Application of Integrated Water, Sanitation and Hygiene (WASH) Assessment Tool in Displaced Settings in Rakhine State, Myanmar

Abstract

This study aimed to apply the integrated WASH assessment tool and assess the performance of WASH services in three Internally Displaced Person (IDP) camps in Rakhine State, Myanmar. The tool was applied in a unique non-household setting that is vulnerable to annual storms and storm-induced flooding, while also facing the complexity of political and social constraints. The assessment focused on nine components of the tool: water, sanitation, hygiene, financial, institutional, environmental impacts, technical, social, and climate change. Afterwards, the overall WASH services performance of the three IDP camps was determined. The assessment revealed good performance in water, financial, institutional, and social components across all camps. However, environmental impact, technical, and climate change components showed the need for improvement due to recurrent climate hazards, and their impacts on WASH facilities, such as latrine destruction, saltwater intrusion into handpumps, and increased diarrhea cases. Based on the findings, the study recommends constructing disaster-resilient latrines, reinforcing handpumps with watertight materials, elevating wellheads to prevent contamination, and forming emergency response teams with appropriate training. Overall, Ohn Taw Gyi (South) and Kaung Doke Khar (2) camps had a good level of WASH performance with a 6.38 sum of net scores of components (SAS), and with 6.06 SAS, respectively. Thet Kae Pyin camp had a moderate level of performance with 5.35 SAS. The application of the assessment tool provided valuable data to support evidence-based decision-making. It serves as a useful resource for WASH professionals, humanitarian organizations, and local governments to evaluate service performance and ensure sustainable service provision in their areas.

1. Introduction

The Water, Sanitation and Hygiene (WASH) interventions have been acknowledged for its significance for all aspects of human recovery and development [1]. This recognition is based on the fact that people affected by disasters are highly vulnerable to morbidity and mortality related to inadequate sanitation, insufficient access to clean water, and the inability to maintain proper hygiene practices [2]. Humanitarian crises, including social unrest, conflicts, disasters (such as cyclones, floods, and droughts), disease outbreaks, and complex emergencies, have become increasingly frequent, impacting a larger number of people [3]. Displaced populations are increasing internationally because of these social and political repercussions in some countries. Displaced persons are people forced to leave or flee their homes in the situation of armed conflicts or intercommunal violence [4]. Having access to improved WASH services is critical for people’s survival and dignity during humanitarian crises [5]. In a displaced setting, where large groups of people live together in a crowded area, there is a high risk of spreading pathogens and occurrence of environmental health-related diseases such as diarrhea, cholera, and other infectious diseases [6].

In 2012, intercommunal violence between ethnic Rakhine and Rohingya communities in Rakhine State, Myanmar, led to the widespread displacement of approximately 140,000 Rohingya people [7]. To relocate the Rohingya communities, 24 internally displaced person (IDP) camps were established across the state. Of these, 14 camps are located in Sittwe and have been accommodating around 130,000 displaced people [8]. Many IDPs in these camps do not have citizenship, face movement limitations, have limited access to market, lack strong shelters. They are heavily dependent on humanitarian aid for their daily survival [3]. Following their forced evacuation, IDPs require essential services such as shelter, water, food, fuel, and healthcare. They continue to be at risk of exposure, illness, and famine without these necessities [9].

These vulnerabilities are further exacerbated by annual floods and cyclones, as many IDP camps are situated in disaster-prone areas. In May 2023, severe cyclone Mocha made landfall in Rakhine State with a wind speed of 250 kmph approaching the coast. The cyclone destroyed an estimated 85% of shelters and sanitation facilities in the camps [10]. As a result, the incidence of waterborne diseases increased due to the lack of sanitation infrastructure, environmental pollution, improper waste disposal, and water contamination. Humanitarian organizations were required to mount a large-scale emergency response: repairing damaged infrastructure, restoring WASH services, and addressing public health needs. This event called for strengthening WASH infrastructure and resilience in IDP camps to ensure that poor and vulnerable people have access to basic services. It also highlighted the need to enhance community resilience to cope with climatic hazards and natural disasters [11] Without these efforts, achieving Sustainable Development Goal (SDG) 6, which promotes universal access to safe water and sanitation, will be hindered. Displaced and marginalized populations will be excluded from accessing WASH services, which is a fundamental human right.

In this context, data that can be quickly and meaningfully analyzed are essential for providing policymakers and WASH planners with conclusive information to plan, target, and prioritize interventions in displaced settings [12]. Therefore, developing and applying tools that comprehensively analyze the progress of WASH services in such settings plays a pivotal role. However, previous studies conducted in IDP camps and similar contexts have primarily focused on assessing specific components of WASH, rather than developing and utilizing an integrated tool to collect robust data and perform a comprehensive analysis [11,12,13,14,15]. Although WASH indices have been developed and applied in other settings [16,17,18], only one study by Tsesmelis et al. [19] developed a WASH index and applied it in European humanitarian camps. That study was based on WASH Rapid Assessment questionnaires developed by United Nations High Commissioner for Refugees (UNHCR) and included only three main components: water, sanitation, and hygiene. While some earlier assessment tools incorporated five conventional sustainability components—financial, institutional, environmental, technical, and social—they have not been applied in displaced settings. More importantly, none of these tools has integrated the impact of climate change into WASH assessments, nor have they been utilized in disaster-prone areas. The novelty of this study lies in addressing these gaps by applying the Integrated WASH Assessment Tool, which incorporates financial, institutional, environmental impact, technical, social, and climate change components, in IDP camps in Rakhine State following Cyclone Mocha. It comprehensively analyzed WASH services, assessed the cyclone’s impact on them, and determined overall WASH performance. Additionally, the study provided recommendations for improving WASH service delivery and identified the strengths and limitations of the tool.

