Photo credit: CJ Clarke / Save the Children, 2015

Scaling-up first-time and young parent access to postpartum family planning: Could small shifts change the game?

In many contexts, the youngest mothers (ages 15-24) are less likely than older mothers to use health services, including postpartum family planning (PPFP), for themselves and their children, increasing their vulnerability to rapid repeat pregnancy and poor health outcomes. At this life stage, a period of rapid change and vulnerability, it is vital young mothers get the support they need, and it is increasingly seen as a window of opportunity to shape life-long practices. A growing body of program experiences have shed light on first-time parents’ (FTPs) needs and related programming considerations. Evidence shows that comprehensive approaches addressing individual, family, community, and health system factors can increase FTPs’ use of PPFP and other essential health services. While showing promising impact, these comprehensive approaches have proven challenging to scale.

In Save the Children’s large-scale projects, we have long seen that the mothers bringing young children to immunization services, participating in community nutrition groups, or receiving household visits from community health workers are often young themselves. FTPs are often being reached, but not necessarily targeted with interventions addressing their family planning needs—despite evidence that improving birth spacing through PPFP contributes to diverse project goals.

This gives rise to two sets of sticky questions:

  1. Could a large-scale project be enhanced to leverage its reach and connect FTPs to PPFP?

Could we add an activity, or rework an existing activity, to take advantage of a large-scale initiative’s reach of FTPs? For example, a community group for pregnant women or mothers could strengthen referral systems to connect the youngest members to health facilities. Alternatively, for FTPs delivering in facilities, we might augment counseling to address their unique needs, facilitating PPFP uptake before discharge. Such a “program enhancement” could maximize impact with limited resources, reducing missed opportunities to target a vulnerable population.

We need to understand whether such an enhancement could be effective in increasing PPFP use. But to be truly instructive, we also need to understand how the enhancement interacts with and is shaped by the “host project” and the broader health system—and how it can be sustained through existing platforms at scale.

Which brings us to the second, stickier question, one that is often ignored in evaluations of this kind.

2. What factors would shape implementation and impact of an enhancement to a large-scale project?

We know that context matters: country- and host project-specific factors—goals, strategies, supervision mechanisms, health worker workloads, even intrinsic and extrinsic motivators—will make or break design, implementation, and scale of even a simple tweak to planned activities. We also know that over time, approaches adapt to context and implementation learning—so that what started as Plan A evolves to become Plan D or H or even Plan M by the time we evaluate and scale up.

In other words, to sustainably embed an enhancement into the health system—and to inform similar endeavors—we’d need to unpack the “black box” between implementation and impact. What unique elements of the host project and health system influence an enhancement—and what questions would others need to raise to layer an enhancement in a different setting? How do the enhancement and its implementation evolve over time and in scale-up, and why? What unintended effects emerge from the interplay between the enhancement, the host project, and the broader health system?

Introducing Connect

Connect, with support from the Bill & Melinda Gates Foundation, is poised to grapple with these questions. Over 4 years, Connect will build on two Save the Children-led projects and design, scale, and evaluate an incremental enhancement to reach FTPs at scale.

In Bangladesh, Connect will partner with the USAID-funded MaMoni-Maternal and Newborn Care Strengthening Project (MaMoni MNCSP), which supports the Ministry of Health and Family Welfare to improve maternal and newborn health in ten focus districts. In Tanzania, Connect leverages the USAID-funded Lishe Endelevu project, which aims to reduce stunting in children under five and improve the diet of 1.5 million women of reproductive age.

Connect will rigorously evaluate the impact on FP use and, drawing from realist evaluation principles, dig into that “black box” between implementation and results. Connect will yield practical how-to guidance, informing other efforts to more efficiently and effectively target FTPs with PPFP.

Connect’s partnership

Save the Children, the project lead, leverages our FTP and health system strengthening expertise and multisectoral operating presence to spearhead the design and implementation of program enhancements with MaMoni MNCSP and Lishe Endelevu and country stakeholders.

The George Washington University Milken School of Public Health (GWU) evaluates the impact of the program enhancements through rigorous quantitative methods and contributes to a qualitative realist-inspired evaluation exploring factors shaping implementation, scale, and sustainability.

We’re excited to dive into these complex questions and look forward to sharing Connect’s results and lessons. For more information, check out Connect’s fact sheet or contact myahner@savechildren.org 

A Tanzanian Doctor’s Insight into the Barriers to Fewer Healthcare-Acquired Infections

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

 

Written by Dr. Joseph Obure
Maternal and Reproductive Health Advisor, Save the Children

Save the Children President Janti Soeripto and I had to cover a lot of ground in just 90 seconds in the video that introduces  BASICS (Bold Action to Stop Infections in Clinical Settings) – from why so many millions of mothers and infants acquire debilitating infections in health facilities to how BASICS’ scalable and sustainable solution will prevent many of these infections.

