Water, Sanitation and Hygiene Improvements Are Key to Sustaining Healthcare’s Ascendency in Cambodia

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 Channa Sam Ol, Manager, Water, Sanitation and Hygiene (WASH)
and Health Programs, WaterAid Cambodia

Over the past 20 years, Cambodia has made remarkable progress in improving health care, as evidenced by declines in maternal mortality from 900 to 170 per 100,000 live births and infant mortality from 115 to 35 per 1,000 live births.

Ongoing health system reforms have addressed the quality of care, access and affordability. The government has supported these reforms by introducing schemes that make care free for families with limited incomes and subsidize health facilities and the women who use them to give birth. This latter scheme has helped to dramatically increase the number of women delivering their babies in facilities, from 22% in 2004 to 83% in 2014[1].

But challenges still cast a shadow on the very positive trajectory that has been established. This manifests in the limited progress in newborn health when compared to the improvements in maternal health. It is much safer for a woman to deliver her baby in a Cambodian health center or hospital today than it was 20 years ago, but it is not as safe as it should be for a newborn baby. The United Nations estimates 1 in 6 newborn deaths are associated with blood infections during delivery and an unhygienic environment after birth[2].

While previous Cambodian health policies and standards rarely mentioned water, sanitation and hygiene (WASH)[3], the current National Health Strategy is the first to set targets for improving WASH. Despite this, many health facilities still do not have sufficient WASH infrastructure and lack good hygiene practices.

Most facilities have a water supply, but only half have enough water for use year-round. Fewer than half of facilities have three adequate latrines. Only 15% have handwashing stations at points of care and only 10% perform basic waste management.

According to a 2016 assessment of WASH in public healthcare facilities in five provinces conducted by the country’s National Institute of Public Health in collaboration with the Department of Hospital Services and health partners, the lack of knowledge and commitment to WASH and infection prevention control were a challenge among healthcare workers and cleaners.  

Neglecting these essentials and improving rural health services is hampering progress towards safe, clean healthcare for all. Without improving the basics, Cambodia will not achieve the objectives set in its health strategy, nor will it see improvements in health as it has in the past.

Clean healthcare is something every patient expects – and it is achievable, as these examples demonstrate.

WaterAid first visited the Peus Pi health centre in Tbong Khmom Province in late 2017. The facility didn’t meet basic hygiene or sanitation requirements. What did that mean? Handwashing stations or alcohol hand sanitizers weren’t available at points of care such as outpatient consulation rooms, near toilets or in the waiting area. Toilets weren’t accessible for all, didn’t have separate facilities for men and women, and there were no facilities supporting menstrual hygiene management or postpartum bleeding.

Waste was not being separated and waste bins were not color-coded according to the national standard for health care waste management. Moreover, most staff were reluctant to share about hand hygiene practices and their knowledge of infection prevention and control.

In collaboration with the Ministry of Health and the provincial health department, we have  been working to upgrade the centre’s facilities and build staff knowledge to improve infection prevention control.

Rodiya, a mother who uses the Peus Pi centre, told us about the significant change compared to how it was several years ago. To Rodiya, the “health centre looks cleaner, has more equipment and materials and staff pays more attention to patients.” And now she can use the latrine and handwashing station inside the postnatal room. These improvements gave her the  confidence to choose the centre when it came time to deliver her third child.



[1] Cambodia Health Demographic Survey 2004 and 2014

[2] UN Inter-Agency Group for Child Mortality Estimation. Levels and Trend in Child Mortality; UN Inter-agency Group for Child Mortality Estimation: New York, NY, USA, 2017

[3] Por, Ir (2015). Towards Safer and Better Quality Health Care Services in Cambodia: A Situation Analysis of Water, Sanitation and Hygiene in Health Care Facilities. Phnom Penh, Cambodia: WaterAid.


The Clean Clinic Approach: All Guatemalan Health Facilities In Project Achieve ‘Clean Clinic’ Status Within One Year

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. Sergio Tumax Sierra, Water, Sanitation and Hygiene Manager, Guatemala

As the water, sanitation and hygiene (WASH) manager for Save the Children’s Clean Clinic program in Guatemala, I saw firsthand how this novel, low-cost strategy delivered very encouraging results over a short period of time in 2018-19.

