Infection control scores climb at 37 Tanzanian referral hospitals, study finds

Infection prevention and control performance improved significantly across Tanzania’s referral hospitals between 2021 and 2022, according to a retrospective mixed-methods study published in Discover Health Systems. The median adherence score across 37 facilities rose from 46 percent in 2021 to 64 percent in 2022, a difference the authors report as statistically significant using the Wilcoxon signed-rank test with a p-value below 0.001. Despite the gain, most hospitals still fell short of the national target of 80 percent or higher, and only 41 percent of facilities reached the 70 percent threshold used in the study to designate high performers.

Their secondary data analysis, completed in 2025, covered all 28 available regional referral hospitals, all 6 zonal referral hospitals, and 3 of the 6 national super-specialized hospitals, the latter limited because assessments were only funded for three of them. Two referral hospitals could not be assessed in 2021 owing to national resource constraints, although they were implementing IPC interventions like their peers. Facilities with completely missing performance scores across both years were excluded.

Assessments were carried out by teams of four to six nationally trained assessors using the National IPC Standards Tool for Hospitals, which is embedded in the Ministry of Health’s Digitalized Joint Afya Supportive Supervision System. The tool evaluates standards at each functional unit or service delivery point through direct observation, interviews with healthcare workers, and document review. Unit scores are calculated as the proportion of standards met, multiplied by 100, and facility scores aggregate these unit results. The national tool classifies scores of 0 to 59 percent as poor performance, 60 to 79 percent as moderate, and 80 to 100 percent as outstanding. Each assessment round was paired with mentorship of healthcare workers based on the gaps identified.

The quantitative results showed both progress and unevenness. Mentorship reached 1,850 healthcare workers in 2021 and 1,955 in 2022, yet the average number of workers mentored per facility actually declined, from 59.7 to 52.8, reflecting an unequal distribution of mentorship activity. Some zonal referral hospitals recorded substantial increases, with one facility mentoring 134 workers in 2022, while others stagnated, declined, or lacked data. The proportion of high-performing hospitals, defined in the study as scoring 70 percent or above, climbed from 6 percent in 2021 to 41 percent in 2022. By facility level, regional referral hospitals rose from 4 percent to 46 percent high performers and national super-specialized hospitals from none to 33 percent, while the percentage among zonal hospitals decreased.

To explain why some hospitals improved while others struggled, the researchers turned to the Consolidated Framework for Implementation Research, a widely used implementation science framework with five domains: intervention characteristics, the outer setting, the inner setting, characteristics of the individuals involved, and the implementation process. Qualitative data had been collected in 2022, shortly after the performance assessment, through key informant interviews with medical officers in charge, matrons or patrons, quality improvement focal persons, and IPC focal persons, along with two focus group discussions each involving 10 to 12 frontline healthcare workers drawn from different functional units across the 37 hospitals.

The qualitative analysis used deductive coding onto the framework’s established domains and constructs, supplemented by inductive coding to capture context-specific factors, with valence and intensity ratings determining whether each factor helped or hindered implementation. Twelve constructs emerged across the five domains. In the inner setting domain, the analysis identified vision and priorities for IPC, teamwork and communication, leadership engagement, and organizational learning. The outer setting contributed inter-facility networking and patient needs and resources. The intervention domain yielded existing IPC practices relative to the 2018 guidelines and the complexity or simplicity of compliance, while individual characteristics produced building support for change and knowledge and beliefs, and the process domain produced innovation-value fit and holistic engagement.

High-performing hospitals shared a distinctive culture. Their leaders allocated annual IPC budgets for training and supportive supervision, gave technical advice on adherence to standard practice, and publicly recognized well-performing units. Quality improvement teams at these facilities were described as knowledgeable, collaborative, and committed, running active training and coaching plans, distributing standard operating procedures, and supervising departments regularly. Teamwork was reinforced through peer mentorship in which staff visited high-performing units, IPC meetings, posters and reminders, and regular internal assessments whose results were shared facility-wide. These hospitals also prioritized patient needs, conducting surveillance for healthcare-associated infections such as surgical site infections, with one informant noting that such data helped plan IPC interventions around identified gaps.

Inter-facility exchange emerged as another hallmark of success. Staff at high-performing hospitals shared lessons and innovations through Zoom meetings where facilities presented milestones, through WhatsApp groups used by quality improvement teams, and through physical visits to high-performing hospitals to observe practices and return home to train colleagues. Ongoing on-the-job training, continuous medical education, regular meetings with work improvement teams composed of IPC champions from each functional unit, and engagement during supportive supervision all characterized the implementation process at successful sites. The availability of clear guidelines and standard operating procedures explaining how and when to perform activities was reported to simplify compliance.

Low-performing hospitals, by contrast, lacked defined IPC visions and priorities, a problem the authors link to frequent turnover in quality improvement and IPC leadership and the absence of succession plans, which left interventions uncoordinated and priorities poorly communicated. Some workers at these facilities were unaware of the newer guidelines, with one reported example being the common malpractice of applying disinfectants immediately to instruments and surfaces rather than following recommended processing steps. Barriers also included inadequate supervision by quality improvement teams, poor documentation and sharing of IPC activities, negative attitudes, beliefs that IPC was a project for a few cadres or a means of earning money, workload and staff shortages, and resistance from workers who regarded IPC as someone else’s responsibility. Inadequate infrastructure to support IPC practices was reported by all hospitals as a source of complexity.

The authors conclude that IPC implementation in Tanzanian referral hospitals improved over the study period but remains suboptimal, with only 41 percent of facilities achieving 70 percent or above in 2022 against the national target of 80 percent. They recommend that all healthcare facilities strengthen adherence to IPC guidelines, standards, and standard operating procedures to reach at least the 70 percent recognition threshold, cultivate continuous engagement of all cadres through on-the-job training, mentoring, supportive supervision, and exchange of best practices, and build collaborative, committed facility management teams and quality improvement teams from planning through implementation. Because the study is retrospective, relies on secondary data with some incompleteness, and uses a national assessment tool that limits comparison with other studies, the findings describe these 37 referral hospitals specifically. The authors note that the majority of facilities remain in the low-performing category, implying a continued need for investment at national, subnational, and facility levels.

Subject of Research: Changes in infection prevention and control implementation across 37 Tanzanian referral hospitals from 2021 to 2022, analyzed with the Consolidated Framework for Implementation Research.

Article Title: Improvement of infection prevention and control at 37 Tanzanian referral hospitals between 2021 and 2022 through the application of the consolidated framework for implementation research

Article References: Bahegwa, R. P., Hokororo, J. C., Msigwa, Y. S., Ngowi, R. R., German, C. J., Marandu, L. E., Nasoro, O. A., Kinyenje, E. S., Degeh, M. M., Machibya, M., Masuma, J. S., Lutkam, D. S., Mwaisengela, S., Abdulahi, M., Mohamed, H., & Eliakimu, E. S. (2026). Improvement of infection prevention and control at 37 Tanzanian referral hospitals between 2021 and 2022 through the application of the consolidated framework for implementation research. Discover Health Systems, 5(1), Article 79. https://doi.org/10.1007/s44250-026-00419-7

Image Credits: AI Generated

DOI: 10.1007/s44250-026-00419-7

Keywords: infection prevention and control, Tanzania, referral hospitals, healthcare-associated infections, implementation research, CFIR, mentorship, quality improvement, health systems, COVID-19, supportive supervision, low-resource settings