Seminar: WASH and Quality Improvement at Health Facilities

Title: ‘How clean are your hands? Linking the hardware & the software of quality care’

Why does the interface between the enabling environment of health facilities [the hardware] and the behaviour of providers [the software] matter, for example in relation to WASH on maternity units?

At this seminar, held at DFID Whitehall, on 30th September 2015, our guest speaker, Professor Wendy Graham, Emeritus Professor of Obstetrics and Epidemiology at the University of Aberdeen, shared insights about how focused lesson-learning from specific aspects of maternity services, such as WASH, can complement broad systems approaches to tackle the significant weaknesses across the multiple dimensions of quality that persist in many low-income country settings.

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Presentation by Wendy Graham at DFID Whitehall, September 2015

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Professor Wendy Graham is Emeritus Professor of Obstetrics and Epidemiology at the University of Aberdeen and honorary Professor at the LSHTM. She has a long standing interest in the design and evaluation of complex interventions to reduce maternal mortality in low income countries. Since completing her secondment to DFID as senior Research Fellow in 2012, her research has focused on healthcare-associated infections in maternity units and preventative options. She is the co-lead of the new Lancet maternal health series.

Summary prepared by: Adrian Bannister and Sue Newport, HEART-IDS

The purpose of this seminar was to be provocative in promoting thinking about the connections between quality of care (used in a general sense to cover systems, services and care) and water, sanitation and hygiene (WASH); and specifically, linkages between the “hardware” infrastructure of an environment and the “software”, such as behaviours.

Quality of care, with its multiple facets, is important as part of the pathway to making a difference, and integrating WASH is a core part of this. Quality of care is composed of many different levels and tiers. Much of the focus in the past has been at the macro level, whereas this presentation focuses on the micro level, specifically WASH and hand hygiene

WASH is a broad and complex area and not related only to health care. There are also socio-economic and cultural aspects which disproportionately affect women and girls; for example, access to WASH has an impact on girls attending school. Within the health arena, WASH is not limited just to facilities but also has an impact at community and household level. The impact of WASH through the life-course is also significant (Benova et al., 2014). This presentation, however, focuses predominantly on the point of childbirth or delivery.

WASH is a missed opportunity in improving quality of care and health outcomes. Although this is of growing importance as institutional delivery rates are increasing globally, in many places the demand is outstripping the resources and capacity available. This has the potential to compromise the benefits of institutional delivery and even to bring about perverse effects. There is a need and opportunity to “get ahead of the curve of institutional delivery”.

Despite the opportunity, there is a silence in relation to WASH at the moment and a failure to use the platforms, instruments and language associated with quality improvement and assurance in relation to WASH. There is a need to have the two working more closely together. WASH is not being positioned adequately in discussions around universal health coverage in a way that will achieve the gains needed to make a difference.

Why hand hygiene specifically?
Hand hygiene is an entry point or lens to examine or illuminate complex and composite issues in quality of care. It promotes starting with something which, although micro, is amenable to change and leads to real feelings of motivation among staff.

Using hand hygiene as a lens can help to create and promote connections from micro to macro level, between infrastructure and behaviour and other areas beyond the health facility. It is also a preventive opportunity – prevention is better than cure – and an opportunity that can be monitored. In addition, it is relevant across many tiers and levels of health care provision and of quality of care. Assessments of hand hygiene activities illustrate the multiple tiers to quality “care” and demonstrate where gaps in hand hygiene help to illuminate the multiple dimensions to quality “care”.

Image evidence for the opportunities:
By using image evidence methodology, we can ‘walk through’ a facility to raise key questions and issues in relation to WASH and hand hygiene in particular. Such images raise critical questions, including:

  • Who would want to practice there?
  • What sort of practice could you undertake in that environment?
  • What would it mean from a woman’s point of view to ask her to deliver in this environment?

Using images we can show the physical evidence of the challenges of maintaining infrastructure and the lack of maintenance strategies. We can also see the lack of basic plumbing in some facilities. In an assessment using established WASH criteria, some facilities would meet the criteria for having a sink, for example, however on closer examination it was not fit for purpose or not working. Images can also show that many facilities lack the resources to fully comply with hand hygiene best practices which require alcohol rubs and gloves, not just hand washing.

