Frequently Asked Questions
The BASICS team is grateful for all the helpful feedback we received from our peer reviewers. In the below FAQ document, we aim to acknowledge our peer feedback and respond to some of the issues we thought would benefit from more clarification. BASICS is committed to our vision to stop infections in clinical settings, transform healthcare and ensure quality livelihoods for communities in low and middle income countries.
Q: What does the situation look like in the four countries where BASICS will be implemented and why do you believe this solution will be sustainable?
A: The four countries BASICS initially targets (Bangladesh, Cambodia, Nigeria and Tanzania) account for almost 10% of the burden of healthcare-associated infections in low- and middle- income countries. Infections account for a high proportion of newborn deaths in each country (24-27%). Bangladesh, Nigeria and Tanzania also have high proportions of maternal deaths from infections (10-14%).
However, all target countries have demonstrated strong commitments to reducing infection risk and improving the quality of care through new policies and costed action plans. Nigeria’s Ministry of Health, for example, recently created the new position of a national Infection Prevention Control (IPC) coordinator, who is charged with leading the creation and implementation of a national IPC plan.
Q: Beyond changing health workers’ behavior, how does BASICS address all the factors putting people at risk of a healthcare-associated infection, such as lack of infrastructure, lack of funding or lack of human resources?
A: BASICS embeds system-wide changes that simultaneously address all contributing factors to ensure healthcare workers are empowered and encouraged to make effective infection prevention practices part of their daily routine. BASICS is designed to simultaneously remove or reduce barriers to action and encourage consistent behavior compliance through improvements made to:
- Pre-service training for all relevant healthcare facility staff through accredited training institutions (quantity and quality of training)
- Water, sanitation and hygiene infrastructure – including design, placement and management
- In-service trainings through existing Ministries of Health platforms
- Management of infection prevention supply chains and Water, Sanitation and Hygiene (WASH) infrastructure
- Use of Monitoring, motivation and accountability systems
Q: People sometimes tend to go back to their usual behavior after being trained. How will the behavioral change of health workers be maintained beyond the project?
A: We recognize that infection prevention is a continuous process. It is important to note that BASICS is not a one-time or periodic training that health workers attend. It is a multi-faceted approach that is institutionalized within training and health systems. BASICS was designed by technical experts and behavior scientists based on proven behavior change methodology.
Evidence around behavior change in the clinical settings suggests that multi-modal approaches (like BASICS) are necessary to achieve lasting change. Routine cleaning, disinfection and hygiene practices are behaviors that must be consistently reinforced and encourages by multiple systems to ensure they become routine for healthcare workers and institutionalized in facility management and culture.
To ensure sustained behavioral improvements among healthcare providers, facility managers, health workers, patients and visitors, we will apply the proven Behavior Centered Design (BDC) approach. It consists of a five-step process (ABCDE) to engage stakeholders in a collaborative, cooperative process to identify interventions that addresses the key emotional, cognitive and environmental drivers of behaviors.
The steps align with the larger phases of the BASICS program. Assess and Build coincide with the planned inception period, allowing partners to complete needs assessments and formative research activities in target countries. Create involves the development of an over-arching, transformational behavior change strategy, linking the multiple intervention components into a cohesive and coordinated whole. Deliver and Evaluate align with the BASICS period of scale and evaluation.
More information about staff experiences when implementing infection prevention and control guidelines can be found in this study.
Q: Are BASICS members using the Behavior Centered Design approach now?
A: Our work with training institutions will ensure that future generations of healthcare workers will be ingrained with best practices as their “default” behaviors. To improve practices among the current healthcare workforce, we will leverage our team’s experience from Cambodia. The London School of Hygiene and Tropical Medicine and WaterAid are collaborating on the development of an innovative intervention to improve handwashing among midwives and caregivers during labor, delivery and post-natal care using the BCD methodology.
This includes expanding on current best practices for sustained infection prevention control and hand hygiene behaviors in healthcare facilities with innovate approaches such as the use of environmental nudges, pubic commitment and routine self- and peer-assessment tools, and automatic reminders regarding hand hygiene for healthcare workers.
These experiences will provide an overarching framework for the development of a facility and health-system wide behavior change strategy.
Q: Why will people pay for Highlight® once the program ends?
A: Highlight® is a novel color additive that increases the efficiency and effectiveness of cleaning and disinfection by making chlorine visible, changing chlorine’s liquid properties to achieve full surface coverage, and color-fading after optimal disinfection time. BASICS will partner with governments and accredited training institutions to use Highlight® as a tool to enhance the quality of training for healthcare facility staff. The product will ingrain and reinforce optimal cleaning and disinfection routines among healthcare workers during pre-service and in-service trainings.
