MOMENTUM Presents

Innovating in a Pandemic: Improving water, sanitation, and hygiene services and infection prevention control in health facilities

• USAID MOMENTUM

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Dr. Surendra Sharma, MOMENTUM Country and Global Leadership’s State Team Leader in India,  shares how he and his team worked with public and private health providers to safely deliver care across eight districts and three states in India during the COVID-19 pandemic. Listen to this episode for more details about innovative approaches to improving water, sanitation, and hygiene and infection prevention and control during the COVID-19 pandemic. 

Narrator:

MOMENTUM Presents: bringing in-depth experience in improving maternal, newborn, and child health services, family planning, and reproductive health care in countries around the world; providing technical and capacity development assistance to country leaders and governments; and ensuring that mothers and babies have access to essential care in order to reach their full potential. We are MOMENTUM Country and Global Leadership, funded by the U.S. Agency for International Development, and we welcome you to MOMENTUM Presents. This is the exclusive podcast series highlighting strategies for maintaining essential maternal newborn and child health services, family planning, and reproductive health care in the face of the COVID-19 pandemic. We are discussing challenges and sharing solutions with country leaders around the world and keeping the momentum going in responding to the global pandemic. Welcome to MOMENTUM Presents Episode One: Innovating in a Pandemic.

Julia Bluestone:

Good afternoon and welcome to MOMENTUM Presents. My name is Julia Bluestone and I'm the Senior Capacity Building Advisor for MOMENTUM Country and Global Leadership. In this episode, we're going to chat with Dr. Surendra Sharma, who's the state team leader for Jhpiego and MOMENTUM Country and Global Leadership in India. Dr. Sharma will be highlighting India's pandemic experience and sharing how their team's been using technology to improve water, sanitation, and hygiene services and infection prevention control in health facilities. Good afternoon, Dr. Sharma and welcome to MOMENTUM Presents.

Dr. Surendra Sharma:

Good afternoon, Julia. And thank you very much for inviting me for this first episode of MOMENTUM Presents. It's indeed an honor to represent my team who is working in the field to ensure that our health workforce stay healthy and they are protected from the onslaught of the pandemic. Really excited to be part of this. Thank you.

Julia Bluestone:

Yeah, thanks so much. I really appreciate the fact that you're connecting in from home and, you know, over the last few months I've been so impressed watching how your team has adapted and pivoted and brought in new innovations to support your work. So, yeah. Thank you so much for joining. So let's jump right in. So Dr. Sharma, you know, you've been working in public health a long time. You've worked on immunization, disease surveillance, project and research management, as well as family planning. And based on what you've seen, tell us why is water, sanitation, and hygiene services, and infection prevention control measures, why are they so important to ensure mothers and children receive the care they need during this pandemic?

Dr. Surendra Sharma:

Great question, Julia. When I look back into my journey of 15 years across different sectors that you just mentioned, one common thing that I have observed, which denies us health seekers from their services, is fear. It's the fear of unknown. When I say fear, when I was working in the field of polio immunization, the fear of well, what will happen to my kid when they receive the vaccine? When I was working in the field of disease surveillance, they were afraid if they report a disease, what will be the perception among the people in their community? How will they respond? When we j umped right into the pandemic, the f ear was threefold here. The fear was among the healthcare providers. F ear was among the healthcare seekers and fear was among h ealthcare facilitators. The providers were afraid that if they go to the facility where e verybody i s coming to s eek care, they are bringing it with them, the COVID-19. The fear was among the mothers. If they go to the facility, then they may c atch the disease without actually knowing it. If they come for examinations, antenatal checkups checkups, they might catch it. T hey're going to immunize their kids, they can catch t he infection. Similarly, when we look at the facilitators, like the frontline workers, what we call"Asha" in India, they were afraid how to connect the dots, provide us with the healthcare seekers. They were afraid for their own safety. So that is one common theme that I h ave been observing over the last 15 years. If we can somehow address that fear, then everything falls in place. So yeah, that is one thing that has been common even before the p andemic and even beyond the pandemic.

Julia Bluestone:

Yeah. And thanks for raising that. And you know, I'd like to follow on the theme of fear. You know, you mentioned health workers, families, as well as patients. And, you know, the World Health Organization has designated 2021 as the International Year of Health and Care Workers, you know, recognizing the dedication and sacrifice of millions of health and care workers at the forefront of the COVID-19 pandemic. So you've talked a lot about fear. Tell us a little bit, how has your team been working to address the fears, specifically of healthcare providers, and make sure that they're protected from the spread of the virus?

Dr. Surendra Sharma:

Uh, when we began our operation in August last year, uh, that was a time when COVID was peaking in our country. When we initially contacted them that,"yes, we are coming in with this approach" wherein we will be supporting them to respond to acute shortages of infection control measures, and some of the issues related to the WASH services there. And they are, they were afraid that we are seeing so many patients right now, if you come to that, how will we provide our services to them, then? Now this was an added fear that they don't have time. They are responding to the acute emergency right now. And if we go there, we might deviate them from the active services that they are delivering right now. And this was a way we use our virtual media. I think that was one of the first brush of us. And we tried to mitigate that challenge.

Julia Bluestone:

Yeah. Thanks, Dr. Sharma, I think it's a great illustration of how you're meeting health workers, where they are and directly addressing their concerns. And again, if you're joining us now, my name is Julia Bluestone and you're listening to MOMENTUM Presents, the exclusive podcast series highlighting strategies for maintaining essential maternal, newborn, and child health services, family planning, and reproductive health care in the face of the COVID-19 pandemic. In this episode, we're highlighting the pandemic experience in India and talking about leveraging technology to improve water, sanitation, and hygiene services and infection prevention control with State Team Leader, Dr. Surendra Sharma from MOMENTUM Country and Global Leadership and Jhpiego. So Dr. Sharma, I want to pick up on your thread, you know, you've addressed the health provider concerns, and I understand once you started working with the facilities that they decided they wanted additional infection prevention control training. So please tell us a little bit more like, how did you make this happen?

Dr. Surendra Sharma:

When we initially did our orientation, and then we worked with the facilities who identified the gaps, using tools that we derive from national and global resources. And once we could report on the gap, one of the things that you just mentioned was the need of training. It was common in forced lockdown. We could not move freely. They could not move freely. They cannot leave their facilities. So it was a Catch 22 situation wherein if we ask them to come out of their facilities for training, it will impact the discharge of their clinical services. And if we don't provide the training, the services are not going to improve. So what we did is went back to the drawing board. And I'm proud of my team who really worked hard to find out a judicious mix of how to deliver this training virtually. We've developed six capsules of training package, uh, which were to be delivered over six days. And each capsule was around one and a half hour, like 60 to 90 minutes long. And we kept a provision of, uh, two hours for each of the sessions so as to allow for frequent question and answer and explanation during the course of delivery. After that, we did a dry run with some of the facilities and could finally formulate the final program. With the blessing of state government and the support of district teams, we could finalize a program. And this was falling directly during our[inaudible] break. And, uh, uh, thankfully with the help of the facility providers and administrator, we could provide those trainings using Zoom platform. Now again, when we are doing this training, another new problem popped up and that was access to smartphones. Not everybody owns a smartphone in the facility, especially those like cleaning workers. They do not own and operate from a smartphone. They use a basic, uh, talk and text phone, like a keypad phone. Now it was again, a challenge. And we spoke to the facility in charge and ask them to arrange a kind of a monitor, a screen or a projector, which they can plug with their devices and ask everybody who does not own a smartphone to come to that particular room and attend sessions with proper precaution, safety masks, and physical distancing. And if they had any question, one person was manning the keyboard wherein they can chat their questions or raise a hand to ask the questions on their behalf. So yeah, we could reach more than 300 logins in those six days of training. And everybody really appreciated the efforts that were made to ensure that everybody was training. So after those training, and even during those training, we formed the some WhatsApp groups for each of the districts wherein we had participants from all the cadres. And if they had any question, or any clarification was required from the topics that were covered in those trainings, they could ask in those groups and somebody from our side could respond. That's really helped us to gain a real 180 degree of[inaudible] conversation with them even beyond the official training time.

Julia Bluestone:

Yeah. Thanks Dr. Sharma, that's a wonderful example. And I know, you know, that many countries are switching and transitioning to using Zoom, and I love that you're using WhatsApp for ongoing performance support. That's so important. You talked about, you know, the fear, um, from health workers and how you helped people voice those fears and ask the questions. You know, we know how important personal protective equipment is for healthcare providers. And can you talk a little bit about how your team has applied innovation to expand access to personal protective equipment for health workers?

Dr. Surendra Sharma:

Sure, why not? So, the personal protective equipment, while they are necessary and are a must when we are dealing with the pandemic, like COVID-19, uh, when we started in August or even right now, when we are sitting in March and seeing the resurgence of cases in our community, uh, we, we had a twofold problem. Number one, uh, the PPEs were not coming in enough quantity. And number two, even if there were enough quantity, the logistics were not streamlined in a way that it could reach each and everybody who needs them. Now to answer, uh, what the, uh, issues, what we did. We said, uh, with the facility in charges, we kind of quantified their demands on the week and monthly basis and try to find out what was the most commonly missing factor. And I mean, we found that, uh, the PPEs were missing mainly for the cleaning staff. Um, this was included, uh, gumboots, long gloves, facial face mask. And oftentimes we found that the color coded aligners were not available in supplies. Then we, what we did, we sat them and we quantified the demand for a month and using our project money, we procured this, uh, supplies for a month and delivered to them and also showed that, yes, it can be done using a very minimal amount. Like in, in this case for each of the facilities, we had hardly more than 10,000 rupees, which is roughly$180 for one month supply for cleaning staff. And when we, uh, justify saying that if one of the cleaning staff gets contaminated or acquires one of the infections, then your entire chain gets broken. And, uh, that unfortunately, cost is really higher than what you're spending on the PPEs. So that was one part. The second part was when we are thinking of N95 mask, which was really essential to keep our health workforce healthy, that was really in short supply because costly equipment compared to other pieces. Uh, and, uh, uh, to answer and mitigate those challenge, we joined hands with one of the tech startup, just housed in Institute of Technology, Delhi, Chakra Innovation. And what they have is they have a machine with liquid ozone, uh, that effectively, uh, decontaminates used N95 masks and makes them as good as new and reusable. We can process N95 masks up to 10 times, and they are as good as new after the processing. So we asked with the state officials and identified two facilities, one in each of the initial states, Manipur and Chhattisgarh. And there, we tried to install this machine.

Julia Bluestone:

Great, thanks. I know you've been working hard and it's wonderful that you're moving forward with helping India look at PPE and specifically N95 mask reuse and sterilization. We'll be really interested to see the outcomes from that. Tell us, you know, how else did your team innovate to improve water, sanitation, and hygiene services within facilities? You know, what other ideas and innovations did you bring?

Dr. Surendra Sharma:

One important part that we often noticed was the routine maintenance of water services was something that was really missing. And this did not cost a lot of money. Uh, something, uh, as small as elbow tap, if that is missing, then the entire process of proper handwashing is defeated. So we worked with the facilities to find out those small gaps. We, uh, kind of, uh, ask the unskilled or senior skilled laborers who are in the same vicinity work with them to identify and quote the prices of repair. We've worked with our team internally who ensure those resources are available. We often found that in the remote facility, a simple solution like an elbow tap was not available. So we, uh, worked with our team who ensure those simple supplies can be procured from a district level place and sent to those facilities to ensure it gets done. So that was one piece. I can say, uh, this minor repair for one piece. The second piece was major repairs, like a facility requires a new toilet. Talking about innovation. Uh, we are now joining Hanford, another tech startup, uh, which is using, uh, imaging analytics to identify what is a good handwash. This is interesting, very interesting case. Uh, the company is Data Cult, which is housed in the Silicon Valley of India, Bangalore. And, uh, their machine user patented idea wherein they, uh, set up a tub or wash basin and look at the hand movement during handwash. And if the hand wash, uh, go through all the nine steps that is recommended and has a duration of say 20 seconds or more, there is labeled as a right hand wash. Otherwise they will flag all the missing steps and report out to the provider who is there and the WASH person immediately, and also create a dashboard, kind of analytics for the facility, for the internal discussion and action taken. So, yeah, we are working with this other technology piece, which might be a game changer in coming days.

Julia Bluestone:

Wow. I think your team has done a beautiful job at really increasing and addressing local commitment. In addition to the innovations you guys are doing, which is really exciting, like using AI instead of, you know, human observers to make sure handwashing is done correctly, know, we're really interested to see, you know, the great work that comes out of this. Um, I'd like to just, if you could speak briefly, you know, a lot of us are using Zoom and WhatsApp now to support, you know, capacity building. And if you could speak briefly, like, what are maybe one or two of the most important challenges, you know, when it, when it comes to reaching health facilities virtually?

Dr. Surendra Sharma:

The most important part of reaching anybody virtually is whether they have access to the logistics. They have the machine, a smartphone with a dependable network availability. That is one part. And second is group management. When you are talking with many people, uh, at the same time who are, uh, with a heterogeneous group, then oftentimes you'll find some people will talk a lot and will not allow others to speak and vice versa. So what happens, um, those people who really need the support might get left out. And there you need to find a way to complement beyond Zoom. And I think that's where we, when we use WhatsApp, we could hear even those people who were not active in the actual virtual training, they could ask questions and we couldrespond adequately with them. At the same time, uh, while virtual mediums are great, they can supplement in-person training. They cannot replace completely. We are on the journey to, uh, you know, find the perfect mix of a virtual training platform. But these challenges will be there when we look forward.

Julia Bluestone:

Great, thanks so much for addressing that. And I agree a hundred percent with, um, how important it is to blend and combine virtual with in-person. So I'd like to move us along now and, and, you know, think broader, uh, in what's happening in India. You know, the, um, global, What Women Want campaign, which was led by the White Ribbon Alliance. Um, I'm sure you've heard of it. They surveyed like over a million women across 114 countries to say,"what do you want for maternal reproductive health care?" And, you know, the second, you know, most reported demand was improved water, sanitation, hygiene services. They want clean facilities, they want clean toilets. They want healthcare providers using sterile supplies and they want access to soap and water. It is a basic needs, you know, beyond what you've described, you know, what else is happening, you know, in India to make sure that these demands are met, especially during COVID?

Dr. Surendra Sharma:

Thank you, Julia. I think this is very pertinent to what we are doing and why we exist. We exist to ensure that every woman gets what they need, what they desire when they are coming to the facility and having a proper toilet, having a place where I would like to take my wife for delivery, is what we aim for. I think in our program, what we have been trying to ensure is, I will not name the facility, but one of the facility in charge doing this, and when I spoke about it and said, sir, we don't have a latch, a latch on the bathroom doors, and the doors are broken. Using our funds we replaced those doors immediately, and now any woman who is in the facility and using those toilets will definitely feel more protected and more respected when they use those clerical services. I think there are baby steps we have not yet applied where I can say the job is done, but yes, the journey has begun.

Julia Bluestone:

Great. Thanks so much, Dr. Sharma for that response. Um, so I, I wanna again, thinking bigger picture, sustainability is key for MOMENTUM Country and Global Leadership. You know, what are your thoughts of how this work to improve water, sanitation, hygiene and infection prevention control?

Dr. Surendra Sharma:

So, yes, sustainability is a cornerstone of our program. We kept it as one of our program deliverable and objectives. And in my opinion, the most crucial piece is to ensure ownership. If the facility staff and the government system own a program and a policy level change can be done to incorporate this activity, I think that will ensure sustainability. The second part is ownership by the facilities themselves or the providers who we are working with. They understand that it is critical to ensure this proper handwashing, IPC practices, and WASH services. I think the program will continue and sustain even beyond the lifetime of project.

Julia Bluestone:

Thank you so much, Dr. Sharma, you know that it's wonderful to hear all the incredible work your team has been doing. Thanks for joining us from your home on MOMENTUM Presents and sharing such rich information on how India has been innovating in a pandemic to leverage technology and innovations and improve water, sanitation, and hygiene and infection prevention control. And it's been incredible. The things that you guys have done so quickly. So as we close, what advice do you have for others who might be interested in doing something similar?

Dr. Surendra Sharma:

All right. Uh, I would like to have a five pointer for anybody who wants to do something similar. The first point is do a proper landscaping. Understand where you are, what are your immediate challenges, what kind of resources you have, and then plan. Plan small, but dream big. The second is ensure a network is built around what you're trying to do, a network wherein you have all the stakeholders on a common pace where they understand why it is being done and what will be done and what kind of timeframe you have. The third is involve everybody. By everybody, I mean, everybody. Like in our program, I have mentioned, we have often found that the most important and most often ignored parties, the weakest link, and that is the cleaning staff. And if they are not part of the solution, I'm sorry to say the the solution will not work. Fourth will be innovate, innovate, and innovate. There's no other option when we think of public health. Often we have found that we are reinventing the wheel. Don't reinvent, learn from what has been done in the place at the same time, innovate what you are doing. It may be a process innovation. It may be a productive innovation. It may be asking others, join with people who have already been doing amazing work. But when we said landscaping, that is also part of it. What other people are doing, what other advice they can provide, what other solutions they can bring on table and be ready to engage with them. And lastly, when I say build for sustainability, if you have not built a solution that is going to sustain beyond your intervention, I think you're planning to fail. I would like to quote Benjamin Franklin here. If you fail to plan, you're planning to fail. I think that's all. Thank you.

Julia Bluestone:

Well, thank you so much, Dr. Sharma, you know, it's, it's been incredible to hear about all the work you've been doing.

Dr. Surendra Sharma:

Thank you so much Julia, and thank you for inviting us and present our work with larger audience in this podcast. Thank you so much. Have a good day.

Julia Bluestone:

Absolutely. An honor to have your time. My name is Julia Bluestone and thank you for listening to this episode of MOMENTUM Presents with Dr. Surendra Sharma from MOMENTUM Country and Global Leadership.

Narrator:

This concludes this edition of MOMENTUM Presents. For more information about our work, please visit www.usaidmomentum.org, and follow us on Twitter@USAID_MOMENTUM for additional resources.