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Provision of safe water, sanitation, and hygiene (WASH) services in health care facilities is a priority at the global, national, and local levels. To inform improvements planning, conditions of WASH, waste management, and environmental cleaning were assessed in 81 facilities in the Autonomous Province of Vojvodina, Serbia, as part of a nationally representative survey in 2019. The survey included on-site checks, structured interviews, and drinking-water quality analysis. WHO/UNICEF indicators for WASH service levels and an advanced service level defined at the national level were applied. The results showed that all investigated facilities provided basic water services; 94% of facilities provided basic hygiene and waste management services; 58 and 2%, respectively, provided basic cleaning and sanitation services. Only 1% of investigated facilities met the basic level for all five WASH dimensions. Advanced service levels were only met for hygiene, waste management, and/or cleaning in 15–38% of facilities. In 33% of health care facilities, drinking-water quality was not in compliance with the national standards. The results revealed that there is a need for increased awareness and efforts to ensure basic provisions for sanitation, environmental cleaning, and drinking-water safety. HIGHLIGHTS The majority of health care facilities (HCFs) in Autonomous Province Vojvodina provide basic services for drinking-water, hygiene, and health care waste management.; Basic provisions for sanitation and environmental cleaning in HCFs emerged as priorities for future action.; There is a need to increase efforts to ensure advanced WASH services (observed in up to 38% of facilities), to strengthen the provision of people-centred, quality health care, and outbreak preparedness.;

The WHO recommends a risk management approach to ensure safe drinking-water and sanitation, so-called Water Safety Planning and Sanitation Safety Planning. However, applying these risk management approaches separately in small-scale drinking-water supply and sanitation systems might be challenging for rural communities with limited human, financial, and administrative resources. An integrated approach seems a better option. In this study, an integrated water and sanitation safety planning (iWSSP) approach was developed together with guidance and training material for the practical application of this novel approach. The integrated approach was piloted in three small systems in rural Serbia to identify benefits and suggestions for improvement which can be used for potential future scaling-up. Implementing iWSSP at the pilot sites contributed to a better understanding of both drinking-water supply and sanitation systems. It also resulted in increased awareness, knowledge, and understanding among staff of drinking-water supply and sanitation services. Key experts, including external facilitators, played a crucial role in the implementation of iWSSP. Future scaling-up of the integrated approach could be enabled if more guidance, easy-to-use training materials and templates become available which can be adapted and updated as needed. HIGHLIGHTS We developed and tested integrated drinking-water safety planning and sanitation safety planning (iWSSP).; iWSSP helps small rural systems to better understand how both systems influence each other which supports identifying hazardous events.;