Images of crowded post-delivery rooms highlight the challenges of infection control where well and sick newborns share cots. Healthcare-associated infections are also increasing globally and at great cost: an estimated 1 million deaths are associated with an unclean birth (in and out of facilities). This is exacerbated by the challenges of cleaning care environments, often as a result of a lack of access to water, cleaning products or appropriate equipment. Likewise, keeping on top of laundry is problematic in some facilities. Often cleaners and laundry workers have inadequate protective equipment and training and there may be cultural and social issues associated with these roles which have an impact on motivation and status.

The value of assessments:
There have been a number of large assessments providing some information on the current situation. For example, WHO and UNICEF (WHO/UNICEF, 2014) recently assessed 66,000 facilities and found that a third did not meet the water and sanitation (WATSAN) criteria. An example of a national assessment in Tanzania revealed that on average, the rate of WATSAN compliance in labour wards is approximately 50% lower than the average rates at facility level.

In addition to gathering evidence, WASH assessments are valuable in including a wide range of stakeholders, which allows for connections from macro to micro level to be identified. As such, it can also help to address some practical issues that are identified. Examples include learning from the implications of outdated and poor infrastructure in Ethiopia (WHO and UNICEF, 2015) and the issues relating to the misuse of routine antibiotics in Bangladesh (Soapbox Collaborative, website) to counteract the impact of unclean environments.

The assessments also show the power of using microbes to convince people about hand hygiene and WASH. Using images of swab results for Staphylococcus aureus within facilities helps to demonstrate how these potential pathogens are spread and the value of hand hygiene and effective cleaning.

The sensitivities of assessments and of external inspections in particular, which may raise questions at many levels, are a challenge. Facility managers need to take responsibility for providing quality care and also for assessing it. Management buy-in is critical to effective assessments and improvement plans, with the ideal being self-assessment and self-improvement.

Key implications and conclusions:

  • The DFID concept paper (forthcoming) on WASH and health facilities is an opportunity – DFID as a development agency should make the connection with the agenda around universal health coverage (UHC) and WASH as a core part of quality of care.
  • Monitoring is an essential component – environmental hygiene, cleaning and monitoring is too often neglected but some progress is being made e.g. in India (World Health Organization, 2008) (Dancer S.J, 2014), and learning resources are available to support this.
  • Micro interventions are important – both bottom up and top down approaches have a role to play in quality improvement strategies.

The following is a précis of the discussion that was had between those present:

Relevance and value of the presentation:
Feedback highlighted that the presentation was useful and also timely, considering the DFID concept note (forthcoming) and the need to make connections as part of the overall strategy. The response to and learning from the recent Ebola outbreak, the ongoing challenge of antimicrobial resistance and example of routine use of antibiotics as an entry point were also recognised as potential opportunities to make connections which need further consideration. The timeliness in relation to reaching the “tipping point” of 50% of deliveries being institutional was also noted. Health Advisers were encouraged to think really hard about how to address this within programmes and policy discussions and ways to prioritise this issue over the next few years.

Connectivity is essential, along with joined up thinking when developing strategies and subsequently joined up action (Velleman et al., 2014). Primary prevention strategies need to include rather than limit the focus of infection control to resistance and new drugs.

Challenges for Health Advisers:
The presentation promoted thinking around the structural issues of hand hygiene, not just as a behavioural issue, which was a new way of thinking for some. With that comes a challenge of a lack of good overviews of the costs of addressing structural issues and of specific commodities required. There are potential tensions between balancing capital and recurring costs.

There is some information on costing available as it is included in the assessments. There are some challenges associated with budget setting and procurement. These include the widespread sale and use of ineffective counterfeit bleach and the fact that many cleaning and infection prevention commodities are not within the Commodities Commission’s work; there is scope to do more in this area. A case study from Ethiopia (Bradley E. et al, 2008) highlighted the benefits of budgets being set and controlled at local level. Budgets should not be considered just at the macro level which may preclude small level changes which can be the stimulus for bigger changes. Hand hygiene is important, for example for safe cord care for the newborn. There are some very concrete interventions that can make a difference.

Balance between structural and behaviour issues:
One participant posed the question as to whether structural issues/lack of resources was compromising behaviours, so that even where a practitioner had been trained in hygiene, their behaviour deteriorated due to lack of opportunity to practice good hand hygiene.

This is an interesting area – there has been some recent work (Radhakrishna K et al., 2015) looking at the effectiveness of hand hygiene interventions and some devices promoted good practice, such as self-gelling door handles in key clinical areas, or immediate staff feedback on compliance. However, the drivers behind behaviours are not fully understood and may change with context (for example, between domestic and workplaces). It is known that multifactorial interventions are more likely to be successful but the provision of resources does not necessarily result in best behaviours being practiced.