Having been educated in and practiced clinical obstetric and gynecology medicine in Tanzania – one of the four countries where BASICS will be launched with 100&Change funding – I know firsthand of the challenges of preventing infections in places where resources can be precious and where dedicated, overworked staff labor daily to deliver the best care they can.

What does the situation look like in Tanzania when it comes to health care and hygiene? What does a day look like for a doctor in a Tanzanian government hospital?
Like any other developing country, Tanzania faces health systems bottlenecks that affect the provision of quality health care. While there have been significant gains in improving access to services, quality continues to be a problem.

Many health posts, particularly those at the primary care level (health centers and dispensaries) do not have adequate water, sanitation and hygiene (WASH) facilities. These places serve approximately 80% of the people in Tanzania’s rural areas, therefore impacting a huge population.

The lack of reliable clean water is just one problem. Toilets and bathrooms may not be available, and those that are available  can be dirty. Without a place to wash hands and no supplies,  hygiene and infection control practices are poor.

These problems underscore the need to increase investments and support for sustainable solutions like BASICS that improve clinical outcomes, reduce patient and health system costs and lead to a more positive care experiences.

What are the biggest barriers to implementing hygiene protocols?
Funding to support hygiene interventions and health facility infrastructure is limited due to many competing priorities and there’s a focus on coverage of primary care rather than the  quality of care. Health systems have only a limited capacity to operationalize WASH protocols; both health providers and communities have poor behaviors relating to hygiene; and there is little understanding of the cost benefit of improved quality of care on clinical and economic levels.

Lastly, there is a lack of evidence-based policies for hygiene and limited use of simple and feasible solutions based on the context.

Why is BASICS a good solution?
BASICS is unique in that it applies simple, effective and feasible interventions to improve the quality of care, with particular focus on WASH and infection prevention control. It focuses on maternal and newborn delivery points because these environments are quite complicated and overloaded. It’s in these wards that BASICS can achieve a major impact, where we will learn what works best and then scale up the intervention to other service delivery points in health facilities.

 

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings) is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%, visit savethechildren.org.

Knowing and Respecting Support Staff: A Vital Step in the Journey to Reducing Healthcare-Associated Infections

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by Lydia Di Stefano
Research Assistant, Maternal and Newborn Health Group – London School of Hygiene and Tropical Medicine

 

I met Dorcas Gwata during the London School of Hygiene and Tropical Medicine’s 120th anniversary celebrations. An alumni, Dorcas had returned to present on her inspiring career as a public health specialist and activist.

While her achievements are remarkable and many, they weren’t what caught my attention. Rather, it was what she had done at the beginning of her career that intrigued me: Dorcas began in the relatively unglamorous role of a hospital cleaner.

Through my work with BASICS (Bold Action to Stop Infections in Clinical Settings), I know  the importance of support workers in healthcare settings – cleaners, porters and security guards – in contributing to a functioning system. In particular, their vital role in hygiene: low-cost interventions aimed at educating and training workers in water, sanitation and hygiene (WASH) are an important way to reduce healthcare-associated infections.  But there are barriers to their education and training.

One barrier is the lack of value and respect for cleaners and their exclusion from the umbrella term “health workers.” BASICS pioneer Professor Wendy Graham has written about how to overcome such barriers elsewhere.   

I was intrigued about Dorcas’ journey from student in Zimbabwe, to hospital cleaner in Scotland, to specialist nurse in London. Dorcas has been on two sides of the hospital workforce – as a support worker and a professional – so I was intrigued about her view of the lack of value that cleaners can face and how to combat this. Finally, as someone with experience in  health systems in low- and high-income countries, I was curious about how she would compare the two settings.

Dorcas attended school until she was 18. However, she didn’t get the marks to pursue the nursing career her mother wanted for her. After graduating, she pursued occupational courses but nothing really stuck. She spent time volunteering in a health clinic.

When Dorcas joined her sister in Scotland, she found work as a cleaner at a local hospital. Although it wasn’t her first preference, she reflected “out of all the jobs I’ve had so far, that is probably the one where I learnt the most.” The work was demanding – carrying heavy buckets of water and hours of scrubbing.

She received no training – in cleaning, let alone education on infection prevention – and was told in two weeks she’d lose her job if she wasn’t good enough. It was hard, physical work. It was also challenging socially.

Despite the difficulties of their job, Dorcas felt that she and the other cleaners were barely acknowledged, let alone thanked by most of the hospital staff. She had come to expect so little in the way of respect, that she would be shocked if clinical staff said “good morning” when they walked past her.

She said that staff should not just see cleaners by their job title, but should look past this to explore the other side of who they are. We should be more curious and ask people about their stories: where they’re from, what they do on weekends, who their children and grandchildren are.