2. Materials and Methods

2.1. Ethical Approval

This study received approval from the Walailak University Ethics Committee in Human Research (Approval Number: WUEC-23-114-01).

2.2. Tool Application Area

The integrated WASH assessment tool was applied in IDP camps situated in Sittwe, Rkahine State, Myanmar (Figure 1). Rakhine State, located along the Bay of Bengal, is highly vulnerable to natural disasters such as cyclones, storm surges, and flooding due to its coastal geography. Especially, IDP camps in Sittwe township are located in flood-prone areas [20]. According to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), there are 24 IDP camps in total, with 14 of them situated in Sittwe. From among the 14 IDP camps in the Sittwe municipality, three camps—a small-size camp with a population of (2000–5000), a medium-size camp with a population of (5000–10,000), and a big-size camp with a population of more than 10,000—were chosen as the study areas. This selection was made in order to reflect situations in all sizes of camps. These three camps were also selected based on the feasibility of data collection and collaboration of stakeholders from the study areas. The name of the camps, household numbers, and population are mentioned in

Table 1. Information of IDP Camps in Sittwe Township, Rakhine State, Myanmar [8].

No	Name of the Camp	Households	Population
1	Thet Kae Pyin—TKP	1013	5950
2	Thae Chaung	2038	13,016
3	Say Tha Mar Gyi	2690	16,761
4	Ohn Taw Gyi (South)—OTG (S)	2275	12,495
5	Ohn Taw Gyi (North)	2640	15,931
6	Ohn Taw Chay	784	5340
7	Maw Ti Ngar	657	3844
8	Kaung Doke Khar 2—KDK (2)	400	2259
9	Kaung Doke Khar 1	386	2058
10	Dar Pai	1753	11,737
11	Baw Du Pha 2	1370	8908
12	Baw Du Pha 1	1012	5156
13	Basare	380	2506
14	Phwe Yar Kone	400	2357

.

2.3. Overview of Integrated WASH Assessment Tool

The integrated WASH assessment tool was developed to assess WASH services in a comprehensive way in non-household settings including displaced camps, schools, health care facilities, and prisons. The tool is composed of nine components: a water component, a sanitation component, a hygiene component, a financial component, an institutional component, an environmental impacts component, a technical component, a social component, and a climate change component. Under each component, there are indicators, corresponding scores (1, 0.67, 0.5, 0.33, 0), and definitions for each score. For example, the first indicator under the water component is “access to improved water supply sources”. There are four scores for this indicator: 1, 0.67, 0.33, and 0. A score of 1 means “all the water sources in the study area are improved sources”. A score of 0.67 means “most of the water sources are improved sources (≥70%)”. A score of 0.33 means “some of the water sources are improved sources (≥50%)”, and a score of 0 indicates that “only a few water sources are improved sources (<50%)” [22]. Each indicator has similarly specific definitions for each score. We used all the indicators and scoring definitions from [22] without modification.

Table 2. Components and indicators of the integrated WASH assessment tool, data from [22].

