& Hygiene in HCF, with a focus on climate Session 1 11th March - - PowerPoint PPT Presentation

SEARO ONLINE TRAINING

Improving Water, Sanitation & Hygiene in HCF, with a focus on climate

Session 1 11th March 2020

A framework for building Climate Resilient and Environmentally Sustainable health care facilities

Elena Villalobos Prats Carlos Corvalan

Pathways of climate change and human health

Social Infrastructure Direct exposures: Flood damage Storm vulnerability Heat stress Indirect exposures: Mediated through natural systems: Allergens; Disease vectors, Increase water/air pollution Economic and social disruption: Food production/ distribution Mental stress Climate change

• Precipitation
• Heat
• Flood
• Storm
• Drought
• Increased

water temperature Health impacts

• Undernutrition
• Heart disease
• Injuries
• Vector-borne

diseases

• Infectious

diseases Social infrastructure Direct exposures

• Flood damage
• Storm, drought

vulnerability

• Heat stress

Indirect exposures Mediated through natural systems:

• Disease vectors
• Water scarcity
• Increased water/air

pollution Via economic and social disruption

• Food production

and distribution

• Migration
• Mental stress

Modified from Smith 2014

Pathways of climate change and human health

Social Infrastructure Direct exposures: Flood damage Storm vulnerability Heat stress Indirect exposures: Mediated through natural systems: Allergens; Disease vectors, Increase water/air pollution Economic and social disruption: Food production/ distribution Mental stress Climate change

• Precipitation
• Heat
• Flood
• Storm
• Drought
• Increased water

temperature Health impacts

• Undernutrition
• Heart disease
• Injuries
• Vector-borne

diseases

• Infectious

diseases Social infrastructure Direct exposures

• Flood damage
• Storm, drought

vulnerability

• Heat stress

Indirect exposures Mediated through natural systems:

• Disease vectors
• Water scarcity
• Increased water/air

pollution Via economic and social disruption

• Food production

and distribution

• Migration
• Mental stress

Modified from Smith 2014

IPCC: The health of human populations is sensitive to shifts in weather patterns and other aspects

• f climate change (very high

confidence)

Environmental conditions

• Baseline weather
• Baseline air/ water

quality

• Geography
• Soil/dust
• Vegetation

Social Infrastructure Direct exposures: Flood damage Storm vulnerability Heat stress Indirect exposures: Mediated through natural systems: Allergens; Disease vectors, Increase water/air pollution Economic and social disruption: Food production/ distribution Mental stress Climate change

• Precipitatio

n

• Heat
• Flood
• Storm
• Drought
• Increased

water temperature Health impacts

• Undernutrition
• Heart disease
• Injuries
• Vector-borne

diseases

• Infectious

diseases Social infrastructure Direct exposures

• Flood damage
• Storm, drought

vulnerability

• Heat stress

Indirect exposures Mediated through natural systems:

• Disease vectors
• Water scarcity
• Increased water/air

pollution Via economic and social disruption

• Food production

and distribution

• Migration
• Mental stress

Modified from Smith 2014

Environmental conditions

• Baseline weather
• Baseline air/ water

quality

• Geography
• Soil/dust
• Vegetation

Social Infrastructure Direct exposures: Flood damage Storm vulnerability Heat stress Indirect exposures: Mediated through natural systems: Allergens; Disease vectors, Increase water/air pollution Economic and social disruption: Food production/ distribution Mental stress Public health capability and adaptation Climate change

• Precipitatio

n

• Heat
• Flood
• Storm
• Drought
• Increased

water temperature Health impacts

• Undernutrition
• Heart disease
• Injuries
• Vector-borne

diseases

• Infectious

diseases Social infrastructure Direct exposures

• Flood damage
• Storm, drought

vulnerability

• Heat stress

Indirect exposures Mediated through natural systems:

• Disease vectors
• Water scarcity
• Increased water/air

contamination Via economic and social disruption

• Food production

and distribution

• Migration
• Mental stress

Mediating factors

• Socioeconomic

status

• Health and

nutrition status

• Primary health

care

• Early warning

systems

• Climate resilient

health systems & HCF

Modified from Smith 2014

Environmental conditions

• Baseline weather
• Baseline air/ water

quality

• Geography
• Soil/dust
• Vegetation

Social Infrastructure Direct exposures: Flood damage Storm vulnerability Heat stress Indirect exposures: Mediated through natural systems: Allergens; Disease vectors, Increase water/air pollution Economic and social disruption: Food production/ distribution Mental stress Public health capability and adaptation Climate change

• Precipitation
• Heat
• Flood
• Storm
• Drought
• Increased

water temperature Health impacts

• Undernutrition
• Heart disease
• Injuries
• Vector-borne

diseases

• Infectious

diseases Social infrastructure Direct exposures

• Flood damage
• Storm, drought

vulnerability

• Heat stress

Indirect exposures Mediated through natural systems:

• Disease vectors
• Water scarcity
• Increased water/air

contamination Via economic and social disruption

• Food production

and distribution

• Migration
• Mental stress

Mediating factors

• Socioeconomic

status

• Health and

nutrition status

• Primary health

care

• Early warning

systems

• Resilient health

systems & HCF

Modified from Smith 2014

IPCC: In recent decades, climate change has contributed to levels of ill health (likely) though the present worldwide burden of ill health from climate change is relatively small compared with other stressors on health and is not well quantified

Environmental conditions

• Baseline weather
• Baseline air/ water

quality

• Geography
• Soil/dust
• Vegetation

Social Infrastructure Direct exposures: Flood damage Storm vulnerability Heat stress Indirect exposures: Mediated through natural systems: Allergens; Disease vectors, Increase water/air pollution Economic and social disruption: Food production/ distribution Mental stress Public health capability and adaptation Climate change

• Precipitation
• Heat
• Flood
• Storm
• Drought
• Increased

water temperature Health impacts

• Undernutrition
• Heart disease
• Injuries
• Vector-borne

diseases

• Infectious

diseases Social infrastructure Direct exposures

• Flood damage
• Storm, drought

vulnerability

• Heat stress

Indirect exposures Mediated through natural systems:

• Disease vectors
• Water scarcity
• Increased water/air

contamination Via economic and social disruption

• Food production

and distribution

• Migration
• Mental stress

Mediating factors

• Socioeconomic

status

• Health and

nutrition status

• Primary health

care

• Early warning

systems

• Resilient health

systems & HCF

Modified from Smith 2014

In summary

IPCC: The most effective measures to reduce vulnerability in the near term are programs that implement and improve basic public health measures such as provision of clean water and sanitation, secure essential health care including vaccination and child health services, increase capacity for disaster preparedness and response, and alleviate poverty (very high confidence)

Building climate resilient and environmentally sustainable health care facilities: Framework elements

Climate change

Healthy people Health Care Facilities Global environment

Climate change

Healthy people Health Care Facilities Global environment Wastes Air pollution Water Sanitation Chemicals GHGs GHGs

Health Care Settings Goal: “all health care facilities and services are environmentally sustainable: using safely managed water and sanitation services and clean energy; sustainably managing their waste and procuring goods in a sustainable manner; are resilient to extreme weather events; and capable of protecting the health, safety and security of the health workforce” WHO global strategy on health, environment and climate change (2019)

Global environment

Climate change

Healthy people Climate-resilient and environmentally sustainable Health Care Facilities

Safely managed water and sanitation services Clean energy and low-carbon health care Sustainable waste management Sustainable procurement Resilient to extreme weather events Protecting the health, safety and security of the health workforce Sustainable infrastructure and technologies

Environmental requirements for safe and quality care

Healthcare workers WASH Energy Infrastructure & technologies Health care facilities