Clean Clinic – one of the three pillars of the BASICS initiative – is our proven process that empowers healthcare staff to make infection prevention improvements through easy-to-use monitoring, accountability and rewards systems.

In Guatemala, we implemented Clean Clinic at 11 Ministry of Public Health and Social Assistance health facilities, including district and department hospitals. It enabled and motivated the facilities to set WASH goals and make incremental improvements towards the ultimate goal of obtaining “Clean Clinic” status.

Within the year, after our close work with the Ministry to develop a weighted evaluation for conducting standardized ward evaluations in each health facility, all 11 had achieved one of three “Clean Clinic” certification levels. Facility staff, from cleaners and nurses to doctors and management personnel, were motivated to make actions sustainable.

We found that even small improvements made a difference in providing patients with better quality services. For example, facilities enrolled in Clean Clinic:

  • Improved the management of water quality for consumption
  • Improved solid and liquid waste management processes
  • Ensured that hand-washing stations were identified and functional and had the necessary supplies
  • Assigned operation and maintenance roles and responsibilities

Clean Clinic’s 10-step improvement process and monthly action plans made it easier for facilities to make WASH improvements despite limited external financing. These activities contributed to quality of care improvements and very likely the reduction of puerperal and neonatal sepsis infections.

The innovativeness of the strategy was also seen in the establishment or revitalizing of infection prevention and control committees at each facility. They monitored bi-monthly evaluations and made plans for timely improvements to achieve Clean Clinic standards in the least time possible.

Evaluations were conducted by personnel outside the healthcare facility, including regional Ministry of Health staff, after which committees made their improvement plans and assigned responsibilities for their management and monitoring. Likewise, a monitoring team was established at the Ministry’s head office to help manage resources and for sensitizing staff on the topic of infection prevention.


To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.







BASICS: Helping the Fight Against Antimicrobial Resistance

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

Every use of an antibiotic, whether appropriate or inappropriate, gives resistant bacteria an advantage and accelerates the development of resistance. Drug-resistant infections are associated with higher morbidity, mortality and health expenditures, and resistant infections are becoming a significant cause of death, particularly for children.

An estimated 700,000 lives are lost to these antimicrobial resistant (AMR) infections every year. Around 200,000 newborns die annually because they catch infections that simply do not respond to drugs. According to the World Health Organization, around 40% of infections contracted by newborn babies resist available treatments[1]

The burden of resistance falls heavily on low- and middle-income countries (LMICs). Here, some population groups suffer from frequent and rapid spread of infectious disease and poor nutrition. Healthcare systems in these countries are often less able to manage this burden, and the situation is exacerbated by increasing rates of antibiotic consumption in humans and animals and by limited standards and regulations that govern access, use and quality of antibiotics[2].

Many infections, both drug-resistant and drug-susceptible, are acquired in hospitals. Healthcare-acquired infections (HAIs), particularly sepsis, are a danger for both neonates and their mothers, who are increasingly being encouraged to seek birth and delivery care at hospitals. Increasing rates of drug resistance render many such infections untreatable.

Professor Clare Chandler, Co-Director of the London School of Hygiene and Tropical Medicine’s Antimicrobial Resistance Centre, and Dr. Laurie Denyer Willis, Assistant Professor at the School, have conducted extensive research in East Africa on the roles that antibiotics play in LMICs beyond their immediate curative effects. Their findings suggest that antibiotics have become a “quick fix” for care available through fractured health systems and, among others, for the lack of hygiene in settings of limited resources.

Although there is no single silver bullet, the most obvious solutions – improved infection prevention and control practices – remain among the most effective interventions[3]. All health care facilities, at a minimum, must have clean running water and sanitation services, and healthcare professionals must follow good hygienic practices such as handwashing[4].  Many LMICs face significant challenges in setting up effective systems that can achieve these basic objectives.