No	Indicators of Water Component
1	Access to improved water supply sources (Examples of improved water supply sources—piped water supply and protected handpumps and protected open wells)
2	Functionality of water supply sources (function of extracting, collecting and distribution of water)
3	Water points (hand pumps, open well, public tap, etc.) to users’ ratio
4	Flow rate of water points (hand pumps, open well, public tap, etc.)
5	Distance between water points (taps, hand-dug wells, open wells, etc.) and households
6	Distance between water points (taps, hand-dig wells, open well, etc.) and excreta containment facilities (e.g., latrines)
7	Water fetching time
8	Water quality (Turbidity)
9	Water quality (E. coli)
10	Availability of water for drinking and personal hygiene (quantity, reliability and continuity)
11	Contingency plan for water shortage
12	Provision of water containers with lids for fetching and safely storage water
13	Monitoring water quality testing (E. coli)
No	Indicators of Sanitation Component
1	Access to improved latrines (Example of improved latrines—flush/pour flush to piped sewer system, septic tank, pit latrines, ventilated improved pit (VIP) latrines, pit latrine with slab, composting latrines)
2	Latrines to users’ ratio
3	Distance to latrines from users
4	Cleanness of the latrines (free from faeces and insects (flies))
5	Availability of adequate amount of water to clean latrines
6	Conditions of the latrines (superstructure)
7	Presence of vectors (flies, mosquitoes, rats, etc.)
8	Vector Control Activities (flies, mosquitoes, rats)
9	Presence of cleaning materials inside latrines
10	Presence of fecal sludge management activities
11	Presence of waste segregation system and waste management facilities
12	Presence of waste disposal bins
13	Waste collection system
14	Frequency of waste collection
15	Proper waste disposal
No	Indicators of Hygiene Component
1	Availability of handwashing facilities
2	Accessibility of handwashing facilities
3	Provision of hygiene items
4	Provision of menstrual waste or pad bins
5	Presence of laundry space
6	Presence of bathing space
No	Indicators of Financial Component
1	Allocation of annual budget for maintenance of WASH facilities
2	Allocation of budget for daily operation of WASH facilities
3	Utilization of allocated budget for maintenance of WASH facilities
4	Utilization of budget for daily operation of WASH facilities
5	Allocation of budget for disaster mitigation, prevention, preparedness, and response
6	Utilization of allocated budget for budget for disaster mitigation, prevention, preparedness, and response
No	Indicators of Institutional Component
1	Existence of clear policies for the provision of WASH services
2	Existence of policies for Solid Waste Management
3	Existence of WASH facility management structure
4	Presence of community-based associations or groups to maintain WASH facilities
5	Functioning of community-based associations or groups to maintain WASH facilities
6	Building capacity of WASH committee/water committee/sanitation committee, parent-teacher association (PTA) or other community-based associations or persons who are involved in WASH facilities operation, maintenance, monitoring and management
7	Existence of a WASH monitoring system
No	Indicators of Environmental Impact Component
1	Free from human feces in an environment where people live, learn and work
2	Overflow or leakage from excreta containment facilities (e.g., latrine pits, septic tanks, or other black water treatment units)
3	Presence of run-off water near water points
4	Management of drainages
5	Signs of releasing leachate from temporary waste collection site
6	Wastes are not littered and accumulated in the premises
No	Indicators of Technical Component
1	Quality of Construction
2	Easily maintained with local capacity and skills
3	Consideration of potential local hazards during construction
4	Accessibility of technicians
5	Safety usage of WASH facilities at night
6	Provision of safety, operation, and maintenance trainings to desludging workers
7	Safety equipment for sanitation workers
No	Indicators of Social Component
1	Existence of culturally accepted latrines
2	Existence of disabled-friendly latrines
3	Existence of child-friendly latrines (latrines with enough lighting, with small size latrine pans, cartoon on the wall and/or low height latrine with lower footsteps)
4	Existence of gender-segregated latrines
5	Presence of a functioning complaint mechanism
6	Conflict among different user groups or conflicts with host communities
7	Participation of users and/or host communities in WASH activities
8	Involvement of women in decision-making process
No	Indicators of Climate Change Component
1	Weather change events which can impact on WASH services
2	Impacts of weather change events on water points
3	Impacts of weather change events on sanitation facilities
4	Impacts on health after weather change events
5	Presence of plans for reducing the quantity of water
6	Presence of plans for deterioration of quality of water
7	Mitigation of natural disaster impacts on water infrastructure damage
8	Presence of plans for water infrastructure damage
9	Mitigation of natural disaster impacts on latrines and other sanitation facilities
10	Presence of plans to respond latrines and other sanitation facilities damage
11	Presence of emergency response plans to prevent WASH disease outbreak after climate change events
12	Building capacity of users

provides a comprehensive list of all indicators of the assessment tool. Detailed scores and definitions for each indicator can be found in Supplementary File S3.

Step-by-Step Application of the Tool

There are six steps in the application of the tool: (1) assigning weights to each indicator, (2) calculating attainable component scores, (3) data collection and calculation of component scores, (4) assigning weights to the components, (5) calculating attainable net component scores, and (6) calculating net component scores [22].

• Assigning Weights to the Indicators

To assign weights to the indicators, we invited four experts: two water and sanitation professionals, a researcher with a focus on sanitation, and a university lecturer. They were asked to provide weights to the indicators according to the scales from [22]. These scales are: 0 = weakly important, 0.25 = less important, 0.50 = moderately important, 0.75 = more important, and 1 = extremely important, respectively [22]. After all the experts assigned the weights to the indicators, average weights were calculated. These average weights were used to calculate the attainable component scores and the component scores of the study areas. The weights provided by the experts, along with the average weights, can be found in Supplementary File S1.

2.

Calculating Attainable Component Scores

The integrated assessment tool already provided the component scores for each performance by assigning a weight of 1 (extremely important) to every indicator. However, in this study, instead of using the same weight (1), experts’ opinions on the relative importance of each indicator were gathered by asking them to provide weights for each indicator. Thus, the attainable component scores for this study were calculated. The attainable scores were calculated by multiplication of the average weight of each indicator, and the scores of each indicator from the best optimum to the least optimum. The integrated WASH assessment tool has three set of indicators: two-value fuzzy set (1, 0), three-value fuzzy set (1, 0.5, 0) and four- value fuzzy set (1, 0.67, 0.33, 0) [22]. When calculating the attainable component scores, the best optimum score was 1 for all set of indicators. Middle scores (1) were also 1 for crisp set indicators, and 0.5 for three-value fuzzy set indicators, and 0.67 for four-value fuzzy set indicators. Middle scores (2) were 0 for crisp set indicators, 0 for three-value set indicators, and 0.67 for four-value fuzzy set indicators. Middle scores (3) were 0 for crisp set indicators, 0 for three-value set indicators, and 0.33 for four-value fuzzy set indicators. The least optimum score was 0 for all set of indicators. The details calculation can be seen in the Supplementary File S2.