Imagining how things might be different in a low-income setting like Zimbabwe, Dorcas suggested that cleaners may actually be more respected there, where they would be known by their totem (tribe name). Dorcas feels that there is strong sense of cultural capital that comes with respect and validation in Zimbabwe, which is lacking in high-income countries.

Dorcas was ambitious to move to a clinician role. She once asked a matron what she could do to join the profession and was ignored, yet this did not put her off. Eventually, she moved to London, where she visited hospitals to offer her services. After a day, she had two job offers: one as a cleaner and the other as a healthcare assistant. She took the assistant job and has worked her way up to where she is today.

When we spoke, Dorcas wondered where she would be now, had she been offered two cleaning jobs that day.

I think everyone who works in hospitals can take Dorcas’ advice and try a little harder to acknowledge all staff, including cleaners. My challenge to health workers reading this is to get to know the cleaners on your ward. Although their jobs aren’t necessarily the most glamorous, they are essential to a functioning health care system and are key to infection prevention efforts.

Photo credit: Save the Children

Basics: Scaling Up Affordable and High-Impact Healthcare Practices

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by the BASICS Team

Bold Action to Stop Infections in Clinical Settings (BASICS) is centered on an important principle: low-cost interventions accompanied by minimal changes in healthcare practices will have a considerable impact on disease incidence. The cost of preventing an infection is a fraction of the cost of treating one. High infection prevalence and infection-related mortality are a sizeable economic and social burden, especially in low-income countries. BASICS will catalyze marginal resources in four demonstration countries – Bangladesh, Cambodia, Nigeria and Tanzania – to reduce that burden significantly.

The evidence from high-income countries on the economic impact of reducing healthcare-associated infections (HAIs) is compelling, and suggestive of what might be achieved in lower resource settings (though with different cost structures). One study estimated that the costs of one single severe lower respiratory infection in a U.S.-based hospital would cover the annual budget for antiseptics used for hand hygiene (Boyce, 2001)1  .  A study of a Russian neonatal ICU found that one healthcare associated bloodstream infection would cover 3,265 days of hand antiseptic use (Brown, 2003)2  . A Swiss study found that the total cost of hand hygiene promotion was roughly one percent of the cost of nosocomial infections (Pittet et. al, 2004)3  .

BASICS is metric driven, which allows us to capture the economic impacts in lower-resource settings. It will establish a baseline of current expenditures, track recurrent and investment costs and link those to program outcomes.

BASICS will generate substantial savings from its projected reduction of 1.4 million patient stay days. Our economic analysis will illustrate those savings and build a government and stakeholder coalition to fund BASICS in national and local budgets.

More developed healthcare systems have learned the lessons on hygiene and taken them to scale. The past several years have seen a groundswell of global attention and support towards achieving universal access to quality of healthcare (Sustainable Development Goal 3). Many of these efforts – some listed below – directly address, or align with, water, sanitation and hygiene (WASH) and infection-related challenges in healthcare:

  • The World Health Organization’s (WHO) Global Action Plan on Antimicrobial Resistance (2015)
  • WHO’s Guidelines on Core Components of Infection Prevention and Control Programmes (2016)
  • WHO’s Supporting Countries to Achieve Health Service Resilience (2016)
  • Every Woman Every Child Global Strategy to end all preventable maternal, newborn and child deaths, including stillbirths, by 2030, and improving their overall health and wellbeing
  • Launch of the Quality, Equity, Dignity (QED) Network for pregnant women and newborn infants (2016)
  • WHO’s Standards for improving Quality of Maternal and Newborn Care in Health (2016)
  • WHO Handbook for National Quality Policy and Strategy (2018)

BASICS will develop a scaling pathway for countries with fewer resources. Global health expenditure has risen progressively since 1995 (Global Burden of Disease Health Financing Collaborator Network, 2019)4  , providing some fiscal space to allocate government resources to BASICS once the payoffs are demonstrated. Securing government commitment will be critical in the four BASICS countries, as the public budget accounts for most health expenditure in these countries. The BASICS teams will engage with health ministries on the implications of BASICS for the composition of a country’s health expenditure.

The four BASICS demonstration countries have already shown strong political will to improve infection prevention procedures.

BASICS will deliver cumulative local impacts in each country that will deepen their commitment to the approach. Our learning model will engage government, civil society and private partners on the lessons being generated on the costs and benefits of BASICS, building a powerful local coalition for change. Once that change is delivered, the economic impacts should ultimately prove irresistible to other countries interested in infection prevention.

Ways countries have demonstrated political will on this topic:

Cross-country:

  • All four of our demonstration countries have shown a commitment to improve infection prevention and broader quality of care priorities.
  • All four countries signed onto the 2019 World Health Assembly Resolution to improve WASH in healthcare facilities and are engaged in post-resolution implementation activities.
  • All four countries have national action plans to combat anti-microbial resistance.
  • Three of the four countries (Bangladesh, Nigeria, Tanzania) signed up to be initial priority countries under the QED Network.

