# The Global call for action on infection prevention and control: Implication for low income countries

Gertrude Sika Avortri (Department of Health Systems and Services, World Health Organization, Harare, Zimbabwe)
Juliet Nabyonga-Orem (Department of Health Systems and Services, World Health Organization, Inter-Country Support Team for Eastern and Southern Africa, Harare, Zimbabwe)

ISSN: 0952-6862

Publication date: 8 July 2019

## Abstract

### Purpose

Healthcare-associated infections (HAIs) constitute a major threat to patient safety and affect hundreds of millions of people worldwide. The World Health Organization in 2016 published guidelines on the core components for infection prevention and control (IPC) programme. This was in response to a global call for focused action. The purpose of this paper is to examine and promote understanding of the tenets of the IPC guidelines and highlight their implications for implementation in low-income countries.

### Design/methodology/approach

Drawing from personal experiences in leading the implementation of health programmes as well as a review of published and grey literature on IPC, authors discussed and proposed practical approaches to implement IPC priorities in low-income setting.

### Findings

Availability of locally generated evidence is paramount to guide strengthening leadership and institutionalisation of IPC programmes. Preventing infections is everybody’s responsibility and should be viewed as such and accorded the required attention.

### Originality/value

Drawing from recent experiences from disease outbreaks and given the heavy burden of HAIs especially in low-income settings, this paper highlights practical approaches to guide implementation of the major components of IPC.

## Keywords

#### Citation

Avortri, G. and Nabyonga-Orem, J. (2019), "The Global call for action on infection prevention and control: Implication for low income countries", International Journal of Health Care Quality Assurance, Vol. 32 No. 6, pp. 927-940. https://doi.org/10.1108/IJHCQA-03-2018-0063

### Publisher

:

Emerald Publishing Limited

## Introduction

Globally, the burden of diseases attributable to healthcare-associated infections (HAIs) is huge with millions of people being affected each year (Allegranzi et al., 2011). The cost of managing these infections in a year runs into millions of dollars (Zimlichman et al., 2013), not to mention the pain and other social costs to individuals and relations. Figures from Europe and USA indicate that on the average 5–10 per cent of hospitalised patients will acquire an infection in a year (ECDC, 2008). Figures for developing countries are not readily available but the general view is that HAIs rates are far higher ranging 25 to 70 per cent (Nejad et al., 2011). Adherence to recommended infection prevention and control (IPC) strategies in low-income countries (LICs) is generally suboptimal across a wide variety of setting (Weinshel et al., 2015). The Ebola virus disease outbreak in West Africa invariably highlighted the extent to which unacceptable IPC practices can pose significant personal and health system problems (World Health Organization, 2017; Kieny et al., 2014). A number of World Health Assembly resolutions have drawn attention to the need for improved patient safety and IPC systems (World Health Assembly, 2002; World Health Organization, 2015a). The World Health Organization (WHO) notes that many health systems still fail to build strong foundations to reduce the risks and spread of HAIs thereby tolerating unacceptable levels of suboptimal IPC practices (World Health Organization, 2017). The need for renewed efforts to improve IPC practices and ensure safe care in all settings and most importantly, prevent and/or drastically reduce the effect of such large scale epidemics is globally recognised (World Health Organization, 2017). An international meeting with participants from high-, middle-, and low-income countries was held in 2016 to assess the challenges in IPC implementation and to identify approaches that could be better adapted to the needs of countries (Sastrya et al., 2017). It is anticipated that the efforts in IPC will also help address the challenges of antimicrobial resistance and enhance the quality of care which impacts on the achievement of the Universal Health Coverage and the Sustainable Development Goals.

In 2016, the WHO established the Global IPC unit and also published guidelines on the core components of national and acute health care facility level IPC programmes (World Health Organization, 2016). The Global IPC unit in collaboration with the Global Infection Prevention and Control Network developed global priorities to address IPC measures at both the country and global level in 2017 (World Health Organization, 2017). This paper examines the IPC interventions in the core component guidelines and discusses their implication for countries. The paper also offers some perspectives on measures to advance the IPC interventions in the context of LICs. The aim is to raise awareness; foster understanding of the strategies and interventions amongst stakeholders in health service delivery; and offer suggestions to enhance IPC implementation.

