Access to and challenges in water, sanitation, and hygiene in healthcare facilities during the early phase of the COVID-19 pandemic in Ethiopia: A mixed-methods evaluation.

BACKGROUND: Inadequate water, sanitation, and hygiene (WASH) in healthcare facilities (HCFs) have an impact on the transmission of infectious diseases, including COVID-19 pandemic. But, there is limited data on the status of WASH facilities in the healthcare settings of Ethiopia. Therefore, this study aimed to assess WASH facilities and related challenges in the HCFs of Northeastern Ethiopia during the early phase of COVID-19 pandemic.
METHODS: An institution-based cross-sectional study was conducted from July to August 2020. About 70 HCFs were selected using a simple random sampling technique. We used a mixed approach of qualitative and quantitative study. The quantitative data were collected by an interviewer-administered structured questionnaire and observational checklist, whereas the qualitative data were collected using a key-informant interview from the head of HCFs, janitors, and WASH coordinator of the HCFs. The quantitative data were entered in EpiData version 4.6 and exported to Statistical Package for Social Sciences (SPSS) version 25.0 for data cleaning and analysis. The quantitative data on access to WASH facilities was reported using WHO ladder guidelines, which include no access, limited access, and basic access, whereas the qualitative data on challenges to WASH facilities were triangulated with the quantitative result.
RESULTS: From the survey of 70 HCFs, three-fourths 53 (75.7%) were clinics, 12 (17.2%) were health centers, and 5 (7.1%) were hospitals. Most (88.6%) of the HCFs had basic access to water supply. The absence of a specific budget for WASH facilities, non-functional water pipes, the absence of water-quality monitoring systems, and frequent water interruptions were the major problems with water supply, which occurred primarily in clinics and health centers. Due to the absence of separate latrine designated for disabled people, none of the HCFs possessed basic sanitary facilities. Half (51.5%) of the HCFs had limited access to sanitation facilities. The major problems were the absence of separate latrines for healthcare workers and clients, as well as female and male staffs, an unbalanced number of functional latrines for the number of clients, non-functional latrines, poor cleanliness and misuse of the latrine. Less than a quarter of the HCFs 15 (21.4%) had basic access to handwashing facilities, while half 35 (50%) of the HCFs did not. The lack of functional handwashing facilities at expected sites and misuse of the facilities around the latrine, including theft of supplies by visitors, were the two most serious problems with hygiene facilities.
CONCLUSION: Despite the fact that the majority of HCFs had basic access to water, there were problems in their sanitation and handwashing facilities. The lack of physical infrastructure, poor quality of facilities, lack of separate budget to maintain WASH facilities, and inappropriate utilization of WASH facilities were the main problems in HCFs. Further investigation should be done to assess the enabling factors and constraints for the provision, use, and maintenance of WASH infrastructure at HCFs.

Background

The provision of water, sanitation, and hygiene (WASH) facilities plays a crucial role in the reduction of healthcare-acquired infection (HCAI). Proper utilization of these facilities in healthcare settings is considered as a cornerstone for providing good quality care [1]. The common prevention measures against HCAI are source control, respiratory hygiene, early identification and isolation of patients with suspected disease, handwashing, and use of personal protective equipments (PPE) [2, 3].

The issue of adequate WASH is a regional problem in countries around the world, it is most severe in low-and middle-income countries (LMICs), including Ethiopia [4]. It is usually aggravated by the presence of a weak healthcare system and insufficient investment in healthcare safety. Hence, the implementation of proper infection prevention and control measures is challenging due to inadequate supplies of PPE. During the COVID-19 pandemic, adequate care of COVID-19 patients and prevention of HCAI among healthcare workers is difficult because of simple, but often neglected factors such as a lack of water [5]. Around 1.4 million people are affected by a lack of clean and safe healthcare facilities around the world. The problem is 2 to 20 times higher in low-resource countries than in developed countries [6].

A quarter of HCFs worldwide lack basic water services, exposing 1.8 billion people at risk, especially the most vulnerable groups of the population, such as healthcare workers and patients that attend HCFs. Furthermore, one-third of HCFs lack hand hygiene facilities at the point of care, and 10% of HCFs lack sanitation services. Globally, in 47 least-developed countries, an estimated half of HCFs do not have basic water services and two-thirds of HCFs lack basic sanitation services. Seven out of ten HCFs in least-developed countries do not have basic healthcare waste management services. About 50% of the HCFs in least-developed countries had basic water services, 37% had basic sanitation, and 74% had basic hand hygiene facilities at the point of care [7].

Despite the improvement in access to essential health services in sub-Saharan Africa in recent years, the quality of care received remains inadequate to improve health outcomes. Health facilities lack the necessary infrastructure, equipment, medicines, commodities, and trained personnel to create an enabling environment, resulting in missed opportunities to provide good quality essential health services. About one-fifth of deaths occurring in LMICs are attributable to the lack of access to health services, one-third of deaths are a result of receiving poor quality of care, which is often linked to insufficient readiness of the facilities to provide services [8].

Access to WASH facilities in HCFs is a cornerstone of safe healthcare services [9]. The lack of these facilities poses significant health risks to patients, healthcare workers, and the whole community. WASH facilities in HCFs are fundamental to health security, preparedness, and response efforts, including the effort to stop the COVID-19 pandemic [7]. The lack of WASH facilities is one of the primary causes of the transmission of HCAI, including COVID-19 [10]. The Sustainable Development Goal (SDG) target 6 calls for universal access to WASH services in HCFs [11]. Globally, improving WASH facilities has the potential to prevent at least 9.1% of the disease burden in disability-adjusted life years or 6.3% of all deaths [12].

A study conducted in LMICs reported und that 38.0% of HCFs did not have a basic water supply, 19.0% did not have basic sanitation, and 35.0% did not have water and soap for handwashing [13]. The rate of provision of water is lowest in the African region, with 42.0% of all HCFs lacking an improved water source on-site or nearby [14]. Inadequate WASH in HCFs has a significant negative influence on the status of hospital patients’ health during their stay. Globally, an estimated 15% of patients may acquire one or more infections during their stay in the hospital. But, the prevalence may be even higher in LMIC where it ranges from 5.7% to 19.1% and the risks associated with sepsis are 34 times higher [15].

Effective WASH plays a vital to prevent and control the transmission of COVID-19 [16]. The current COVID-19 pandemic has highlighted deficiencies in access to WASH services in HCFs and underscored the need for increased political commitment and enhanced accountability to address WASH gaps in health facilities [8]. According to the reports of WHO, confirmed cases of COVID-19 reached more than 228 million as of September 19, 2021, and caused more than 4.7 million deaths across the world [17]. The number of COVID-19 infections among healthcare workers is far greater than among the general population due to their role in treatment and management of cases [18, 19]. Globally, healthcare workers represent less than 3% of the population but account for 14% of COVID-19 cases [20]. The first case of COVID-19 in Ethiopia was reported on March 13, 2020 [21-24]. As of October 24, 2021, Ethiopia had reported a total of 362,088 COVID-19 confirmed cases and 6,347 deaths [25].

In May 2019, the World Health Assembly passed a resolution to accelerate global efforts on WASH in HCFs. This resolution led to a subsequent global meeting where countries presented their national commitments with concrete actions [26]. The government of Ethiopia has also implemented various COVID-19 prevention measures, such as partial or total lockdown, physical distancing, handwashing, and others [27-29].

