WASH infrastructure.

Participant selection

This qualitative study employed a purposive and stratified random sampling approach to select participants from various levels and HCFs. The targeted interviewees were two national-level officials, eight provincial-level officials (i.e., two per province), 14 district-level officials (i.e., two per district), and 90 staff from 30 HCFs. The 30 HCFs were selected from 100 WASH FIT intervention sites for this qualitative study. All the hospitals that received interventions (n = 7) were included to ensure adequate inclusion of large HCFs across four provinces. The rest of HCFs including health centers and clinics (n = 23) were sampled through stratified random sampling. In each selected HCF, participants were also purposively selected to explore experiences and perceptions of Nurses in Charge, Environmental Health Technicians (EHTs), and other HCF staff including cleaning staff. Additionally, sub-national government officials involved in WASH FIT implementation at the provincial and district levels were also interviewed to provide a comprehensive understanding of the program’s implementation and its effects on HCFs and services.

Data collection

In-depth interviews were employed to collect qualitative data using specific interview guides for each interviewee type. On average, each interview lasted for 45 min. To enhance uniformity in data collection, NIHR staff received training in qualitative research and data collection techniques before data collection began. Two teams of trained interviewers from NIHR conducted a total of 90 interviews. At the beginning of each interview, participants provided written informed consent after receiving an explanation of the purpose of this study, confidentiality, and the use of recording devices for transcription. Data were collected in English, Shona, or Ndebele. All interviews were recorded and transcribed verbatim. The transcripts in local languages were translated into English for analytical purposes.

Data analysis

This study performed thematic analysis to identify key themes on WASH FIT experiences and perceptions. Three analysts (MH, AM, AR) read transcripts multiple times to conduct coding. None of the analysts was directly involved in the interview process. A draft codebook was developed through open coding and the identification of a key code to group open codes (e.g., axial coding) [18]. Based on the initial codebook, three analysts independently coded 10 randomly selected transcripts, discussed discrepancies, and reached a consensus for the final coding. Microsoft Word was used for coding, and AM entered coded data to Microsoft Excel to summarize the number of codes that appeared in the transcripts. During this coding process, any emerging code was added to the codebook. Quotes were selected to highlight key points in each theme and covered both majority and minority perspectives.

Ethical approval and accordance

This study received ethical approval from the Medical Research Council of Zimbabwe (MRCZ/A/2947) and was conducted in accordance with the ethical principles of respect for persons, beneficence, and justice. CDC’s Institutional Review Board also reviewed the research protocols and relevant data collection instruments for this study, which was determined to be a non-research public health activity.

Results

A total of 89 people from Harare, Bulawayo, Manicaland, and Matabeleland Provinces and one national government staff were interviewed in this study (Table 1). The sub-national level participants included 13 provincial government officials, 9 district government officials, 26 nurses in charge, 10 environmental health technicians (EHTs), and 31 other HCF staff including 24 cleaning and maintenance staff. Of these interviews, 81 were fully transcribed and coded. However, due to various constraints, nine interviews were not transcribed. The reasons for this include: (1) language barriers where one interview was not fully translated; (2) audio quality issues where three interviews were not audible, making transcription difficult; and (3) data saturation where no new theme or insight emerged from the remaining five interviews. Table 1 below describes the participant characteristics of those interviews that were fully coded.

Table 1.

Number of WASH FIT interviews conducted in Zimbabwe in 2022

Personnel type	National govt	Provincial govt	District govt	Nurse in charge	EHT	HCF staff (general)	Cleaning/ maintenance staff	Total
Central Government (National) staff	1	0	0	0	0	0	0	1
Harare Province staff	0	3	1	7	1	1	7	20
Bulawayo Province staff	0	3	0	7	0	2	5	17
Matabeleland South Province staff	0	2	2	4	3	0	1	12
Manicaland Province staff	0	3	5	8	4	3	8	31
Total	1	11	8	26	8	6	21	81

Table 2 summarizes key themes, sub-themes, and categories identified from in-depth interviews. The three major themes identified are WASH FIT implementation, results, recommendations and plans. The sub-themes of WASH FIT implementation include training, awareness, assessment, team membership and roles, meetings, HCF activities, and improvement plans. The sub-themes of WASH FIT results include improvements and positive changes, remaining gaps, challenges, and perceptions. The sub-themes of WASH FIT recommendations and plans include additional implementation, recommendations for other HCFs, continuation and expansion.

