Discussion

This national assessment provides a comprehensive overview of the status of IPC implementation in Zambian public hospitals using the WHO IPCAF tool.

The overall mean IPCAF score of 558/800 indicates that Zambia has achieved considerable progress toward strengthening IPC systems in line with WHO recommendations. The findings demonstrate encouraging progress in establishing IPC structures across both secondary and tertiary hospitals, with most hospitals achieving intermediate to advanced levels of IPC implementation. Similarly, a previous study in Zambia also found that IPC implementation in some Zambian hospitals was at an intermediate level with an average IPCAF score of 594, slightly higher than the current finding. ^{Reference Mudenda, Chizimu and Ndegwa11} This finding aligns with similar assessments from other LMICs, where median IPCAF scores often fall within the intermediate range (401–600). ^{Reference Jingini30,Reference Asgedom31} The presence of established IPC committees, focal persons, and integration of IPC into quality improvement structures across most hospitals reflects successful national efforts led by the Ministry of Health (MoH) and the AMRCC. These achievements are attributable to recent initiatives, including the NAP on AMR (2017–2027), IPC training programs, and technical support from WHO and partners. Nevertheless, continued efforts are needed in LMICs, including Zambia, in order to achieve high IPC scores in secondary and tertiary hospitals as observed in some high-income countries. ^{Reference Rüther, Gropmann, Hansen, Behnke, Geffers and Aghdassi13,Reference Aghdassi, Hansen, Bischoff, Behnke and Gastmeier32}

In our study, the strongest performance across the IPC core components was seen in the areas of IPC programs, HAI surveillance, and IPC guidelines. This is consistent with earlier research from Zambia, which also reported that IPC programs achieved the highest scores among the eight core components. ^{Reference Mudenda, Chizimu and Ndegwa11} These results suggest that many hospitals in Zambia have well-established IPC programs aimed at preventing the development and spread of infections, including HAIs. The present study findings, to some extent, reflect those reported in other LMICs where most hospitals have established IPC programs, developed IPC guidelines, and conduct HAI surveillance, although with some variations. ^{Reference Jingini30,Reference Wood, Tembele and Hema33}

Our study showed that tertiary hospitals had more advanced IPC implementation than secondary hospitals, which generally achieved intermediate IPCAF scores. Tertiary hospitals also demonstrated stronger IPC programs and better implementation of IPC guidelines, likely reflecting greater availability of specialized personnel, infrastructure, and institutional resources. These findings are consistent with those of Kabego et al., who similarly reported higher IPC performance among tertiary healthcare facilities, with a median IPCAF score of 70%. ^{Reference Kabego, Balde and Barasa34} An intermediate IPCAF classification indicates that most IPC core components are in place but require further strengthening to achieve full compliance. These findings underscore the need for sustained investment in workforce development, surveillance systems, infrastructure, and continuous quality improvement, particularly in secondary hospitals, to reduce disparities in IPC implementation and improve healthcare quality.

Another prominent finding in the present study was the significant disparity in IPC implementation between tertiary (mean IPCAF score 622) and secondary (mean IPCAF score 507) hospitals reflect ongoing health system inequities and technical capacity, as tertiary hospitals have more specialized human resources, better infrastructure investments, and greater access to partner support, whereas secondary hospitals, which often serve large rural populations, face shortages of trained IPC personnel, erratic supply of essential materials, and infrastructural limitations. Secondary-level hospitals, particularly those in remote districts, reported shortages of dedicated isolation spaces, limited laboratory capacity, and frequent stockouts of essential supplies, including disinfectants and personal protective equipment (PPE). This imbalance in capacity across hospitals is consistent with findings from Malawi and Rwanda, where tertiary or central hospitals tend to have higher IPC performance than secondary or peripheral hospitals. ^{Reference Irakiza, Mazimpaka and Ndatimana20,Reference Jingini30} Furthermore, this demonstrates that IPC resources must be decentralized to support all the appropriate lower levels of care in each context. ^{Reference Borodova, Diallo and Songbono16,Reference Storr, Twyman and Zingg35,Reference Leong, Picton, Wratten, Mahe and Zimmerman36} These findings underscore the need for a tiered national IPC strengthening strategy that prioritizes lower-level hospitals through equitable resource distribution, targeted supervision, and integration of IPC indicators into performance monitoring frameworks. Therefore, deliberate policy efforts should be implemented to ensure that secondary hospitals receive equitable investments in IPC in order for all patients to benefit from standardized IPC prevention measures.

