icddr,b Study Reveals Poor Toilet Access, Hygiene in Dhaka Hospitals

Condition of a toilet at one hospital in Dhaka. icddrb.

Dhaka, Bangladesh: A recent study across 12 government and private hospitals in Dhaka found that 68% of government hospital toilets were functional, with only 33% clean, while in private hospitals, 92% were functional, but only 56% were clean. Conducted by icddr,b scientists in collaboration with partners at the University of Technology Sydney, Australia, and the Directorate General of Health Services (DGHS) at the Ministry of Health and Family Welfare Bangladesh, the study was recently published in the journal PLOS ONE.

Poor toilet access and hygiene pose significant health risks, potentially spreading diseases like cholera and typhoid. Proper sanitation and its accessibility are particularly crucial in hospitals, where disease-causing pathogens are expected to commonly circulate. The study evaluated 2,459 toilets in Dhaka's healthcare facilities to assess the availability, functionality, and cleanliness of toilets.

High user-to-toilet ratios were observed in outpatient facilities, with one toilet for every 214 users in government hospitals and 94 users in private hospitals, significantly below the recommended standards set by WaterAid. According to their guidelines for the construction of institutional toilets in outpatient facilities, there should be one toilet for every 20–25 patients or carers, up to the first 100 individuals, with an additional toilet for every additional 50 patients or carers.

Additionally, both government and private hospitals failed to meet the criterion of one toilet per six inpatient beds by the Bangladesh national WASH standard and implementation guidelines from 2021. There were 17 users for each toilet in government hospitals and 19 users per toilet in private hospitals. Beyond basic functionality, hygiene, and availability, less than 1% of toilets had facilities for disabled people, and only 3% of toilets had a trash bin for menstrual pad and solid disposal.

The researchers defined toilet functionality according to criteria used by the World Health Organization (WHO) and UNICEF and assessed toilet cleanliness based on the presence of visible faeces on any surface, strong faecal odour, flies, sputum, insects, rodents, and solid waste.

“The actual sanitation conditions in Dhaka hospitals may be worse than what we found as our study was conducted in the aftermath of the COVID-19 pandemic when many hospitals were shifting from mainly treating COVID-19 patients to general medical care. This could have led to reduced patient flow and toilet usage,” said icddr,b’s Associate Scientist and principal investigator of the study Dr Md. Nuhu Amin. Dr Nuhu Amin said directed increase in resources allocated for maintaining clean and working toilets in hospitals is needed, with a particular focus on meeting gendered needs and those of disabled persons.

Globally, there is a lack of studies characterizing toilet conditions and estimating user-to-toilet ratios in large urban hospitals in low- and middle-income countries (LMICs). Ensuring basic sanitation for all is a priority for countries to achieve the United Nations Sustainable Development Goals (SDGs) by 2030. The study addresses the research gap in LMICs and provides important data to drive policy changes at the national level to tackle the critical health problem of inadequate sanitation in healthcare facilities in Dhaka.