## The WHO IPC core components

The WHO proposes eight interlinked IPC core components as a guide for implementation of IPC measures in all settings – shown in Figure 1. They were derived from extensive review of the literature and further subjected to an international expert panned review. The IPC core components were based on the premise that although LICs may have some health system peculiarities, there are cross-cutting HAIs determinants inherent in all settings that demand institutionalising these mechanisms (World Health Organization, 2016). The core components constitute an interrelated global blue print that is expected to guide healthcare decision makers and service providers at national and international levels (World Health Organization, 2017). Countries are called upon to institutionalise governance, coordination and organisational structures that are linked or integrated into all existing health programmes at all levels of service delivery. The call is also for countries to, amongst others activities: develop/review/adapt and widely disseminate relevant standards, guidelines, protocols and algorithms; develop IPC professionals (if not existent) and update the knowledge and skills of all health workers using standardised context specific training materials and approaches; systematically improve quality of microbiological, laboratory support and appropriate information technology to support HAI surveillance, undertake supportive supervision (SS), monitoring and evaluation; continuously assess and invest in improving the built environment, institutionalise mechanisms to ensure uninterrupted availability of commodities/logistics; and foster partnerships and collaboration with local and internationals agencies and networks.

IPC is not an entirely new concept in any health system (Dixon, 2011). It has and continues to be an essential component of services delivery in all settings. Health care, irrespective of the setting, needs to be planned with an awareness of the factors that increase infection risk as well as techniques to minimise risks. In fact, it is a key component of almost all health professional training programmes, including medicine and nursing. Evidence further shows that IPC strategies in countries vary in type, scope and robustness. For example, some LICs have well-established HAI surveillance mechanism and antimicrobial stewardship programmes, while others continue to struggle with the implementation of all IPC aspects (Sastrya et al., 2017). The authors are of the view that outlining the IPC core components will greatly help to refocus the important role of IPC in efforts in ensuring that health systems are resilient. The following sections discuss issues to be considered in the implementation of these components in the context of LICs.

## Institutionalisation of country governance, coordination and organisational structures for IPC

An IPC programme is a collection of activities, resources, policies and procedures designed to control and prevent the transmission of infectious diseases essentially within the healthcare environment (Fishman et al., 2012). A number of publications give credence to this strategy as imperative to reduce HAIs, address public health threats of international concern and improve patient safety as a whole (World Health Organization, 2016; Fischer et al., 2014). Per the global recommendations, all countries are expected to develop a standalone national IPC programme as well as a programme in each health facility. Evidence shows that many countries already have on-going IPC activities even if not as comprehensive as is expected (Nejad et al., 2011). Setting up a programme is a whole health system undertaking for which the evidence shows is very challenging in many LICs (Sastrya et al., 2017). Having a standalone programme may be the ideal; however, it should be possible for countries based on their context, to strengthen a department/unit or a coordinating body for IPC implementation. IPC could even be a part of a quality management programme. The location of the IPC programme in the organisational structure of the Ministry of Health (MoH) or the health facility is important. In many settings, people are inclined to associate IPC with clinical care which tends to limit the ownership and acceptance of its across-cutting nature. Personal experience of the authors shows that it takes a lot of advocacy and convincing for all to understand that IPC is for all and that all have a role to play. A country’s inability to institute a comprehensive programme should not hold back IPC efforts. It is acknowledged that IPC programmes may not be comprehensive initially, but step-wise expansion can be planned based on available resources and buying-in from various stakeholders (World Health Organization, 2016; Manchanda et al., 2018). For example, implementation could start at hospitals with fairly good mix of professionals or could even be initiated in some of the high-risk areas (e.g. intensive care units or operating room) and then expanded to other units. Irrespective of the scope, effective implementation and a coordinated approach is important.