3.

Data Collection and Calculation of Component Scores

In August 2023, data were collected from key individuals who knew much about WASH service provision in each camp. Relevant scores were provided to each indicator according to answers from the participants on current conditions of WASH services. The participants were also asked the number of WASH facilities in the camp before Cyclone Mocha was used to evaluate the cyclone’s effect on WASH services. The participants included five representatives from Ohn Taw Gyi (South)—OTG (S) camp, four representatives from Thet Kae Pyin (TKP), and four representatives from Kaung Doke Khar 2—KDK (2) camps, totaling 13 participants. The representatives were two senior management-level staff, two mid-management-level staff, two field staff, and seven camp-based staff. These individuals were the staff of two international non-governmental organizations providing WASH services in the three IDP camps. After collecting data, the component scores were calculated by using Equation (1) [23].

$$CS\left(a\right)={\sum }_{n=i}^{Ind}{Ind}_i{W}_i/{\mathrm{Sthl}}_{\mathrm{n}}$$

(1)

where,

CS(a) = net score of component “a”

Ind_i = score of indicator “i” of component “a”

W_i = average weight of indicator “i” of component “a”

Sthl_n = number of stakeholders

4.

Assigning Weights to the Components

After the participants were interviewed about the WASH service conditions in the camps, their opinions were collected regarding the relative importance of the nine components to ensure sustainable WASH service provision in their areas. This was done through pairwise comparison. Each participant was asked to compare one component against another in pairs and determined which component was more important in providing WASH services. The comparison was based on a weighing scale, where: (1 = equal important, 3 = moderately more important, 5 = strongly more important, 7 = very strongly more important, and 9 = extremely more important) [22]. For example, if a participant believed that the water component was extremely more important than the sanitation component, he/she assigned a value of 9 to water component when compared to sanitation component. Conversely, the reciprocal value (1/9) was assigned to sanitation component when compared to water component. This process continues until all nine components have been compared against each other.

After gaining the full matrix, the matrix was normalized to transform the values into a standardized scale, ensuring that the weights are comparable [24]. The normalized values were then summed row-wise to compute the criteria weights for each component. The criteria weights were obtained by averaging the row values, and the sum of the weighs must be 1 (100%). The final weights were determined by averaging all the criteria weights provided by all participants. These weights represent the relative importance of each component, and used to calculate the overall WASH service performance of each study area. Consistency check was also carried out to check the consistency of pairwise comparison matrix. A detailed calculation can be seen in Supplementary File S4.

5.

Calculating Attainable Sum of Net Component Scores

Just as the attainable component scores were calculated, the attainable sum of net component scores was also calculated, as the participants’ opinions were taken into account in evaluating WASH services performance instead of assuming all components are equally important. These scores were calculated using Equation (2), with the component weights from the previous step and the attainable component scores of WASH services. The detailed calculation of the attainable sum of net component scores can be seen in Supplementary File S5.

$$ASAS={\sum }_{n=i}^{CS}{ACS}_i{W}_i$$

(2)

where,

ASAS = attainable sum of net score of the components

ACS_i = attainable net score of component “i” (i = a, b, c,…)

W_i = weight of component “i” (i = a, b, c,…)

6.

Calculation of Sum of Net Component Scores

Finally, the sum of the net score of the components to determine the overall WASH performance was calculated by using Equation (3). Figure 2 demonstrates the sequential calculation of WASH performance score using the integrated WASH assessment tool.

$$SAS={\sum }_{n=i}^{CS}{CS}_i{W}_i$$

(3)

where,

SAS = sum of net score of the components

CS_i = net score of component “i” (i = a, b, c,…)

W_i = weight of component “i” (i = a, b, c,…)

Figure 2. Step-by-step application of integrated WASH assessment tool.

Figure 2. Step-by-step application of integrated WASH assessment tool.

3. Results

This section presents the attainable component scores, the scores of the nine components, the weights of the components, and the overall WASH performance of the three IDP camps.

Table 3. The attainable component scores of WASH services.

Components	Water Component	Sanitation Component	Hygiene Component	Financial Component	Institutional Component	Environmental Impact Component	Technical Component	Social Component	Climate Change Component
Good Performance	7.97–11.08	8.58–12.02	3.47–5.08	3.33–4.94	3.16–5.19	3.81–4.94	3.39–5.25	5.43–7.30	6.51–8.38
Moderate Performance	6.34–7.96	7.01–8.57	1.77–3.46	1.77–3.32	2.19–3.15	1.56–3.80	2.98–3.38	2.18–5.42	0.39–6.50
Below-average Performance	3.13–6.33	3.46–7	0.88–1.76	0.88–1.76	1.08–2.18	0.77–1.55	1.48–2.97	1.08–2.17	0.19–0.38
Poor Performance	0–3.12	0–3.45	0–0.87	0–0.87	0–1.07	0–0.76	0–1.47	0–1.07	0–0.18

presents the attainable component scores of the study.

