Challenges and barriers to the formulation of infection control policy
There is a lack of evidence that HCAI is important in Mongolian hospitals
The majority of the participants claimed that, due to a lack of good statistics and evidence, infection control receives less attention and consequently gets few resources. The MoH officials and some hospitals administrators explained that “feeling that infection control is important is not enough to allocate limited resources”.
"“I haven’t seen any reports on the burden of HCAIs in Mongolian hospitals. I remember only one number −0.05% in the annual statistics book which is very low”[MoH]"
"“Generally, I feel that there is a mess..and something has to be done [in infection control]…but to make a decision we need evidence, statistics which we don’t have. …In recent years, the health budget has been increasing rapidly. Therefore, it is not that difficult to fund activities. Now, there is money, but it is limited and [we] only need to allocate [the budget] wisely, which means we must carefully choose the really important activities… To choose the right one we should look at evidence. We can’t always spend money based on our feeling that is important” [MoH]"
"“It is very difficult to allocate resources to activities without justification,…For example, since last year we have been spending money for disposable syringe boxes. And now after18 months, I don’t have any idea what effect is given by this money. Actually, it wasn’t a small amount of money. We spent money but there are no measured outcomes.”[Hospital director]."
The MoH lacks experts in modern infection control
Participants from the MoH and ICPs perceived that they have difficulty in updating guidelines and implementing surveillance and control measures due to a lack of technical knowledge in modern infection control. Key informants from the MoH and HRISRU explained that, in 2007 the MoH faced a problem of finding technical experts to update existing infection control guidelines. A doctor who recently completed a degree in infection control abroad was assigned to lead the working group, but the team was unable to fully amend the guidelines due to limited technical knowledge in some specific areas of infection control. Some issues such as developing laboratory-based surveillance and surveillance for antibiotic resistance were omitted. Participants from the SIA voiced the opinion that, since the transition to democracy, the MoH has been employing many non-specialized professionals in positions that require technical expertise and therefore many programmes are not implemented fully.
"“All our infection control people are graduates of the old Russian program. There is a shortage of manpower trained in modern or western infection control [HRISRU]."
"Last year [2007], we had difficulties to find a person who can lead the committee to update guideline. Luckily, we found someone who just completed [a degree] in infection control … …but the working group couldn’t finish all the chapters of the guideline” [MoH]."
Punitive attitudes are existing in infection control
Study participants perceived that many officials believe that “HCAI is a serious violation of quality of care that should result in the application of strict administrative measures” and, therefore, the HCAI rate was included in the targeted performance evaluation in 1997 and, since then, hospitals and professionals who reported HCAI cases have been penalised. Participants believe that this strict control and penalization as a response to reported cases has led to dishonest reporting of infection control data.
"“It is just rumour… people say that big hospitals don’t report their cases in order to avoid trouble. [ICP]."
"“According to the law, it’s our responsibility, and we do apply administrative sanctions.” [SIA]."
There is no focal point at the MoH
According to the participants, the MoH has no staff in-charge of HCAI control policy and, therefore, infection control issues (related to HIV, blood transfusion, sterilization of equipment, etc.) are solved independently in different ministry divisions. The HRISRU staff claimed that for infection control issues they have to “approach different ministerial people from different divisions”. Officials from the MoH explained that “If there is no internal person who brings issues to attention, then problems remain unsolved” and therefore infection control remains neglected.
"“At the MoH, infection control issues are solved in separate clinical divisions. Therefore, some divisional infection control plans are not well synchronized with other divisional plans. In the new MoH structure, I have suggested to create a new position which will be in-charge for coordinating infection control policy and plans at the national level” [MoH]."
"“As I am in charge of maternity health, I only coordinate infection prevention and control activities for newborns and their mothers” [MoH]."
The infection control committees at both national and hospital levels are not functioning well
Study respondents explained that the National Committee for the Prevention and Control of Hospital Acquired Infections that was formed at the MoH from various organizations and expert representatives has never held a meeting since its establishment in 1997. They claimed that this was because the committee was “too big” to meet regularly; the committee’s terms of reference were not clear, particularly in terms of when the meetings should be called and by whom; and the committee has no budget to sustain regular activity. Participants from the HRISRU explained that because the committee has not been active, the MoH has amended the composition of the committee twice in the last 11 years. Due to the last amendment [May 2008], the committee came to consist of only three people from one tertiary hospital where the HRISRU is based, with none from the MoH. According to the ICPs, the situation passed from one extreme (too big) to the other: “tiny and powerless”.