The authors cannot agree enough with the recommendations to have passionate, dedicated and trained professionals to oversee IPC at all levels. Though some countries may have difficulty in identifying competent professionals for these positions, it should be possible to train people within short periods using local and international opportunities. Even in situations where IPC leadership is seen as an added on responsibility for professionals (Lipke et al., 2016), advocating for dedicated time for IPC work will be a logical move.

There is a saying that “when you fail to plan, you plan to fail”. Planning (whether strategic or action plan) is important at all levels of service delivery. The plan should address all the agreed components that will facilitate programme implementation. The current evidence supports the multimodal strategy (World Health Organization, 2016). This strategy usually comprises a set of three or more IPC components (e.g. improve governance, leadership and accountability; education and training of service providers; surveillance, monitoring and evaluation; and effective communication) that are implemented collectively and continuously to maximise outcomes and behaviour change. The ultimate objective is to create the organisational culture and patient safety climate that support quality improvement as a whole (World Health Organization, 2016). Evidence shows that using multimodal interventions are effective (Price et al., 2017). Examples of such strategies exist in many LICs. For example, the IPC programme in South Africa, Namibia, Jordan and Ethiopia used continuous self-assessment tool (ICAT) coupled with continuous quality improvement approach, waste management training and development and strengthening of national IPC policy (Goredema et al., 2016). Similar strategy was also used to reduce HAI rates in five developing countries (Rosenthal et al., 2012).

### Funding for IPC

Financing forms the lifeline of health programmes. The general scarcity of resources in LIC means all programmes have to compete for funding. There are instances when budgets could be allocated yet cannot be accessed. In the WHO African Region, majority of health systems are underfunded with a current per capita expenditure on health below $50 in 22 out of 47 countries as opposed to the estimated requirement of$105 to meet grand convergence on health (Boyle et al., 2015). The underfunding impacts the overall implementation, including availability of required commodities and supplies to implement IPC interventions. Most health systems in LIC are donor dependent (Bayarsaikhan and Musango, 2016). Programme managers are strongly encouraged to think outside the box to surmount the financial burden. What options are available? How much can we realise from result based financing initiatives to improve IPC if quality of care in included as one of the indicators? Those who lead the implementation of IPC must have the skills and ability to make a cogent business or investment case for IPC (Pyrek, 2011). The global call is for stakeholders, including international development partners and donors interested in AMR containment to consider prioritising support for IPC systems-strengthening interventions. Success in this venture however requires making a good investment case. Unfortunately, many LICs are rarely able to generate local evidence to advocate for such assistance (Zimlichman et al., 2013; Graves et al., 2010). The authors argue that a good case can still be made by collating and using data on the effect of infections on patients that cause serious harm/complications and mortality, as well as data on reduction in length of stay, and patient and staff satisfaction, as much as possible demonstrating some “value for money” of IPC. For example, WHO cites the beneficial effects of IPC in reducing outbreaks and epidemics like Ebola in West Africa (World Health Organization, 2015b). In the absence of local data, IPC leadership could use international figures/data and extrapolate to the local situation to justify demands. Most importantly, LIC must explore non-traditional domestic sources, for example the private sector, for assistance in addition to exploring efficiency measures. Implementing IPC is cost-effective, especially when resources are allocated to efficient IPC strategies (Graves et al., 2010; Dick et al., 2015).

### Regulation and enforcement

Another important aspect that can greatly enhance IPC implementation is regulation and enforcement of laws. Although the trend is improving, many LICs may lack or have inadequate regulatory and legislative support IPC measures. For example, Zambia has adapted regulations requiring health facilities to employ trained IPC professionals in health facilities (Health Professions Council of Zambia, 2010). Regulatory and autonomous bodies in India have incorporated IPC in their assessment and certification processes (Swaminathan et al., 2017). In Ghana, healthcare facility accreditation is a legal requirement for all health facilities that want to be part of the National Health Insurance Scheme as such the National Health Insurance Authority in collaboration with the Health Facility Regulatory Agency undertakes accreditation/credentialing exercise for the purpose (Republic of Ghana, 2012; National Health Insurance Authority, 2013). Other avenues that could be explored are inclusion of: training on IPC and patient safety as a criterion for the reviewal of professional registration/licence; and making IPC and patient safety part of the health facility/team/individual performance appraisal mechanisms. Promotion of IPC in all health policies could also be beneficial.

