Who is a Nurse?

Nurses provide a wide variety of services for people in all health care settings, from specialist hospitals to health posts and communities. Nurses hold a diverse set of job titles, roles, and educational paths. The six most common nursing job titles are registered nurse, nurse, licensed practice nurse, advanced practice registered nurse, nurse practitioner, and nursing assistant. However, the role of a nurse in one country may be different from the role of a nurse in another country, even if their job title is the same. This makes it not appropriate to use a job title as a method of classification and analysis at an international level. 

This report aims to present the best available, internationally comparable data on the nursing workforce, as defined by the ILO 2008 International Standard Classification of Occupations (ISCO-08) and reported and checked by WHO Member States. To help achieve this aim, the National Health Workforce Accounts (NHWA) use the ISCO-08 system to categorize the health workforce. Countries were asked to classify their nursing workforce into one of two main ISCO-08 codes: professional nurse (ISCO code 2221) and nursing associate professional (ISCO code 3221). The present section reports on nursing personnel as an occupational group defined above, but it should be noted that “nursing care”, putting the nursing personnel within a multidisciplinary health system, involves several

other occupations not described in the present section. For example, the ISCO classification and a country’s system following ISCO would classify “nurse aids” as health care assistants, a broader support occupational group. ISCO guidance provides detailed descriptions of which health workers should be counted under each category (Box A1.1). In summary, professional nurses assume responsibility for the planning and management of the nursing care of patients, working autonomously or in teams with medical doctors and others.

Nursing associate professionals provide basic nursing and personal care. Generally, they work under the supervision of medical, nursing, or other health professionals. However, in some countries, the distinction between professional and associate nurses and nurse aides is not clear.

In these cases, an element of judgment was required from national stakeholders. Countries were advised to consider both the roles and responsibilities, and the duration of pre- service education when deciding whether to classify an occupation group as professionals, associate professionals, or not nurses at all. For example, as a general rule, a professional nurse will have completed a pre-service education course lasting at least three years.

In case a country was not able to decide which category to use, NHWA included a “nurses: not further defined” option, and some countries opted to place some or all of their nursing employees into this category. This category corresponds to either nursing professionals or nursing associate professionals, but it excludes nursing aides, who belong to the health care assistant occupational group, not analyzed in the present report.

12 ILO International Standard Classification of Occupations: https://www.ilo.org/public/english/bureau/stat/isco/.

108    State of the world’s nursing 2020

Nursing Professional Tasks  

• Planning, providing, and evaluating nursing care for patients
• Coordinating the care of patients in consultation with other health professionals
• Developing and implementing care plans for the treatment of patients in collaboration with other health professionals
• Planning and providing personal care, treatments, and therapies, including administering medications and monitoring responses to treatment or care
• Cleaning wounds and applying dressings
• Monitoring pain and discomfort in patients and alleviating pain using therapies, including painkilling drugs
• Planning and participating in health education programmes, health promotions, and nurse education activities
• Answering questions from patients and families and providing information about prevention of ill-health, treatment and care
• Supervising and coordinating the work of other health workers
• Conducting research on nursing practices and procedures

Nursing Associate Professional Tasks

• Providing nursing and personal care and treatment and health advice to patients according to care plans established by health professionals
• Administering medications and other treatments to patients, monitoring patients’ condition and responses to treatment, and referring patients and
• their families to a health professional for specialized care as needed
• Cleaning wounds and applying dressings
• Updating information on patients’ conditions and treatments received in record-keeping systems
• Assisting in planning and managing the care of individual patients
• Assisting in giving first-aid treatment in emergencies

NOTE: Professional and associate professional nurses have different roles. These roles are clarified by the tasks listed above. Qualifications such as training arrangements can make distinctions between the two roles, but vary over-time and between countries.

Hand Hygiene for All

This section contains information from the World Health Organization’s brief titled “Hand Hygiene for All Initiative” and is available under the CC BY-NC-SA license.

This content provides insights into available strategies and approaches to hand hygiene improvement in health care facilities (HCFs) in support of the new United Nations Children’s Fund (UNICEF)/World Health  Organization (WHO) Hand Hygiene for All Initiative, including continuous interventions. This article uses legacy work and current evidence base and emphasizes the relationship between infection prevention and control (IPC) and water, sanitation, and hygiene (WASH) in HCFs. It also summarizes how collaboration is essential for improvement (in the context of the coronavirus disease response and beyond).