3.1. Component Scores of WASH Services in Three IDP Camps

The water component achieved a good level of performance in all three camps because most of the water sources (>70%) are improved sources (protected hand pumps) with a water-point to users ratio of (1:60 in OTG (S) camp, 1:90 in TKP and KDK (2) camps) and are functional most of the time. Additionally, hand pumps are located within 200 m of most IDPs’ households and at least 30 m away from latrines and septic tanks. The water quality meets acceptable standards (turbidity < 5 NTU, E. coli = 0 or 1–10 MPN/100 mL) according to monthly water quality test. A water supply of more than 15 L per person is consistently available throughout the year. Cyclone Mocha destroyed a few hand pumps (22 in OTG (S) camp, 9 in TKP camp, and 2 in KDK (2) camp), but it did not significantly affect water availability, as all camps had sufficient water sources. The hand pumps that were contaminated after the cyclone were chlorinated by the responsible WASH service provider in each camp.

Sanitation component showed below-average performance in OTG (S) and TKP camps and moderate performance in KDK (2) camp. This was primarily due to the destruction of most latrines by Cyclone Mocha, which significantly reduced their functionality. Before the Cyclone Mocha, the OTG (S) camp had 806 latrines for a population of 12,495 (latrine-to-user ratio: 1:16), the TKP camp had 237 latrines for 5950 people (1:25), and the KDK (2) camp had 104 latrines for 2259 people (1:22). After the cyclone, these ratios turned to 1:50 (248 latrines for the same population) in OTG (S) camp, 1:142 (42 latrines for the same population) in TKP camp, and 0 functional latrines in KDK (2) camp. As a result, camp communities reverted to open defecation, leading to an increase in diarrhea cases. Additionally, the lack of cleaning materials inside the latrines due to theft, the absence of an effective waste disposal system, and the practice of burning all waste contributed to the below-average performance. In the KDK (2) camp, waste disposal bins were placed in each barrack for temporary storage, after which cleaners collected the waste and transported it to the incinerators for burning.

The hygiene component showed below-average performance in all three camps. This was because handwashing stations were not present near the latrines (within 5 m), and very few handwashing stations (fewer than five per camp) were available in all three camps. In addition, these handwashing stations were not accessible to elderly individuals, children, or people with disabilities. Every family had to share a small room with inadequate space for bathing and washing, and common bathing and laundry spaces were not adequately provided in the camps. Each camp had only one or two bathing and washing facilities. These conditions were not related to Cyclone Mocha, as the situation was the same before the cyclone. However, hygiene kits (bathing soap, laundry soap, and sanitary pads) were distributed in the camps every month. Menstrual waste bins are present in few latrines.

Financial component showed a good level of performance in all three camps. This was because the respective WASH service provider for each camp had allocated budgets for the daily operation of WASH facilities, renovations (both major and minor), and disaster preparedness and response measures. In terms of utilizing the allocated budget, the daily operation funds were used to pay cleaners who cleaned latrines and collected waste around the camp, as well as workers who carried out desludging and other related costs, such as fuel for operating desludging trucks and incinerators. Although renovation budgets are needed after cyclone destruction to repair damaged facilities and construct new ones, the local government imposed restrictions on running disaster response operations. This caused serious delays in the rehabilitation process and increased the burdens on the camp communities.

Institutional component demonstrated a good level of performance across all three camps. This was due to the presence of well-defined policies for the provision of WASH services, aligned with the National Strategy. Moreover, solid waste management policies were in place, alongside the established WASH facilities management structure. The presence of functional camp-based associations played a significant role, as did the implementation of effective WASH monitoring systems. Capacity-building training was offered to WASH committees, with annual refresher training provided in the OTG (S) camp, and refresher training provided every two to three years in the TKP and KDK (2) camps.

The environmental impact component showed moderate level of performance across three camps. This was attributable to visibility of feces near toilets and overflow from latrine pits. However, stagnant water was visible near a few water points (<50%). In most parts of the drainage pathways, water flowed well, and the accumulation of waste at some points within the camp area occurred. After the cyclone, overflows from latrine pits became more common due to the damage of latrine pits caused by the cyclone. The existing open defecation practices worsened in the aftermath of Cyclone Mocha due to the lack of functioning latrines.

The technical component showed moderate performance across the three camps. This was due to the necessity of minor repairs resulting from poor quality. However, major repairs were required post-cyclone, repairs could not be initiated within 48 h, despite the presence of local technicians. In these camps, lighting was absent within the latrines but available along the pathways leading to them, and these lights were functioning in many areas of the camps.

The social component showed a good level of performance at the TKP camp, and moderate performance in the OTG (S) and TKP (2) camps. This was due to the presence of culturally acceptable WASH facilities, the presence of disabled-friendly latrines or defecation chairs for households with disabled individuals in each camp. Child-friendly latrines were also accessible. Mechanisms for handling complaints were in place. Conflicts were minimal, both in terms of equity in WASH service provision and in interactions with host communities. The camp communities engaged in health education sessions, sanitation campaigns, and various WASH initiatives when initiated by organizations. Despite the involvement of women in community-based associations, such as WASH committees, their voices remained relatively unheard. In the OTG (S) camp, latrines were handed over to households (four households per latrine), while in the TKP and KDK (2) camps, latrines were segregated by gender. Nonetheless, in all three camps, adherence to these segregation rules by the communities was inconsistent.