Healthy people, Healthy environment Climate change:

• Floods,
• Droughts,
• Fires,
• Storms,
• Temperature

extremes,

• Sea-level rise
• Climate

sensitive diseases

• utbreaks

Climate resilient health care facilities are those that are capable to anticipate, respond to, cope with, recover from and adapt to climate-related shocks and stress, so as to bring ongoing and sustained health care to their target populations, despite an unstable climate

Climate resilient health care facilities

Environmental requirements for safe and quality care Healthcare workers WASH Energy Climate Resilience Health care facilities

Healthy people, Healthy environment

Climate resilience: Protect HCF from external shocks and stresses

Climate change:

• Floods,
• Droughts,
• Fires,
• Storms,
• Temperature

extremes,

• Sea-level rise
• Climate

sensitive diseases

• utbreaks

Infrastructure & technologies

Climate resilience

Sample questions on resilience  Is the infrastructure of the health care facility able to withstand climate-related emergencies?  Is it able to provide safety for patients, staff and visitors?  Does the health care facility have protocols to secure back-up supplies of water in the event of an emergency?  Does the health care facility have an emergency energy plan?  Are training exercises and drills to evaluate and validate disaster plans carried out at the health care facility regularly?  Does the health care facility participate in community educational and communication programs to assist the local community in reducing climate risk and vulnerabilities?

Environmental sustainability is the health care facility’s responsible interaction with the environment to avoid depletion or degradation of natural resources, ensuring long-term environmental quality and the strengthening of resilience to extreme weather events and climate change

Environmental sustainability in the health care facilities

Environmental requirements for safe and quality care Healthcare workers WASH Energy Health care facilities

Healthy people, Healthy environment

Environmentally Sustainable Interventions

Environmentally sustainable interventions:

• Optimize consumption (e.g. water, energy)
• Reduce emissions (e.g. GHGs, wastes)

Climate change:

• Floods,
• Droughts,
• Fires,
• Storms,
• Temperature

extremes,

• Sea-level rise
• Climate

sensitive diseases

• utbreaks

Infrastructure & technologies

Environmental sustainability

Sample questions on environmental sustainability  Does the health care facility implement energy conservation?  Does the health care facility have established procedures for proper disposal of pharmaceuticals?  Does it use solar panels or other type of renewable energy such as wind?  Does it have programmes to build awareness among staff, patients and visitors of the importance of being a sustainable health care facility?  Does the health care facility have an environmentally responsible purchasing program?

Framework for climate-resilient and environmentally sustainable healthcare facilities

Framework for building climate-resilient health systems

Framework for building climate-resilient health systems

Health workforce Infrastructure & technologies WASH + HC wastes Energy

Framework for building climate-resilient and environmentally sustainable health care facilities

Climate resilience Environmental sustainability Health workforce

☐ A disaster risk reduction plan to

prepare for, respond to and recover from extreme climate events is available

☐ The health workforce is trained in

the management of health care wastes WASH

☐ Water services are not affected by

seasonality or climate change related extremes

☐

Wastewater is safely managed through use of on-site treatment Energy

☐

An energy backup source is available if the main source fails during an extreme climate event

☐ Renewable energy powers energy

efficient lighting Infrastructure & technology

☐ Health care facilities are built or

retrofitted to cope with extreme climate events

☐ Environmentally sustainable supplies

are purchased from local sources

Sample interventions on climate resilience and environmental sustainability in health care facilities