This is the core of what BASICS aims to achieve: supporting the institutionalization of simple, inexpensive hygiene measures in healthcare facilities through effective training platforms, monitoring and accountability systems, reliable supply chains and upgraded water, sanitation and hygiene infrastructure. This will create a clear roadmap for national healthcare systems to take comprehensive action to improve infection prevention and control and dramatically lessen the burdens that HAIs place on under-resourced systems and impoverished families.

BASICS projects a 50% reduction in HAIs in participating facilities based on robust evidence linking improvements in hygiene and cleanliness in healthcare facilities with improved patient outcomes.[1-4] These improvements will significantly reduce the usage of antibiotics – and, in turn, dramatically curb the development of new AMR pathogens.

BASICS is where it can start and it should start now.

To learn more about AMR and how to fight back, watch this roundtable discussion with Professor Chandler – one of our BASICS team members at the London School of Health and Tropical Medicine.


Acknowledgements: Professor Wendy Graham and Professor Clare Chandler from LSHTM – a BASICS partner – provided comments and review.

 To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.



[1]        P.C. Carling et al., “Improving environmental hygiene in 27…,” Crit. Care Med., vol. 38, no. 4, Apr. 2010. https://www.ncbi.nlm.nih.gov/pubmed/20081531

[2]        R. Orenstein et al, “A targeted strategy to wipe out Clostridium…,” Infect. Control Hosp. Epidemiol., vol. 32, no. 11, Nov. 2011. https://www.ncbi.nlm.nih.gov/pubmed/22011546

[3]        S. J. Dancer et al., “Measuring the effect of enhanced cleaning…” BMC Med., vol. 7, p. 28, Jun. 2009. https://www.ncbi.nlm.nih.gov/pubmed/19505316

[4]        B. Allegranzi et al., “A multimodal infection control and patient safety…,” Lancet Infect. Dis., vol. 18, no. 5, May 2018. https://www.ncbi.nlm.nih.gov/pubmed/29519766


[1] https://www.who.int/mediacentre/commentaries/antibiotic-resistant-bacteria/en/

[2] https://www.ncbi.nlm.nih.gov/books/NBK525181/

[3] https://www.infectioncontroltoday.com/antibiotics-antimicrobials/antimicrobial-resistance-stewardship-and-strategies-conquering-global

[4] https://www.who.int/mediacentre/commentaries/antibiotic-resistant-bacteria/en/

Integrating Water, Sanitation and Hygiene (WASH) and Health for Improved Universal Health Outcomes: What Governments Must Do to Deliver Quality Care

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 Blessing Sani, WaterAid Communications Officer, Nigeria


As the world accelerates progress toward quality healthcare, governments must prioritize increased access to inclusive and sustainable water, sanitation and hygiene (WASH) services in healthcare facilities.

Clean water, decent toilets and good hygiene help to control and prevent diseases and their spread. They protect health workers and patients and allow the delivery of quality health care services. Sadly, these normal things are the forgotten foundations for good health. The impact on women and children is alarming – estimates are that one in five births globally takes place in least-developed countries and, each year, 17 million women in these countries give birth in health centers with inadequate water, sanitation and hygiene.1

In Nigeria – one of the four countries that BASICS initially targets – half of healthcare facilities lack clean water, 88% are without basic sanitation and 57% lack handwashing facilities with soap. In a corroborative assessment by WaterAid in 2016 in six Nigerian states (Bauchi, Benue, Ekiti, Enugu, Plateau and Jigawa), primary healthcare centers assessed in urban, semi-urban and rural areas generally had low access to piped water within the facility; more than 20% lacked toilets. In addition, our assessment found there were no structured systems for the operation and maintenance of water and sanitation facilities.

For health workers like Gloria Samuel, the lack of water makes it difficult for her to carry out her duties as a cleaner at the Bwari Town Clinic in Abuja.

“We don’t have water so we buy it from the vendor or practice rain harvesting during the rainy season,” Gloria says. “The rain-harvested water is used to clean the toilets and water bought is used for cleaning more sensitive instruments and for patients who need clean water to wash up, but we still do not know how clean the water is.