"“There is a committee at the MoH but I don’t know if they meet … [MoH]."
"“I don’t remember when the [national] committee held a meeting. Perhaps, not once since its establishment in 1997” [HRISRU]."
Hospital ICPs claimed that in many hospitals, the Hospital Infection Control Committee (HICC) “exists only on paper”. HICCs do not hold meetings as often as guidelines recommend because the committee members are not willing to participate. Some hospital managers acknowledged that, to overcome audit from the Inspection Agency, ICPs are sometimes advised to write false minutes to show that HICC meets regularly. This is a form of gaming.
"“When I call them for a meeting, everyone becomes busy and we couldn’t meet this year …occasionally, I write fake meeting minutes to show inspectors…”[ICP]"
"“I chair 13 to 14 committees at our hospital… I can’t attend all of them” [Hospital manager]"
The HRISRU staff claimed that they face difficulties in managing infection control programs at the national level because both MoH and hospitals are not supportive. According to them, many HRISRU suggestions sent to them were not absorbed or implemented. At the same time, they complained that none of the six HRISRU staff had completed any formal training in infection control and they experience challenges in their everyday work.
"“We have no support from both the “top” and surrounding people… 6 people share two computers… We don’t have a budget for travel, thus we can’t reach province hospitals…We don’t know what to do and how to do it. However, we do train others [HRISRU]."
"“These people [at the HRISRU] are graduates of the old Russian time. They need to learn modern infection control [MoH]"
The current health financing system doesn’t account for the financial burden of HCAIs
Many hospital managers highlighted the importance of building financial mechanisms in Mongolia to motivate infection prevention. They criticized the MoH and the Health Insurance Fund for not establishing structures and mechanisms that produce evidence on how much money is “wasted” on treatment of HCAI in Mongolian hospitals and claimed that they “don’t care because it is public money”. Respondents from Health Insurance Fund explained that because the current health insurance system has no access to hospital adverse event data, they can’t use any incentives to make hospitals motivated in reducing costs for HCAI.
"“It’s public money, who cares…? Hospitals don’t care how much they spend for antibiotics and doctors just bombard patients with antibiotics”[Hospital director]"
"“At the moment, our [Health Insurance] system cannot estimate the financial burden of HCAIs” [Health Insurance Fund]."
Challenges and barriers to the implementation of infection control policy
Resource allocation decisions are often made by non- medical professionals
Study participants claimed that MoH officials, mainly those who have a non-medical background, tend to cut resources planned for infection control activities. Participants claimed that the “situation is worse” in non-MoH hospitals [hospitals for defence, police and transport sectors are managed by their respective Ministries], where all decisions are made by non-medical ministerial officials.
"Last year, our [hospital] budget for syringe boxes was cut by the financial people at the Ministry of Health and later in the Ministry of Finance. I was blamed… for not meeting these people and explaining properly for what and why this money was planned [ICP]"
"“It is extremely difficult to convince people at the ‘top’ because they are non-medical” [Military hospital doctor]"
Hospital ICPs also explained that, at the hospital level, many infection control decisions are made by finance or human resource managers, or engineers and, thus, infection control receives a low priority.
"“Are you really going to throw this money to garbage?” asked our hospital financial officer about the budget proposal for syringe boxes” [ICP]"
ICPs are distracted by administrative tasks
Hospital ICPs explained that because the HICC has not functioned well and other colleagues are not cooperative, ICPs are alone in the hospital in their efforts to deal with all sorts of infection control issues. They complained that hospital administrators give ICPs a variety of tasks that are not fully related to infection control. This was supported by the managers of some hospitals that, with the intention of empowering ICPs, made them the head of their Infection Control Department, which includes units for cleaning and housekeeping, and sterilization and disinfection. This made ICPs more involved in administrative work rather than infection prevention and control.
"Most of my time I spend doing various administrative tasks plus dealing with waste disposal, cleaning, sterilization, sewage problems and even fighting against cockroaches and mice” [Hospital ICP]"
"“Managing a department of over 20 staff is a high workload…The intention was to give her [ICP] more power but I suspect that the current structure distracts her [ICP] from infection control tasks” [Hospital director]"
The laboratory system has limited capacity to support surveillance of HCAI
All group participants expressed concerns about the limited capacity of hospital laboratories. Laboratory physicians explained that due to outdated equipment and limited supply of consumables, anaerobic and viral cultures are not performed; bacteria are not identified to species level; some hospitals restrict the number of specimens that can be processed daily; and approximately half of hospital laboratory resources are spent on analysis of environmental swabs. Participants from district hospitals explained that none of six urban district hospitals of Ulaanbaatar have a microbiological laboratory.
"“Most of our lab equipment is from the 60s and 70s… often we face shortages of reagents and disks… we only do bacteriology tests …it is rare for anaerobic bacteria…we don’t identify bacteria to species level. There are no national standards for laboratory methods… we have a very high workload” [Tertiary hospital lab physician]"
"“We don’t have a bacteriology lab at all …like all other district hospitals we send specimens to tertiary or private hospital labs.” [District hospital ICP]"
Additionally, doctors participating in our study raised two concerns. First, because testing methods are not standardized across all hospitals, doctors commonly request that tests are repeated at their hospital adding more load to the laboratory. Secondly, some doctors, especially surgeons, prefer to prescribe antibiotics empirically because patients tend to be discharged around the time that antibiotic susceptibility test results are sent to the ward.
"“I can’t order bacteriology tests… because test results come on the day of the patient’s discharge or a day before, it’s just useless…” [Surgeon]"
Antibiotic usage is not well regulated
All group participants recognised that antibiotic usage is not well regulated in Mongolia. While MoH officials were concerned more about the quality of antibiotics and the sale of antibiotics by the pharmacy without a physician prescription, hospital managers and ICPs worried about poor implementation of antibiotic guidelines by doctors which resulted in overuse of antibiotics. Doctors disagreed with this statement by complaining that tertiary hospital laboratories are not capable of providing fast and reliable susceptibility testing, no metropolitan district hospitals have a bacteriology laboratory, and hospitals provide cheap, simple and often fake antibiotics. Therefore, when patients take strong antibiotics prior to admission to hospital, doctors have to require patients to bring stronger antibiotics from the community pharmacy which is contradictory to hospital antibiotic guidelines.
"“Every patient is treated with antibiotics, even children with viral diarrhoea… There are many fake drugs in the market…Doctors complain that some antibiotics have no effect, …and presumably that’s why our doctors tend to prescribe the strongest and most expensive one” [Hospital director]"
"“Patients take strong antibiotics prior to admission to hospital… and, at the hospital, they [patients] will need stronger antibiotics” [Doctor]"
"“Bacteria became more resistant… we need different antibiotics but the hospital supplies the same cheap antibiotics every year” [Doctor]"
Hand-hygiene compliance is low
All group participants perceived that hand-hygiene compliance among health professionals of Mongolia is low. While participants from province and district hospitals reasoned it is mainly due to unavailability of hot water and sinks and a poor supply of soap, participants from urban tertiary hospitals claimed that it is because of poor supply of alcohol based hand sanitizers, skin care products and high workload of health professionals. Although many doctors and nurses complained about skin dryness and irritation, hospitals managers and ICPs noted that skin care products are not supplied in any Mongolian hospitals. Hospital ICPs also wonder that, despite most hospitals conducting staff hand-hygiene training once or twice a year, hand-hygiene compliance remained poor. According to them to improve hand-hygiene training they need well-designed training materials, posters and reminders. Hand–hygiene compliance level is not monitored in any hospitals.
"“People know that they should wash their hands, but they don’t. It’s poor accountability…We are planning to install camera systems in hospital delivery rooms to monitor hand washing”[MoH]."
"“Everybody knows when and how to wash their hands but they don’t ”[Hospital manager]"
"“My skin often gets dry… and I buy hand cream..because the hospital doesn’t provide it” [Doctor]"
Poor disinfection and sterilization
Participants from the HRISRU explained that no one is in charge of disinfection and sterilization at the MoH and there are no sanitation experts in the HRISRU team. They are confused about whether or not they are responsible for disinfection and sterilization. According to them, standards and guidelines for disinfection and sterilization have not been updated and hospital equipment remains obsolete. Hospital managers were sceptical about the quality of the few medical disinfectants and antiseptics available in Mongolia and doctors were concerned about the way disinfectants were used. They explained that hospitals don’t monitor levels of active compounds in the disinfectants. Hospitals managers said that they face a severe shortage of staff in charge of disinfection and sterilization, because they have the lowest salary in the health sector, and at remote clinics they have to hire untrained personnel to operate autoclaves. Additionally, ICPs from HRISRU explained that they face challenges to control disinfection and sterilization in private hospitals, which use various equipment and liquids bought from local markets.
"“It [disinfection and sterilization]is the most unattended area of infection control. What we do is just replace a few autoclaves in hospitals and that is it. We need to do a lot in this area”[MoH]"
"“We are not sure who should manage this issue” [HRISRU staff]"
"“Our hospital has two BK-75 autoclaves [made in the 1970s in Russia]. They lose pressure, often break and we hardly ever find spare parts” [Hospital ICP]"
"“We use chloramines everywhere but nobody monitors whether these disinfectants are capable of killing pathogens” [Surgeon]."
Poor implementation of occupational health programmes
Based on some hospital studies, study participants claimed that there is high level of occupational exposures and infections among health professionals of Mongolia. However, they explained that, due to budget limitations, personal protective equipment (PPEs) such as masks, gowns and gloves are supplied with occasional interruptions and no vaccination and treatment is provided to health professionals. While MoH officials announced that, since March 2008, a new policy required hospitals to provide syringe boxes in all clinical areas to reduce sharps injuries and spill exposures, ICPs explained that its implementation has been delayed due to severe budget shortages and as a result many hospitals use handmade boxes that are not needle-stick and liquid-spill safe. According to the HRISRU, hospitals were advised to start occupational exposure registration in 2008 but data are not yet collected at national level.
"“…60-80% of our surgeons are diagnosed with hepatitis B and C virus infections… but there is no money for treatment…and vaccination” [Hospital director]"
"“Now, I have positive tests for chronic hepatitis B. I was young and healthy when I started my work here in this hospital 25 years ago…But I don’t know when I was actually infected with this hepatitis infection. Hospital annual health check-ups started recently [early 2000]”[Surgeon]"
"“As syringe boxes are expensive, our nurses make them from ordinary boxes” [ICP]"
Poor hospital infection control knowledge among health professionals
All study group participants acknowledged their poor knowledge of infection control. Infection control is not well taught at the undergraduate level. Hospital ICPs complained that the current 5-year university programme they have completed is designed for hygiene -inspectors and they had to learn hospital infection control “from scratch”. Doctors said that they “don’t remember” what they were taught on infection control during their undergraduate studies. Study participants suggested urgently updating the current Mongolian university and college curriculum. Recently, the Health Sciences University of Mongolia has established a 6-month post-graduate course for ICPs but due to a shortage of lecturers the course is managed by HRISRU staff.
Copies exist of only one infection control book in Mongolia which was translated by the HRISRU in 2002. Participants claimed that the internet is the main source of new information but access to the internet, a lack of subscriptions to infection control journals and language barriers limit the ability of health professionals to update their knowledge. Infection control does not seem to be a favourite subject for research in Mongolia. According to HRISRU staff, only three masters and one PhD student graduated in infection control in the last two decades. They explained that professional associations in infection control are not well established in Mongolia, mainly due to financial difficulties, and a lack of expertise and support from the government
"“At the medical university I trained to be a hygienist. Most of our classmates now work as hygiene inspectors. It was quite challenging for me to decide to work at the hospital. When I started work, I had to learn [IC] from scratch from our colleagues” [Hospital ICP]"
"“ I don’t remember what I was taught at Uni on infection control” [Doctor]"
"“It is common that ICP can’t answer questions from staff and I had to manage to not embarrass her [the ICP] in front of their colleagues…”[Hospital director]"
"“Those doctors and nurses who went for overseas training or those who have good English quite often bring me information about new modern hospital infection prevention methods… and disinfectants. Every time they explain something to me, I felt that was I supposed to be teaching them, not them teaching me.” [Hospital ICP]"