Ongoing ac activities & priorities at t country le level for CR CR-HCFs

1. Capacity building for healthcare workers on climate change and health (special focus on adaptation); 2. Health component of National Adaptation Plan (HNAP) – inclusion of specific action in HCF; 3. Energy access (focus on solar energy) and energy efficiency measures to lower environmental footprint; 4. WASH: access to WASH services, including environmentally friendly waste management (also waste water disposal) and development of standards for CR-WASH; CR-WSPs; 5. Infrastructure and environmentally friendly technologies in health service delivery – climate resilient buildings and promotion of non- burning technology in HCWM (e.g. autoclave); 6. Vulnerability and Adaptation Assessment (V&A) - to identify climate change vulnerable HCF and population 7. Defining scope and developing guideline for CRESHCFs; 8. Construction and maintenance of model CRESHCF; 9. Disaster risk reduction (DRR): conduct drills; development of disaster management and response plans for HCFs; and appointment of disaster focal point in disaster-prone major healthcare institutions;

• 10. Promotion of climate resilience measures in health programmes – as part of building climate resilient systems;
• 11. Research and development

Summary presentations countries: CR-HCFs

Key hazards:

• Extreme weather events; flooding; landslides, bush fires, heatwave, cold wave,

glacial lake outburst flood (GLOF) Main challenges:

• 1. Baseline information on capacities and gaps in health system to face challenges

posed by CC;

• 2. Lack of evidence linking CR-HCFs to reduced disease burden due to CC;
• 3. Working in silos – CC not strongly integrated in existing health program;
• 4. Financial issues and coordination among different stakeholders;
• 5. Water supply and energy back-up. High cost of installation of solar panels.
• 6. Lack of human resources
• 7. Dedicated section for environmental health and HCWM but not explicitly for

Climate Change.

BETTER WASH FOR QUALITY CARE IN HEALTHCARE FACILITIES

WASH in health care facilities & health

SEARO Online training Session 1 11th March 2020

Video: from Resolution to Revolution (August 2019)

31

https://www.youtube.com/watch?v=Su53NTLFkdA&feature=youtu.be

32

“QUALITY”: an empty promise without basic services

• 8.6 million deaths per year in 137 LMICs are due to inadequate

access to quality care.

• Of these, 3.6 million are people who did not access the health

system.

• Whereas, 5.0 million people who sought care but received poor

quality care.

• Up to 1.0 million mothers and newborns die from preventable

infections linked with unclean births.

https://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(17)30101-8.pdf https://www.healthynewbornnetwork.org/hnn-content/uploads/CBK_brief-LOW-RES.pdf

33

Quality care, WASH & IPC

Dimensions of quality care:

• 6. Safe
• 5. Effective
• 7. People-centered
• 1. Timely
• 2. Efficient
• 3. Equitable
• 4. Integrated

WASH – a fundamental building block

WASH supports & strengthens IPC to prevent: i) the spread of infection, ii) the overuse/unnecessary use of antibiotics & iii) outbreaks

Lack of WASH in health care means care is less effective, less safe & harmful

Globally, WASH remains shockingly inadequate

3 4

• 1 in 4 lack basic water
• 1 in 5 have no sanitation
• 42% lack hand hygiene at point of care
• 40% lack systems to segregate waste

WHO/UNICEF, 2019 Global Baseline Report https://www.who.int/water_sanitation_health/publications/wash-in-health-care-facilities-global-report/en/

Find your country’s data: www.washdata.org/healthcare

Only half of delivery rooms in 6 countries have all basic WASH and infection prevention and control supplies

Antibiotics a quick fix for poor WASH in fractured health systems?

Willis and Chandler, 2019. Quick Fix for care, productivity, hygiene and inequality: reframing the entrenched problem of antibiotic overuse. BMJ Global Health.

In some countries, 90% of women receive prophylactic use

• f antibiotics

during childbirth.