 Bangladesh:

  • In 2017, the Community Based Health Care (CBHC) under Directorate General of Health Services of the Ministry of Health and Family Welfare conducted a rapid assessment of the state of WASH in 13,000 community clinics with help from WaterAid, WHO and UNICEF.
  • Formal guidelines on WASH for community clinics in 2019 with the support of WaterAid, WHO and UNICEF.

Cambodia:

  • In 2016, in response to a baseline study assessing the status of WASH led by the National Institute for Public Health, the Ministry of Health set water and sanitation targets as part of its National Health Strategic Plan 3.
  • In addition, the national quality of care mechanism, which has been rolled out across all public health care facilities, has WASH targets which are tied to performance-based financing mechanisms.
  • In 2019, national guidelines on WASH in health care facilities were endorsed.

Nigeria:

  • In 2018, the government created a new Infection Prevention Coordinator position within the Ministry of Health to lead the design and implementation of a national infection prevention improvement strategy.

Tanzania:

  • In 2019, the government announced a commitment to develop a national roadmap to improve WASH in healthcare facilities, implement improvements in 1,000 facilities and to integrate WASH into new health sector policies.

 

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings) is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%, visit savethechildren.org.

 

1. Boyce JM. Antiseptic technology: access, affordability, and acceptance. Emerging Infectious Diseases. 2001;7:231–233. 

2. Brown SM, et al. Use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a Russian neonatal intensive care unit. Infection Control and Hospital Epidemiology. 2001;7:231–233. 
3. Pittet, D., Sax, H., Hugonnet, S., & Harbarth, S. (2004). Cost Implications of Successful Hand Hygiene Promotion. Infection Control & Hospital Epidemiology 
4. Pittet, D., Sax, H., Hugonnet, S., & Harbarth, S. (2004). Global Burden of Disease Health Financing Collaborative. Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995–2050. 2019.  The Lancet.
 

Mali: Babies Born Too Soon Can Survive and Thrive

Written by By Fatoumata Namandou Traore and Nathalie Gamache
This blog was originally published on Healthy Newborn Network

 

At 23, Fatoumata Coulibaly, a mother of two, added to her family when she gave birth to twins at the community health center of Didieni, Mali, in April 2017. Born in this rural village, 40km from a district hospital and 180km from the capital city of Bamako, the babies (a girl and a boy, weighing 1860g/4.1lbs and 1910g/4.2lbs, respectively) were small. So small, in fact, that the family did not believe they could survive.

“When my mother-in-law saw the babies, she told me we should go home, that they were too small and not viable. She did not want us to stay at the facility as she thought it would just be wasting time,” Fatoumata recalls.

Despite her family’s reticence, Fatoumata wanted to give her babies a chance, and was willing to try Kangaroo Mother Care (KMC)  1 as advised by the health center nurse. Fatoumata practiced KMC for two weeks at the health center and then was discharged to continue KMC at home, with follow-up appointments at the health center. When the family tried to leave the facility early, without an official discharge, the President of the health center management committee intervened with Fatoumata’s husband, mother-in-law and father-in-law, to convince them to stay. Two and half years later, Fatoumata is proud of her twins, who are alive today in great part to the KMC Services offered at the Didieni community health center.

Fatoumata’s story is one of many in Mali, where babies born too soon or too small are proving that they can survive and thrive.

In Mali, neonatal mortality is alarmingly high at 33 per 1,000 live births (DHS 2018). Prematurity accounts for 33% of the causes of these deaths (Lancet 2012). Among 440,688 births registered in health facilities in Mali, between January and September 2019, 5% of newborns (23,814) were recorded as low birth weight, or under 2,500 grams (Mali National DHIS2).

Although being born too soon or too small might be seen as a death sentence in Mali, stories of success are changing the norms in the country.

Since January 2019, half (46%) of low birthweight (LBW) babies benefited from KMC in the regions of Kayes, Sikasso, and Koulikoro where the USAID-funded Services de Santé à Grand Impact (SSGI) project intervenes. This is a notable increase from 30% in the same regions in 2018 (Mali National DHIS2).

Save the Children has supported the Ministry of Health and Social Affairs since 2002, seeking to understand newborn health challenges and establish actionable plans to eliminate preventable deaths in Mali. In 2006, KMC was integrated into national policies, norms and procedures as a recommended intervention for management of LBW babies, followed in 2007 by the initiation of KMC services at the Gabriel Toure University teaching hospital located in Bamako. However, access to the hospital is incredibly limited for most LBW babies such as Fatoumata’s twins.

Efforts to introduce KMC services in district referral hospitals began in 2008 through the Saving Newborn Lives program. Subsequently, the USAID-funded MCHIP, MCSP and SSGI programs – all led by Save the Children in Mali – supported service expansion. Gradually, KMC was brought closer to families and made available at community health centers (CSComs). Currently, 931 providers in 430 health facilities in 30 health districts supported by Save the Children through the USAID/SSGI project have been trained and equipped to deliver KMC services.

