Global capacity for implementing the Eight Practical Steps to achieve universal access to water, sanitation, and hygiene in healthcare facilities: a qualitative study

Targets to achieve universal access to environmental health services include healthcare facilities. To support improvement efforts, the World Health Organization and UNICEF published the "Eight Practical Steps," a roadmap for countries to achieve universal access. This document provides clear directions, but many steps are ambitious, and countries readiness to complete them is unclear. We conducted a qualitative study to evaluate stakeholder readiness to implement the Eight Practical Steps and documented capacity development needs, using interviews with 45 participants. We applied an implementation science theory--organizational readiness for change--to structure our interviews around factors influencing readiness. Readiness was highest for conducting baseline situation assessments (Step 1), establishing standards (Step 3), improving infrastructure (Step 4), and strengthening the health workforce (Step 6). Readiness was enhanced by stakeholder cooperation, positive attitudes for change, and availability of tools for monitoring, risk assessment, and healthcare worker training. Capacity development was needed to tailor situation assessment tools, training materials, and standards for different contexts. Readiness for change was lower for developing costed roadmaps (Step 2), monitoring progress (Step 5), engaging communities (Step 7), and conducting operational research (Step 8). Stakeholders prioritized earlier steps and had not yet dedicated substantial effort or resources to later ones. Barriers included a lack of tools and guidance. Our results indicate enthusiasm and cooperation to improve environmental health services, but rapid action sometimes came at the expense of strategic planning and learning opportunities. We recommend strengthening funding, personnel, and technical support for planning, monitoring, evaluation, and operational research.