Our study found that the surveillance of HAIs and AMR remains another major gap. Although most hospitals reported collecting infection-related data, few conducted systematic HAI surveillance or analyzed antimicrobial susceptibility trends. Similarly, although most hospitals had established HAI surveillance programs and dedicated surveillance personnel, important gaps remained. Only half of the hospitals prioritized HAIs for surveillance, surveillance of device-associated infections was limited (16.7%), regular AMR data analysis was conducted by only 55.6% of hospitals, and surveillance feedback to non-clinical management was inconsistent. These findings indicate that HAI surveillance systems are established but remain inconsistently implemented, highlighting the need to strengthen surveillance coverage, AMR data utilization, and feedback mechanisms to support evidence-based IPC improvement. This limitation hampers early outbreak detection and evidence-based decision-making. Similar challenges have been observed in other LMICs, where weak surveillance systems and limited microbiology capacity constrain the detection and reporting of HAIs. ^{Reference Matee, Mshana and Mtebe37,Reference Yamba, Chizimu and Mudenda38} Consequently, countries can strengthen their HAI surveillance by implementing the protocols as guided by the WHO. ³⁹ Strengthening laboratory infrastructure, enhancing data management systems, and linking facility-level surveillance with the national AMR surveillance network would be critical to improving infection monitoring and control in Zambia.

Despite the abovementioned progress, the study revealed persistent weaknesses in several core components. Notably, IPC education and training, multimodal strategies, and workload, staffing, and bed occupancy were the lowest-performing areas. The absence of structured, routine IPC training for all healthcare workers undermines the sustainability of infection prevention practices, particularly in hospitals with high staff turnover. These gaps are consistent with findings from studies conducted in Burkina Faso and the DRC, where irregular training and limited mentorship were cited as major barriers to IPC compliance. ^{Reference Wood, Tembele and Hema33} To address this, Zambia’s IPC programs need to institutionalize regular capacity-building using the national IPC and AMS curriculum, supported by periodic refresher sessions and practical mentorship.

Infrastructure-related barriers also contribute to inconsistent IPC performance. Inadequate isolation hospitals, overcrowded wards, and unreliable water, sanitation, and hygiene (WASH) systems were common across several hospitals. Such challenges not only increase the risk of HAI transmission but also undermine compliance with hand hygiene and environmental cleaning protocols. Investment in facility infrastructure, WASH improvements, and supply chain resilience must therefore be prioritized to sustain IPC progress and ensure safe healthcare environments. The present study also revealed weaknesses in monitoring, audit, and feedback mechanisms, with limited documentation and the absence of standardized audit tools. Continuous monitoring and feedback are essential for sustaining IPC improvements, as demonstrated in countries where routine auditing led to measurable reductions in HAIs. ^{Reference Allegranzi, Kilpatrick, Storr, Kelley, Park and Donaldson40} Introducing national IPC audit tools and integrating them into existing hospital quality assurance systems could enhance accountability and promote a culture of continuous improvement.

We are aware of the limitations of this study. Its cross-sectional design provides only a snapshot of IPC implementation and cannot establish causality or assess changes over time. Although the WHO IPCAF is a validated assessment tool, it relies partly on self-reported information, which may be subject to reporting bias despite document verification. In addition, the study included only selected public hospitals with established IPC committees, limiting the generalisability of the findings to private and lower-level healthcare facilities. Future longitudinal studies incorporating direct observations and healthcare-associated infection surveillance are needed to evaluate the effectiveness and sustainability of IPC programs.

Overall, IPC structures are in place but require strengthened coordination, regular training, and sustainable resource support for effective implementation (Table 3). Collectively, these findings have important implications for national policy and practice. Zambia’s current progress toward advanced IPC implementation demonstrates a strong foundation upon which to build a resilient, evidence-based IPC program. To accelerate progress, the MoH and partners should strengthen training systems, expand surveillance coverage, improve infrastructure, and ensure a consistent supply of IPC commodities. Moreover, IPC should remain central to the broader One Health approach to AMR, complementing initiatives in AMS, water and sanitation, and infection surveillance.

Table 3.

Strengths and weaknesses of IPC implementation in selected hospitals in Zambia

Table 3. Long description

A table with nine rows and three columns comparing strengths and weaknesses of IPC implementation in hospitals. The columns are labeled Aspect, Strengths, and Weaknesses. The aspects include IPC program and governance, training and capacity building, guidelines and policies, surveillance of HAIs and AMR, multimodal strategies, infrastructure and resources, supplies and equipment, monitoring, audit, and feedback, and staffing and resource allocation. Each row details specific strengths and weaknesses for each aspect.

Note: IPC, Infection Prevention and Control; HAI, healthcare-associated infections.