Improving WASH in HCFs facilities is considered as a first-line defense against infectious disease [30]. But still there is no standard WASH guideline in HCFs of Ethiopia. To date, there is a lack of evidence on access to and challenges around WASH facilities in Ethiopian HCFs, including South Wollo Zone health facilities in Northeastern Ethiopia. Therefore, this study was designed to assess WASH facilities and related challenges in healthcare facilities of Northeastern Ethiopia in the early phase of the COVID-19 pandemic.

Methods and materials

Study design, period, and area

An institution-based cross-sectional study was conducted during July and August 2020 in 70 HCFs found in the South Wollo Zone, one of 15 Zones in the Amhara Region of Ethiopia. Based on the 2014 population projection, South Wollo had a total population of 2,925,559 of which 1,448,174 and 1,477,385 were male and female, respectively [31]. According to the Zonal Health Department report, South Wollo Zone has 7 governmental hospitals and 3 private hospitals, 135 health centers, 496 health posts, and 175 clinics [32].

Source and study population

All HCFs that existed in the South Wollo Zone at the time of data collection were the source population. All randomly selected HCFs in South Wollo Zone were the study population.

Sample size determination and sampling procedures

From the total number of HCFs, 70 HCFs were randomly selected using a lottery method from the lists of HCFs from the zonal health department of South Wollo. For the qualitative data collection, senior janitors, WASH coordinators of the HCFs, heads of HCFs, and clients from in-patient departments were purposively selected. A total of 14 participants, including 3 heads of HCFs, 3 WASH coordinators, 4 janitors, and 4 clients from in-patient departments were participated in the qualitative data collection.

Operational definitions

Healthcare facilities

All formally recognized facilities that provide healthcare, including primary (health posts and clinics), secondary, and tertiary (district or national hospitals), public and private (including faith-run), and temporary structures designed for emergency contexts [33].

WASH

All works related to water, sanitation, and hygiene, including the provision of safe and affordable access to a clean water supply, sanitation, and hygiene service facilities [33].

Improved water source

Water sources from piped water, boreholes or tube wells, protected dug wells, protected springs, and rainwater [33].

Improved sanitation

Facilities that are designed to hygienically separate excreta from human contact, including flush/pour-flush to a piped sewer system, septic tank, or pit latrine; ventilated improved pit latrines, composting toilets, or pit latrines with slabs [33].

Water supply

Basic access water supply

Water is available from an improved water source on the premises [34].

Limited access water supply

Improved water sources within 500 m of the premises but not all requirements for basic services are met [34].

No water access

Water is taken from an unprotected dug well or spring or surface water source or improved water source that is located more than 500 meters from the premises, or there is no source of water [34].

Sanitation

Basic access sanitation

Improved sanitation facilities that are usable with at least one toilet dedicated for staff, at least one sex-separated toilet with menstrual hygiene facilities, and at least one toilet accessible to people with limited mobility [34].

Limited access to sanitation

At least one improved sanitation facility is available, but not all requirements for basic service are met [34].

No sanitation access

Toilet facilities are unimproved (e.g., pit latrines without a slab, or platform, hanging latrine, bucket latrine, or there is no latrine [34].

Hygiene facilities

Basic access hygiene facilities

Functional handwashing facilities (with water and soap and/or an alcohol-based hand rub are available at the point of care and within five meters of toilets [34].

Limited access hygiene facilities

Functional hand hygiene facilities are available either at the point of care or near toilets, but not both [34].

No hygiene facilities access

No functional hand hygiene facilities are available either at the point of care or near toilets [34].

Proper waste management

Waste is safely segregated into at least three bins, and sharps and infectious waste are treated and disposed of safely [34].

Low cleanliness latrine

Visible faeces and/or urine observed on the floor around the latrine and latrine not swept at the time of data collection [35].

High cleanliness latrine

Pit not full, no faecal matter seen around the pit latrine, area properly swept, and absence of bad smell at the time of data collection [35].

Data collection tools and quality assurance

A structured questionnaire that was adapted from WHO guidelines and published papers [34, 36–38] and contextualized based on the study setting. The questionnaire was prepared in English, translated to the local language (Amharic), and then re-translated to the English language for consistency. The questionnaire consisted of questions on general background information on the HFCs, water supply, sanitation facilities, hygiene facilities, and major challenges of the WASH facilities.

The quantitative data was collected using a combination of an interviewer-administered questionnaire and an observational checklist. For the qualitative data, we used key-informant interviews from purposively selected janitors, WASH coordinators of HCFs, heads of HCFs, and clients of the HCFs from in-patient departments. The data were collected by four professionals with Bachelor of Science (BSc.) in environmental health who had experience of working in WASH activities and supervision was conducted by two WASH experts.

Two days of training was given by the principal investigator for the data collectors and supervisors on the data collection procedures, the content of the tool, and ethical considerations. The questionnaire was pre-tested in 5% of the final sample size to assure the validity of the measuring tool; amendments were made based on the feedback from the pre-test including improving the order of questions, editing unclear questions, and eliminating less important questions. The collected data was checked daily and any missed data were collected immediately by re-visiting the health facility. Re-checking of the entered data was done using 10% of the sample size to control data entry errors and then data cleaning was done before statistical analysis.

Data processing and analysis

The data were entered in EpiData version 4.6 and exported to Statistical Package for Social Sciences (SPSS) version 25.0 for data cleaning and analysis. For quantitative data, descriptive statistics were calculated for categorical variables and mean ± standard deviations (SD) for continuous variables. The access to WASH facilities at HCFs was categorized based on WHO ladder guidelines in terms of basic, limited, or no access. The finding of the qualitative survey was triangulated with the access to WASH in HCFs findings to provide stronger evidence.

Ethical considerations

Ethical clearance was obtained from the ethical review committee of Wollo University, College of Medicine and Health Sciences with ethical letter protocol number: CMHS/451/013/2020. Permission was obtained from South Wollo Zone Health Bureau and the respective HCFs. Before beginning data collection, the purpose of the study was explained to the study participants. Written consent was obtained from participants who could read and write whereas verbal/ oral consent was obtained from those who could not. The data collectors wore facemasks and maintained social distancing as per the WHO guidelines for the prevention of COVID-19. Facemasks were provided for study participants who did not wear them during the data collection period. The anonymity of the study participants was ensured by avoiding possible identifiers such as names. All the information obtained from the study participants was kept confidential.

Results

Background information of the HCFs

Of the total surveyed 70 HCFs, three-fourths 53 (75.7%) of them were clinics, 12 (17.2%) were health centers, and the remaining 5 (7.1%) were hospitals. More than three-fourths 57 (81.4%) of the HCFs employed Environmental Health professionals who were responsible for coordinating WASH facilities in the healthcare setting. The mean daily client flow rate was 55±108 (Table 1).

Table 1

Background information of the healthcare facilities in Northeastern Ethiopia from July to August 2020.

Variable	Category	Type of healthcare facility (N = 70)			Frequency (n)	Percentage (%)
		Hospital (n = 5)	HC (n = 12)	Clinic (n = 53)
Ownership	Private	3	0	53	56	80
	Government	2	12	0	14	20
Location of HCF	Urban	5	11	50	66	94
	Rural	0	1	3	4	6
Presence of WASH coordinator	Yes	2	11	0	13	19
	No	3	1	53	57	81
Presence of WASH committee	Yes	3	8	3	14	20
	No	2	4	50	56	80
The average number of employees	Mean ±SD	192±122	32±4	10±2	27±57
The average number of patients	Mean± SD	319±212	90±40	18±6	55±108

The head of HCF reported that “the major problem of WASH in our healthcare facility is the absence of environmental health professionals to monitor WASH facilities and unorganized WASH committee.”