(Bonet et al., 2017, Cochrane Database

• Syst. Rev)

2020: transitioning from Resolution to Revolution

72nd World Health Assembly (WHA) approves a Resolution

April 2019 January 2020 2030

Every user has quality care and universal WASH

May 2019

Global baseline and guidance form basis for strategic action WASH in HCF recognized by WHO as urgent health challenge

• f decade

May 2020

Event on progress and investments at World Health Assembly Advocacy, technical support to countries, documenting what works

Ongoing 2020

2020: Year of Nurse and Midwife #YNOM

38

Global targets for WASH in health care facilities

• By 2020, 60% of all health care facilities

globally and in each SDG region have at least basic WASH services;

• By 2025, 80% have basic WASH

services, and

• By 2030, 100% have basic WASH

services

• By 2022 higher levels of service are

defined and monitored in countries where universal basic WASH services have been achieved already;

• By 2030, higher levels of WASH

services are achieved universally in 80% of those countries

Basic services Higher service levels

Calls for Countries to:

• Establish national roadmap, targets and

implement WASH in HCF and infection prevention and control (IPC) standards

• Integrate WASH and IPC standards and

indicators into health programming and monitoring

• Address inequities, especially in primary health

care facilities and facilities where births occur

• Increase domestic funding for WASH in HCF

Calls for the WHO Director General:

• Provide leadership, technical guidance and

regularly report on status

• Mobilize partners and investments

2019 World Health Assembly Resolution

Resolution 72.7 available at http://apps.who.int/gb/ebwha/pdf_files/WHA 72/A72_R7-en.pdf

39

40

Practical steps for improving and sustaining services:

A distillation of “what works” in 30+ countries

https://www.who.int/water_sanitation_health/publications/wash-in-health-care-facilities/en/ Empowering cleaners in Ethiopia. WASH FIT improvements, Indonesia

1.

Situational analysis: approach paper (coming soon)

2.

Roadmaps & targets: list of costing resources

3.

Standards: cheat sheet with terms, definitions & guidance for developing standards

4.

Improve & maintain infrastructure: checklist of major considerations for choosing infrastructure; WASH FIT guide

5.

Monitor & review data: list of useful resources for collecting, analyzing and/or applying WASH in HCF data

6.

Health workforce: aide memoire resource pack

7.

Community engagement: guide to stakeholder mapping; guide on how to involve communities in each of the practical steps

8.

Research: summary of existing evidence and research; expert group to provide technical support to those conducting operational research Visit www.washinhcf.org/resources and search “global meeting”

Resources to support practical (steps) action

Priorities for 2020

• Continue to advocate, elevate & integrate with

Health

• Develop and disseminate global tools and

resources, implement in country

• Global report on progress (status of services,

policies and investments)

• Investment case and costing tool
• WASH FIT updates
• Webinar series on practical actions
• Regional/global events and trainings
• Latin America, East Africa, South Asia
• World Health Assembly

42

LEARN: Visit www.washinhcf.org for practical tools, case studies, news and stories. CONNECT: Join the community @wash_for_health COMMIT: Support country commitments and/or encourage

• thers to commit at

www.washinhcf.org/commitments IMPROVE: Identify health entry points; work on one or more practical actions; implement & document.

Join the Revolution! Be a part of the solution.

1.

What are the first thing(s) you will do immediately to address the situation?

2.

In one, five and ten years from now, where do you want to be?

3.

What are the top challenges preventing you from getting there?

Questions

44

45

COVID-19 virus

• No evidence that the COVID-19 virus is found in drinking-

water or sewage

• Furthermore, no evidence that other surrogate, human

coronaviruses are present in surface or groundwater

• Enveloped virus, surrounded by weak lipid membrane
• Relatively fragile in the environment and will become

inactivated faster than non-enveloped human enteric viruses (e.g. adenoviruses, norovirus, rotavirus, hepatitis A)

• Few patients have diarrhoea (2-10%)
• COVID-19 virus RNA fragments have been detected in

reasonably high concentrations in stools of patients; however only one study has cultured COVID-19 virus from the stool of one patient

46

Survival of surrogate, human coronaviruses

Media Temp (OC) Time Removal Reference Dechlorinated tap water 20 2 days None surviving

