The ongoing decline in under-5 mortality ranks among the most significant public and population health successes of the past 30 years. Deaths of children under the age of 5 years have fallen from nearly 13 million per year in 1990 to less than 6 million per year in 2015, even as the world's under-5 population grew by nearly 100 million children. However, the amount of variability underlying this broad global progress is substantial. On a regional level, east Asia and the Pacific have surpassed the Millennium Development Goal target of a two-thirds reduction in under-5 mortality rate between 1990 and 2015, whereas sub-Saharan Africa has had only a 24% decline over the same period. Large differences in progress are also evident within sub-Saharan Africa, where mortality rates have declined by more than 70% from 1990 to 2015 in some countries and increased in others; in 2015, the mortality rate in some countries was more than three times that in others.

What explains this remarkable variation in progress against under-5 mortality? Answering this question requires understanding of where the main sources of variation in mortality lie. One view that is implicit in the way that mortality rates are tracked and targeted is that national policies and conditions drive first-order changes in under-5 mortality. This country-level focus is justified by research that emphasises the role of institutional factors in explaining variation in mortality—factors such as universal health coverage, women's education, and the effectiveness of national health systems. It is argued that these factors, which vary measurably at the country level, fundamentally shape the ability of individuals and communities to affect more proximate causes of child death such as malaria and diarrhoeal disease.

An alternate view has focused on exploring the importance of subnational variation in the distribution of disease. In the USA, studies on the geographical distribution of health care and mortality have been influential for targeting of resources and policy design. Similar studies in developing regions have shown the substantial variability in the distribution and changes of important health outcomes such HIV, malaria, and schistosomiasis—information that can then be used to improve the targeting of interventions. Nevertheless, the relative contribution of within-country and between-country differences in explaining under-5 mortality remains unknown. Improved understanding of the relative contribution of national and sub-national factors could provide insight into the drivers of mortality levels and declines in mortality, as well as improve the targeting of interventions to the areas where they are most needed.

The number of people served by networked systems that supply intermittent and contaminated drinking water is increasing. In these settings, centralized water treatment is ineffective, while household-level water treatment technologies have not been brought to scale. This study compares a novel low-cost technology designed to passively (automatically) dispense chlorine at shared handpumps with a household-level intervention providing water disinfection tablets (Aquatab), safe water storage containers, and behavior promotion. Twenty compounds were enrolled in Dhaka, Bangladesh, and randomly assigned to one of three groups: passive chlorinator, Aquatabs, or control. Over a 10-month intervention period, the mean percentage of households whose stored drinking water had detectable total chlorine was 75% in compounds with access to the passive chlorinator, 72% in compounds receiving Aquatabs, and 6% in control compounds. Both interventions also significantly improved microbial water quality. Aquatabs usage fell by 50% after behavioral promotion visits concluded, suggesting intensive promotion is necessary for sustained uptake. The study findings suggest high potential for an automated decentralized water treatment system to increase consistent access to clean water in low-income urban communities.

Objective

This paper describes the physical structure and environmental contamination in selected hospital wards in three government hospitals in Bangladesh.

Methods

The qualitative research team conducted 48 hours of observation in six wards from three Bangladeshi tertiary hospitals in 2007. They recorded environmental contamination with body secretions and excretions and medical waste and observed ward occupant handwashing and use of personal protective equipment. They recorded number of persons, number of open doors and windows, and use of fans. They measured the ward area and informally observed waste disposal outside the wards. They conducted nine focus group discussions with doctors, nurses and support staff.

Results

A median of 3.7 persons were present per 10 m² of floor space in the wards. A median of 4.9 uncovered coughs or sneezes were recorded per 10 m² per hour per ward. Floors in the wards were soiled with saliva, spit, mucous, vomitus, feces and blood 125 times in 48 hours. Only two of the 12 patient handwashing stations had running water and none had soap. No disinfection was observed before or after using medical instruments. Used medical supplies were often discarded in open containers under the beds. Handwashing with soap was observed in only 32 of 3,373 handwashing opportunities noted during 48 hours. Mosquitoes and feral cats were commonly observed in the wards.

Conclusions

The physical structure and environment of our study hospitals are conducive to the spread of infection to people in the wards. Low-cost interventions on hand hygiene and cleaning procedures for rooms and medical equipment should be developed and evaluated for their practicality and effectiveness.