As evidenced by Fatoumata’s story, bringing care closer to communities is the key to saving premature and low birthweight babies. It requires not only health provider training, but also behavior change interventions among providers, families, and community leaders to recognize and support mothers practicing KMC as the primary intervention for preterm and low birthweight management.

As Mali celebrates World Prematurity Day, we salute premature babies like Fatoumata’s twins, who survived, mothers like her, who accepted to practice KMC, family members that support the mothers and even practice KMC themselves, and health workers who have integrated this practice into everyday service delivery.

 

1. Kangaroo Mother Care (KMC) involves continuously carrying a premature or low birthweight baby on the chest, using early and prolonged skin-to-skin contact, combined with exclusive breastfeeding (direct suckling or cup). This practice helps improve health and prevent the death of premature and small newborns by protecting them against infection, regulating body temperature, breathing, and brain activity, and supporting bonding between mother and baby. Once the baby is stable and gains weight, and the mother is confident she can continue KMC at home, mother and baby are discharged. They return to the health facility for monitoring of weight gain, feeding practices and to ensure that there are no signs of infection or other health complications, till the baby graduates from KMC. 

Frustration and Optimism: My Mixed Emotions for Reducing Healthcare-associated Infections at Birth

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by Wendy J. Graham
Professor of Obstetric Epidemiology, Department of Infectious Disease Epidemiology

Today, advances in healthcare routinely enable miracles of survival and recovery. But some discoveries have been forgotten or demoted in the race to implement the latest. The importance of hygiene at the time of birth goes back centuries.* Yet here in the 21st century, so-called “places of care” bring increased risks of infection to patients and health workers when basic preventive principles are not followed. Safe water to drink, a clean surface to deliver upon, and good hand hygiene by those attending you – how more basic can it be?

After nearly 40 years in public health, I am re-invigorated by the chance to be part of what the BASICS partnership proposes: integrating four agencies’ best practices and learning in infection prevention in healthcare settings into one systematic approach in partnership with countries to dramatically reduce infection rates at the point of care.

Health facilities – and especially maternity wards – are the natural environment of my interest and passion for change. Initial work in Botswana in the late 1970s and early 1980s – at the time when HIV/AIDS was just emerging, gave me a firm grounding in the tough realities of healthcare in under-resourced settings, together with a lifelong admiration for health workers who provide care 24/7 in such circumstances.

It’s in these maternity wards where many mothers and newborns acquire infections. They’re often busy and overcrowded places, with invasive procedures, instruments that may not be sterilized between use, and major infrastructural and supply challenges to maintaining cleanliness and hygiene. The photo here of a ward in West Africa captures this situation – indeed, with women being asked to bring their own bottle of bleach when they came to deliver as there had been no cleaning fluids in the maternity for months.

This is a striking reminder of the hidden costs of care families endure and the weakness in the health system, which means women deliver where “safe care” cannot be guaranteed and where health workers cannot protect themselves from infection risks either. Both “cannot’s” are violations of basic human rights.

This is why I’m so excited about the potential of BASICS to empower all health workers about proper hygiene and infection prevention practices and enable health systems to provide safe care equitably and routinely. And we mean “all” – acknowledging the crucial role in facilities played by workers who are not care practitioners – such as cleaners, orderlies and maintenance staff –  in creating a clean environment. These often-forgotten “workers for health” also have great potential to be agents for change.

But, of course, it’s not just the four BASICS collaborators and the crucial country partners who want better health outcomes for mothers and their newborns, and for them to leave a facility without a life-threatening infection.

Access to health facilities providing clean care was the second-highest demand of the 1.2 million women and girls in 114 countries who took part in the White Ribbon Alliance’s 2018 global What Women Want campaign on reproductive and maternal health needs. Women and girls overwhelmingly demanded clean facilities, clean toilets in maternity wards, a clean bed, and skilled health providers with sterile supplies and clean hands. 

None of these demands are impossible to achieve. The crucial innovation proposed by BASICS is to take the best evidence-based practices of each partner and create one comprehensive package of training, access to clean water in facilities, an innovative cleaning product and systems change in order to institutionalize and sustain clean care in the partner countries.

I am optimistic that BASICS can result in better quality healthcare that will save tens of thousands of lives and millions of dollars by averting healthcare-acquired infections.

In the time it has taken to read this, many more health workers’ could have washed their hands, many more women could have delivered on clean beds and with sterile instruments, and many more babies could have been discharged home without an infection from the facility. This advance does not require a new discovery – we know what to do now.

BASICS will be a catalyst for the miracle of survival and good health for mothers and newborns. 

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings) is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%, visit savethechildren.org.