Improving monitoring tools in relation to WASH:
Tools, such as Service availability and readiness assessment (SARA) and Service Provision Assessment (SPA), are used globally, and one participant asked how effective these are in managing and tracking WASH in facilities and how could that be strengthened?

Assessments need to be connected to an improvement process. Assessments such as SARA are important but don’t always identify and work at the level of the drivers in the facility, nor give confidence for sensitive information to be shared openly, such as doctors not washing their hands. The local level is where powerful self-improvements can be made in areas such as environmental cleaning and monitoring.

There are a number of different platforms, such as the WHO multimodal strategy for hand hygiene, but they are not connected. The impact across the health systems of connecting the multiplier effect could be enormous.

The relationship between stigma, externalities such as HIV and WASH/quality of care:
Zimbabwe shows one example where it was assumed that infection prevention and control would be stronger where vulnerable patients are being treated, but this was not the case. This is a missed opportunity. The impact of stigma in maternal care is recognised, and the very big “cultural overlay” needs to be understood. Stigma towards cleaning and cleanliness is significant in some areas. This is due to issues such as caste and also to the general derogatory view of the cleaning profession. This is underpinned by a widespread lack of representation and professionalisation which bears resemblance to the previous lack of professionalisation for midwives.

Supporting Governments in improving WASH:
Hand hygiene is an important entry point and the presentation identified two further issues:

  1. The value of the whole management of WASH within a facility
  2. The possible lack of resources. 

What can governments in developing countries do to address these and how can funders, such as DFID, best support that especially where there are existing resource constraints?

Assessments and hand hygiene are an entry point for picking up other issues. The whole issue is at multiple levels and inclusion of the management is critical. Challenges with monitoring progress may be related to inadequate local stakeholder engagement in this sensitive area; ideally it should be via self-assessment and as transparent and constructive as possible.

Although issues such as culture and stigma are very sensitive and deep issues, it is possible to start with practical interventions. For example, placing posters promoting hand hygiene in strategic locations and encouraging facilities to undertake environmental monitoring. She further argued for making room for primary prevention alongside other treatment interventions in the MNH “space”, such as EmONC.

This seminar relates to a number of key themes and issues outlined by the learning resource:

Topic / issue Related learning resource section:
Impact of WASH on burden of MNH Major causes of maternal and neonatal deaths (Section A)
‘Hardware’ for Quality of Services Alternative dimensions of quality (Section B)
‘Software’ for Quality of Services Providing quality services: skilled birth attendants (Section B)
Strategies for improving hardware and software for WASH Quality improvement strategies; Professional strategies; Financial strategies; Regulation, multifaceted and other strategies (Section C)
WASH and strengthening demand Safety and acceptability in quality improvement (Section C)
Tools for gathering and monitoring of essential data on WASH Capturing structural dimensions of quality; Capturing process dimensions of quality (Section D)
Indicators of Quality Capturing health outcomes (Section D)

The following resources provide more information about this specific case study, and related examples:

  • Action for Global Health and WaterAid (2014) Making Health a Right for All: Universal Health Coverage and Water, Sanitation and Hygiene. Discussion paper, May 2014 – read full text
  • Benova, L., O. Cumming, and O.M.R. Campbell (2014), Systematic review and meta-analysis: association between water and sanitation environment and maternal mortality. Tropical Medicine & International Health,19(4): 368-387 – read full text
  • Benova, L., et al. (2014) Where there is no toilet: Water and sanitation environments of domestic and facility births in Tanzania. PLoS ONE 9; e106738 – read full text
  • Graham WJ, Dancer SJ, Gould IM, Stones W. (2015) Childbed fever: history repeats itself. British Journal of Obstetrics and Gynaecology; 122:156–159. – read full text
  • Velleman Y, Mason E, Graham WJ et al. (2014) From joint thinking to joint action: A call to action on improving water, sanitation and hygiene for maternal and newborn health. PLoS Med, 11(12) – read full text
  • WHO/UNICEF (2014) Joint Monitoring Programme for Water Supply and Sanitation 2014 – view website
  • WHO Multimodal Improvement Hand Hygeine Strategy – (summary) – read full text


Seminar: WASH and Quality Improvement at Health Facilities was last modified: July 6th, 2016 by Adrian Bannister