Integrating quality improvement approaches in health centres’ sanitation and hygiene promotion in Omoro District, Uganda

23 September 2021

Poor WASH services compromise the ability to provide safe and quality healthcare, which leads to high morbidity and mortality, and poses a significant economic and social burden. Safe water, functioning handwashing facilities, latrines, and hygiene and cleaning practices are especially important for improving health outcomes for both the general population and health workers.

In order to provide quality healthcare and reduce infections, facilities must have the appropriate infrastructure and staff capacities to provide safe, effective, equitable and people-centered services. However, this was poorly done in the health facilities within Omoro district, Uganda.  Health workers were at a higher risk of contracting diseases and the surrounding communities were at risk to hazards posed by healthcare waste.

This blog shows how USAID Regional Integration to Enhance Services – North Acholi (RHITES-N Acholi) project supported Omoro District Health Office to address this problem. The project introduced the Water Sanitation and Hygiene Facility Improvement Tool (WASH FIT) and integrated it with Quality Improvement Methodology.

This blog outlines the experience and outcomes of using these combined approaches with the hope to encourage other healthcare professionals to use and adapt these approaches in their healthcare facilities.

Training in WASH FIT and Quality Improvement Methodology

USAID Regional Integration to Enhance Services – North Acholi (RHITES-N Acholi) supported training of key health workers from health facilities and members of the District Health Management Team (DHMT) in Omoro district on water, sanitation and hygiene plus infection prevention and control (IPC).

Further training was done for members of DHMT on Quality Improvement and use of the WASH FIT tool. Trained members of the DHMT were assigned and supported to coach health workers at the health facilities on water, sanitation and hygiene plus infection prevention and control.

Methodology used

A baseline assessment was done using WASH FIT and this guided the district and project staff to support the district health facilities with drinking water jerrycans, color coded healthcare waste bins, information, education and communication materials, and personal protective equipment for waste handlers, handwashing facilities plus other facilities that promotes hygiene and sanitation in the healthcare facility.

After provision of all those facilities, a WASH FIT/Infection Prevention Control committee was set up in the health facilities.  Based on the gaps identified using WASH FIT, a quality improvement project was instituted by having onsite mentorship on WASH/IPC among health workers in the health facilities. Health facility staffs were also mentored on 5-S approach (Sort, set, shine standardized and sustain) which is the foundation of improving standards of care of patients through improved working environment

5S approach

  • In the first stage 5s (sort), items in the different sections of the health facility were distinguished between wanted and unwanted. For those which are unwanted (and also depending on the level of infectiousness or toxicity) they were put in the waste bins.
  • The second stage in the 5s (setting), health workers ensure that everything needed for work is put in the right place. Arranging things in such a way that they are easy to use for instance the colour coded waste bins were put in all strategic points where waste are being produced and those without a label were clearly labeled to show the kind of waste to be put in. Handwashing facilities were also put at their strategic location. This is because in most health facilities in developing countries do not have sinks or functional ones for handwashing therefore small containers are usually provided to serve as hand washing materials in health facilities. The cleaners ensure that all these facilities are put in the right places.
  • In the third stage of 5s (shine), cleaning was being done routinely and the health facility Manager inspects cleaning
  • The fourth stage is to standardize what has been achieved. This is through training, development of job description and work schedule. This was done for cleaners in most health facilities. This was to ensure that the first three (5s) becomes people’s habit. Protocols/ guidelines were developed and put into use by health facility staff. Incharges of the health facilities always do periodic visual inspection and also uses checklist to ensure that sanitation items are in place and rightly use by health workers, patients and caretakers.
  • For the fifth stage, to sustain the gains, Incharges of health facilities demonstrate what is required of him or her by talking about it in regular meetings and by doing regular audits. At the end of the calendar year rewards are given to good performing staffs.

5S is a simple and practical method to instill a quality culture at the workplace. It is relatively easy to undertake, and requires minimal additional resources. The first and small investment made in time and effort pays off in a much bigger manner when the results are realized and maintained. In this, the benefit of 5S is that workplace becomes cleaner, safer well organized and more pleasant. It is the foundation for improving standards of care of patients through improved working environment.

A Nurse at Ongako Health Centre using handwashing facility provided by RHITES-N Acholi project. Above her is are posters to remind health workers on handwashing
A Nurse at Ongako Health Centre using handwashing facility provided by RHITES-N Acholi project. Above her is are posters to remind health workers on handwashing

Changes implemented within the health facilities

  • Placing Step-by-step instructions (SOPs) and reminders on handwashing facilities (both in English and local language) in latrines and at all care points,
  • Daily review of cleaning rota, involving care givers and non-clinical staff in filling hand washing facility with water and,
  • Continuing Medical Education (CME) and health education,
  • Assigning focal person to oversee waste management,
  • WASH/IPC Committee monthly meetings, provision of book to document minutes.
  • Quarterly, mentorship and monitoring of progress on WASH indicators on the WASH FIT were continuously assessed and action points developed.

Results of intervention

After every assessment feedback was given and whenever there is a gap, action points were usually developed jointly by both health workers and the officer who did the assessment at the facility. The assessment is usually done using WASH FIT and by members of the District Health Management Team.

The dashboard below shows improvement between September 2018 to December 2020 as follows

  • Water indicators from 47% to 73%
  • Sanitation indicators from 63% to 92%
  • Hygiene indicators from 49% to 94%
  • Management from 50% to 83%


Integrating 5S and regular use of WASH FIT improves WASH indicators at facility level. The 5S is a good step in ensuring continuous improvement in sanitation in the healthcare facility. It is a process designed to organize the workplace, keep it clean, maintain effective standard conditions. It instills discipline among health workers which enable an individual to maintain a safe working environment.