Introduction and Background

Access to quality health care for all is a human right. The United Nations (UN) have set goals to improve the quality of healthcare; however many HCFs still lack WASH and good IPC practices.

According to global estimates released in 2020 by WHO/UNICEF, 1 in 4 facilities lack basic water; 1 in 10 facilities have no sanitation; 1 in 3 facilities lack hand hygiene facilities at points of care; and 1 million of the 4.1 million maternal and neonatal deaths per year may be related to unhygienic birthing practices.

In Key Facts and Figures from the World Health Organization (WHO) site, it states, “The scientific evidence overwhelmingly demonstrates that appropriate hand hygiene is the single most effective action to stop the spread of infection, while integrated with other critical measures” (2021). According to PW Schreiber et al., effective IPC measures could reduce health care-associated infections by as much as 55%. H. Blencowe and S. Cousens state that newborn survival rates could potentially increase by 44% when hand washing and clean birthing kits are in place.

In 2005, WHO launched the First Global Patient Safety Challenge Clean Care is Safer Care and 142 countries pledged their commitment, allowing them to initiate powerful actions to reduce infections occurring during healthcare delivery through the promotion of IPC measures and improvements in WASH4. Building on this strong foundation, the SAVE LIVES: Clean Your Hands5 global campaign was launched in 2009 by marking the first world hand hygiene day on May 5. It continues with a different theme proposed each year.

In 2003 and 2010, two important acknowledgments, considered essential to human rights,  and focused on improving hand hygiene, were made within and outside of healthcare:

1. The right to water entitles everyone to have access to sufficient, safe, acceptable, physically accessible, and affordable water for personal and domestic use.
2. The right to sanitation entitles everyone to have physical and affordable access to sanitation in all spheres of life that is safe, hygienic, secure, and socially and culturally acceptable and that provides privacy and ensures dignity.

Furthermore, the 2018 Global Call to Action on WASH in HCFs by the United Nations Secretary-General has raised this issue among all United Nations agencies, partners, and Member States.  All 194 WHO Member states unanimously approved a resolution on WASH in HCFs at the 2019 World Health Assembly.8

The resolution invites countries to strengthen WASH and IPC in HCF by establishing baselines and setting targets, embedding WASH and IPC in key health programmes and budgets, and regularly reporting on progress. These rights provide an important basis to comprehensively address WASH and IPC needs in HCFs.  

In response to the COVID-19 pandemic, WHO, UNICEF, and other stakeholders called upon governments to place hand hygiene at the heart of strategies to protect patients, communities and  health workers from the virus as a basic, achievable, and simple intervention.  

On 1 April 2020, WHO issued a formal recommendation for all Member States to 1) Provide universal access to public hand hygiene stations and make their use obligatory, and 2) Improve access to and the practice of hand hygiene in HCFs9.

On June 26, 2020, WHO and UNICEF  launched the new Hand Hygiene for All Initiative which aims to create a culture of hygiene to support the implementation of these recommendations. There were two specific measures:  

1. Reinforcing the importance of hand hygiene to reduce the spread of COVID-19 and other communicable diseases - within the context of the pandemic and beyond - through policies,  regulation, innovation, private sector engagement, and behavior change strategies.
2. Calling to action international partners, national governments, the public and private sectors, the civil society, and donors and financers to accelerate progress on hand hygiene at the global, national, and community levels.

Hand Hygiene at the Heart of the Core components for Effective IPC Programmes

IPC is an evidence-based and practical solution designed to prevent harm to patients and health workers at every healthcare encounter by stopping the spread of infection through best practices. WHO has identified eight core components that make IPC programmes impactful and effective (10).

WASH provides the necessary infrastructure, materials, and equipment to enable the implementation of appropriate IPC practices and behavioral change among health workers and the community. WASH has critical connections to the IPC core components. To visualize how important it is for all actors to recognize WASH in the role of achieving IPC going forward, Box 1 shows how WASH forms the building blocks in relation to the IPC core components, and not just where hand hygiene is specifically noted.