Table 2.

Key themes, sub-themes, and categories identified from in-depth interviews on WASH FIT during 2022 in Zimbabwe

Themes	Sub-themes	Categories
Theme 1: WASH FIT Implementation	1.1. Training (394)	• Training status • Timing • Trainer • Contents • Adequacy • Request for Additional Training
	1.2. Awareness (127)	• General knowledge of WASH FIT by HCF staff • Knowledge of WASH FIT steps • Knowledge of WASH FIT domains
	1.3. Assessment (238)	• Participation status • WASH FIT forms and tools used • Appropriateness of WASH FIT assessment indicators
	1.4. Team Membership and Roles (507)	• HCF staff participation • Community participation • Skillset of WASH FIT team • Supervision and monitoring • Technical guidance and training • Newly created or existing team • Environmental cleaning
	1.5. Meetings (312)	• Participation status • Frequency • Meeting records and minutes • Chairperson • Encouragement for meeting participation • Topics covered
	1.6. HCF Activities (548)	• Frequency • Required resources • Source of resources and support • Supervision visits • Problem solving • Supply use
	1.7. Improvement Plans (157)	• Development of improvement plans • Timeline • Progress monitoring • Contents
Theme 2: WASH FIT Results	2.1. Improvements and Positive Changes (601)	• Health service utilization by patients • Patient and staff satisfaction • Reductions of infections and health improvements • Water supply and storage • Water availability for washing instruments, handwashing, cleaning, and sanitation facilities • Sanitation infrastructure • Handwashing infrastructure and behaviors • Waste management and separation • Environmental cleaning practice and cleanliness • Energy and solar geyser • IPC knowledge and measures • HCF management, protocols, and procedures • Utilization of improved WASH services and assessment findings • Tasks changed after the introduction of WASH FIT
	2.2. Remaining Gaps (155)	• Limited documentation • Water supply • Sanitation facilities • Handwashing infrastructure • Waste management • Energy availability
	2.3. Challenges (357)	• Staff shortage • Lack of skills • Contractor management • Time not a challenge • Senior management support not a challenge • Limited funding • Transport • Supply shortage • Funds not a challenge • Supplies not a challenge • Skills not a challenge
	2.4. Perceptions (410)	• Water improvements as the best part of WASH FIT • No worst part in WASH FIT • No negative experience • Perceived cost effectiveness of WASH FIT • Positive perceptions of WASH FIT by other HCF staff • WASH FIT tools working fine • WASH FIT approach working fine
Theme 3: WASH FIT Recommendations and Plans for the Future	3.1. Additional Implementation and WASH FIT Updates (285)	• More supervision visits • More training opportunities • Training for all cadres of HCF staff • More infrastructure upgrades • Inclusion of more people in WASH FIT team
	3.2. Recommendations for other HCFs (17)	• Acceptance • WASH FIT implementation • Monitoring and assessment support
	3.3. Continuation and Expansion (140)	• Willing to continue implementing WASH FIT • Willing to expand WASH FIT to other HCFs

Figures in parentheses show how many times sub-themes were coded through the listed categories

Theme 1: WASH FIT implementation

Training

The first major theme in this study was WASH FIT implementation. Most of the interview participants received WASH FIT training in 2021 or 2022 from the MoHCC and NGO partners as they were responsible for implementing WASH FIT interventions in their HCFs. While some participants were satisfied with the adequacy and quality of training, other participants requested additional training:

“WASH FIT facilitators were very fluent. It was very easy to understand, and the team participated so we benefited a lot” (Nurse in Charge, Manicaland).