Beyond use in training, studies in the United States have shown significant improvements in routine cleaning and disinfection within healthcare facilities. Although BASICS will not actively promote the use of Highlight®, if governments or local partners value the additional benefits of Highlight® beyond its use in training, they can independently establish procurement mechanisms with Kinnos. As a social venture, Kinnos provides Highlight® at cost in developing markets.
Q: How will BASICS be implemented in other countries over time? Has the team created a strong sustainability plan for reaching people beyond the four countries where it will be rolled out?
A: BASICS is seizing a growing global movement to improve infection prevention in healthcare facilities for better health outcomes for patients and to address the threat of antimicrobial resistance.
In May 2019, 194 countries agreed to a resolution at the World Health Assembly stressing the critical need to improve Water, Sanitation and Hygiene (WASH) in healthcare facilities. The resolution calls on countries to commit to eight practical steps to improve the quality of healthcare through WASH and infection prevention improvements. The steps are:
- Conduct a situation analysis and assessment
- Set targets and define a road map
- Establish national standards and accountability mechanisms
- Improve and maintain infrastructure
- Monitor and review data
- Develop health workforce
- Engage communities
- Conduct operational research and share learning
Our team will initially assist the four selected governments in operationalizing these steps through BASICS, which provides a cost-effective and scalable approach to realizing the ambitions laid out by the World Health Organization (WHO) and agreed to by 194 national governments. We will leverage our consortium’s extensive relationships with national governments, donors, professional associations and local partners to share learnings and advocate for the uptake of BASICS by at least three more governments within the initial five-year implementation timeframe. Specific expansion countries will be identified by the end of our third year of implementation. We will select the countries based on political will, our operational capacity and the results from an upcoming WHO assessment of national action plans for WASH in healthcare facilities. After 10 years, we plan to be actively supporting at least 15 national governments to implement and continuously improve upon the BASICS package.
Q: BASICS is an ambitious project that integrates the work of four organizations. How will a project of this size be managed?
A: Save the Children, the London School of Hygiene and Tropical Medicine, WaterAid and Kinnos have committed experienced international public health experts to lead the BASICS partnership. BASICS’ leaders have a combined 60-plus years’ experience developing, managing and leading health and WASH programs and trainings in low- and middle-income countries. They also have a wealth of experience in strategic, technical and financial program oversight and research and advocacy. (Read our team leaders’ credentials here)
Save the Children and WaterAid have extensive operational platforms across a combined 121 countries. As the lead partner on BASICS, Save the Children has a global health portfolio of more than $975 million and approximately 130 awards in 50 countries.
In addition to our robust operational platforms, the BASICS consortium has very strong leadership. In addition to being technical leaders in their fields, our key staff members have extensive program management experience working with multiple partners and across dozens of countries. They are supported by the robust management systems and deep technical expertise housed within our four organizations.
All partners have established a framework of cooperation and have well-defined roles and responsibilities for BASICS. (Read our partners’ roles and responsibilities here)
Q: BASICS has huge savings based on the cost model. The program’s success seems to depend on government cooperation and reinvesting the cost savings to sustain the project. How does BASICS address the risk that governments might not support the institutional changes required?
A: While there are no guarantees that governments will reinvest savings realized by the BASICS approach, there is a growing commitment among national governments to strengthen infection prevention and control programs.
In May 2019, 194 countries passed resolutions at the World Health Assembly stressing the critical need to improve WASH in healthcare facilities and improve the quality of healthcare services. Each of our target countries has demonstrated strong commitments to reducing infection risk and improving quality of care through new policies and costed action plans on WASH in healthcare facilities, reducing antimicrobial resistance and achieving universal coverage of quality healthcare services. BASICS will be an attractive implementation model to national governments because it will demonstrate marked improvements in health and quality of care outcomes while saving families and governments money.
Q: You’ve chosen Nigeria as one of the countries to introduce BASICS. Given the country’s conflicts and challenging context, how will BASICS be successfully scaled in such an environment?
A: BASICS is a solution driven by need. Despite its many operational challenges, Nigeria is an important context for BASICS because of the overwhelming need that exists. It has a large population, high proportion of infections and infection-related deaths and increased outbreak risks that arise from insecure environments.
Our strategy is to introduce, assess and refine our approach in multiple countries and contexts – including volatile and unstable places that pose significant challenges to the delivery of health care. We are conscious of the many different operating contexts and the unique challenges they present because our partnership has longstanding presence working in those environments.
To ensure success in fragile contexts like Nigeria, our consortium will rely on our collectively strong national and local partnerships. For example, in Nigeria Save the Children, WaterAid and the London School of Hygiene and Tropical Medicine have strong relationships with federal and state governments in both stable and insecure areas of the country. Our team has many longstanding local partnerships – like those with the Wellbeing Foundation and the National Association of Nigeria Nurses and Midwives – that will allow us to successfully design, institutionalize, implement and handover BASICS activities.
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