Wang et al, J Virol Methods, 2005

Dechlorinated tap water 23 8-12 days 99.9%

Gundy et al Food Environ Virol, 2009

Hospital wastewater 20 2 days None surviving

Wang et al, J Virol Methods, 2005

Settled sewage 25 14 days 99.9%

Casanova, et al, Water Research, 2009

Wastewater 23 2-4 days 99.9 %

Gundy et al Food Environ Virol, 2009

Baby faeces 20 3 hours* None surviving

Lai, et al., Clinical Infectious Disease, 2005

Adult faeces 20 1 day None surviving

Lai, et al., Clinical Infectious Disease, 2005

Cotton gown 20 5 min- 24 hours** None surviving

Lai, et al., Clinical Infectious Disease, 2005

Various surfaces (review of 22 studies) Average 20 2 hours-9 days None surviving

Kampf, et al., Journal of Hospital Infection, 2020.

*Quicker die off attributed to lower pH in baby feces (pH 6-7). *Quicker die off when there is a lower initial concentration of the virus.

WASH in HCF

WHO/UNICEF 2018. Water and Sanitation for Health Facility Improvement Tool (WASH FIT). http://www.who.int/water_sanitation_health/publications/water-and-sanitation-for-health-facility-improvement- tool/en/ (currently being updated) WHO, 2008. Essential environmental health standards in health care. www.who.int/water_sanitation_health/publications/ehs_hc/en/. WHO, 2014. Safe management of wastes from health care activities. Second Edition. World Health Organization,

• Geneva. www.who.int/water_sanitation_health/publications/safe-management-of-wastes-from-healthcare-

activities/en/ WHO, 2017. Safe management of wastes from health care activities: a summary. World Health Organization,

• Geneva. www.who.int/water_sanitation_health/publications/safe-management-of-waste-summary/en/

WHO, 2019. Overview of treatment technologies for infectious and sharp waste from health care facilities. www.who.int/water_sanitation_health/publications/technologies-for-the-treatment-of-infectious-and-sharp- waste/en/ WHO (2016) Standards for improving quality of maternal and newborn care in health facilities http://www.who.int/maternal_child_adolescent/documents/improving-maternal-newborn-care-quality/en/# WHO (2016) Global guidelines on the prevention of surgical site infection http://www.who.int/gpsc/ssi- guidelines/en/ WHO Clean Care is Safer Care http://www.who.int/gpsc/5may/en/

48

WASH & COVID-19

Download the WASH and COVID 19 technical brief at: https://www.who.int/publications-detail/water-sanitation-hygiene-and-waste- management-for-covid-19

CDC, 2019. Best practices for environmental cleaning in health care facilities: in resource limited settings. US Centers for Disease

• Control. USA. https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-508.pdf

WHO, 2020. Infection prevention and control during health when novel coronavirus (nCoV) infection is suspected. https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection- is-suspected-20200125 WHO/WEDC, 2013. Technical notes on water, sanitation and hygiene in emergencies. World Health Organization, Geneva. http://www.who.int/water_sanitation_health/publications/technotes/en/ WHO, 2008. Essential environmental health standards in health care. World Health Organization, Geneva. http://www.who.int/water_sanitation_health/hygiene/settings/ehs_hc/en/ WHO, 2011. Guidelines for drinking-water quality, 4th edition. World Health Organization, Geneva. http://www.who.int/water_sanitation_health/publications/2011/dwq_chapters/en/index.html WHO, 2019. Results of Round II of WHO International Scheme to Evaluate Household Water Treatment Technologies. https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-508.pdf WHO, 2018. Guidelines on sanitation and health. World Health Organization, Geneva. https://www.who.int/water_sanitation_health/publications/guidelines-on-sanitation-and-health/en/ WHO, 2014. Safe management of wastes from health-care activities. World Health Organization, Geneva. http://www.who.int/water_sanitation_health/medicalwaste/wastemanag/en/ WHO, 2019. Overview of technologies for the treatment of infectious and sharp waste from health care facilities. https://www.who.int/water_sanitation_health/publications/technologies-for-the-treatment-of-infectious-and-sharp-waste/en/

Ensuring cleaner, safer health facilities: Improved quality and safety contributing to sustainable universal health coverage

Anjana Bhushan

Regional Advisor, Service Delivery Systems, Health Systems Development

50

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Quality and safety A core dimension of UHC in the SDGs:

– Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

Promotion Prevention Treatment Rehabilitation Palliation

People

Adequate qualit ity and safety reaffir irm…

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Why the attention to quality and safety - and why now?