Access and challenges water supply facilities in HCFs

Regarding water supply, all investigated HCFs used tap water as the main source of water. Eight (11.4%) of HCFs did not have water during the time of data collection. One-third 27 (38.6%) of the HCFs had water storage containers that could be used as a reservoir during interruptions of the main water supply. The average number of taps in hospitals, health centers, and clinics were 80, 10, and 5, respectively. More than three-quarters of the HCFs 56 (80%) did not have a system for frequent water quality monitoring in their healthcare setting. Finally, 62 (88.6%) of the HCFs had basic access to a water supply (Table 2).

Table 2

Water supply facilities in healthcare facilities of Northeastern Ethiopia from July to August 2020.

Variable	Category	Type of healthcare facility (N = 70)			Total
		Hospital(n = 5)	HC (n = 12)	Clinic (n = 53	Frequency (n)	Percentage (%)
Presence of alternate water storage container	Yes	5	10	12	27	39
	No	0	2	41	43	61
Time to fetch water in minutes	<5	0	0	22	22	31
	5–10	5	6	23	34	49
	10–15	0	6	3	9	13
	>15	0	0	5	5	7
Presence of water during survey	Yes	5	12	45	62	89
	No	0	0	8	8	11
Presence of water during the last two weeks	Yes	5	11	48	64	91
	No	0	1	5	6	9
Water supply present on an annual basis	Yes all year	5	9	21	35	50
	Most of the time	0	3	30	33	47
	Not present mostly	0	0	2	2	3
Presence of water quality monitoring program	Yes	4	2	8	14	20
	No	1	10	45	56	80
Average number of taps available		80	10	5
Average number of functional taps		72	8	4

The head of HCFs said that: “the major problem regarding the water supply was the absence of a separate budget for WASH facilities such as repairing of the damaged pipes.”

Clients from an inpatient department said that “we do not use water from healthcare facilities especially at night because of its distance from the in-patient ward; as a result, we are obligated to use other sources of water such as bottled water, which exposes us to extra cost.”

Access to and challenges around sanitation facilities in HCFs

About half 36 (51.5%) of the HCFs used improved sanitation facilities. This study also revealed that slightly more than half 39 (55.7%) of HCFs had separate toilets for male and female while one-third 23 (32.9%) had separate toilets for clients and workers. None of the HCFs had a latrine designed for disabled people. More than three-quarters 57 (81.4%) of the HCFs reported that there was an insufficient supply of PPE for healthcare workers in their healthcare setting (Table 3).

Table 3

Sanitation facilities based on the type of healthcare facility in Northeastern Ethiopia from July to August 2020.

Variable	Category	Types of healthcare facility			Total
		Hospital (n)	Health center (n)	Clinic (n)	Frequency (n)	Percentage (%)
Type of latrine	Flush	0	1	1	2	3
	VIP	5	4	23	32	46
	Pit latrine with slab	0	1	1	2	3
	Pit latrine without slab	0	6	28	34	49
Presence of functional doors and locks in toilets	Yes	5	6	27	38	54
	No	0	6	26	32	46
Absence of odor	Yes	5	7	28	40	57
	No	0	5	25	30	43
Separate toilet for male and female staff	Yes	5	11	23	39	56
	No	0	1	30	31	44
Separate toilets for patients and workers	Yes	5	7	11	23	33
	No	0	5	42	47	67
Number of toilets	Mean	20.4	5.08	3	323	5
Patient to latrine ratio		16	18	6	3635	12
Frequency of toilet cleaning	Twice a day	0	2	2	4	6
	Three times a day	0	4	23	27	39
	More than three times a day	5	6	28	39	56
Do janitors use PPE while cleaning?	Yes	5	12	40	57	81
	No	0	0	13	13	19
Overall latrine cleanliness	High	5	8	12	25	36
	Medium	0	3	37	40	57
	Low	0	1	4	5	7
Excreta disposal method when latrine is filled	Emptying	5	11	49	65	93
	Covering with soil	0	1	4	5	7

The focal persons of WASH said that “the major problem with sanitation in the HCFs was unbalanced patient load with the availability of a functional latrine on selected dates Monday, Friday, and market days, particularly in the morning session.”

An in-patient client of HCF said that “the major problem of sanitation in the HCF was the non-functionality of latrines (broken doors, locked latrines), absence of separate toilets to take a sample, and lack of cleanliness of the surface of the latrine.”

A janitor of the healthcare facility said that “the existing challenges regarding sanitation are that although we clean the slab of latrine frequently, there are great problems in proper disposal of faeces and urine, particularly during sample collection by clients for laboratory examination.”

Access to and challenges around hygienic facilities in HCFs

In this study, half 35 (50%) of HCFs had no access to handwashing facilities and 28 (40%) had functional sinks. Less than a quarter 15 (21.4%) of the HCFs had handwashing facilities (soap and water) at the point of care and near latrines. The study also showed that only 28 (40%) of HCFs practiced proper segregation of waste using three color-coded collection containers. On the contrary, 42 (60%) of HCFs (mainly clinics and health centers) had no proper waste management system (Table 4).

Table 4

Hygiene facilities based on the type of healthcare facility in Northeastern Ethiopia from July to August 2020.

Variable	Category	Types of healthcare facility (N = 70)			Frequency (n)	Percentage (%)
		Hospital (n = 5)	HC (n = 12)	Clinic (n = 53)
Presence of functional sinks	Yes	4	8	16	28	40
	No	1	4	37	42	60
Presence of handwashing facility (soap, water/ABHR) at point of care and toilet	Yes	4	5	6	15	21
	No	1	7	47	55	79
Presence of handwashing facility (water, soap/ABHR) at point of care	Yes	4	8	14	26	37
	No	1	4	39	44	63
Presence of handwashing facility (water, soap/ABHR) at toilets	Yes	4	5	12	21	30
	No	1	7	41	49	70
Presence of handwashing poster about COVID-19	Yes	5	10	46	61	87
	No	0	2	7	9	13
Segregation of types of waste into three bins accordingly	Yes	4	7	17	28	40
	No	1	5	36	42	60

ABHR = Alcohol-based hand rub.

A client from a private hospital said that “the major WASH problem was the owner of the healthcare facility mainly focuses on owner’s benefit rather than providing necessary facilities.”

A client from a health center said that “there were no sufficient supplies of handwashing materials (water, soap or alcohol-based hand rub), mainly around latrines.”

A WASH coordinator said that “Although we put out handwashing materials (water, soap and alcohol-based hand rub), there is a behavioral problem in the utilization of the facilities and some clients may even steal from these facilities, particularly at latrines.”

Discussion

Lack of access to WASH services hampers the implementation of preventive measures against SARS-CoV-2 and causes high mortality from diseases caused by diarrhea and lower respiratory infections [39]. Therefore, ensuring good and consistent WASH facilities in all settings, particularly in HCFs helps to prevent transmission of the SARS-CoV-2 virus.

A safe and adequate water supply in healthcare facilities is vital for reducing the transmission of infectious diseases, including the current pandemic of COVID-19. HCFs require adequate quantity and quality of water to maintain a safe environment [40]. This study revealed that most 62 (88.6%) of the HCFs had basic access to a water supply, which was higher than the studies conducted in African countries (71.2%) [41], Ethiopia (30%), Uganda (44%), Tanzania (56%), Somalia (67%), and Rwanda (73%) [7], and Uganda (86%) [14].