### Partnership and collaboration for IPC

Partnerships are important. As much as this is required across all health disciplines to advocate and strengthen IPC visibility, engagement with the private sector on all fronts cannot be underestimated. IPC leadership, based on stakeholder analysis, should identify common areas of interest and proactively pursue their implementation. For example, health insurance schemes could be engaged to provide incentives for health facilities by tying reimbursement to IPC and patient safety performance indicators.

## Promoting the availability and use of IPC guidelines and protocols

Globally, it is recognised that guidance documents for health services delivery should be evidence based. In many LICs, limited availability of evidence greatly hinders the development of such guidance to shape policy and practice (Price et al., 2017), thus relying on adapting global guidelines developed by international organisations. The situation is not different regarding IPC. The WHO after a comprehensive synthesis of available evidence came up with the Global IPC core component guidelines (World Health Organization, 2016). Being a global document, it is strongly recommended that the strategies and guidelines should be adapted in line with available resources, health system capacities and public health needs of each country.

The adaptations/reviews may not necessarily be informed by systematic evidence but should at least be informed by an assessment of the local situation. The adaptation process normally comprises: determination of clear objectives for the adaptation/review of the policy/technical guidelines; formation of advisory/technical working group(s) under the leadership of the MoH/IPC leadership to draft the document; and obtaining inputs from key stakeholders (including lay and service users) through series of engagement before finalisation (Atkins et al., 2013). This process has its strengths in terms of enhancing plurality of experiences, perspectives and backgrounds to inform recommendations but careful selection of the drafting team members is imperative to avoid negative impacts of group dynamics (Atkins et al., 2013).

Evidence shows that in many LICs, policies and guidelines are often not disseminated effectively to the lower levels for implementation (Tawiah-Agyemang et al., 2008). Amongst the several factors that contribute to this phenomenon are: limited availability of the documents at the point of use and ineffective dissemination and training of users on their use (Baker et al., 2012). Systematic dissemination (not just distribution) of the documents at all levels and to all who are expected to use them is important. Targeted sessions should be held based on need for stakeholders such as the private sector, professional associations, regulatory bodies, health training institutions and development partners. The dissemination process should take advantage of established health sector meetings, seminars and conferences as well as other health professional groupings. Make electronic copies widely available in addition to availing hard copies. Production of abridge pocket size versions, fliers and posters and use of available information and communication technologies are additional options that can be explored to enhance uptake.

## Human resource for IPC

One of the imperatives for effective IPC is having appropriate numbers and mix of health workers competent to deliver services. It is well-known that most LICs countries are currently struggling to ensure availability of even the minimum number and mix of requisite staff at all levels (Global Health Workforce Alliance, 2013). As much as staffing levels and workload are vital for IPC implementation, actions to address them may not be the direct responsibility of the IPC team. However, the IPC team need to lead the determination of the requirement for IPC professionals/specialist. In the same vain, the team has a responsibility to gather information to effectively advocate and communicate the link between staffing/workload and HAI rates. The IPC leadership at all levels should necessarily work collaboratively with the Human Resource team on these aspects.

### IPC education and training

Research findings on IPC knowledge and skills amongst health workers are generally inconsistent, while some studies report low knowledge (Buregyeya et al., 2016), others report the contrary (Brouwer et al., 2014; Wasswa et al., 2015). Irrespective of the local situation, the key issues under this component are ensuring the availability of training opportunities and learning materials, and putting in place mechanisms for all relevant staff to possess the requisite IPC competence in relation to their job/role. All staff members, including housekeeping staff, need to be trained on IPC procedures. They should also receive regular updates. The WHO emphasises the importance of this strategy and recommends that IPC education and training should be a part of an overall education strategy and incorporated in employee orientation and induction programmes for all staff, regardless of level and position (World Health Organization, 2016).

