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Estimating the Cost of Interventions to Improve Water, Sanitation and Hygiene in Healthcare Facilities Across India

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Estimating the Cost of Interventions to Improve Water, Sanitation and Hygiene in Healthcare Facilities Across India Original research BMJ Glob Health: first published as 10.1136/bmjgh-2020-003045 on 21 December 2020. Downloaded from Estimating the cost of interventions to improve water, sanitation and hygiene in healthcare facilities across India Katie K Tseng,1 Jyoti Joshi,1,2 Susmita Shrivastava,3 Eili Klein1,4,5 To cite: Tseng KK, Joshi J, ABSTRACT Key questions Shrivastava S, et al. Estimating Introduction Despite increasing utilisation of institutional the cost of interventions to healthcare in India, many healthcare facilities (HCFs) lack What is already known? improve water, sanitation and access to basic water, sanitation and hygiene (WASH) hygiene in healthcare facilities The burden of healthcare- associated infections services. WASH services protect patients by improving ► across India. BMJ Global Health (HAIs) worldwide is substantial but poses the great- infection prevention and control (IPC), which in turn can 2020;5:e003045. doi:10.1136/ est risk to patients in low/middle- income countries reduce the burden of healthcare- associated infections bmjgh-2020-003045 (LMICs), where common lapses in infection preven- (HAIs). However, data on the cost of implementing WASH tion and control (IPC), such as poor hand hygiene, interventions in Indian HCFs are limited. Handling editor Seye Abimbola can lead to the spread of HAI- causing pathogens. Methods We surveyed 32 HCFs across India, varying in Although adequate provision of water, sanitation and ► Additional material is size, type and setting to obtain the direct costs of providing ► hygiene (WASH) is crucial to the appropriate practice published online only. To view improved water supply, sanitation and IPC- supporting please visit the journal online of IPC, gaps in WASH infrastructure remain a signifi- infrastructure. We calculated the average costs of WASH (http:// dx. doi. org/ 10. 1136/ cant problem in healthcare facilities (HCFs) of LMICs, interventions and the number of HCFs nationwide requiring bmjgh- 2020- 003045). and knowledge of the cost to implement WASH inter- investments in WASH to estimate the financial cost of ventions in LMIC HCFs is lacking. improving WASH across India’s public healthcare system Received 1 June 2020 over 1 year. What are the new findings? Revised 19 November 2020 Results Improving WASH across India’s public healthcare ► Improving WASH coverage across the Indian public Accepted 21 November 2020 sector and sustaining services among upgraded facilities healthcare system over a 1- year period would re- for 1 year would cost US$354 million in capital costs quire an estimated US$354 million in capital costs and US$289 million in recurrent costs from the provider and US$289 million in recurrent costs. perspective. The most costly interventions were those ► The most costly intervention would be on water ser- on water (US$238 million), linen reprocessing (US$112 vice (US$238 million), followed by linen reprocessing million) and sanitation (US$104 million), while the least (US$112 million), sanitation (US$104 million), sur- http://gh.bmj.com/ costly were interventions on hand hygiene (US$52 face cleaning (US$80 million), medical device repro- million), medical device reprocessing (US$56 million) and cessing (US$56 million) and hand hygiene (US$52 environmental surface cleaning (US$80 million). Overall, © Author(s) (or their million). employer(s)) 2020. Re- use investments in rural HCFs would account for 64.4% of total ► Investments in primary health centres would ac- permitted under CC BY- NC. No costs, of which 52.3% would go towards primary health count for the majority (US$336 million) of total costs, commercial re- use. See rights centres. followed by district hospitals and medical colleges on September 27, 2021 by guest. Protected copyright. and permissions. Published by Conclusion Improving IPC in Indian public HCFs can (US$178 million), and community health centres BMJ. aid in the prevention of HAIs to reduce the spread of (US$129 million). 1Center for Disease Dynamics, antimicrobial resistance. Although WASH is a necessary Economics and Policy, Silver component of IPC, coverage remains low in HCFs in India. What do the new findings imply? Spring, Maryland, USA ► The need for greater WASH investments in primary 2 Using ex- post costs, our results estimate the investment Amity Intitute of Public Health, levels needed to improve WASH across the Indian public care facilities serving rural populations in India is an Amity University, Noida, Uttar healthcare system and provide a basis for policymakers opportunity to address inequities in public health- Pradesh, India care financing through improvements in WASH. 3Independent Consultant, New to support IPC- related National Action Plan activities for ► However, the immediate and long- term costs of Delhi, Delhi, India antimicrobial resistance through investments in WASH. 4Department of Emergency these interventions would be substantial and would Medicine, Johns Hopkins require a coordinated effort from all national and School of Medicine, Baltimore, subnational levels of government willing to provide Maryland, USA INTRODUCTION long-term political and financial commitments. 