The major problems regarding the water supply were interruption of the water supply system, absence of a water quality monitoring system, and a lack of a separate budget for the WASH services. The finding also revealed that no HCFs had any plan for WASH risk assessment maintenance. The lack of planning may be due to the absence of a separate budget for WASH service at HCFs mainly in LMICs which reported between 0.08 and 2.54% of Gross Domestic Product (GDP) invested in WASH. The major sources of funding are official development assistance, foundations and charities, and loans from international sources, which accounted for 12% of total finance in 2016–2018 [42].

Regarding sanitation, only half (51.5%) of the HCFs had improved sanitation facilities, which was lower than the studies conducted in African countries, such as Ethiopia (66%), Kenya (86%), Mozambique (79%), Rwanda (93%), Uganda (93%) and Zambia (96%) [41], LMIC (67%) [12], Rwanda (44%) [40], sub-Saharan Africa (94.3%) [8], LMIC (81%) [39], Ethiopia (76%), Rwanda (99%), Djibouti (95%) and Uganda (75%) [7], and Zimbabwe (98%) [28]. The average ratio of latrines to clients for HCFs were 1:12 which was lower than the WHO guideline of 1:20 [7]. Clinics had the highest ratio (1:6), followed by health centers (1:16), and hospitals (1:18), which was consistent with a study conducted in Uganda [13]. In low resource settings, including Ethiopia, sanitation services in HCFs are of low priority and are often neglected [43].

Although all the HCFs had access to sanitation services, none of them had basic sanitation services, which was mainly attributed to the absence of latrines designed for disabled people. Half (51.5%) of the HCFs had limited access to sanitation services, which was lower than the finding in Uganda (84.5%) but higher than the finding in Ethiopia (17%) [7]. The possible reason for this variation may be the change in the study period and government commitment towards improving WASH facilities in healthcare settings.

WHO recommends people with suspected or confirmed SARS-CoV-2 should be provided a separate toilet, and if not possible, certain toilets should be designated as solely for the shared use of COVID-19 patients and not used by non-COVID-19 patients [20]. In this study, 56% of the HCFs had separate toilets for males and females, which was lower than the study finding in Ethiopia 94.3% [44]. This finding also revealed that 7.1% of HCFs had low cleanliness of the latrine, which may be associated with the absence of a functional lock on the latrine door and lack of lighting, frequency of cleaning, and the behavior of clients in utilizing of latrines. A systematic review conducted in LMIC revealed that the lack of cleanliness of toilets was a bigger problem than the absence of toilets, and that was attributed to a lack of safe and adequate access to water [43].

The presence of handwashing facilities with clean water and soap is a key preventive measure against the transmission of infectious diseases, including COVID-19 [27]. According to the WHO standard, functional hand hygiene facilities should be available at all critical points of the HCFs [7]. Less than a quarter (21.4%) of the HCFs had functional handwashing facilities (with water and soap) both in latrines and at point of care, which was lower than the studies conducted in Africa (28%) [41], Zimbabwe (30%) (26), LMICs [12], sub-Saharan Africa (67%) [8], Rwanda (32%) [40], Nigeria (66%), Rwanda (65%), Zimbabwe (58%) [7] and Ethiopia (74.28%) [44] but higher than Niger (4%) [7].

Only half (50%) of the HCFs had basic access to handwashing facilities, which was lower than the studies conducted in Uganda (56.9%) [45], sub-Saharan Africa (74%) [8], and Nigeria (85%) [46]. On the other hand, the current finding was higher than a study conducted in LMICs (22%) [40]. This low achievement of hygiene facilities may be due to poor access to water supply and misconduct of clients in the utilization of these facilities. Hence, the lack of fundamental hygiene facilities in HCFs may affect the quality of service given and may create a suitable environment for the transmission of HAI, including COVID-19 [12, 47].

One-third (37.1%) of the HCFs, soap was observed at the point of care, which was in line with a study conducted in Rwanda (33%) [40]. On the other hand, it was lower than the studies conducted in LMICs (61%) [13], Uganda (75%), Rwanda (70%), Burundi (66%), Ethiopia (65%), and Somalia (58%), but higher than Djibouti (35%) [7]. On the other hand, heads and WASH coordinators of HCFs reported that they had put sufficient soap near the latrine and at the point of care, mainly since the occurrence of the COVID-19 pandemic in Ethiopia. But, they mentioned that there is misuse and/ theft of handwashing facilities, which was supported by a study conducted in Rwanda [40]. Therefore, the provision of adequate hand hygiene facilities requires not only the presence of access to washing materials (water and soap) but also appropriate behaviors [42, 48].

Limitation of the study

This study has certain limitations. Due to the nature of the data, which was taken from a small sample size, we were unable to carry out statistical analysis. The health posts were excluded from the study due to their insignificant roles in the treatment and management of COVID-19. The other limitation of the study is that the exact number of HCFs with basic access to the water supply may be lower than the current finding due to the lack of laboratory examination of water quality assessment. Furthermore, the use of a cross-sectional study design, which cannot show the causality of the study, was also a limitation of the study.

Conclusions

Although most of the HCFs had basic access to a water supply, there were frequent interruptions of water, absence of water quality monitoring system, absence of a separate budget for WASH services, and non-functional water sources. About half of the HCFs had limited access to sanitation facilities. The major problems were the absence of accessible latrines for disabled people, lack of separate latrines for healthcare workers and clients, as well as female and male staff, unbalanced numbers of functional latrines with number of clients, non-functional latrines, and misuse of the latrine mainly during sample taking for laboratory investigation. Less than a quarter of the HCFs had basic access to handwashing facilities at both the point of care and near the latrine.

The major problems were the lack of functional handwashing facilities at the critical points and misuse, particularly around the latrine. Therefore, to reduce the risk of HAIs, including COVID-19, immediate actions should be taken by the concerned governmental and non-governmental organizations to provide sufficient water for all users, disability-friendly sanitation facilities, and handwashing facilities. The issue of WASH should be encouraged in government planning and budgeting. The technical and logistical capabilities of health and safety committees should be strengthened in order to prevent the spread of coronavirus through education and awareness campaigns. Further investigation should be done to assess the enabling factors and constraints for the provision, use, and maintenance of WASH infrastructure at HCFs.

Annex I English version questionnaires.

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Annex II Amharic version questionnaires.

(DOCX)

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(XLSX)

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1 Dec 2021

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Comments to the Author

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Reviewer #1: No

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

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Reviewer #1: No

Reviewer #2: Yes

**********

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Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This paper looks at water, sanitation and hygiene access during the period of COVID-19 in Ethiopia.

1.) The name of the institutional review board that approved the study is included only. Please add the approval number and indicate the form of consent obtained (written/oral). The research does not meet all applicable standards for the ethics of experimentation and research integrity.

2.) Data Availability states “Yes - all data are fully available without restriction.” Please include the full dataset as a supplement to this paper or include a link where it can be downloaded. The article does not adher to appropriate reporting guidelines and community standards for data availability.

3.) Line 69. Reference is missing to the WHO/UNICEF WASH in healthcare facilities (https://washdata.org/sites/default/files/2020-12/WHO-UNICEF-2020-wash-in-hcf.pdf)

4.) Line 69 to 73, this data is out of date. Please update and use the most recent 2020 WHO/UNICEF report.

5.) This statement is false “HCAI including the current pandemic of COVID-19 has occurred due to a lack of WASH facilities and improper utilization of it (9)” COVID-19 is a respiratory disease. Correct this statement.

