This study, concentrating on the adherence of health facilities to IPC standards in NES, offers in-depth perspective in an environment where similar studies are noticeably absent, and provides a contribution to the academic discourse in a context where analogous research is markedly scarce. In summary, our findings reveal the severe underperformance of the surveyed health care facilities in meeting the stipulated IPC minimum requirements. We found that 91% (equivalent to 30 of the 33 examined facilities) did not achieve half of the WHO's IPC minimum requirements. A detailed analysis reveals that PHCs show marginal adherence, with 57% meeting only 0-50% of the benchmarks. Conversely, 43% (representing three distinct facilities) adhered to 51-75% of the standards. Furthermore, both SHCs and THCs exhibited deficiencies. Every SHC and THC assessed (100% in both categories) failed to meet more than half of the IPC standards.

To our knowledge, the interconnection of the tools used in this study has only been documented in one other instance [14]. It is essential to highlight that, within the broader Syrian context, this represents the first effort, as there is a paucity of published studies that systematically assess IPC practices across the region's health care landscape. Furthermore, the importance of our findings is heightened given that most health facilities under investigation by IPCAF and HHSAF were classified as ‘inadequate’ or ‘basic’. The classification of health facilities as ‘inadequate’ or ‘basic’ is of concern. ‘Inadequate’ suggests that the facilities might need to improve in meeting even the most fundamental IPC standards, posing considerable risks to patients and health care professionals. Meanwhile, ‘basic’ implies that while some foundational measures might be in place, they need to be more comprehensive to meet the comprehensive standards required to ensure optimal patient safety and service quality. Such classifications indicate a potential for increased infections, compromised patient care, and reduced trust in the health care system.

Our study differed methodologically from other studies published on the topic, lending robustness to the findings in various ways. Firstly, the selection of facilities was predicated on well-defined criteria, eschewing the self-selecting surveys commonly observed in broader global assessments; this approach could skew the global IPCAF and HHSAF scores towards an overestimation [14,[18], [19], [20]]. It is worth noting that extant literature, particularly studies contextualised to specific regions, has also used specialised criteria for facility selection. Secondly, evaluations were undertaken through on-site visits by our dedicated teams, who received comprehensive IPC training focusing on the tools under study. This represents a new approach relative to the dominant methodology in the literature, which frequently relies on self-survey mechanisms [14,[18], [19], [20]]. We assume this approach is more appropriate for health environments in conflict areas, where many facilities lack IPC specialists [21]. This stance aligns seamlessly with our findings.

The inadequacy starkly contrasts with the global trend, as illuminated by the global survey data from 2019 [14]. This comprehensive survey, encompassing 4440 health care facilities in 81 countries across all six WHO regions and spanning diverse income levels, showcased that 92.9% of health facilities worldwide met at least half of the assessed indicators. This further underscores the pressing need for enhanced efforts and targeted strategies to bridge this significant NES health care quality gap. The worldwide data reveal that 15.2% of all health facilities met 100% of the minimum requirements. While this number may seem modest, it becomes even more significant when considering that this figure plunges to 0% in low-income countries [14].

Reflecting on our results by classifying the surveyed health facilities according to the tools used, the vast majority (81.8%) of the surveyed facilities failed to meet the basic criteria for IPC, resulting in their classification as ‘inadequate’. While 18.2% managed to achieve a ‘basic’ level, none could reach the ‘intermediate’ or ‘advanced’ thresholds. A more detailed analysis of the IPC components reveals that the lowest scores were attributed to the first (IPC programme) and fourth (HAI surveillance) components, followed by the fifth (multimodal strategies for implementing IPC) and third (IPC training and education) components. These results highlight potential areas that require urgent attention and resource allocation. Conversely, the highest scores were in the eighth (built environment, materials, and equipment) and the seventh (workload, staffing, and bed occupancy) components. This implies that while structural and material infrastructure is in better condition, IPC programmes, HAI surveillance, training, and improved multimodal strategy mechanisms require immediate enhancement. It corroborates a 2018 study that emphasised the establishment of a robust surveillance HAI system in Syria [5]. This pronounced inadequacy is especially concerning when juxtaposed with global standards. Globally, the 2019 survey indicates a clear correlation between a nation's economic status and IPC standards, with high-income countries often achieving the ‘advanced’ IPC level. In contrast, low-income countries hovered around a ‘basic’ level with a median of 385.0, while our results showed a median of 167.5 (an inadequate level). However, this economic gradient in IPC standards does not uniformly dictate the quality of IPC practices, as variations are observed even within similar income brackets [14]. While countries such as Germany and Austria showcased IPC results consistent with their high-income status, which is not comparable to the situation in NES, countries with contrasting economic capabilities portrayed mixed results [22,23]. For instance, Ghana, despite its partial completion of the IPCAF assessment, reported a majority of facilities at ‘basic’ or ‘intermediate’ levels [24]. In stark contrast, hospitals in Islamabad, Pakistan mirrored NES's dire situation, being labelled ‘inadequate’ [25]. However, despite their economic challenges, nations such as India and Türkiye reported many facilities reaching ‘advanced’ or ‘intermediate’ IPC levels, suggesting that economic constraints are not the sole determinants of effective IPC practices [26]. However, the situation in NES cannot be compared to either countries given the difference in health system capacity. The scenario in Afghanistan and Côte d'Ivoire further solidifies this observation, where, despite economic limitations, facilities varied widely in their IPC implementation, ranging from ‘inadequate’ to ‘intermediate’ [27,28]. An analysis of the global results concerning specific IPC components further accentuates the standard divergence. The eighth component (built environment, materials, and equipment for IPC) globally scored the highest, a trend also observed in NES. Core component 3 (IPC education and training) was among the lowest-scoring globally and in NES, emphasising the pronounced need for bolstered IPC education in the region [14]. The vast chasm in scores for core components 1 and 4 between low-income countries and their high-income counterparts further amplifies the challenges that regions such as NES face in this domain. In light of these findings, it is believed that understanding the gaps in IPC, and subsequently addressing them, could have implications for the wider health system in NES, by offering a cost-effective public health solution to issues that, if left unaddressed, can place great burden on a health system that is already overextended because of years of conflict.