5Department of Epidemiology, Though essential to patient safety and universal ► Findings from this study can aid health policy Johns Hopkins Bloomberg health coverage, access to water, sanitation planners allocate resources for future financing of School of Public Health, and hygiene (WASH) in healthcare facilities WASH programs in HCFs and make informed de- Baltimore, Maryland, USA (HCFs) is poor in developing countries, espe- cisions that improve the efficiency of healthcare 1 delivery. Correspondence to cially in rural, public and primary healthcare. Katie K Tseng; tseng@ cddep. org WASH infrastructure provides the enabling Tseng KK, et al. BMJ Global Health 2020;5:e003045. doi:10.1136/bmjgh-2020-003045 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2020-003045 on 21 December 2020. Downloaded from environment for healthcare workers to practice infection The unit costs of improving WASH in HCFs are largely prevention and control (IPC), particularly basic practices, unknown in LMICs at a facility, system and country level. which require access to water, such as hand washing, medical While numerous cost studies in India exist for different device reprocessing and environmental surface cleaning. tiers of healthcare services, healthcare providers and Inadequate WASH services and subsequent gaps in IPC diseases,20–26 little to no literature exists on the cost of increase patient risk for healthcare-associated infections improving WASH services in Indian HCFs. Rather, the (HAIs) and contribute to the growing problem of antimicro- majority of WASH- related cost studies in the Indian bial resistance (AMR).1–5 Higher rates of HAIs can lead to context are specific to the community setting,27–30 and/or more frequent use of antibiotics and an overdependence on address only a component of WASH improvement.28 31 32 antibiotic prophylaxis, thereby accelerating AMR.6 Failures Knowledge of the unit costs for various WASH interven- in WASH and IPC can also reduce institutional care- seeking, tions is important for budgeting and decision- making lower patient confidence in the healthcare system, and and can help policymakers in resource- limited settings adversely impact individual and public health outcomes.7 8 strengthen health infrastructure for quality improve- With healthcare utilisation on the rise in low/middle-income ments in service and improve the efficiency of healthcare countries (LMICs), improving WASH services in HCFs is crit- service delivery. Therefore, the purpose of this study was ical to reducing the burden of HAIs and ensuring patient to estimate the financial cost of implementing WASH safety.9 10 services across the Indian public healthcare system to In India, more than one in four HCFs lack basic water inform allocation strategies of central and state govern- service (ie, a water source within 500 m of the facility).11 ments responsible for the organisation and delivery of Sanitation coverage is especially low with only 55% of healthcare services. facilities having access to improved sanitation compared with the global average of 79% across LMICs.12 Even in facilities where WASH infrastructure is available, the METHODS accessibility, quality and functionality of services are Study setting and aim often inadequate and/or inappropriate (eg, lack of The Indian public healthcare system is organised into potable water or safe water storage).13 Large discrepan- three principal levels of care: (1) PHCs, which are often cies in WASH exist throughout the country with poorer the first point of contact for many patients, (2) commu- WASH provision generally observed in rural as opposed nity health centres (CHCs), which act as referral units to urban areas.14–16 The need for water infrastructure and for five or six PHCs, and (3) subdistrict/district hospitals WASH- related IPC resources also depends on the scope (DHs) and tertiary care facilities (eg, medical colleges of services provided at different levels of the healthcare (MCs)), which provide specialised care to patients system.13 Compared with subcentres and primary health typically referred from primary or secondary health centres (PHCs), which deliver routine outpatient care centres.33 Though less regulated, the private sector is to patients, secondary care and tertiary care facilities as equally extensive and commonly overburdened, with provide both inpatient
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