6.) Line 80 to 82, this data is out of date. Please update and use the most recent 2020 WHO/UNICEF report.

7.) Line 96, “October 29” What year?

8.) Line 98. The date of the first case of COVID-19 globally is incorrect. It was in December 2019.

9.) Line 105. There is data on Ethiopia and COVID-19 in the WHO/UNICEF report. “In Ethiopia, a large assessment of facilities carried out as part of the COVID-19 response resulted in the mobilization of US$ 5 million to support IPC and WASH activities in 74 high-load hospitals. WHO and UNICEF launched the ‘Hand Hygiene for All’ (HH4A) global initiative in June 2020. It is a call to action for all of society to achieve universal hand hygiene and to stop the spread of COVID-19”

10.) Line 127, what is tottery?

11.) Was distance to water sources measured with a tape measure?

12.) Statistics, and other analyses are not performed to a high technical standard and are not described in sufficient detail. This is listed as a limitation later, but needs to be done prior to acceptance of the paper.

13.) The N=70, there is not a large enough dataset to have results to 0.1%. Please round all results presented to the nearest whole number.

14.) The study needs to compare to the recent Ethiopia WASH in healthcare facility work during COVID-19, this is a major gap of this manuscript https://washdata.org/sites/default/files/2020-12/WHO-UNICEF-2020-wash-in-hcf.pdf

15.) The study presents the results of original research, but does not compare to other recent studies in Ethiopia or other low- and middle-income countries during COVID-19.

16.) Conclusions presented are not supported by the data. Expand the conclusions. How could the findings of this work be implemented for better access, not just in Ethiopia but lessons learned for other low- and middle-income countries? At least give some practical options for solutions in a bulleted list. What can be done within resource limited environments? How much financial investment is needed at a minimum to improve conditions? Also, I missed seeing what further research you can suggest in this field.

17.) Finally, when you submit the corrected version, please do check thoroughly, in order to avoid grammar, syntax or structure/presentation flaws - please seek for professional English proofreading services or ask a native English-speaking colleague of yours in order to refine and improve the English in your paper.

Other comments:

1.) healthcare facilities should not be in capital in the title, or throughout the manuscript. Only proper nouns should be in capital letters.

Reviewer #2: Abstract

Sampling why not you use proportional allocation to the number of health care facilities since all health facilities are known by the regional health bureau.

Line 33 add the word “by” before the word “using “ and add “interviewer administered” before “structured questioner”

Line 50 who are nongovernmental health facilities? Change the word either NGO or partners

Background

line 98 it doesn’t state in which country specifically that CoVID-19 is occurred on March 13, Hence re-write this sentence.

Line99-100 the sentence is not complete.

Line 101 278 HCFs are in nationwide, or regionally or zonal level???????

Study design

Remove line 113,114,115 which talks about the boarder of Wello zone that much is not necessary

Source and study population

Line 121 All HCFs which is present…… change the word present by the word “exist”

Sample size determination and sampling procedures

Line 125 why not you mention the number of the total health facilities found in the zone to see whether the sample (70) is representative or not? And what was your base to take 70? Why not 80, 90,100 or above?

Out of the total sample, 80% are private clinics what was your base to take larger sample from private clinics.

Line 125 Since there is enough data on the number of health institutions found in the zonal health department, why don’t you use proportional sampling technique rather than simple random to make it more uniform and representative of each health facility category?

Line 127-131 how qualitative data were collected? Is it in-depth interview or FGDs? Explain well which method is best in exploring the challenges of an issue?

Line 150 what about the definition of limited access for sanitation??

Data collection tools and quality assurance

Line 165 contextualized to the study……

Line 170 you use spot observation to collect data but you didn’t mention the result that you obtain through this method in your result part.

Line 188 how the qualitative data were analyzed? It is not exhaustively written. Hence you should mention the method that used to analyze it.

Line 204-206; do you think that your result represent the HCFs that are found in the zone?

Line 206 are an environmental health professionals the only professionals who coordinates the WaSH activities? Did you ask the presence of even other professionals in the position?

Line 207 average is not the appropriate measures rather you use mean +/- SD since the average is 55 but the highest value is 320, do you see the gap?

Line 208; though the highest number of patient flow is in the hospital, you included in your study only 7% of them. Do you think your sample is representative?

Line 234 I think it is better to write “…HCFs was unbalanced patient load with functional…. ”

Line 240 it is better to change the word “the floor” by the word “the slab”…..disposal of “faces” by “faeces “ after that add the word “and” before urine

Line 242 ….challenges of hygienic facilities

Line 243 since it is 35 or half of your sample, you can’t say more than half of…..

Line 248 “proper waste management” what does it mean in this research context. It needs operational definition for this research

Line 248 …..and they disposed off …. Add one “f”

Line 249-252; the sentence is not clear. Is it about cleaning or cleaning protocol or the janitors training status?

Line 253-255 I didn’t understand about your sample the person from private health care facilities customer? If it is so remove it since they are two independent setting i.e governmental and private hospitals you compared two different institutions. Besides, in your sampling section, there is no list of participant from private health institution users. From where did you bring this information?

Line 262-263 it is better to add references to the written sentence

Line 265-267 the sentence which describes the aim should be omitted since it is already mentioned earlier

Line 267. Can we say all HCFs have accessed to water supply? In you result part line 214, 11% of them have no water during data collection time. Some time it is more than that. Hence you should modify this statement

Line 267-271 you should treat each component independently otherwise there will be writing the result repeatedly which will be boring to the reader. Hence write the discussion separately for water, sanitation and hygiene

Line 273 and 274 it needs re-writing and is it possible to put the different country status by average number? Why not you mention for each country status to know and compare it

Line 275; your justification doesn’t convince the reader i.e why don’t you find the similar setting to compare it either rural or urban?

Line 278 your justification is the variation in the HCFs why not you compare with similar setting?

Line 278 remove the bracket at the end of line 278

Line 279-282 “almost all …….in private clinics” this statement should be placed after discussing water, sanitation and hygiene results and even compare the result and the situation with studies done in other parts of Ethiopia.

Line 287 you said that the ratio 11.5 is greater than WHO standard. What is the WHO standard put the number. Besides, there is no reference, hence put your reference

Line 288 the statement “….between the level….” Should be changed to between the HCFs. Even it is better to put the ratio result (in number) with in each HCF.

Line 291-301 the paragraph seems the result part since you didn’t discuss any of your result by comparing your result with the other studies. Hence this paragraph needs re-writing again

Line 304 “HCFs had no function…..” change the word function to “functional”

Line 305 what about the other study setting you didn’t discuss your finding simply put the number that you wrote in the result part here again.

Line 307-309; this justification is for the 60% (HCFS had no function hand washing facilities) or 21% (HCFs had functional handwashing facilities with water and soaps)? It is confusing discussion part. Hence it is better to treat independently.

Line 314-320 you simply put your result again that you wrote in your result part. Hence it needs further discussion by comparing your result with other findings and give your justification why the variation occurs.

Where is the qualitative data discussion part? you didn’t put anything. Why you collect the qualitative data? And how you analyzed it? Is it by open code, thematic, ATLAS-Ti or by what technique? Nothing is said about this. Please write something on it. You said in your methodology mixed where is the mixed nature? I didn’t see it or realized it.