The climate change component showed moderate performance across all three camps. This was attributable to occurrences of annual climate hazards, notably storms and flooding induced by storms, and tangible repercussions from these climate-related challenges on both WASH facilities and public health, encompassing issues such as saltwater intrusion into handpumps, latrine damage, and a rise in cases of diarrhea. In terms of response strategies, the distribution of ceramic water filters was implemented, with a subsequent redistribution carried out after a two-year interval. A budget was allocated for the repair of the WASH facilities, and comprehensive emergency response plans were formulated to address potential outbreaks of WASH-related diseases. Moreover, efforts were directed toward disseminating knowledge about climate change and disaster preparedness within the camp communities.

Table 4. The component scores of WASH services of three IDP camps.

Components	Water Component	Sanitation Component	Hygiene Component	Financial Component	Institutional Component	Environmental Impact Component	Technical Component	Social Component	Climate Change Component
Component Scores of OTG (S)	10.05	6.79	1.51	4.17	4.61	2.27	3.34	5.12	5.55
Component Scores of TKP	8.27	5.84	1.62	4.3	3.48	1.56	2.98	5.53	3.99
Component Scores of KDK (2)	9.41	7.51	1.61	4.11	4.04	2.47	3.23	5.31	4.63

presents the component scores of the three IDP camps. The result scores of each indicator and detailed calculation of each component score can be seen in Supplementary File S4.

3.2. Weights of the Components

Table 5. Weights of the nine components.

No	Components	Weighing Factors
1	Water Component	0.37
2	Sanitation Component	0.07
3	Hygiene Component	0.06
4	Financial Component	0.07
5	Institutional Component	0.12
6	Environmental Impact Component	0.07
7	Technical Component	0.07
8	Social Component	0.07
9	Climate Change Component	0.09

presents the weights of the components. Among the nine components, the water component received the highest weight, the institutional component the second highest, and the climate change component the third highest, while the hygiene component received the lowest weight. The sanitation, financial, environmental, technical, and social components received equal weights. These scores reflect participated stakeholders’ opinions about which components are most important for their implementation areas. Detailed calculations of the weights of the components can be found in Supplementary File S2.

3.3. Attainable Sum of Net Component Scores

The attainable sum of net component scores can be seen in

Table 6. The attainable sum of net component scores and their levels of performance.

Level of WASH Services Performance	Sum of Net Score of Components (SAS)
Good Performance	5.84–8.19
Moderate Performance	3.84–5.83
Below-average Performance	1.89–3.83
Poor Performance	0–1.88

, and the detailed calculation can be seen in Supplementary File S5.

3.4. Sum of Net Component Scores or Overall WASH Performance of Three IDP Camps

Overall, the OTG (S) and KDK (2) camps had good level of performance, and the KDK (2) camp had a moderate level of performance in the provision of WASH services. Water, financial, and institutional components were on track in all three camps, but the two main pillars of WASH, sanitation and hygiene components, need significant improvements as below-average performance and moderate performance were seen in these components as the result of a lack of functioning latrines and hygiene facilities. The sum of the net component scores of the three IDP camps can be seen in

Table 7. The sum of net component scores of WASH services of the IDP camps.

Name of the Camp	Sum of Net Component Scores
OTG (S)	6.38
TKP	5.35
KDK (2)	6.06

, and the detailed calculation can be seen in Supplementary File S6.

4. Discussion

Under this section, the effect of climate change and disaster on WASH services, recommendations to improve WASH services in IDP camps, and the strengths and weaknesses of the tool were discussed.

4.1. Effect of Climate Change and Disaster on WASH Services

The significant alteration in the users-to-toilet ratio (from 1:16 to 1:50 in OTG (S), from 1:25 to 1:142 in the TKP camp, and from 1:22 to 0 functional latrines) indicates that climatic events impact WASH performance scores, especially concerning the sanitation component. The WHO discussion paper [25] emphasizes the need for climate-resilient sanitation infrastructure as a core strategy for sustainable WASH services. The cyclone’s destruction of latrines in the camps illustrates this vulnerability, revealing a lack of adaptive design and risk mitigation planning, which WHO identifies as critical for WASH resilience in disaster-prone settings. The cyclone-induced collapse of latrines (both superstructures and pits), a technical failure, causes environmental contamination as people revert to open defecation (OD), and excreta overflows from the latrine pits. The situation worsens as desludging activities cannot be carried out as before due to flooded roads after the cyclone. These failures also have impacts on the social component. According to Domini et al. [12], before Cyclone Mocha, latrines had already been handed over to households in the OTG (S) camp, while WASH organizations in the TKP and KDK (2) camps were in the process of continuing the handover [11]. After the cyclone, widespread damage to latrines forced households to share the few remaining functional units, setting back the allocation process and making further distribution increasingly difficult. As a further consequence, gender-segregated practices have been disrupted. Communities are now compelled to share limited facilities, eroding privacy and increasing exposure to unsafe sanitation conditions. The loss of gender-segregated latrines particularly affected women and girls, who rely on separate facilities for privacy and safety. Without them, many women are forced to wait until dark to relieve themselves, increasing their vulnerability to harassment and reducing their personal dignity and health [26]. Together, these failures show that WASH infrastructure in the camps lacks not only technical resilience but also the systemic capacity to adapt to climate-related shocks, calling for an integrated approach that considers infrastructure, environment, and social equity as interdependent pillars of sustainable WASH service delivery.