 

*Graham WJ, Dancer SJ, Gould IM, Stones W. (2015) Childbed fever: history repeats itself? BJOG, 122:156–159.

The Blue Dye Innovation that Makes Disinfecting Health Facilities More Effective and More Visible

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by Jason Kang, Co-founder and CEO, Kinnos

In 2014, I co-founded Kinnos in response to the West Africa Ebola crisis. At the time, one of the biggest problems contributing to high rates of infection was ineffective surface decontamination caused by human error and gaps in training.

Disinfectants like bleach are transparent, making it easy to miss spots; hydrophobic, making it bead up and roll off the surfaces it’s meant to disinfect; and only effective if used for a specific contact time, meaning healthcare workers must ideally wait for a certain period for pathogens to be inactivated. These problems are universal to disinfection in facilities outside the scope of epidemic outbreaks.

Highlight, our patented additive, colorizes the disinfectant so that users can easily see where it has been applied. Highlight modifies the liquid properties to eliminate droplet formation and improve adherence to surfaces. The color fades as the contact time needed for the disinfectant to work passes, indicating when decontamination is done.

To put this into context, our time at the Ebola Treatment Unit in Ganta, Liberia, was particularly memorable – I remember the intense heat and how incredible it was that staff were wearing layers of stuffy, personal protective equipment for 4 to 6 hours at a time. However, this also meant that they were only too eager to remove their protective gowns and coveralls, often not waiting the requisite contact time for the disinfectant sprayed on their protective garments to work.

Combined with the inherent difficulties of achieving full coverage with bleach, we quickly understood why health staff were up to 32 times more likely to be infected with Ebola than the average person.

When healthcare workers started telling us that Highlight was making them feel more confident in their own safety and easing their stress in such high-risk situations, we realized that our technology was tapping into an invaluable resource: peace of mind. Interacting with the healthcare workers who had volunteered to put themselves directly in danger to help others was humbling and inspiring, and doing our part to make their lives even a little bit better was incredibly motivating.

The breakthrough that Highlight represents – the ability to overcome training and language barriers to empower health workers and those who clean facilities with a feeling of confidence through disinfection they can see – can have a profound impact in reducing healthcare-associated infections globally as part of the BASICS solution. In our mission to prevent infections and improve patient safety, we have not forgotten about the people who are tasked with the important step of disinfection.

In addition to our humanitarian focus in low- and middle-income countries, Kinnos is working to radically reduce healthcare-associated infections and the prevalence of antimicrobial resistance within the U.S. healthcare system.

We’ve partnered with leading medical organizations to pilot our technology in hospitals, ambulatory surgical centers and other facilities. It’s a sober reminder that infections affect society at large and are an urgent global problem that require a concerted effort to solve.

The fact that someone today can receive a life-threatening infection from a place where they expect medical care and treatment is unacceptable, and we are motivated to make this a problem of the past.

Historically, so many resources have been devoted to diagnosis and treatment, even though it’s recognized that prevention is key to sustainable healthcare. We always knew that surface disinfection was only one key part of the larger infection prevention ecosystem, so having the opportunity to enact a system-wide program with the rest of the BASICS team is extremely exciting to me.

The world has been waiting too long for an initiative like BASICS to set the standard of infection prevention.

Why I’m Passionate About Reducing Infections in Health Care Facilities

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by Alison Macintyre, Health Technical Lead – WaterAid

Having spent a lot of my childhood in and out of hospitals, I believed that hospitals were a place where you go to get better, get well; where you leave feeling more positive and healthier than when you arrived. And, I still do.

As I embarked on my career in the field of water, sanitation and hygiene (WASH), I realized for most of the world, that isn’t true. We, the global health community, are currently failing to achieve the absolute basics. Right now, we can’t ensure we are, at an absolute minimum, doing no harm to the millions of people who use health care systems every day. Too many health care facilities operate without water, without toilets that everyone can use, and without water and soap to stop the spread of infection.

This failure is what motivates me. We will only see dramatic, sustained changes in health if we get the basics right. 

Early in my WASH career I was in Papua New Guinea, undertaking a study on the role of WASH during childbirth for women. Most of the women I interviewed were unable to reach a facility to give birth and had to deliver their babies, often alone, on coffee plantations, in pig pens or on the side of the road.

As part of the study, we also visited health facilities. I had hoped that they would provide a potential solution for improving maternal and newborn mortality in these remote communities. One facility has always stuck in my mind.

Despite the newness of the facility (it was only five-years old), water, sanitation and hygiene were not available. A refrigerated, fully stocked drug cabinet was present, but gloves and soap were not. There was a sophisticated rainwater collection system, but the pump to distribute the water to the facility was broken and they weren’t able to fix it. There were two modern toilets, but they were locked and reserved for staff – patients had to go out to a hole dug in the back of the facility, passing an open waste pit on the way, to relieve themselves.