It has been noted that IPC education and skills development systems that exist in the high-income countries do not always apply in low technology or rural environments and that it is essential that the principles of IPC practice and implementation are designed to fit healthcare systems with low resources settings (Mehtar, 2014). It is worth noting that there are a number of training and certification programmes (from basic to advance levels) in different healthcare settings and countries that could be tapped into (Lipke et al., 2016). Where these do not exist locally, IPC leadership should advocate and facilitate their establishment; engage health training institutions and universities to incorporate IPC in their curriculum and/or develop standalone training programmes; make use of opportunities at seminars and conferences to make presentations; and take advantage of networks such as the Infection Control Africa Network which are being formed to harmonise and offer standardised training in defined geographical areas. Educational resources (e.g. flyers, video recording and other computerised learning packages), whether locally or internationally developed, should be simple and made readily available. Systems for regular updates of learning and training materials as well as regular audit and evaluation to determine effectiveness should be put in place. Countries, as much as possible, should adopt structured approach to all education and training in IPC.

Additionally, we call for the use of SS as a major strategy to improve IPC performance, especially at the health facility level. SS is a continuous process of guiding, helping, teaching and encouraging staff at their place of work to improve their performance so that they meet the defined standards of their organisation. SS has been found to be associated with increased productivity in health (Frimpong et al., 2011), and as a strategy that promotes quality at all levels of the health system through the development of professional competence (Rowe et al., 2005). Scholars have reported improved adherence to guidelines and good service delivery outcomes as a result of SS (Bello et al., 2013; Som et al., 2014).

### Public awareness creation and education on IPC

Health facility promotion and hygiene education approaches should take advantage of all health worker–patient/client interactions to reinforce IPC measures. For example: waiting areas should have IPC learning materials; IPC should be included in both individual and group education sessions; and Televisions in wards and waiting areas must air IPC health promotion contents. Preparations for discharge session should reinforce and document discussion on IPC.

The vital role of the public and community in preventing and controlling the spread of infections was amply demonstrated in the Ebola epidemic interventions in West Africa. Community partnerships can prevent rumours, fear and distrust that have sometimes resulted in the hiding of ill or dying family members (Marais et al., 2016). Further, bad cultural and burial practices that lead to further spread of diseases can be obviated. The IPC programme has the responsibility to collaborate with health promotion, Water Sanitation and Hygiene (WASH) programme and other community structures in an integrated manner to create awareness and prepare communities to effectively play their role in the prevention and control of infections. Targeted campaigns and sessions for identifiable groups (e.g. churches and associations) are important. Learning and information materials (e.g. infographics and fliers) should not only be in English but must be translated relevant local languages.

## Built environment, materials and equipment for IPC at the facility level

Contamination of the health facility environment greatly contributes to HAIs, thus, appropriate design of physical infrastructure and equipment that enhance proper cleaning and disinfection is necessary to reduce infection exposure (Boyce, 2016; Agency for Healthcare Research and Quality, 2014). The built environment of the health facility includes: work surfaces; hand hygiene facilities; water supply; sanitation/toilet facilities; ventilation; traffic flow; lighting; facilities for healthcare waste management; and domestic room or areas for storing cleaning items such as mops and buckets.

In a number of LICs, health facilities were built at periods of minimal concerns about serious infectious diseases that are currently emerging, but now it is fundamental to consider IPC requirements in designs. For example, all work areas need to: have easy access to equipment and persons; be of adequate size to accommodate the workload; have facilities for storing outer garments and personal items; have adequate spacing between beds; and be designed to allow thorough cleaning and disinfection of all surfaces. Other major considerations include availability of wholesome and potable water and toilet facilities for patients and staff. Having an isolation unit/ward or designating an area that could be used for isolation cannot be underemphasized. Cameron et al. (2006) cited challenges with entry controls during the Severe Acute Respiratory Syndrome outbreak as a result of multiple public entrances in health facilities. The Ebola outbreaks in West Africa also highlighted the importance of ensuring that health facility structures at all levels can support IPC as well as reflect clients’ needs and preferences (personal experience of authors).

