Barriers and Challenges of Implementing WASH FIT in Healthcare Facilities in Bangladesh

The World Health Organization and UNICEF developed the Water, Sanitation, and Hygiene Facility Improvement Tool (WASH FIT) as a continuous risk-based quality improvement tool to strengthen WASH services in healthcare facilities. Despite its increasing global adoption, evidence about the operationalization of WASH FIT in public health systems in resource-limited settings is still insufficient. Therefore, the study aims to investigate operational, institutional, and systemic barriers to WASH FIT implementation at 16 government healthcare facilities located across six divisions of Bangladesh in 2023. In-depth interviews, focus group discussions, participatory workshops, and key informant interviews were used to collect data, which were then thematically analyzed. The findings indicate that the implementation of WASH FIT is not hampered by a lack of awareness or acceptability, but rather by a fundamental misalignment between the tool's design and the realities of the decentralized public health system in Bangladesh. Five interrelated thematic barriers were identified: chronic workforce shortages that impede team-based implementation; insufficient training and limited technical capacity to operationalize complex assessment and monitoring requirements; lack of dedicated and flexible financing for WASH improvements; weak governance, accountability, and intersectoral coordination; and weak monitoring, feedback, and continuity mechanisms. These difficulties stopped WASH FIT from being consistently adopted and institutionalized. Effective scaling up and institutionalization require dedicated budget, simplified and digitized monitoring tools, regular training, protected time for WASH responsibilities, and intersectoral coordination between the health sector and local government authorities. Contextual adaptation of WASH FIT is critical for long-term improvements in WASH services at healthcare facilities.