Box 1: WASH as building blocks for IPC in health care: a summary of key principles related to the IPC core components

• In the context of IPC programmes, the IPC team within a facility should have established links and communication mechanisms, particularly with those providing waste management, sanitation, and water supply services.
• IPC guidelines should include reference to waste management, adequate access to safe water, a reliable electricity supply, sanitation, and environmental cleaning.  
• Building and continuously operating and improving the WASH infrastructure is a critical element of multimodal strategies, which have proven to be the most successful approach for implementing IPC interventions in health care.
• IPC monitoring should provide information on the existence and functioning of the WASH infrastructure,  such as water and electricity supplies, toilets, and health care waste disposal and treatment (11).

To provide clean care and combat outbreaks, antimicrobial resistance, and ongoing infections in health care, countries need to have effective IPC programmes and functioning WASH services in place.

To achieve strong, effective IPC programmes at the national and facility level, countries should have at least the minimum requirements in place12 as these represent the starting point for providing basic protection and safety to patients, health workers, and visitors, and to progressively fully establish all  IPC core components.

WASH is represented in the IPC core component 8 (Built environment, materials and equipment for  IPC), which recommends that patient care activities should be undertaken in a clean and/or hygienic  environment that facilitates practices related to the prevention and control of infection. This includes  all elements related to the WASH infrastructure and services, as well as the availability of appropriate  IPC materials and equipment. The minimum requirements for core component 8 are summarized in  Box Table 1.

These standards draw upon a more comprehensive, but still minimal set of WASH services that  should be in place in all HCFs13. These include aspects of water quality and quantity for cleaning, bathing, drinking, hand washing, sanitation, safe health care waste management, and vector control. More recent WHO guidance on drinking water, sanitation and health care waste provide a strong basis for improving and regulating WASH in HCF (14-16).

Evidence on hand hygiene supports all the core components especially core component 5 (that is, using “multimodal strategies” for effective IPC interventions) in particular (17).

Two Strong Hand Hygiene Recommendations

There are two strong hand hygiene recommendations made in the WHO guidelines on the core components of IPC programmes, as critical evidence on hand hygiene formed a large part of their developments.  

Core Component 8 Recommendation

Materials and equipment to perform appropriate hand hygiene should be readily available at the point of care. An appropriate infrastructure including the HCF building. The availability of safe water and sanitation facilities according to international and national standards is an essential requirement.

Core Component 6 Recommendation

Hand hygiene monitoring and criticism should be a key performance indicator at the national level. Acquiring data and providing timely information are critical elements that can help tailor a strategy so gaps can be addressed, thus promoting the ideal behavioral change (sustained hand hygiene by frontline health providers). Similarly, aspects of the infrastructure need to be addressed in order to achieve the standards. Resources on WASH in HCFs support this step and efforts to align standards should allow the recommendations for obligatory hand hygiene stations to be addressed, as outlined in the improvement strategy.

Translating Guidelines into Actions: WHO’s Strategy & Global Campaigns on Hand Hygiene and WASH in HCFs

WHO’s Multimodal Hand Hygiene Improvement Strategy (MMIS) and Global Campaign

Over the last 15 years, WHO has promoted a MMIS and a global campaign to engage and support countries and facilities worldwide to achieve comprehensive enhancement of hand hygiene practices in health care.  

Multimodal means that multiple elements, all essential and complementary, must be put in place as part of interventions to achieve outcome improvements and optimal hand hygiene behavioral change.  

The MMIS has proven to be highly effective, leading to a significant improvement of key hand hygiene indicators, a reduction of health care-associated infections and antimicrobial resistance, and substantially helping to stop outbreaks.  

For these reasons, it is actively encouraged to support the two specific core components’  recommendations to be addressed at this critical and opportune time in relation to hand hygiene and improved WASH in HCFs.

The WHO MMIS includes five critical elements to be implemented at the facility level in an integrated manner (shown in Box 3).  

Alcohol-based hand rubs are the preferred method for hand hygiene as they offer a broad antimicrobial spectrum, are highly effective, well tolerated by the skin, and can be made available at the point of care, thus overcoming key behavioral barriers to compliance in health care. Supplies, clean water and facilities for hand washing are also needed for specific uses in HCFs. Hospitals in low-middle-income countries face the challenge of securing a reliable and continual supply of alcohol-based hand rub. However, there are many countries that have successfully established local ABHR production within their facility using the WHO-recommended formulations18. It is imperative that a facility makes alcohol-based hand rub of an adequate quality continuously available and at the point of care.  

A wide range of implementation resources and tools (see also Annex) are available to support countries and represent a framework for implementing the hand hygiene MMIS and developing a  locally-adapted plan for hand hygiene promotion.