 Poor quality care remains common, especially in LMIC countries. “Poor quality care is a bigger barrier to reducing mortality than insufficient access. 60% of deaths amenable to health care are due to poor quality care ” (Lancet Commission).  The most vulnerable populations are particularly affected.  Associated costs are high – billions of $.  Progress towards UHC will be constrained without improved quality in frontline services.  Requests for support from countries – who are already doing quite a lot.

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 Despite lower health-care use rates, LMICs bear the majority of the global burden of adverse events  Surgical site infections are markedly higher in LMICs than in HICs  Adverse events also occur to outpatients: medication errors, infections resulting from poor hand hygiene, unsafe injections, blood samples, or reusable equipment  LMICs’ estimated rates of medication-related adverse events similar to those of HICs, but result in twice the years of healthy life lost, because more younger patients are affected  Across 54 LMICs, 35% of facilities lack water and soap for handwashing and 19% lack improved sanitation  Low adherence to hand hygiene even in facilities with available supplies

How big is the problem?

Evidence from LMICs

54

|

• A. Adherence to

evidence-based guidelines and

• B. Diagnostic

accuracy

55

|

What is the size of the problem in SEAR? (data scarce)

• 1. Significant variation and gaps in basic amenities

Basic amenities in frontline facilities

56

|

What is the situation in SEAR?

• 2. Hypertension: low detection, lower control

Source: Calculations from different STEP or Equivalent population-based

• Surveys. India for selected 15 states.

*among people who were measured to be hypertensive at the time of the survey.

54.3 65.7 72.3 66.5 52.4 79.8 62.1 44.7 93.5 18.2 21.1 13.3 11.5 21.2 7.4 10.7 6.1 2.2 16.5 9.9 8 12.8 15.9 9.4 15.9 19.5 2.4 11 3.3 6.4 9.3 10.5 3.5 11.2 29.7 1.8 0% 20% 40% 60% 80% 100% Bangladesh (2018) Bhutan (2014) India (2017-18) Maldives (2011) Myanmar (2014) Nepal (2013) Sri Lanka (2015) Thailand (2014) Timor Leste (2014) Undiagnosed Diagnosed but untreated Treated but uncontrolled Treated and controlled

57

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What is the size of the problem in SEAR?

• 2. Low level of hypertension detection, lower control

Hypertension detection and control, selected countries

58

|

What is the situation in SEAR?

• 3. High % upper respiratory tract infections prescribed an antibiotic

Source: WHO SEARO country case studies, 2014–2015.

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What is the size of the problem in SEAR?

• 4. Cancer survival lower than rich countries (data v scarce)

Breast cancer 5-year net survival (%), adults 15-99 years, 2010-14

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Regional strategy for patient safety in the WHO South-East Asia Region (2016–2025)

1. Improve structural systems to support quality and efficiency of health care; place patient safety at the core at national, subnational and healthcare facility level 2. Assess nature and scale of adverse events in healthcare and establish system of reporting and learning 3. Ensure competent and capable workforce, aware and sensitive to patient safety 4. Prevent and control healthcare associated infections 5. Improve implementation of global campaigns; strengthen patient safety in all health programmes: safe surgery, safe childbirth, safe injections, medication safety, blood safety, medical device safety, and safe… transplantation 6. Strengthen capacity for, promote patient safety research

