Identifying the gaps between infection prevention and control and water, sanitation and hygiene in Malawi

5 min read
Steria Botoman, community midwife assistant, washing her hands using a hands-free station, Kangolwa Health centre, Ntchisi district, Malawi.
WaterAid/Dennis Lupenga

Water, sanitation, hygiene (WASH) is a prerequisite for infection prevention and control (IPC), yet in many countries there are huge gaps in practice between the two. Kyla Smith and Natasha Mwenda introduce how we are developing innovative training for WASH and IPC stakeholders in Malawi to bridge these gaps and support work towards safe healthcare for all.

Thousands of people die every day from infections acquired while receiving healthcare – 15% of patients in low- and middle-income countries acquire at least one infection during a hospital stay. WASH services and behaviours are a prerequisite for IPC and the safety of health service users and health workers, and fundamental to strong, resilient health systems that can deliver quality healthcare. But one in three healthcare facilities globally lack hand hygiene facilities at points of care, one in four lack clean water, and one in ten don’t have decent toilets. We will not reduce the number of people dying from hospital-acquired infections, or achieve safe healthcare in low- and middle-income countries without adequate – and integrated – WASH and IPC.

WASH in healthcare facilities is a flagship area of our WASH and health work. It focuses on strengthening the health and WASH systems needed to provide sustained and inclusive water and sanitation services and hygiene behaviours in healthcare facilities, to ensure patient safety, quality and dignity of care.

The need to bridge practice gaps between WASH and IPC

In December 2019, with the Infection Control Africa Network (ICAN) we hosted WASH and IPC training for WASH professionals in government ministries, civil society organisations and non-governmental organisations across seven African countries and Myanmar. This initial training introduced IPC, with specific focus on WASH-related elements. The session highlighted that further attention was needed to address knowledge and practice gaps in this area and make specific additions to training materials to help elevate the role of WASH for IPC.

We also noted the need to continue to bring IPC and WASH stakeholders together, at all levels, to understand one another's areas of expertise, ensure clarity of language, and to share approaches and ways in which these areas intersect and support each other. The World Health Organization’s latest report on IPC reinforces this – it highlights "the importance of integration and alignment of IPC and water, sanitation and hygiene (WASH) within wider efforts on AMR [antimicrobial resistance], health emergencies, quality and safety and beyond".

Loveness Saulosi, mother of seven children, sitting with her daughter Siteliya Felix and newborn grandson in Mkunzi Health Centre, Mthumba village, Malawi.
Loveness Saulosi, mother of seven children, sitting with her daughter Siteliya Felix and newborn grandson in Mkunzi Health Centre, Mthumba village, Malawi.
WaterAid/Dennis Lupenga

Our project to improve WASH services and behaviours in healthcare facilities

Globally, an estimated 20% of annual deaths are due to sepsis, and newborns, pregnant and recently pregnant women, and people in low-resource settings are disproportionately affected. In Malawi, 24% of healthcare facilities have no or limited access to water and 73% have no or limited access to hygiene services. This limited access to WASH services is a contributing factor to Malawi having among the highest maternal and neonatal mortality rates in the sub-Saharan region and globally (PDF), at 439 per 100,000 live births and 26 per 1000 live births, respectively. In 2020 the Government of Malawi developed new IPC and WASH guidelines in recognition of how crucial WASH is to quality healthcare.

WaterAid in Malawi, with funding from the Wimbledon Foundation, is working in four healthcare facilities in Ntchisi District, aiming to model and improve their WASH status. The project aims to do this through constructing WASH and waste management infrastructure; promoting adoption of good hygiene behaviours; capacity building in operation and maintenance for sustainable management of infrastructure; and capacity building on IPC.

A key initiative within the Ntchisi project is to work with Malawi Government ministries, IPC and WASH experts, and healthcare staff to develop innovative, creative and interactive WASH and IPC training materials. This will fill a critical gap in understanding of those working in WASH and IPC, and provide practical digital and in-person training resources.

Hastings Chaomba, senior health attendant, cleaning hospital corridors, Kamgolwa Health Centre, Ntchisi district, Malawi.
Hastings Chaomba, senior health attendant, cleaning hospital corridors, Kamgolwa Health Centre, Ntchisi district, Malawi.
WaterAid/ Dennis Lupenga

Working in partnership to ensure sustainability and expertise

We work through partnerships, and collaboration is one of our core values. This approach is crucial for knowledge sharing, leveraging on existing resources, strengthening local systems and structures and contributing to achievement of national and global priorities.

To ensure the new IPC and WASH training materials are relevant, add value to existing training offered and fill the need observed by the Malawian Government, for our gap analysis we held a series of engagements with key stakeholders. First, we met with the Director of Quality Management, then through them engaged with heads of directorates within the Ministry of Health and local government. These leaders, who are members of a steering committee for an ongoing District Health Management Team leadership programme, guided us on how best to work with them without overloading the Ministry with committees.

To enhance acceptance, ownership and sustainability of outcomes, representatives from professional bodies including the Malawi Environmental Health Association, the Infection Prevention and Control Association of Malawi and the research institution Malawi University of Business and Applied Sciences are also taking part in the project. At global level we are partnering with IPC and WASH experts, and with two centres of WASH and IPC expertise – London School of Hygiene and Tropical Medicine and Infection Control Africa Network.

How we will develop the IPC and WASH training materials

We will share progress of this initiative as we follow these steps:

  1. A structured review (PDF) of existing IPC and WASH resource gaps to inform the new training materials, and to ensure this initiative fills gaps and signposts existing training materials where appropriate and does not re-invent the wheel. – Completed October 2021.
  2. Formative research in four healthcare facilities: 

    - Identified gaps in understanding, training and practical application of normative guidance for WASH professionals and actors in healthcare facilities and IPC objective.
    - Defined target audiences for the training.
    - Determined drivers and barriers to uptake of the training among facilities and ministries.
  3. Collaboration with Government officials, IPC and WASH experts, researchers and a creative agency to develop pilot creative training materials.
  4. Pilot the materials, incorporate feedback from trainers and trainees, and review and finalise the materials.
  5. Provide digital materials to other stakeholders working on WASH and IPC to be contextualised for different settings. Share the process followed and lessons learned so others can apply them to their IPC and WASH training.

To make sure you read the next blog in our series of four on this project, sign up to receive our monthly WASH Matters newsletter featuring the latest WaterAid expert opinion, publications and more.

Kyla Smith is WaterAid’s Senior Manager for Health. Natasha Mwenda is Acting Sustainable Delivery Programme Manager for Deliver Life II.

Top image: Steria Botoman, community midwife assistant, washing her hands using a hands-free station, Kangolwa Health centre, Ntchisi district, Malawi.