Line 323 “exclusion of health post” I preferred you were included these health post rather than the private clinics that you included. The reason is that

1. There is a mix up of different setting that is governmental and private which are almost completely different setting in Ethiopian condition

2. Your study design is not comparative cross sectional method

3. You didn’t compare the result of private clinics with the government or even to the other similar setting of different countries. The data that you got from private clinics are confined in the governmental HCFs and treated as they are governmental HCFs

Limitation part what about the cross-sectional nature of the data?

Line 335 make correct on the word “…..concerned exerts……” change to concerned experts

Annex

Table 3 on page 24 “overall latrine cleanliness” i.e high, medium, low, it needs operational definition.

**********

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Reviewer #1: No

Reviewer #2: Yes: Mathewos Moges

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Submitted filename: comment.docx

Click here for additional data file.

15 Feb 2022

Response to editor

Question #1 Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: Thank you for this remark. We re-formatted the revised manuscript using the PLoS ONE format guidelines. The whole content of the manuscript, including the abstract, introduction, methods, discussion and reference are formatted using the guidelines (Please see the revised version for each section).

Question #2 Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.” as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. This information should be included in your cover letter; we will change the online submission form on your behalf

Response: thank you for your remark; we have incorporated it in the cover letter.

Question #3. Data availability

Response. We have attached the data on the supplementary information

Response to Reviewer 1

Question ##1) The name of the institutional review board that approved the study is included only. Please add the approval number and indicate the form of consent obtained (written/oral). The research does not meet all applicable standards for the ethics of experimentation and research integrity.

Response: We have added the approval number and the form of consent in the revised manuscript.

Question #2.) Data Availability states “Yes - all data are fully available without restriction.” Please include the full dataset as a supplement to this paper or include a link where it can be downloaded. The article does not adhere to appropriate reporting guidelines and community standards for data availability.

Response: We have included all necessary supplementary data in the revised version manuscript.

Question #3.) Line 69. Reference is missing to the WHO/UNICEF WASH in healthcare facilities (https://washdata.org/sites/default/files/2020-12/WHO-UNICEF-2020-wash-in-hcf.pdf)

Response: we have included the reference in the revised manuscript.

Question #4.) Line 69 to 73, this data is out of date. Please update and use the most recent 2020 WHO/UNICEF report.

Response: thank you for your comment. We have used the most recent WHO/UNICEF 2020 report in the revised manuscript.

Question #5.) This statement is false “HCAI including the current pandemic of COVID-19 has occurred due to a lack of WASH facilities and improper utilization of it (9)” COVID-19 is a respiratory disease. Correct this statement.

Response: sorry for the confusion we have created. Hence, we have re-written the sentence in the revised manuscript. Question #6.) Line 80 to 82, this data is out of date. Please update and use the most recent 2020 WHO/UNICEF report.

Response: thank you for your comment. Hence, we have used the most recent 2020 WHO/UNICEF report in the revised manuscript.

Question #7 Line 96, “October 29” What year?

Response: Sorry for the problem we have created. Hence, we have incorporated the missed data in the revised version of the manuscript.

Question #8.) Line 98, the date of the first case of COVID-19 globally is incorrect. It was in December 2019.

Response: Sorry for the confusion we have created in the original manuscript. The idea of the sentence was the first case of COVID-19 in Ethiopia, not at the global level. Hence, we have rephrased the sentence accordingly in the revised manuscript.

Question #9) Line 105. There is data on Ethiopia and COVID-19 in the WHO/UNICEF report. “In Ethiopia, a large assessment of facilities carried out as part of the COVID-19 response resulted in the mobilization of US$ 5 million to support IPC and WASH activities in 74 high-load hospitals. WHO and UNICEF launched the ‘Hand Hygiene for All’ (HH4A) global initiative in June 2020. It is a call to action for all of society to achieve universal hand hygiene and to stop the spread of COVID-19”

Response: thank you very much for your comment. We have included further literatures based on your recommendation in the revised version of the manuscript.

Question #10) Line 127, what is tottery?

Response: sorry for the editorial problem we have created. Hence, we have edited the word tottery to the word lottery method in the revised manuscript.

Question #11) Was distance to water sources measured with a tape measure?

Response: If the water source is available in the premise of the Healthcare facilities, no need of measuring the distance. On the other hand, when the water source is out of the premise, the distance of water source was measured using appropriate distance measuring tool.

Question 12). Statistics and other analyses are not performed to a high technical standard and are not described in sufficient detail. This is listed as a limitation later, but needs to be done prior to acceptance of the paper.

Response: thank you very much for your comment. The statistical analysis depends on the objective of the study. The objective of the current study can be expressed by using descriptive statistics using frequency, mean with standard deviation. Furthermore, we have presented the absence of advanced statistical analysis as the limitation of the study.

Question#13). The N=70, there is not a large enough dataset to have results to 0.1%. Please round all results presented to the nearest whole number.

Response: We have incorporated your comment in the revised version of the manuscript.

Question#14) The study needs to compare to the recent Ethiopia WASH in healthcare facility work during COVID-19, this is a major gap of this manuscript https://washdata.org/sites/default/files/2020-12/WHO-UNICEF-2020-wash-in-hcf.pdf

Response : Thank you very for your comment we have tried to use further papers which were conducted indifferent parts of the world for comparison with the finding the current study. (See the revised version of the manuscript)

Question#15.) The study presents the results of original research, but does not compare to other recent studies in Ethiopia or other low- and middle-income countries during COVID-19.

Response Thank you very for your comment. We have used similar papers which were conducted in low resource setting mainly in African countries in order to compare with this study finding. But there is limitation of the stud in these areas (See the revised version of the manuscript)

Question#16.) Conclusions presented are not supported by the data. Expand the conclusions. How could the findings of this work be implemented for better access, not just in Ethiopia but lessons learned for other low- and middle-income countries? At least give some practical options for solutions in a bulleted list. What can be done within resource limited environments? How much financial investment is needed at a minimum to improve conditions? Also, I missed seeing what further research you can suggest in this field.

Response: We have tried to modify the conclusion based on the finding of the study. (See the revised version of the manuscript).

Question#17.) Finally, when you submit the corrected version, please do check thoroughly, in order to avoid grammar, syntax or structure/presentation flaws - please seek for professional English proofreading services or ask a native English-speaking colleague of yours in order to refine and improve the English in your paper.

Response: Thank you very much for your valuable comment. We have modified all the problems you mentioned. (See the revised version of the manuscript)

Response to Reviewer 2

Question #1 Healthcare facilities should not be in capital in the title, or throughout the manuscript. Only proper nouns should be in capital letters.

Response: thank you for your comments; hence we have incorporated it in the revised manuscripts

Question #2 sampling why not you use proportional allocation to the number of health care facilities since all health facilities are known by the regional health bureau.

Response: Ok thank you for your comments. We have lists of Healthcare facilities in the study catchment. Therefore we can use sample random sampling technique to select the study participants using the lists of the healthcare facilities as the sampling frame.

Question #3 Line 33 add the word “by” before the word “using “ and add “interviewer administered” before “structured questioner”

Response: we have amended it accordingly.

Question #4 Line 50 who are nongovernmental health facilities? Change the word either NGO or partners

Response: sorry for the confusion. We want to say concerned partners. Hence we have amended it accordingly.

Question #5 line 98 it doesn’t state in which country specifically that CoVID-19 is occurred on March 13, Hence re-write this sentence.

Response: sorry for the confusion; it is to mean for Ethiopia therefore, we have amended it accordingly in the revised manuscript.

Question #6 Line99-100 the sentence is not complete.

Response: sorry for the confusion, we have improved it in the revised manuscript.