“I need more training. It was really a rushed program” (IPC Focal Person, Manicaland).

Awareness

Regarding awareness of the five WASH FIT steps, a clear difference in the knowledge was noted across personnel types. While most provincial and district government staff demonstrated knowledge of the WASH FIT steps, less than a half of the HCF staff in this study, including nurses in charge, EHTs, and other HCF staff, were able to explain the steps. Some participants were not aware of the key steps but shared their knowledge of WASH FIT domains, such as water, sanitation, and hand hygiene. Other participants also shared the training content of another WASH/IPC training conducted in May 2022 (e.g., importance of cleaning floors from clean areas to dirty areas), similar to that of the WASH FIT training.

Some participants from all provinces and across all personnel also showed their understanding of WASH FIT as a project where external partners support infrastructure upgrades and supply provision in their HCFs rather than a facility-based tool.

Assessment

Interviews also provided insights into how the training prepared WASH FIT teams to use assessment forms and tools, which were perceived as useful to identify gaps in WASH services and inform their actions:

“Some of the things we didn’t know how to use them [WASH FIT assessment forms and tools]. But now, after training on WASH FIT, we now know what to do. The correct thing to do.” (EHT, Matabeleland South).

“[WASH FIT assessment forms and tools] are useful because they helped us to say we need a change in this area and in that area. And we are working hard right now with the assistance of WASH FIT to put in place those things which we didn’t have.” (Nurse in Charge, Bulawayo).

The perceived utility of WASH FIT assessment tools was common, but participants also shared mixed perspectives on the appropriateness of WASH FIT assessment indicators. While some participants shared that the indicators were appropriate, one of the participants shared that some indicators were not relevant:

“Some of them do not apply…not only to our clinics but to the Zimbabwe situation. They apply to private HCFs. For example, it asks about how much money we budget for payment of employees, but in these government institutions that is done centrally.” (EHT, Manicaland).

Additionally, other participants explained that some indicators were not applicable to small HCFs and a skip pattern needed to be inserted to avoid collecting information on irrelevant indicators.

The bottom-up approach of the WASH FIT assessment was also well received. One of the EHTs stated that:

“The best part of WASH FIT is that it is needs-based…It’s not like someone is coming from somewhere just to say, ‘I’m going to replace your window panes,’ but it is starting from the ground where we were saying we do an assessment of the facility. We note our needs and then we develop a plan from the needs that we note.” (EHT, Manicaland).

Team membership and roles

Interviews also covered the WASH FIT team membership and roles. While the exact WASH FIT team composition varied across HCFs, participants reported that it included key HCF staff members, such as Nurses in Charge, nurse aides, cleaning staff, and IPC focal persons. Additionally, EHTs and community members were mentioned as key members of the WASH FIT team. In some HCFs, a WASH FIT team was newly established, while other HCFs incorporated WASH FIT activities into the existing HCF team (e.g., IPC committee).

Three of the most mentioned WASH FIT team member roles are: (1) staff supervision; (2) monitoring; and (3) environmental cleaning. Other roles included community engagement, health education and promotion, resource mobilization, technical guidance on WASH services, training, and development and implementation of improvement plans.

Meetings

WASH FIT meetings were typically held at least once a month led by a Nurse in Charge, IPC focal person, or EHT. While WASH FIT team leaders in some HCFs were providing general encouragement for participation in WASH FIT meetings, participation did not require additional incentives. Some HCFs, however, shared how and why WASH FIT meetings may not be held regularly. One of the participants mentioned competing priorities as a barrier to conducting regular WASH FIT meetings:

“Due to some programs that come up, we are not able to meet every week or every month. We meet…once in a while when we have the time. Most of the staff will not be there. Maybe they will have gone on an outreach. Or in some instances, people will be off. So, for us to do it…it will be difficult, but when we get time, we sit down and talk” (Assistant Nurse in Charge, Matabeleland South).