In a review of data from 54 countries in LICs, the WHO reported wide variations in the availability and quality of WASH components between health facilities in countries (World Health Organization, 2015c). Boyce (2016) noted similar findings on cleaning and disinfection of surfaces in health facilities and highlighted the contributory factors related to the type of surface/equipment, inadequate knowledge of housekeeping staff, poor work ethics, unclear cleaning and disinfection protocols and guidelines. Shahida et al. (2016) catalogued a number of issues on the physical health facility environment in India – overcrowding, improper placement of patients with different infection/communicable diseases and poor sanitation facilities. The WHO WASH standards for health care facilities are recommended to be used as the yardstick for improvement. The standards cover water quality, quantity and access; sanitation quality, quantity and access; and hygiene requirements (World Health Organization, 2008b). The need to advocate for compliance with IPC requirements in the design of health facilities is imperative. This may involve engaging or being part of the health facility estate management /building committee and/or being part of infrastructure audit/inspection team so as to influence decisions from the planning phase. Also, the IPC team should take advantage of new technologies and infrastructure renovations opportunities to address defects.

### Medical equipment/device

Successful implementation of IPC guidelines also depends on the availability of basic medical devices. Medical device refers to any instrument, apparatus, machine, appliance, implant, reagent for in vitro use, software, material or other similar or related article, intended by the manufacturer to be used alone or in combination for human beings for the purpose of: diagnosis, prevention, monitoring, treatment or alleviation of disease, injury or handicap; investigation, replacement or modification of the anatomy or of a physiological process; control of conception; and disinfection of medical devices that does not achieve its primary intended action by pharmacological, immunological or metabolic means in or on the human body but which may be assisted in its intended function by such means (World Health Organization, 2008a). This definition captures all that will normally be referred to as medical equipment/logistics/supplies.

The selection of medical device will depend on a number of factors including the type of health facility; where the device is to be used; the health workforce available; and the burden of disease experienced in the specific setting (World Health Organization, 2011). Medical device availability and management systems are generally unacceptable in many LICs (Diaconu et al., 2017). The situation is compounded by high percentage of donations from outside the countries, lack of training, lack of spare parts and inappropriate infrastructure (Perry and Malkin, 2011). Some of the challenges with equipment and logistics management emanate from how these items are managed at the unit/ward levels. Unacceptable stock management practices include often unestablished stock levels (minimum, re-order and maximum stock levels), ineffective requisition systems, non-compliance with First-in First-out or First-expired First-out systems and poor record keeping to facilitate audit trail as some of the major challenges.

Despite these challenges, the IPC teams at all levels can still play key role in medical devices management. Not only are they expected to determine need and specifications but they are also required to support systems to avoid stock outs and equipment downtimes. It is recommended to have IPC representation in the procurement decision-making body at all levels. For example, in Ghana, the IPC policy clearly states that the IPC focal person shall be consulted in the procurement of IPC equipment and consumables (Mahomed et al., 2017). Improvements can be achieved by implementing some of the following: ward/unit supervisors should determine their IPC equipment and supplies needs; provide storage facilities and facilitate proper storage of items, including disinfectants and detergents; advocate and facilitate the production of a standard equipment list for locally purchased and donated items, development of planned prevention maintenance systems for key medical devices, and development of instrument to regulate practice; and foster partnerships and engage local companies to produce items locally, e.g. waste bins, bin lines, cleaning and disinfection items, hand washing facilities, etc.