In light of the present study, we elucidated the state of hand hygiene standards in NES by leveraging HHSAF. Our observations reveal a concerning picture. Out of the 33 health facilities surveyed, 34.4% were found to be ‘inadequate’ regarding HHSAF levels, while most (65.6%) were at the ‘basic’ level, with a median score of 157.5. All facilities have yet to reach the ‘intermediate’ or ‘advanced’ tiers, emphasising the region's stark need for comprehensive hand hygiene interventions. When juxtaposed with global trends, the results from NES lag markedly. The global survey from 2015 identified hand hygiene levels at 229 (basic level) for low-income countries, which saw a slight uptick in 2019 to 233. Even more notably, high-income countries demonstrated hand hygiene levels at 381 (advanced level) in 2015, elevating to 395 in 2019. These figures accentuate the disparities between NES and low- and high-income countries globally [20]. The HHSAF component assessment for NES presented critical insights. While ‘system change’ and ‘institutional safety climate for hand hygiene’ secured relatively high medians of 60.0 and 45, respectively, the domain ‘training and education’ drastically underperformed, with a median of 5.0 points. This underscores the dire need for enhanced hand hygiene education initiatives in the region. Moreover, in contrast with the 2019 global survey, the ‘institutional safety climate’ was universally identified as the lowest-scoring component. Yet, in the case of Syria, it was one of the stronger components, suggesting unique regional challenges in other domains, especially in training and education [21]. The comparative scenario in other countries further highlights NES's unique predicament. For instance, Cambodian hospitals in 2020 were predominantly at the ‘basic’ level, mirroring NES's prevalent trend, despite the marked differences in settings [29]. However, Sierra Leone, a setting that is also regularly faced with disease outbreaks, showcased progress in 2021, with most hospitals achieving an ‘intermediate’ level, indicating possible pathways for improvement [30]. Adapting these findings into programmes to improve hand hygiene levels in NES is of high relevance, especially given the frequent disease outbreaks in the area. Therefore, strengthening hand hygiene practices and infrastructure would be of impact in the long term and would play a pivotal role in health system preparedness.

Regarding our results of the association between HHSAF and IPCAF, our study revealed a weak positive correlation between HHSAF and IPCAF scores, diverging from global trends where a strong correlation exists between IPC implementation and hand hygiene [14]. We assume the explanation for our distinct findings is that the health facilities we surveyed largely lacked the foundational IPC programme component (CC1), making them atypical and possibly less reflective of the global trend in this correlation.

In light of our findings, a comprehensive strategy for IPC in the NES is needed to prioritise the adoption of WHO IPC standards. Such a strategy should focus on ensuring long-term improvements in patient and health care worker safety.

Such a strategy cannot be implemented without greater investment in IPC education and training. There is a significant deficit in IPC training within NES, necessitating targeted funding for context-specific training programmes. Insights from successful IPC models in similar low-resource settings should inform these initiatives.

Enhancing HAI surveillance systems is critical. Developing robust mechanisms for monitoring and reporting HAIs will facilitate timely interventions and help mitigate infection risks. Similarly, addressing hand hygiene practices is a priority. Given the alarming scores in hand hygiene assessments, comprehensive training programmes must be introduced to bring NES facilities in line with global standards.

It is also important to leverage local strengths. Despite notable gaps, NES has strengths in areas such as infrastructure and the institutional safety climate for hand hygiene. These strengths should be leveraged to set benchmarks and guide improvements across other sectors.

Further research into the specific challenges faced in NES is necessary. Additional studies should be funded to provide insights that inform tailored interventions and enhance evidence-based practices.

Finally, fostering collaborations with countries that have made progress in IPC despite similar socio-economic challenges can be valuable. Collaborative ventures should promote knowledge exchange and the adoption of best practices.