The lack of water also meant women were turned away if they arrived in labour. The next hospital was 2 hours away on a treacherous road.

How did a hospital have sophistical equipment, but couldn’t fix a water supply and women weren’t able to deliver their babies? How were antibiotics kept cold-chain with a reliable supply, yet soap and gloves were not available?

I left the facility angry, wondering how health systems neglected WASH in so many ways.

This visit made me realize that when statistics show us that health care facilities do not have basic WASH services, it doesn’t always mean the infrastructure is completely absent. Often, it may not suitable (for instance in the case of toilets not being accessible to people of limited mobility) or it is not functioning, or basic commodities like soap are not part of general supply lists.

I also realized that it is the system that’s broken, not just the infrastructure. Health systems that have monitoring and budgets for WASH, trained operation and maintenance staff, in-service and pre-service training on hygiene and cleaning, WASH standards and accountability mechanisms, are uncommon. This should be the norm.

That’s why I’m excited about the prospect of leading the WASH element of BASICS (Bold Action to Stop Infections in Clinical Settings), on behalf of WaterAid. Through the work I’ve done, I have learned the importance of integrating basic WASH into broader patient safety and infection prevention control programes. Without such integration, a system-wide approach is not possible and WASH will never become part of the day-to-day routine of health center operations.

BASICS brings together NGOs, researchers and the private sector to support health systems to sustainably address WASH and patient safety. The BASICS team has a wealth of expertise on health, WASH and evidence-based behavior change. This combination is essential for improving patient safety, health and the quality of health care facilities for all.

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings) is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%, visit savethechildren.org.

Why I Don’t Want Another Mother to Experience My Health Care Scare

Written by Soha Ellaithy
Senior Director, Strategic Foundation Partnerships and Senior Partnership Director, BASICS

I was born and raised in Egypt, a middle-income country that has a functioning healthcare system and universal healthcare coverage – albeit of often dubious quality.

In 2008, one in 10 Egyptians had chronic Hepatitis C, the highest rate of infection in the world. The direct cause of this catastrophic situation is a mass-treatment campaign conducted by the Egyptian government in the 1970’s and 80’s to eradicate schistosomiasis infection. The repeated use of needles resulted in Hepatitis C, a virus not yet known, being inadvertently spread to millions of people.

When, in 2011, my oldest son went on a school trip to Nepal, he contracted a diarrheal infection and had to be rushed to a local hospital to receive intravenous fluids. He called me and, to my horror, described stepping over pools of blood on the floor to get to a bed with no covering. My heart dropped – and to this day it still does when I think about that moment.

I knew exactly what the implications could be.

I’ve witnessed firsthand the terrible devastation of a healthcare-acquired infection on families and could not bear the thought of my son contracting Hepatitis C or HIV. It took a full three agonizing months of tests to clear my son of any possible infections that he might have picked up from a needle prick in an unclean hospital.

Photo courtesy of: FACEBOOK PAGE/ SO THAT HE'S NOT SURPRISED
Egypt’s doctors have been anonymously sharing pictures of the conditions they work in – with stray animals and overflowing sewage on display – after the country’s Prime Minister said he was “surprised” at the state of the country’s run-down hospitals. Photo courtesy of FACEBOOK PAGE/ SO THAT HE’S NOT SURPRISED via BBC

Despite a fairly strong medical education system and a tireless and dedicated medical staff, public health care systems in many countries like Egypt, continue to be plagued by poor adherence to proper hygiene standards and the devastating consequences that result.

As the Senior Partnership Director leading the submission to 100 & Change, when my colleagues first discussed with me the idea of eliminating this risk globally, I was immediately engaged. As we fine-tuned our idea in meeting after meeting, I became very excited that in BASICS (Bold Action to Stop Infections in Clinical Settings) we truly have a solution that will change the way healthcare is delivered across the world.

I feel very passionate about this project because it is inconceivable that in this day and age, we are still grappling with a problem whose solution is so simple: wash your hands, clean your working surfaces and be diligent in using sterilized equipment.

BASICS tackles the root causes of the problem and builds a solution that is self-sustaining. Using behavioral science to modify individual behavior so that simple hygiene routines can become “second nature,” we will build the supporting infrastructure and design a national system that ensures this new normal is part of a fully functioning and supportive national health system.

I dream of the day when no mother would ever take her child for a simple procedure only to go home with a child who has a life-threatening disease for absolutely no good reason!

 

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings) is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%, visit savethechildren.org.

Photo credit: Charlie Forgham-Bailey / Save the Children, Oct 2018

Getting to 2030 Vision to End Preventable Child and Maternal Deaths: Building on the global progress for women and children

Written by Smita Baruah, Senior Director, Global Health and Development Policy, Save the Children

Children today have a better chance than any time in history to grow healthy, be educated and be protected, as noted in Save the Children’s latest report, Changing Lives in our Lifetime: Global Childhood Report. Today there are 49 million fewer children stunted, a form of malnutrition that impacts a child’s ability to survive and thrive than two decades ago. There are 4.4 million fewer child deaths than they were in the year 2000.