A wide range of topics were covered in WASH FIT meetings, such as WASH services in HCFs, WASH FIT implementation progress, IPC measures, and security issues. Some of the common topics were environmental cleaning and hand hygiene as a part of COVID-19 prevention efforts:

“We discussed how we could maintain the place clean, or how we would improve or also how we could make sure that our clients wash their hands as they come in because they are not used to do that. But we are trying to make sure that every day there is someone at the gate with the sanitizer.” (Nurse in Charge, Harare).

HCF activities

Participants explained that some of the WASH FIT activities, such as staff supervision, monitoring, and environmental cleaning, were conducted on a daily basis. Supervision visits by national and sub-national government officers were completed less frequently (e.g., quarterly). These visits allowed HCFs to receive technical and operational guidance to improve the overall HCF operations and management, including WASH FIT-related activities.

Some of the key resource requirements for WASH FIT activities were personnel, funds, and supplies, which were provided by the MoHCC, local authorities, and UNICEF. NGOs and contractors primarily implemented WASH infrastructure upgrades in consultation with local authorities and relevant ministries. Additionally, participants highlighted results-based financing (RBF) as an alternative financial resource to address WASH-related issues in HCFs. Only a limited number of participants were aware of the amount of budget or funds spent for WASH FIT interventions.

Improvement plans

Most participants confirmed the development of WASH FIT improvement plans for their HCFs and shared that the timeline for plan development was realistic. The contents of improvement plans differed among HCFs to address their unique gaps in WASH services for patients and HCF staff. Regular progress monitoring and reviewing of the improvement plans was also evident as highlighted by one of the participants:

“As a team, I would say on a monthly basis, but locally, working on what is being rehabilitated, we normally look at it on a day-to-day basis. We monitor what is happening.” (EHT, Manicaland).

Theme 2: WASH FIT results

Improvements and positive changes

The second major theme identified in this study was WASH FIT results. Participants noted the immediate improvements of WASH services in HCFs following WASH FIT assessments and improvement plan development. More specifically, HCFs improved water supply and water storage, water availability for hygiene purposes, sanitation and handwashing infrastructure, waste management practices, environmental cleaning and cleanliness, and solar-based infrastructure (e.g., geyser, boreholes). Based on the improved WASH services and protocols from WASH FIT implementation, some HCF staff reported having changed the way they clean and manage their facilities. Additionally, increased health service utilization, patient and staff satisfaction, and reductions of infections were perceived as the results of WASH FIT implementation by some HCF staff. One of the provincial government officials explained how water availability benefited patients:

“There was this clinic without water. A patient will have to come with his or her bucket of water for them to be acknowledged. They [patients] had to fetch water but now they are at ease because of its availability. The difference was due to WASH FIT.” (Provincial government official, Manicaland).

A cleaning staff member also explained that adequate availability of water and supplies facilitated environmental cleaning and improved cleanliness:

“We are now having enough water…Our mops, they are always clean. Our area is always clean. It’s easy to be cleaning because we have got everything, and the toilets are always clean.” (Cleaning staff, Bulawayo).

WASH FIT also changed the mindset and actions of some HCF managers by highlighting the importance of constant monitoring and involvement throughout the WASH improvement cycle. A Nurse in Charge stated that:

“We never used to be so particular in these repair issues. We just used to maybe just report when there’s a need but now that I’ve noted that I should be actively involved in identifying the gaps. Then, I should also be involved when there’s maintenance. And recording on how the material is used and whether I think it’s the right quality so I think I’m sort of improved as the sister in charge.” (Nurse in Charge, Harare).

Other participants further explained how patients are motivated to receive health services at HCFs because of increased WASH service availability and improved cleanliness. Additionally, participants shared how WASH improvements resulted in fewer sick leaves among HCF staff:

“At the HCF with WASH FIT, mothers are now attracted to come and give birth.” (District government officer, Manicaland).

“We are seeing less infections, especially amongst our staff members…We have seen less of our staff going off sick due to illnesses because of this handwashing.” (Nurse in Charge, Bulawayo).