## Surveillance, monitoring and evaluation

IPC improvement strategies need to be informed by systematic recording of the magnitude of the infection burden. Surveillance of HAIs constitutes one of the essential pillars to record the size of infection burden (Allegranzi et al., 2011). Surveillance refers to a systematic process of collecting, consolidating, analysing, interpreting and disseminating data about the distribution and determinants of a given disease or event (e.g. infection) for the purpose of action. Many LICs however have no national standardised HAIs surveillance system. This is supported in Allegranzi et al. (2011) in a systematic review of HAIs in developing countries that highlighted the paucity of studies from Africa. Another systematic review also reported that the magnitude of the problem remains underestimated or even unknown largely because HAI diagnosis is complex and surveillance activities to guide interventions require expertise and resources that do not exist in many LICs (Nejad et al., 2011). Some of the contributory factors to the situation were noted as the organisational culture that does not promote the collection of surveillance data; absence of expertise; health professionals feeling that the process added to their workload (i.e. no dedicated human resources); limited financial resources; unreliability of microbiological data and other diagnostic procedures; poorly managed medical records; and inadequate leadership commitment to use data for decision making (Allegranzi et al., 2011; Ministry of Health, 2015).

This however does not indicate that nothing is happening. Nejad et al. (2011) observed that there are encouraging signs that the importance of HAI has started to be recognised in Africa. Vilar-Compte et al. (2017) also reported that most middle-income countries have developed some sort of National Surveillance Programme along with IPC strategies for their health care facilities. Despite the challenges with international standardised definitions, good results can be achieved by focusing on just education and feedback on infection rates and process surveillance (i.e. adherence to infection control measures) (Rosenthal et al., 2012). Similarly, use of checklists for IPC for monitoring and evaluating IPC practices can produce valuable results (Tremblay et al., 2017).

Institutionalising regular systems for SS and monitoring of IPC practices and processes is important while efforts are put in place to build a comprehensive surveillance system. Many LICs are developing plans in line with the Global Action Plan on Antimicrobial Resistance that addressed issues of HAI surveillance (World Health Organization, 2015d). Both international and local networks are being formed to report data on antimicrobial resistant pathogens (Swaminathan et al., 2017). Countries are encouraged to seek and be part of these initiatives.

## Research on IPC

Though there are a number of challenges in the implementation of IPC in LICs that require answers, it is common knowledge that resources for health systems research, including research for addressing IPC problems are limited. Importantly, research is needed to identify and validate innovative technologies and equipment to support IPC, provide a stronger demonstration of the cost-effectiveness of IPC interventions, identify feasible implementation approaches and local solutions for low-resource settings (World Health Organization, 2017). The cultural and social context of the IPC intervention strategy is particularly important with regard to the shortage of research in low-income countries (Price et al., 2017). Limited resources withstanding, countries must identify IPC research priorities and include these as part of the overall prioritised research agenda for the health sector. This will serve as a basis for resource mobilisation.

## Conclusion

The evidence that HAI has a great negative effect on healthcare facilities, national healthcare systems and patients is well documented. The economic and ethical justifications for enhancing IPC are strongly demonstrated in the literature. There are a number of initiatives already taking place in many LICs despite prevailing challenges, and global priority setting must take cognisance of these efforts. We have examined the globally recommended IPC interventions and their implications especially for LICs. We have advanced implementation of the interventions in simple practical ways stressing the importance of country-centred strategies. From our perspective, a lot can be done in all the IPC intervention areas with better planning, innovation, dedication and efficiency improvements. Contextualised evidence must be generated to guide efforts as well as proposing locally feasible options.

## Figures

#### Figure 1

IPC core components

# Glossary

EVD

Ebola Virus Disease

GIPC

Global Infection Prevention and Control

IPC

Infection prevention and control

MoH

Ministry of Health

UHC

Universal health coverage

WHO

World health organization

SDGs

Sustainable Development Goals

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## Acknowledgements

The authors declared no competing and conflicting interest, and no additional data were available. GSA and JNO participated in the conceptualization of the analysis; GSA led the drafting of the manuscript. JNO participated in the drafting of the manuscript; both authors read and approved the final manuscript.

## Corresponding author

Gertrude Sika Avortri can be contacted at: avortrig@who.int