Through the SAVE LIVES: Clean Your Hands global campaign5, every year on and around 5 May,  WHO renews its support to countries and facilities worldwide and promotes innovation to achieve improvements in hand hygiene practices in health care.  

In collaboration with the IPC programme at Geneva University Hospitals (Switzerland), WHO proposes a different theme every year as the campaign focus, as well as promotional and technical tools and activities to be conducted locally and internationally. The annual campaign addresses a wide range of audiences in the health sector, ranging from IPC professionals to all frontline staff, senior managers, health leaders and patients and their families. In the context of the campaign, WHO has conducted eight global surveys on hand hygiene and other IPC indicators.

WASH in HCFs

WHO and UNICEF, together with over 100 partners, have committed to support countries in implementing the World Health Assembly resolution and the 2018 Global Call to Action on WASH in  HCFs by the United Nations Secretary-General. One year after the resolution, 38 countries have made progress on implementing the resolution, especially on updating national standards, establishing baselines and empowering the health workforce. This global vision and associated targets guide future efforts and WHO and UNICEF have established a global portal (www.washinhcf.org) to share tools and experiences, and stimulate commitments and further action.  

Vision

Every HCF has the necessary and functional WASH services and practices in order to provide quality essential health services for everyone, everywhere.

Targets

Basic services

• By 2022, 60% of all HCFs worldwide and in each of the Sustainable Development Goals’ regions have at least basic WASH services. 
• By 2025, 80% have basic WASH services.
• By 2030, 100% have basic WASH services.(19) 

Higher service levels

• By 2022, higher levels of service are defined and monitored in countries where universal basic  WASH services have been achieved already.
• By 2030, higher levels of WASH services are achieved around the world in 80% of these countries.

WHO/UNICEF guidance on practical actions that countries can take to achieve universal access to  WASH in HCFs provides an important framework to guide efforts and track progress (19).  

WHO/UNICEF guidance indicates eight practical steps which are based on a distillation of “what  works” in over 30 countries. Specific steps include defining national roadmaps and setting targets,  establishing and implementing national standards, engaging communities, and conducting  operational research and learning.

At the facility level, WASH improvements and ongoing operation and maintenance are guided by the  Water and Sanitation for Health Facility Improvement Tool (WASH FIT) (20). WASH FIT builds upon water and sanitation safety planning and is an incremental, risk-based approach to assessing, prioritizing,  and continuing to make WASH improvements. It covers four main areas (water, sanitation, health care waste, and hygiene) and is based on existing WHO drinking water (14), sanitation (21), and environmental health (13) standards. It has been implemented in over 30 countries and has recently been adapted to focus on key elements relevant to COVID-19, including water supply and soap for hand hygiene. All the training materials, together with hundreds of other resources, can be found on the global WASH in  HCF knowledge portal (www.washinchf.org).

WHO and UNICEF have conducted joint training on WASH FIT implementation in the context of  COVID-19 and beyond, for over 500 partners. The two organizations continue to offer technical support to countries to implement the WASH FIT.

What collaboration looks like on the ground – the story of Ghana

Improving the quality of care requires WASH and IPC to be prioritized at all levels of a health system.  Ghana presents a compelling story of how WASH and IPC moved from being low to high priority, both nationally and across its health facilities. Policies were out of date and health workers often did not understand the importance of IPC practices like hand hygiene, appropriate use of personal protective equipment, and proper environmental cleaning. In 2016, 30% of facilities across Ghana did not have access to basic water services (22) , and even if hand hygiene was understood, performing it was almost impossible. These gaps in WASH and IPC resulted in high rates of healthcare-associated infections (for example, 19% of babies born at the hospital had sepsis and jaundice (22)), as well as longer hospital stay, loss of productivity, increased health costs, patient and family suffering, and even death.  

Improvement efforts involved a multimodal approach, including engagement by national health authorities and investment in training, the development of IPC champions, improved infrastructures,  including ensuring soap availability and the local production of hand sanitizer, and measurement and feedback.  

These nationally-driven changes were supported by development partners and led to what has been described as a transformational change at the health facility level, greatly improving outcomes for patients and the population. In recent months, building on previous efforts, Ghana has worked to further strengthen  WASH and IPC as part of its preparedness and response efforts in the context of COVID-19. Using a  multimodal approach, hand hygiene infrastructures and practices continue to be the focus of attention.  HCF staff have been further trained on WASH, IPC, safe burials, and waste management. At the lowest level of facilities (community-based service delivery locations for primary health care), water has been made available.  