Remaining gaps

Some of the remaining WASH service gaps in HCFs mentioned by participants include inadequate WASH conditions in staff housing, inadequate waste management infrastructure (e.g., incinerators), and limited power availability. A HCF staff member from a large hospital also highlighted how one project could not cover all areas of the institution and a remaining gap in sanitation affects staff morale:

“Due to lack of resources, especially in our ward, there is no flushing system, poor drainage system and at times we don’t have cleaning detergents, so it doesn’t improve the morale of the staff. It demoralizes everything.” (Nurse Aid, Bulawayo).

Challenges

While some participants faced no challenge with WASH FIT implementation, others highlighted key implementation challenges, such as limited funds availability, supply and staff shortage, time constraints and competing priorities, contractor management, inadequate staff skills, and lack of transport for monitoring visits. One of the most common challenges was related to funding. One EHT explained how funding availability can be exacerbated by economic circumstances in Zimbabwe:

“The issues of funding are always an issue even for this program where we had external funding because of the nature of our economy or our environment. Some of the issues could not be undertaken because prices fluctuated beyond what was budgeted for, which implied that some of the issues that we had noted were not attended to.” (EHT, Manicaland).

A Nurse in Charge also noted a key challenge with operating upgraded WASH infrastructure without adequate training and support:

“We could fail to utilize some of the systems they [contractors] would have installed. Though maybe they would have taught us, but we [were] sort of forgetting, but we would call them back. Especially the solar system and electric system of pumping water into the clinic…We went out through the night without water because we forgot how to operate.” (Nurse in charge, Harare).

Perceptions

In general, WASH FIT is positively perceived and accepted by government officials. However, due to externally funded interventions being implanted at the same time as WASH FIT training and assessments, some Nurses in charge, and other HCF staff perceived it more as a package of funded WASH interventions rather than a facility-based tool. Some participants highlighted these externally funded interventions, such as training, supply provision, and improvements in water access, as the best part of WASH FIT. Others mentioned positive aspects of WASH FIT implementation itself, such as monitoring and ownership of WASH services by HCF staff as the best part of WASH FIT. A few negative perceptions of WASH FIT were raised in interviews, such as limited focus on staff housing, lack of compensation, risk of theft of infrastructure upgrades, and incomplete infrastructure upgrades.

A participant also shared that WASH FIT provides opportunities for HCFs to leverage multiple funding sources to support the improvement plan.

“WASH FIT is worth it and does not confine institutions to only one source of funding since it’s a plan, resources can come from the government, donors, IPs [implementing partners], HCFs, RBFs¸ [and] individuals.” (Provincial government official, Manicaland).

Respondents’ WASH FIT recommendations and plans for the future

Additional implementation and WASH FIT updates

The third theme identified was WASH FIT recommendations and plans for the future.

Some of the key recommendations for additional implementation include more supervision visits, WASH FIT training, infrastructure upgrades, supply provision, and inclusion of additional people in the WASH FIT team. HCF staff expressed their need to receive guidance and feedback from the supervision visits.

“I haven’t received reports [of] late on what their observations are, but I think they [supervision team] would need to avail those reports so that we know those areas that need to be attended to and the support they would give us as well.” (Administrator, Bulawayo).

WASH FIT training could also be conducted for all cadres of HCF staff to ensure that both clinical and non-clinical members appreciate the methodology and implementation approach. Another recommendation was to conduct regular refresher training including a review of WASH FIT topics each month.

While some participants were satisfied with the overall WASH FIT methodology and tools, others provided recommendations to improve WASH FIT tools. One of the key feedback messages was that WASH FIT tools were too long, and shorter tools and modules were recommended:

“One thing I’ve noticed is the tool, I tried to show you, it is too long. It is actually taking time for the people who should be doing something else…As you are going through the tool, you will see them. They are exhausted by the time they finished the WASH FIT” (Provincial government official, Harare).