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Patient safety assessments

Key findings:  Most MS have:

– high level mechanisms – Indicators – national action plans for AMR, blood, lab and medication safety

 Weakest areas:

– adverse event monitoring – competent workforce – patient safety risk management

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 Political commitment to quality and safety as part of UHC increasing. Three key reports in 2018 provided new momentum and ideas.  Most SEAR Member States have policies, strategies or frameworks, some (MAV, INO, KRD) are developing them. Several have accreditation programmes.  Programmatic approaches in SEAR countries: 9 are implementing point of care continuous quality improvement approach in hospital labour rooms and newborn

• units. Most are implementing IPC and WASH in selected settings and scaling up,

including through IPC elements in national AMR action plans. National programmes

• n health-care associated infections: BAN, BHU, DPRK are establishing and MAV, NEP,

TLS are exploring.  All Member States are increasing training on patient safety and quality of care.  Most routine health information systems lack indicators on quality, safety.  More work is needed to establish a culture of safety, improve patient experience and involve patients as partners.

Current situation, response and challenges

(key points from 2019 two-yearly progress report to Regional Committee)

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Interventions to improve quality, by level: what are common? Lancet, 2018

64

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• 1. Ignite demand, create a sense of urgency for cleaner, safer

health facilities: awareness campaign targeting parliamentarians and the public, building on momentum for WASH and IPC.

• 2. Improve communication: develop a “fit for service” dashboard

to measure cleaner, safer health facilities, share with Member States as part of WHO’s annual UHC progress monitoring. Help policymakers use dashboard to drive acceleration.

• 3. Set targets, monitor progress: At Regional Committees, discuss

strategic directions to accelerate progress from 2020-2030; set a mid-decade acceleration target for annual monitoring.

• 4. Strengthen health worker capacity: prioritize CPD and in-service

training in IPC for nurses and cleaners; strengthen capacity of district level facility managers

Conclusions from informal expert consultation on improving quality and safety, March 2019

Basic WASH services at health facilities2

Fit-for-service dashboard

Cleaner safer health care facilities

Draft version 1.2a

Effective services

National guidelines exist Surgical care7 Child birth8 Injection9 Medical devices9 Medication Blood6 Regular electricity3

Clean facility Safe facility

41%

Vacancy rate

Essential medicines available3

Country X

Outpatient visits /person/year10

0.9

Water Sanitation Waste management Cleaning

16 12 7 10 32 30 13 56 59 70 11 11 20 40 60 80 100 National Non hospital National Non hospital National Non hospital National Non hospital

No service Limited service

4.3 % 34%

Doctors4 Nurses5

43%

Yes Partly No

54%

Healthy life expectancy at birth

Male 71.1 (65.4) Female 74.4 (64.1)

2.4%

83%

Yes

Infection prevention control focal point

Progress towards universal health coverage will be seriously constrained without improvement in the quality and safety of both frontline services and inpatient care. Adequate quality and safety, especially in frontline services, can improve the public’s trust in and increase the use of needed health services, reducing the pressure on secondary and tertiary care. However, poor quality care remains common and extracts a heavy toll in the South-East Asia Region. Some real basics -- water, electricity, and medicines -- are too often missing. It’s time to come back to the basics.

Facility utilization

National survey

?%

Healthcare associated infection rate11

60%

children prescribed antibiotics for common cold12

94

%

TB treatment success rate for new and relapse cases14

85

%

children with diarrhoea received ORS or equivalent advice13

11

%

hypertensive s are treated and controlled15

47

%

Antenatal care coverage (4 visits)13

Less is better

Small scale survey

More is better

66

|

Conclusions and way forward

 There is fresh attention to positioning primary health care as the cornerstone for accelerating progress on UHC  For this, some transitions are needed, including: re- examining ways to improve the quality and safety of frontline services, and links to secondary care.  Managing change in countries is both a technical and political challenge.

Thank you