"Ghana understands the  

importance of WASH and  

IPC and its relationship to  

patient safety and quality "

The Ghana story shows the understanding of the importance of WASH and IPC and its relationship to patient safety and quality and that - improving the process of care through better hand hygiene is a matter of quality.  

There has been recognition that all actors in the health arena must commit to prioritizing IPC and WASH in the health infrastructure and overall quality in service delivery for improvements to be viable. Indeed,  the national quality strategic plan includes indicators on WASH and IPC and the health facility regulatory agency verifies that facilities have these services in place before they can be accredited. In addition, the infrastructure unit of the ministry of health has the responsibility to ensure compliance.

The way forward

In the context of current efforts of the Hand Hygiene for All initiative to improve hand hygiene access  and practices in health care, the following key actions (5-year timeline) are proposed:

Global level

• Review and map what major stakeholders, such as the World Bank, other United Nations partners, and non governmental organizations, are doing in HCFs in terms of HCFs design and WASH provision.
• Identify key indicators for hand hygiene in HCFs in the context of outbreaks (short-term).
• Conduct evidence reviews on critical hand hygiene topics, such as determinants of health workers’  behavior (short- and medium-term).
• Continue to update and share data on access to WASH in HCFs (WHO/UNICEF Joint Monitoring  Programme)1 and in implementing practical steps to improve WASH in HCFs (medium- and long term) through reporting on the World Health Assembly resolution.
• Update the hand hygiene implementation tool package (short- and medium-term).
• Update global hand hygiene guidelines (medium- and long-term).
• Make smartphone/tablet applications/tools available for point-of-care hand hygiene improvements and monitoring (short- and medium-term), including through WASH FIT.
• Support countries to achieve improvements in hand hygiene access and behavior in health care facilities (short-, medium- and long-term).
• Complete a global investment case and provide costing tools for planning and improving WASH in  HCFs, including hand hygiene (short- and medium-term).
• Work with innovators to design cost-effective hand hygiene facilities for HCFs in low-cost settings  (short- and medium-term).
• Expand collaborative activities/efforts to other streams of work, such as antenatal care. For example, take advantage of antenatal care to promote hand hygiene during antenatal visits.

Country level

• Define a comprehensive approach across teams to address IPC, using hand hygiene as the entry point, as a key component to improve quality of care at facility and community level. 
• Assess the implementation of hand hygiene in a representative sample of all types of HCFs  (including primary care and long-term care facilities) in the context of the WHO minimum requirements for IPC programmes (short- and medium-term).
• Create action and budget plans to make hand hygiene accessible at the point of care and in toilet facilities in all HCFs as part of wider WASH improvements in infrastructure and supplies procurement (short- and medium-term).
• Conduct a market scoping exercise on the most cost-effective approach to make alcohol-based hand rubs available in all HCFs (short- and medium-term).
• Make necessary system changes (both WASH infrastructure and supplies procurement improvements) to make hand hygiene available at the point of care (short- and medium-term) and in toilets.
• Invest in health workers’ capacity development on hand hygiene and IPC in HCFs as part of a MMIS and create hand hygiene programmes in all acute care facilities at the very least (short- and medium-term). 
• Work with implementation research teams to develop models for working with expectant mothers to promote hand hygiene also in home settings (medium- and long-term).
• Monitor hand hygiene indicators at least in all acute care facilities (short- and medium-term) and across the health system (medium- and long-term). Other indicators for consideration include health care-associated infections, antimicrobial resistance, bed occupancy rates, staff to bed ratios, functionality of WASH services and adherence to hygiene protocols.

Annex

Table of resources

References

(1) WHO/UNICEF JMP. 2020 (https://www.washdata.org, accessed 22 September 2020)).

(2) Blencowe H and Cousens S. Addressing the challenge of neonatal mortality. Trop Med Intern Health 2013; 18: 303–312. (https://pubmed.ncbi.nlm.nih. gov/23289419/, accessed 23 June 2020).

(3) Schreiber PW, Sax H, Wolfensberger A, Clack L, Kuster SP. The preventable proportion of healthcare-associated infections 2005-2016: systematic review and  meta-analysis. Infect Control Hosp Epidemiol 2018;39:1277–95.