Recommendations for other HCFs

Recommendations were also addressed to other HCFs that have not implemented WASH FIT. Participants suggested that they accept the methodology, understand the key steps for implementation, conduct an assessment to identify gaps, and regularly meet as a team to review progress. Additionally, a HCF staff member recommended that HCFs capture all issues through the WASH FIT assessment to address WASH gaps comprehensively:

“I would tell them to put down every challenge, and not to leave out any challenge…and maybe they should also delegate someone who is doing all the follow-ups so that everything will be tackled, and nothing would be left behind.” (Nurse, Matabeleland South).

Continuation and expansion

Interviews also revealed that participants are willing to continue with WASH FIT activities and expand them to other HCFs. Some participants expressed their interest in continuing with WASH FIT activities based on the existing improvement plans, while others recommended that WASH FIT be adopted by partners and additional HCFs. The key reasons highlighted for WASH FIT continuation were potential health benefits from WASH and IPC improvements and the utility of assessment and monitoring to identify gaps. One EHT summarized the reason for continuing WASH FIT and using improvement plans by stating that:

“WASH FIT has been quite good in managing our facilities because, besides improving the state of our facilities, it has also been an eye opener…how we can actually improve our facilities at the local level. Because…the issues of coming up with the improvement plans were not really taken seriously before, but when WASH FIT came, it was taken on board.” (EHT, Manicaland).

Discussion

This study explored the experiences and perceptions of WASH FIT participants in Zimbabwe by highlighting the implementation processes, challenges, improvements, remaining gaps, and recommendations for the future. The overall findings demonstrated that HCF staff members and government officials recognized WASH FIT as a practical methodology that leads to improved WASH service availability, patient and staff satisfaction, health service utilization, ownership of WASH interventions by HCFs, and reductions of infections and staff sick leave over time. The key implementation challenges were constraints on financial resources, supplies, and personnel time and skills.

In-depth interviews suggested that the WASH FIT training might not have been adequate for HCF staff to fully internalize the methodology and five steps of WASH FIT. While people were able to mention key WASH FIT domains, the implementation process was not well-recognized. As having adequate knowledge of the WASH FIT methodology is a key factor for HCF teams to own and implement WASH FIT activities [13], future trainings may provide a three-day training at all levels from national, sub-national, and HCF levels. In the current WASH FIT programming, the training of trainers (ToT) approach only covered national and sub-national levels for three days and held a short briefing session at HCFs. Additionally, refresher training and direct involvement with WASH FIT assessment may also result in the enhancement of knowledge and behaviors by HCF staff.

One key finding from this study was that some participants perceived WASH FIT as a funded package of interventions from the outside rather than owning it as an internal methodology. HCF staff may not conduct continuous monitoring and improvements if they expect additional WASH FIT resources to come from external sources. This finding contributes to understanding why some WASH FIT projects discontinue the methodology after a single round of interventions, as reported in a recent scoping review [19]. The ongoing and future WASH FIT programs are recommended to ensure that HCFs develop a sense of ownership across all steps of WASH FIT implementation. In the future, evaluations should be conducted as stand-alone exercises to better understand the acceptance and utility of WASH FIT without external funding.

This study also highlighted how some WASH FIT indicators were not relevant to HCFs depending on the size and conditions of HCFs, which is in accordance with the WASH FIT guidance [13]. Although WASH FIT includes over 90 indicators in total, not all of them are applicable to every HCF; HCFs may adapt the tool based on HCF size and programmatic contexts [13]. To enhance the usability of WASH FIT assessment tools, a previous study in Kenya proposed how WASH FIT assessment tools may be adapted to large HCFs and hospitals with 65 indicators [16]. To facilitate a facility-specific WASH FIT assessment, the future WASH FIT training at the HCF level may consider including a session on WASH FIT indicator selection. Alternatively, MoHCC may pre-select relevant indicators for primary HCFs and hospitals to facilitate the use of WASH FIT indicators.