4.2. Recommendations to Improve WASH Services in IDP Camps

IDP camps are special settings and differ from traditional rural communities, as residents in camps were forced to displace due to conflict or disasters. These settings were typically established and managed by governmental authorities, humanitarian organizations, or a combination of both [27]. Unlike rural communities where people choose their homes, those in IDP camps lack the freedom to determine their living circumstances and make a living. The well-being of IDPs relies heavily on government policies, management, and support from humanitarian organizations [3]. The findings of this study indicate that delays in response efforts (slow utilization of renovation budgets for latrines after Cyclone Mocha) were exacerbated by restrictions imposed by the local government. This highlights the urgent need to develop emergency WASH response protocols for situations in which the government does not cooperate with humanitarian organizations or imposes restrictions on providing humanitarian assistance to affected communities. It is essential to pre-position WASH supplies by coordinating with suppliers to deliver response items as quickly as possible and to secure fixed prices, as prices often increase immediately after disasters [28,29].

Several recommendations are proposed based on the indicator scores and component scores obtained from the assessment to optimize the overall WASH performance within the IDP camps. Firstly, for the sanitation component, constructing new latrines and renovating existing ones is particularly important to improve sanitation and reduce health problems associated with poor WASH facilities [2]. The establishment of a regular maintenance schedule and a rapid-response repair system for latrines should be considered [30]. The absence of cleaning materials inside latrines is linked to theft problems, which could be addressed by transferring latrine ownership to households. Domini et al. [3] found that family-shared, gender-disaggregated latrines are widely accepted within camp settings. During handover, households should receive hygiene and cleaning kits including cleaning products, a lock, and a key to help secure and maintain their latrines.

Regarding solid waste management, the camps still lack a standardized waste management system, and waste segregation is not yet practiced. To address this, humanitarian organizations should conduct awareness campaigns about the adverse impacts of improper waste disposal on health and the surrounding environment. Additionally, organizations should introduce waste segregation at the source, starting with color-coded disposal bins. While reuse and recycling are already happening informally, organizations should promote 3R (reduce, reuse, recycle) practices and establish small-scale materials recovery facilities within the camps. Moreover, displaced communities should be included in the design and implementation of solid waste management programs. Community members could be trained and employed in waste collection, sorting, and composting initiatives, turning WASH efforts into income-generating opportunities [31]. Currently, small-scale incineration is the final waste disposal method in the camps, however, it often lacks proper design and adherence to best practices. Therefore, well-constructed incinerators are needed to minimize adverse effects on human health and the environment and to ensure a more complete combustion process [32].

Secondly, improving the hygiene component requires installation of accessible, inclusive handwashing stations at key locations, designed with input from community members to ensure they meet the needs of women, children, the elderly, and persons with disabilities. To tackle theft and vandalism, a community-led maintenance group could be formed to oversee public WASH facilities, with rotational leadership and feedback mechanisms to promote shared responsibility and transparency [33]. Beyond addressing the lack of hygiene infrastructure, training programs for camp residents in hygiene promotion, particularly during emergencies, should be institutionalized. These trainings could be conducted through peer educators or WASH focal points from within the community. Unlike some European humanitarian camps that provide shared laundry and bathing spaces, IDP camps in this study lack such facilities [19]. There is a need to build gender-segregated communal bathing and laundry stations with a minimum user-to-facility ratio of 1:50, ensuring both dignity and safety according to the Sphere standards [5]. These spaces should be designed with community input, considering local cultural norms and security needs, and monitored for upkeep and equitable access.

To eliminate open defecation and improve the environmental impact component, community mobilization campaigns must be scaled up. These could include scheduled waste clean-up drives, community-led desludging operations, and training sessions on environmental hygiene. Importantly, these activities should be co-designed and co-led by camp residents, giving them ownership over the outcomes [34]. Furthermore, to improve the technical component, latrines should be built using good-quality materials that account for potential local hazards, and a more appropriate design to cope with the potential hazards. Community workshops can be used to evaluate and improve design features. Finally, the installation of solar-powered lighting systems inside and around latrines and along key pathways will enhance nighttime safety, especially for women and children. Involving residents in identifying priority lighting zones and conducting community safety audits ensures that solutions are rooted in local knowledge and needs [35].

To strengthen the climate change component, strategies to ensure a sufficient and sustainable supply of clean water should be developed. For example, watertight materials should be used to prevent contamination of handpumps during flooding events by creating a barrier between floodwaters and the water source. UNICEF recommended that raising wellheads and placing them on mounds allows floodwater to drain away, reducing the likelihood of damage and contamination. Providing operation and maintenance (O&M) training to field staff and WASH committees will improve system sustainability by empowering local teams to manage and repair infrastructure. In addition to training, storing spare parts and O&M toolboxes in camps enables quicker repairs, reduces service downtime, and fosters a sense of community ownership. Distributing ceramic water filters to households annually or as needed ensures access to safe drinking water during emergencies when handpumps may be compromised and centralized water treatment options are unavailable [36].