“With the water situation, I only wash the toilets once a day and that is not good enough, but if we have constant water flow, we will be happy. When we work without water, it is difficult because this is a hospital. A hospital can’t stay without water because the work will not move forward.”

Globally, an estimated 896 million people use healthcare facilities with no water service, and one in five facilities has no sanitation service, impacting 1.5 billion people.2  Diseases like Ebola, Lassa Fever and cholera spread fastest when these services are lacking. This cycle ensures improvements in health are not sustainable. Often times, the dire consequences are manifested in ill health, deaths, economic losses and a lifetime legacy of disease and poverty.

When clean water, decent toilets and good hygiene services are available, the ripple effect is transforming. Risks of infection for patients and their families, staff and surrounding communities are greatly reduced; people are kept safe from deadly diarrhoeal diseases and are better able to break free from poverty.


Accelerating Quality Healthcare
In 2017, Nigeria launched a scheme to revitalize 10,000 primary healthcare centers across the country to make quality and affordable healthcare accessible to the poor and vulnerable. This commitment presented a window to integrate inclusive and sustainable WASH services into the program plans and design. However, despite this and other efforts around improving maternal and child health and nutrition, achieving the goal of Universal Health Coverage requires increased political commitment, practical policies, strong coordination and partnerships, financing and preventive interventions.

There’s need for better coordination, collaboration and integration between WASH and health actors based on the recognition that WASH underpins quality health outcomes. Furthermore, improving healthcare requires a multi-sector approach that incorporates investments in WASH alongside other sub-sectors like nutrition, maternal and child health, menstrual hygiene management and gender. WASH is an essential building block for patient safety, quality of care, for tackling undernutrition and threats like antimicrobial resistant infections, and for realising Sustainable Development Goal 3 – ensuring healthy lives and promoting well-being for all.

United Nations Secretary-General António Guterres says “Water, sanitation and hygiene services in health facilities are the most basic requirements of infection prevention and control, and of quality care. They are fundamental to respecting the dignity and human rights of every person who seeks health care and of health workers themselves.”

We couldn’t agree more! Only by making clean water, decent toilets and good hygiene available for everyone, everywhere, can we prevent diseases from spreading, transform lives and livelihoods and deliver quality health services that keep people well and unlock their potential.

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.


1,2. World Health Organization and the United Nations Children’s Fund, WASH in health care facilities: Global Baseline Report 2019

Year-long Hospital Pilot Documents Highlight®’s Role in Reducing Failure Rate of Cleaning Sampling to Zero

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


The World Health Organization estimates that 10 out of every 100 hospitalized patients in developing countries will acquire at least one healthcare-associated infection (HAI). Studies have shown that less than 50% of surfaces in healthcare settings are effectively cleaned, but that better cleaning technique could prevent 40-80% of HAIs.

Highlight® addresses this gap in cleaning by providing real-time visual feedback to empower health workers to disinfect surfaces correctly every single time they use a disinfectant. It does this by colorizing existing disinfectants so that workers can easily see exactly what has and has not been covered, so no spots are ever missed. The color then fades after several minutes to provide an approximation of when disinfection is complete.

In 2018, Highlight® was piloted in a 500-bed academic hospital based in Boston, Massachusetts, in 11 medical and ICU inpatient wards.[1] In the U.S., a common method of determining cleaning efficacy is ATP bioluminescence. After a surface has been cleaned, a sample of the surface is taken using a swab, which is then placed in a device that generates a number in relative light units (RLUs). The higher the number, the “dirtier” the surface. The sample is recorded as a pass or a fail depending on a certain RLU threshold.

Across a period of 55 weeks at the hospital, ATP bioluminescence was used to quantify thoroughness of cleaning on over 1,000 high-touch surfaces, such as bedside tables and door knobs, comparing disinfectant alone vs. disinfectant with Highlight®. The study found that introducing Highlight® completely eliminated the failure rate – from 5.7% to 0%.

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 HAIs globally as part of the BASICS solution.


To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.

[1] Tyan et al. Infect Control Hosp Epidemiol. 2019;40(2):256-258.

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:


  • 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.


  • 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.


  • 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.


  • 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.


  • 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.

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.