Another key finding from this study was the limited availability of internal financial resources at HCFs to address gaps identified from the WASH FIT assessment. This finding is consistent with other WASH FIT studies in other countries [14, 20]. While the WASH FIT methodology promotes the ownership and sustainability of WASH services by HCF teams, financial resources may be a key barrier to continuous monitoring and improvements. MOHCC in Zimbabwe has implemented the results-based financing program (RBF) for HCFs to use some funds for HCF improvements; however, the allocated budget may not be adequate to conduct high-cost WASH infrastructure upgrades [21]. Moreover, few HCFs used their internal resources to make WASH improvements partially due to a lack of ownership of the WASH FIT methodology.

As WASH FIT and WASH in HCF efforts are relevant to antimicrobial resistance, workforce development, and infectious disease prevention, detection, and response, the budget for global health security and health systems strengthening programs may incorporate WASH FIT into their programming. Pooling government and development partner resources may also be considered to mobilize sufficient funds for the national rollout of WASH FIT in Zimbabwe.

Limitations

This study included a number of limitations and recommendations for future implementation research. First, this study was conducted when WASH infrastructure upgrades were being implemented at HCFs. Thus, interview participants could have been more prone to identify gaps in WASH infrastructure than challenges with training or other areas of WASH FIT implementation. The risk of collecting only one area of gaps and challenges was minimized by providing qualitative research training to data collection teams who asked probing questions and identified a wide range of gaps and challenges in this study. Second, this study did not collect data from patients and communities who might have provided additional perspectives on WASH FIT implementation. Future studies may conduct qualitative data collection with both patients and communities to understand WASH FIT experiences more holistically. Third, this study explored the experience and perceptions of WASH FIT when WASH in HCF programming was financially supported by development partners (e.g., CDC, USAID, UNICEF). The results could have been different if data collection had been conducted in HCFs without major external funding. Fourth, this study conducted interviews only in four provinces, and the number of interview participants was relatively higher in Manicaland than other provinces. While qualitative analysis reached saturation, additional perspectives on WASH FIT and WASH in HCFs could have been identified if other provinces were included. Finally, qualitative data were collected only at the midline assessment, whereas quantitative data were obtained three times. The absence of longitudinal qualitative data limited the study’s ability to explore temporal changes in WASH FIT stakeholders’ perceptions and experiences.

Conclusions

This study demonstrated that the Government of Zimbabwe, HCF leadership and staff members perceive WASH FIT as a useful and practical methodology. At the same time, the study noted key constraints, such as limited financial resources and gaps in ownership of the methodology. Strengthening facility-level ownership, providing adequate training, and adapting indicators to the facility context are critical for sustaining WASH FIT activities. Future studies may explore how the WASH FIT budget can be estimated to inform the government budgeting process, how WASH and Health programming can incorporate WASH FIT into the broader global health agenda on health systems strengthening, global health security, and emergency preparedness and response, and to what extent trained HCF staff sustained WASH FIT results over time. Expanding the evidence base and scale of WASH FIT implementation in diverse country contexts is a key step toward protecting patients and HCF staff worldwide.

Author contributions

MH, JM, NH, AM, AR, MC, BN, NS, CK, VN, NM, and TH conceptualized the study and wrote the proposal. AM trained data collectors. JM, MC, NH, EZ, WMN, and SS collected data. MH, AM, and AR analyzed the data. MH drafted the manuscript and incorporated all edits into the final draft. All authors reviewed and approved the manuscript.

Funding

The WASH FIT project was funded by the U.S. CDC and BHA.

Data availability

The audio recordings generated in this study are not available to the public for the sake of protecting participant confidentiality. Anonymized transcripts can be made available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study received ethical approval from the Medical Research Council of Zimbabwe (MRCZ/A/2947) and was conducted in accordance with the ethical principles of respect for persons, beneficence, and justice. CDC’s Institutional Review Board also reviewed the research protocols and relevant data collection instruments of this study, which was determined as a non-research public health activity. All participants provided written informed consent after being informed of the study’s purpose, confidentiality procedures, and the use of recording devices for transcription. Participants also understood and agreed that the findings would be used to inform public health interventions in Zimbabwe and other settings.

Consent for publication

Informed consent was obtained from all participants to publish the findings.

Competing interests

The authors declare no competing interests.