Question #7 Line 101 278 HCFs are in nationwide, or regionally or zonal level???????

Response: sorry for the confusion, the report was representing the nationwide of Ethiopia. Hence we have incorporated in the revised version.

Question #8 Remove line 113,114,115 which talks about the boarder of Wollo zone that much is not necessary

Response: thank you for your important comment. We have removed in the revised manuscript

Question #9 Line 121 All HCFs which is present…… change the word present by the word “exist”

Response: thank you for your comment we have modified it accordingly.

Question #10 Line 125 why not you mention the number of the total health facilities found in the zone to see whether the sample (70) is representative or not? And what was your base to take 70? Why not 80, 90,100 or above? Out of the total sample, 80% are private clinics what was your base to take larger sample from private clinics.

Response: thank you for your comment we have already mentioned the total number of healthcare facilities in the method section of the manuscript. The sample was taken based on the number of existence healthcare facilities in the study area. The number of clinics in the study area was higher than other healthcare facilities which motivate us to take larger sample than others. The base for the sample was resource limitations and lockdown which restricts the movements of data collectors.

Question #11 Line 125 Since there is enough data on the number of health institutions found in the zonal health department, why don’t you use proportional sampling technique rather than simple random to make it more uniform and representative of each health facility category?

Response: thank you for your comment. We have frames of healthcare facilities in the health authorities of the study area. Hence, we used simple random sampling techniques using the lottery method to avoid bias in the selection of the study participants.

Question #12 Line 127-131 how qualitative data were collected? Is it in-depth interview or FGDs? Explain well which method is best in exploring the challenges of an issue?

Response: the qualitative data was collected using in-depth interview. But to explore the challenges of such types of issues FGD may be more appropriate

Question #13 Line 150 what about the definition of limited access for sanitation??

Response: sorry for the confusion we have incorporated it in the revised manuscript.

Question #14 Line 165 contextualized to the study……

Response: we have corrected it accordingly in the revised manuscript.

Question #15 Line 170 you use spot observation to collect data but you didn’t mention the result that you obtain through this method in your result part.

Response: sorry for the confusion we have created; as you see in the method section we used different methods of data collection which is interview and observation. The data which was collected by these methods are presented in the result section of the manuscript. For example the data of handwashing facilities were collected by observational methods

Question #16 Line 188 how the qualitative data were analyzed? It is not exhaustively written. Hence you should mention the method that used to analyze it.

Response: the qualitative data was analyzed using thematization method.

Question #17 Line 204-206; do you think that your result represent the HCFs that are found in the zone?

Response: yes; in the study catchment there are heath posts, clinics, health centers, and hospitals. We tried to take samples from different categories of healthcare facility categories based on the number of healthcare facilities existed during the data collection time.

Question #18 Line 206 are an environmental health professionals the only professionals who coordinates the WaSH activities? Did you ask the presence of even other professionals in the position?

Response: Environmental Health professionals are not the only professional who coordinates WASH activities but they are the best professionals who can coordinate such types of activities. Furthermore, we have assessed as there are there professionals who are wring on the position.

Question #19 Line 207 average is not the appropriate measures rather you use mean +/- SD since the average is 55 but the highest value is 320, do you see the gap?

Response: thank you for your comment. Despite we used mean and the highest value in the result section, we have expressed it using mean with standard deviation in the tables. Therefore, we have incorporated it in the result section of the revised manuscript.

Question #20 Line 208; though the highest number of patient flow is in the hospital, you included in your study only 7% of them. Do you think your sample is representative?

Response: we think the sample is representative of the whole sample. This is because the existed number of hospitals in the study catchment is less than 5% but we take larger samples which are 7% to accommodate the highest client flow rate in such types of healthcare facilities.

Question #21 Line 234 I think it is better to write “…HCFs was unbalanced patient load with functional…. ”

Response: Thank you for the comment. We have amended it accordingly in the revised manuscript.

Question #22 Line 240 it is better to change the word “the floor” by the word “the slab”…..disposal of “faces” by “faeces “ after that add the word “and” before urine

Response: we have incorporated your comments accordingly in the revised manuscripts.

Question #23 Line 242 ….challenges of hygienic facilities

Response: We have modified the comment accordingly in the revised manuscript.

Question #24 Line 243 since it is 35 or half of your sample, you can’t say more than half of…..

Response: sorry for the problem. Hence, we have corrected it accordingly in the revised manuscript.

Question #25 Line 248 “proper waste management” what does it mean in this research context. It needs operational definition for this research

Response: thank you for the comment. We have incorporated the comment in the revised manuscript.

Question #26 Line 248 …..and they disposed off …. Add one “f”

Response: we have corrected it accordingly in the revised manuscript.

Question #27 Lines 249-252; the sentence is not clear. Is it about cleaning or cleaning protocol or the janitors training status?

Response: sorry for the confusion. We re-write it in the revised manuscript.

Question #28 Line 253-255 I didn’t understand about your sample the person from private health care facilities customer? If it is so remove it since they are two independent setting i.e governmental and private hospitals you compared two different institutions. Besides, in your sampling section, there is no list of participant from private health institution users. From where did you bring this information?

Response: the study incorporates both government and non-governmental health care facilities (health center, clinics, and hospitals) which exist in the study setting. In the qualitative section, we have selected individual participants using purposive sampling technique using an in-depth interview from both types of institutions to assess the major challenges faced in there heath institutions mainly after the occurrences of COVID-19 pandemic. Therefore, the finding of the current study represents governmental and non- governmental healthcare facilities of the study catchment.

Question #29 Line 262-263 it is better to add references to the written sentence

Response: thank you for your comment. We have added reference accordingly in the revised manuscript.

Question #30 Line 265-267 the sentence which describes the aim should be omitted since it is already mentioned earlier

Response: Ok; we have omitted in the revised manuscript.

Question #31 Line 267. Can we say all HCFs have accessed to water supply? In you result part line 214, 11% of them have no water during data collection time. Some time it is more than that. Hence you should modify this statement

Response: thank you for the comment. We have amended it accordingly (see the revised manuscript)

Question #32 Line 267-271 you should treat each component independently otherwise there will be writing the result repeatedly which will be boring to the reader. Hence write the discussion separately for water, sanitation and hygiene

Response: thank you; we have modified it in the revised manuscript. Hence write the discussion separately for water, sanitation and hygiene in the revised manuscript.

Question #33 Line 273 and 274 it needs re-writing and is it possible to put the different country status by average number? Why not you mention for each country status to know and compare it

Response: we have modified it accordingly in the revised manuscript.

Question #34 Line 275; your justification doesn’t convince the reader i.e why don’t you find the similar setting to compare it either rural or urban?

Response: we have tried to search out similar setting for easy comparison of the current finding with other finding. But, we cannot get sufficient literatures based on your recommendation

Question #35 Line 278 your justification is the variation in the HCFs why not you compare with similar setting?

Response: we have tried to search out similar setting for easy comparison of the current finding with other finding. But, we cannot get sufficient literatures based on your recommendation

Question #36 Line 278 remove the bracket at the end of line 278

Response: we have removed it in the revised manuscript.

Question #37 Line 279-282 “almost all …….in private clinics” this statement should be placed after discussing water, sanitation and hygiene results and even compare the result and the situation with studies done in other parts of Ethiopia.

Response: thank you for your comment; we tried to compare this study finding with other countries mainly in low resource setting for comparison. But there is deficiency of study conducted in Ethiopia in this aspect.