These successes are not by accident.  Strong and increased political leadership at both global and national level have greatly contributed to changing the lives of women and children around the world in addition to scaling up of proven interventions and innovation.

The United States is one donor government who deserves much credit for accelerating progress on women and children’s health, beginning with its leadership at the first child survival resolution in 1982 through hosting the Child Survival Call to Action meeting in 2012 that set the stage for the vision to end preventable child and maternal deaths by 2030.

Critical Role of US Leadership in Reducing Maternal and Child Deaths
Last month, USAID launched its 5th annual progress report, Acting on the Call: A Focus on the Journey to Self-Reliance for Preventing Child and Maternal Deaths.  The report notes that in 2018 alone, USAID helped reach 81 million women and children access essential — and often life-saving — health services. USAID’s contributions have led to significant reductions in child mortality in many countries such as in Bangladesh where child deaths were reduced by 63% since 2000 and in Uganda, which experienced a 66% in reduction of child deaths during the same time period.

The report demonstrates the ways in which USAID has also helped increase national political will. Since the Child Survival Call to Action forum in 2012, governments in more than half of USAID’s priority countries for maternal and child survival have increased their domestic budgets for health.  In Uganda, for example, USAID worked with the Ministry of Health to increase the percentage of the allocated budget for health from 79% to 97%. 

Bangladesh, a USAID maternal and child health priority country, is an example of how donor assistance coupled with national political will, creates change for women and children. According to the Global Childhood Report, Bangladesh has had a sustained commitment to improving child health despite changing leadership. With donor and their own investments, Bangladesh has focused to strengthen health systems and scale up proven solutions for mothers, children and newborns with a focus on equity. However, focusing on health interventions alone did not contribute to Bangladesh’s success.  Women and girls’ education and empowerment are also key factors driving progress as well as the engagement of civil society, including children and young people.

Getting to 2030
In 2015, the United States and other world leaders and stakeholders committed to a set of global goals which includes the ambitious goal of ending preventable and child and maternal deaths by 2030. There is indeed much to celebrate.  To continue on the path to achieve the global goal of ending preventable child and maternal deaths, U.S. and other stakeholders must continue to focus on continuing to invest in maternal and child survival programs and designing and implementing highest-impact evidence based interventions. 

This also includes investing more resources in areas that are becoming the greatest contributions to child deaths: newborn health, pneumonia and addressing malnutrition.  Without increased focus on malnutrition, Save the Children’s report notes that in 2030, 119 million children will still find their physical and cognitive development stunted by malnutrition, with the poorest children at highest risk. Addressing pneumonia must also be prioritized. According to the Global Childhood Report, childhood pneumonia is the leading infectious cause of deaths in children under age 5 and it kills more children than diarrhea, malaria and HIV combined.

While much progress has been made in increasing national governments’ political will to reduce child and maternal deaths, resources must follow this commitment. The U.S. should work with national and local governments to continue to increase its own domestic investments in health, particularly for maternal and child survival interventions. This also includes working with national and local governments in ensuring that these resources are reaching the hardest to reach populations. Women and children who are furthest behind must be identified and prioritized in terms of investments, service provision and decision making. US should also work with governments to ensure that all women and children, especially excluded women and children, are counted to measure progress towards reducing child and maternal deaths. 

Going beyond just working with the Ministries of Health is critical.  U.S. and other stakeholders must continue to engage local civil society in the efforts to change the lives of women and children. In Ethiopia, for example, Kes Melakeselam Hailemnase, a 64 year old Orthodox Priest and head of Embaalaje Woreda Orthodox Churches Forum, reached more than 8.000 individuals with maternal, child, newborn health messages during regular sermons and other religious festivities after receiving training on Community Based Newborn Care, organized for faith-based leaders.  Kes’ efforts helped Abeba Mesele, a 21 year old mother of two, learn the importance of going to a health facility for antenatal check up and early post natal check ups.  

Change often happens at the local, community level. As USAID works with countries in their journey to self-reliance, development plans must be made in consultation with recipient country governments and civil society.  To ensure sustainability and self-reliance, development must be owned by the people of the countries receiving foreign assistance.

As the 2019 report shows, USAID has greatly contributed to building in country capacity by training health professionals including community health workers. This may not be enough. With increased natural disasters and the resurgence of pandemic threats such as Ebola, U.S. should work with governments and other stakeholders in helping to build resilient health systems. 

Finally, continued U.S. partnership and assistance is critical to a country’s success in improving the lives of women and children around the world. USAID should maintain evidence-based, highest-impact interventions and a comprehensive approach to addressing maternal and child survival and continue to provide robust resources.