(4) Health care without avoidable infections. Geneva: World Health Organization; 2020 (https://www.who.int/infection-prevention/publications/ipc-role/en/,  accessed 23 June 2020).

(5) https://www.who.int/infection-prevention/campaigns/clean-hands/en/ 

(6) General comment no. 15: the right to water. Geneva: Office of the United Nations High Commissioner for Human Rights; 20 January 2003 (https://www.refworld. org/pdfid/4538838d11.pdf, accessed 23 June 2020).

(7) Sixty-fourth United Nations General Assembly. Resolution A/RES/64/292, July 2010. The human right to water and sanitation (https://undocs.org/en/A/ RES/64/292, accessed 23 June 2020).

(8) World Health Assembly (WHA 72). 2019. Agenda Item 6.6, Patient safety. Resolution on water, sanitation and hygiene in health care facilities. Geneva: World  Health Organization; 2019 (http://apps.who.int/gb/ebwha/pdf_files/EB144/B144_R5-en.pdf).

(9) Recommendations to Member States to improve hand hygiene practices to help prevent the transmission of the COVID-19 virus. Geneva: World Health  Organization; 2020 (https://www.who.int/publications-detail/recommendations-to-member-states-to-improve-hand-hygiene-practices-to-help-prevent-the transmission-of-the-covid-19-virus, accessed 23 June 2020).

(10) Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health  Organization; 2016 (https://www.who.int/infection-prevention/publications/core-components/en/, accessed 23 June 2020).

(11) Core questions and indicators for monitoring WASH in health care facilities in the Sustainable Development Goals. Geneva: World Health Organization/UNICEF;  2018 (https://www.who.int/water_sanitation_health/publications/core-questions-and-indicators-for-monitoring-wash/en/, accessed 23 June 2020). 

(12) Minimum requirements for infection prevention and control programmes. Geneva: World Health Organization; 2019 (https://www.who.int/infection-prevention/ publications/core-components/en/, accessed 23 June 2020).  

(13) Essential environmental health standards in health care. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/bitstream/ handle/10665/43767/9789241547239_eng.pdf?sequence=1&isAllowed=y, accessed 15 June 2020).

(14) Guidelines for drinking-water quality, 4th edition, incorporating the 1st addendum. Geneva: World Health Organization; 2017 (https://www.who.int/water_ sanitation_health/publications/drinking-water-quality-guidelines-4-including-1st-addendum/en/, accessed 15 June 2020).

(15) Safe management of wastes from health-care activities / edited by Y. Chartier et al. – 2nd ed. Geneva: World Health Organization; 2014. (https://www.who.int/ water_sanitation_health/publications/wastemanag/en/, accessed 5 August 2020)

(16) Guidelines on sanitation and health. Geneva: World Health Organization; 2018. (https://www.who.int/water_sanitation_health/publications/guidelines-on sanitation-and-health/en/, accessed 5 August 2020).

(17) Evidence of hand hygiene as the building block for infection prevention and control. Geneva: World Health Organization; 2017 (https://www.who.int/infection prevention/tools/core-components/evidence.pdf?ua=1, accessed 23 June 2020).

(18) Guide to local production: WHO-recommended handrub formulations. Geneva: World Health Organization; 2015. (https://www.who.int/infection-prevention/ tools/hand-hygiene/handrub-formulations/en/, accessed 5 August 2020).

(19) WHO/UNICEF. WASH in health care facilities: practical steps to achieve universal access to quality care. Geneva: World Health Organization; 2019 (https://www. who.int/water_sanitation_health/publications/wash-in-health-care-facilities/en/, accessed 17 July 2020).

(20) WHO/UNICEF. Water and sanitation for health facility improvement tool. Geneva: World Health Organization; 2018 (https://www.who.int/water_sanitation_ health/publications/water-and-sanitation-for-health-facility-improvement-tool/en/, accessed 17 July 2020).

(21) Guidelines on sanitation and health. Geneva: World Health Organization; 2018 (https://www.who.int/water_sanitation_health/sanitation-waste/sanitation/ sanitation-guidelines/en/, accessed 17 July 2020).

(22) Hand hygiene – a driver of quality care. Geneva: World Health Organization; 2019 (https://www.who.int/news-room/feature-stories/detail/hand-hygiene-a-driver of-quality-care, accessed 22 September 2020).