Like ensuring a sustainable water supply, strengthening sanitation infrastructure to withstand future disasters is also important for enhancing the climate change component. Regular monitoring and prompt repair of latrines help maintain functionality and ensure any damage is addressed before it worsens. It is also necessary to use good quality materials to increase the durability and structural integrity of latrines. Not only using good quality materials, but also improving structural design will reduce the likelihood of damage during extreme weather events. According to experiences from the states of Assam and Gujarat, India, increasing the depth of latrine foundations enhances stability during strong winds and flooding. Increasing the height of the plinth prevents floodwater from entering the latrine, while incorporating pillars at the corners and a doorframe improves structural resilience. Raising the pit lining and increasing its diameter help prevent groundwater contamination, and plastering the pit lining prevents groundwater contamination and leakage into surrounding soil and water sources [37,38,39,40]. To enhance preparedness for recurrent disasters, it is essential to establish emergency response teams and provide comprehensive training for both staff and community members. Simultaneously, increasing public awareness and education around natural disasters should be prioritized to build local resilience and promote proactive response behaviors.

4.3. Strengths and Weaknesses of the Tool

The tool has strengths and weaknesses. On the positive side, it considers various aspects influencing WASH performance, including financial, institutional, environmental, technical, social, and climate change factors. It provides comprehensive indicators, scores and scoring definitions for each component. It assesses financial capability beyond budget availability, evaluating effective utilization. The institutional component assesses institutional capacity of both WASH service providers (in this study, international NGOs) and the displaced communities in providing sustainable WASH services. By using the integrated tool, indicators are weighted, allowing the score to more accurately represent overall functions. Each component is also weighted, ensuring that the net score reflects WASH service performance based on the importance of each component. If conventional tools were used, each component would stand alone, and practitioners would tend to focus more on components they think are important. However, using an integrated assessment tool, it becomes clear that other components also influence overall WASH performance. While the water component performs well, sanitation and hygiene, which are also important for disease prevention, do not. This is clearly seen and compared through the assessment. Thus, components with the lowest scores and indicators with the lowest scores in each component can be prioritized for improvement.

However, the tool also has drawbacks, including occasional oversight of detailed issues, and multiple steps for utilization. For instance, the social component’s indicators did not capture issues related to theft in the study areas, which emerged as significant barriers to maintaining clean facilities, ensuring the availability of soaps at handwashing stations, and preventing the loss of handwashing facilities. These issues came to light through interviews with key informants. As a result, the tool somewhat oversimplified the social challenges affecting the sustainability of WASH services. To prevent the oversimplification of the tool, it is essential to include additional indicators that can effectively capture those specific issues. In a previous study conducted in IDP camps in Rakhine State, Myanmar, the issue of vandalism was also addressed, and it was noted that handing over latrines to households is a strategy to reduce vandalism [11]. Additionally, opportunities for improvement exist, particularly in the technical component, not only considerations of ‘safety usage of WASH facilities at night’, and the condition of roads or pathways leading to latrines require attention, especially after extreme weather events such as heavy rainfall.

5. Conclusions

The integrated WASH assessment tool was applied in displaced settings and evaluated the performance of WASH services. In doing so, three different sizes (small, medium, and large) were selected to enhance the applicability of the tool in all size camps. The tool application was conducted with involvement of stakeholders from providing scores to each indicator to assigning weights to each component. The tool application revealed the performance of WASH services with composite scores at the indicator level, component level, and overall WASH performance level. According to the results, water, financial, institutional, and social components are performing well and are on track. However, the environmental impact, technical, and climate change components are performing at a moderate level, indicating the need for improvements. Among them, the sanitation and hygiene components require significant improvements, as they are below average in performance due to a lack of functioning latrines and hygiene facilities. Overall, OTG (S) and KDK (2) camps had good levels of performance, while the TKP camp had a moderate level of performance. The tool application revealed the impacts of climate change and disasters (such as Cyclone Mocha) on WASH services, especially on sanitation services, and their repercussions on other components, such as environmental and social components.

Therefore, several recommended measures to withstand future disasters were provided. The construction of disaster-resilient latrines is a priority, along with the installation of accessible handwashing stations for all, while considering the challenge of public property theft. Adequate and secure common bathing and laundry spaces are also essential while preventing misuse and ensuring safety. Continuous community mobilization efforts are required to create an environment free from open defecation, along with timely desludging activities and the transformation of solid waste management policies into actionable practices. To ensure the safe usage of WASH facilities, it is necessary to install and maintain functional lights inside and around latrines and water points. Lastly, more attention must be paid to implementing disaster mitigation activities, especially regarding the camps’ vulnerability to annual climatic hazards. Situated in disaster-prone areas, these camps require strategies to mitigate the impact of natural disasters, particularly on sanitation facilities, given the camps’ structural and living conditions. These measures are indeed essential to address the challenges posed by recurrent climatic hazards.

This is the first-time application of the integrated WASH assessment tool in displaced settings. As the tool was developed for all non-household settings, it is recommended to extend its application to other non-household settings, such as schools, healthcare facilities, prisons, and similar environments, including IDP or refugee camps in different local contexts. The application of this tool necessitates the involvement of multiple stakeholders throughout the entire process. Thus, they will gain insights into their implementation areas, leading to the prioritization of necessary actions for the sustainable improvement of WASH service provision.