Question #38 Line 287 you said that the ratio 11.5 is greater than WHO standard. What is the WHO standard put the number. Besides, there is no reference, hence put your reference

Response: we have incorporated your comment in the revised manuscript.

Question #39 Line 288 the statement “….between the level….” Should be changed to between the HCFs. Even it is better to put the ratio result (in number) with in each HCF.

Response: Ok, we have incorporated your comment in the revised manuscript.

Question #40 Line 291-301 the paragraph seems the result part since you didn’t discuss any of your result by comparing your result with the other studies. Hence this paragraph needs re-writing again

Response: thank you for your comment. Hence, we have tried to compare the current finding with other studies conducted in different parts of the word, mainly in developing countries.

Question #41 Line 304 “HCFs had no function…..” change the word function to “functional”

Response: Ok; we have modified in the revised manuscript.

Question #42 Line 305 what about the other study setting you didn’t discuss your finding simply put the number that you wrote in the result part here again.

Response: thank you for your comment. Hence, we have tried to modify the discussion by comparing this finding with other study finding.

Question #43 Line 307-309; this justification is for the 60% (HCFS had no function hand washing facilities) or 21% (HCFs had functional handwashing facilities with water and soaps)? It is confusing discussion part. Hence it is better to treat independently.

Response: sorry for the confusion we have created. Therefore, we have amended it in the revised manuscript.

Question #44 Line 314-320 you simply put your result again that you wrote in your result part. Hence it needs further discussion by comparing your result with other findings and give your justification why the variation occurs.

Where is the qualitative data discussion part? you didn’t put anything. Why you collect the qualitative data? And how you analyzed it? Is it by open code, thematic, ATLAS-Ti or by what technique? Nothing is said about this. Please write something on it. You said in your methodology mixed where is the mixed nature? I didn’t see it or realized it.

Response: thank you very much for your critical comment. We have incorporated the qualitative section in discussion in line with the quantitative one. The qualitative data are very important in identifying the major challenges of WASH facilities in the healthcare setting. The qualitative data was analyzed using the thematization technique. The mixed nature of the study incorporates both qualitative and quantitative. The access of WASH facilities were studied using quantitative method whereas the challenges of WASH facilities were studied using the qualitative technique

Question #45 Line 323 “exclusion of health post” I preferred you were included these health post rather than the private clinics that you included. The reason is that

1. There is a mix up of different setting that is governmental and private which are almost completely different setting in Ethiopian condition

2. Your study design is not comparative cross sectional method

3. You didn’t compare the result of private clinics with the government or even to the other similar setting of different countries. The data that you got from private clinics are confined in the governmental HCFs and treated as they are governmental HCFs

Response: The study tried to associate the COVID-19 prevention in healthcare setting. in the case of Ethiopia particularly in the study setting, most of the populations usually get treatment for different healthcare facilities including hospitals, heath centers, and clinics. In the case of heath posts, the major service usually focuses on the prevention of disease including the current pandemic of COVID-19. Hence, clients are not expected to visit the health post which motivates us to exclude from the study.

Question #46 Limitation part what about the cross-sectional nature of the data?

Response: We have incorporated it in the revised manuscripts accordingly.

Question #47 Line 335 make correct on the word “…..concerned exerts……” change to concerned experts

Response: we have corrected it in the revised manuscript.

Question #48 Annex Table, 3 on page 24 “overall latrine cleanliness” i.e high, medium, low, it needs operational definition.

Response: thank you for your comment. We have included the operational definition of the word latrine cleanliness in the revised manuscript.

Submitted filename: response to reviewers.docx

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28 Feb 2022

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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Reviewer #1: Partly

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: 1.) I continue to be concerned with the wider use of literature. For the use of “worldmeter” references 18 and 22, I would prefer to see official Ethiopian government sources. Also, the use of a WHO/UNICEF 2015 JMP report in reference 38. Please update and use the most recent 2021 WHO/UNICEF report.

2.) The study presents the results of original research, but does not compare to other recent studies in Ethiopia or other low- and middle-income countries during COVID-19.

3.) As previously commented, the authors have not made this change. “The N=70, there is not a large enough dataset to have results to 0.1%. Please round all results presented to the nearest whole number.” In Revision 1, Table 1 and 2 still list results to 0.1%

4.) Finally, when you submit the corrected version, please do check thoroughly, in order to avoid grammar, syntax or structure/presentation flaws - please seek for professional English proofreading services or ask a native English-speaking colleague of yours in order to refine and improve the English in your paper.

Reviewer #2: all comments that I raised in the first round were properly addressed by the authors. That was nice. But I have one comment on the reference section. Your references are not similar in style. Hence you should rewrite all references again

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9 Mar 2022

Response to Reviewer 1

#1: I continue to be concerned with the wider use of literature. For the use of “Worldometer” references 18 and 22, I would prefer to see official Ethiopian government sources. Also, the use of a WHO/UNICEF 2015 JMP report in reference 38. Please update and use the most recent 2021 WHO/UNICEF report.

Response:-thank you very much for your comments. Hence, we have incorporated your comments in the revised version of the manuscript.

2.) The study presents the results of original research, but does not compare to other recent studies in Ethiopia or other low- and middle-income countries during COVID-19.

Response:-thank you for your constrictive comment too. We have tried to use researches which were conducted in Ethiopia and other low and middle countries as much as possible in the revised manuscript.

3.) As previously commented, the authors have not made this change. “The N=70, there is not a large enough dataset to have results to 0.1%. Please round all results presented to the nearest whole number.” In Revision 1, Table 1 and 2 still list results to 0.1%

Response:-ok we have modified it based on your comments in the revised manuscript (see the revised version).

4.) Finally, when you submit the corrected version, please do check thoroughly, in order to avoid grammar, syntax or structure/presentation flaws - please seek for professional English proofreading services or ask a native English-speaking colleague of yours in order to refine and improve the English in your paper.

Response:-thank you for the comment; we have tried to incorporate all issues you have raised.(see the revised version of the manuscript)

Response to reviewer 2

#1: all comments that I raised in the first round were properly addressed by the authors. That was nice. But I have one comment on the reference section. Your references are not similar in style. Hence you should rewrite all references again

Response:-thank you for the comment. We have modified the references based on the standard guideline of the journal. (see the revised version of the manuscript)

Submitted filename: response to the reviwers.docx

Click here for additional data file.

31 Mar 2022

23 Apr 2022

Question #1 I have assessed your submission, and whilst the science is now adequate, I have concerns about the overall readability of the manuscript. I therefore request that you revise the text to fix the grammatical errors and improve the overall readability of the text.

Response: Thank you for this remark. We have revised the whole manuscript to reduce the grammatical errors and improve the overall readability of the text by the help of known researcher Dr Metadel Adane Mesifin (Please see the revised version for each section).

Question #2 Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: thank you very much for critical comment. Hence we have improved the whole listed references using the guideline of PLOSE ONE (see the revised version for each section).

Submitted filename: response to reviewers.docx

Click here for additional data file.

27 Apr 2022

Access to and challenges in water, sanitation, and hygiene (WASH) in healthcare facilities of Northeastern Ethiopia in the early phase of the COVID-19 pandemic: A mixed-methods evaluation

PONE-D-21-35346R3

Dear Dr. Berihun,

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Reviewers' comments:

4 May 2022

PONE-D-21-35346R3

Access to and challenges in water, sanitation, and hygiene in healthcare facilities during the early phase of the COVID-19 pandemic in Ethiopia: A mixed-methods evaluation

Dear Dr. Berihun:

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