Universal hand hygiene: strategies, sustainable financing and implementation at scale

7 min read
Image: WaterAid/ Genaye Eshetu

Om Prasad Gautam and Sophie Hickling discuss the importance of cost-effective handwashing programmes and urge countries to accelerate progress on developing strategies, ensure sustainable financing and scale up implementation to achieve universal hand hygiene.

Handwashing with soap is one of the most effective ways communities, healthcare workers, patients, people in workplaces and schoolchildren can protect themselves and their loved ones from infections and diseases. This year’s Global Handwashing Day theme – Unite for Universal Hand Hygiene – urges governments, donors, businesses, institutions, researchers and advocates to collaborate to create and implement sustainable hand hygiene strategies that will ensure everyone has this vital defence.

Changing people’s hygiene habits for good is only possible if we all unite; from researchers to politicians, donors to governments, activists to businesses, institutions to individuals, we all have a part to play. We need fully costed and funded hygiene strategies, and effective interventions – based on evidence – that can be scaled up to reach everyone, everywhere.

An evidence-based, comprehensive and unified approach empowers people to absorb hygiene into their daily lives, protecting families, lessening the burden on already overwhelmed healthcare services and helping to prevent disease outbreaks and pandemics. Hand hygiene is a cornerstone of public health, and with better health comes fuller lives, stronger economies and brighter futures. 

Why is global unity crucial for hand hygiene?

  • Current progress is too slow.

    The rate must increase by at least four times to ensure universal hand hygiene by 2030 at household level. Globally, three in ten people (PDF) do not have facilities at home to wash their hands with soap and water. