Sub-optimal infection control constitutes an important healthcare problem in Mongolia. This study identified a large number barriers and challenges that hinder effective infection control in Mongolia. Barriers to the formulation of infection control policy include: a lack of valid infection control statistics and experts; the absence of a focal point at the MoH; a poorly functioning national committee; and a lack of power and capacity of the national management unit. Barriers to the implementation of infection control policy and plans include: poor infection control education of health professionals; limited laboratory capacity; inappropriate use of antibiotics; low compliance with hand hygiene; poor disinfection and sterilization; and poor implementation of occupational health programmes. To better interpret these findings, reported barriers and challenges are grouped into the following groups. These are:
Barriers and challenges related to suboptimal knowledge and attitude of health professionals
A lack of expertise and knowledge on modern infection control is a common challenge in developing countries [6
]. In Mongolia, infection control is not well taught both at the under- and post-graduate levels of medical education. This may explain the following:
ICPs are not confident in developing plans, establishing surveillance, updating guidelines and leading other healthcare workers toward building modern infection control systems;
Healthcare workers are not well aware of the importance of infection control and they are not supportive of infection control initiatives;
The traditional approach of policy makers to infection control, which is characterised by the excessive penalization of reported HCAI cases, led to various types of gaming including excessive antibiotic prophylaxis .
Hospitals have limited access to internet and healthcare professionals lack updated clinical guidelines and books in the local language;
As clear policies and active support for training appear to be vital determinants of effective practice and successful change [21–23], Mongolia needs to develop infection control education policy together with organisational mechanisms for supporting continuous professional development. Meanwhile, the International Nosocomial Infection Control Consortium (INICC) collects data from 18 limited-resource countries and provides guidance in improving infection control measures at a local level . Similar initiatives are implemented in Europe [25, 26].
Barriers and challenges related to inadequate management
The review by Griffith et al. (2009) highlighted that positive proactive leadership, support and presence of senior leaders, team commitment, and clear boundaries of roles and responsibilities are prerequisites for effective action to control infections [27
]. Our study revealed the following:
Weak leadership at the policy level has resulted in failure to implement the national plan to establish surveillance for certain HCAIs;
National and hospital level infection control committees lack committed professionals and as a results these committees do not function well;
Infection control regulations, standards and guidelines lack clear descriptions of the roles and responsibilities of individual professionals, committees and organizations. Therefore, National committee members were not sure about when and how they should meet; HRISRU were not sure whether they are responsible for disinfection and sterilization; the MoH had no person in charge of infection control, and hospital ICPs are distracted by administrative tasks.
These findings clearly show that there is a considerable need for raising issues of commitment, accountability and ownership in Mongolia so that: ICPs are enabled to lead others working across various disciplines, units and management levels; clinicians clearly understand and fully implement their roles and responsibilities; and senior level managers enable and support infection control initiatives. To help ICPs overcome local barriers, the WHO “Clean Care is Safer Care” campaign that focuses on hand hygiene received pledges of commitment to make progress from over 120 ministries of health . Although this strategy is implemented on a voluntary basis, more countries are assigning up to membership of these initiatives, building new benchmarks and peer pressure for their lagging neighbours. In addition, increasing public awareness will have a significant impact on accelerating government plans for safety and quality in health care .
Similar to our findings, poor infrastructure, insufficient equipment, understaffing, paucity of knowledge, inappropriate use of antibiotics, and scarcity of local and national guidelines and policies were reported as common barriers to effective implementation of infection control in developing countries [7, 8]. In response, simple, low-cost, high-impact infection control strategies, such as hand-hygiene improvement programmes and simplified process surveillance have been suggested by several authors [20, 30, 31]. However, without necessary training of key personnel, administrative support and provision of necessary resources, it is impossible to implement these recommendations [32–34]. Therefore, actions with logistical, educational and management components that are specific to local circumstances need to be designed and implemented in Mongolia. It is worthwhile to seek support from international professional organizations such as INICC .
This study has the following two main limitations. Firstly, due to resource constraints, the data translation, transcription, coding and quotation selection processes were performed by a single researcher (B-E.I) rather than by two or more investigators. However, the constant iterative discussions within the research team regarding fieldwork experience and analysis maintained the validity of our findings. Secondly, the study examined issues from the participants’ perceptions and there is an obvious need to complement and extend the work presented with large scale quantitative and mixed-method investigations that can provide data and findings on a national scale and with statistical significance. More detailed research will be needed in each area of infection control, including hand hygiene, disinfection sterilization, occupational health, waste management, infection control education and ICP workload, to fully comprehend all of the issues related to their implementation. Moreover, it is important to fully understand interactions and interrelationships of the existing aforementioned contributory factors to poor infection control practice in Mongolia. Root cause or system analysis methods could provide a suitable framework for further research on infection control in Mongolia.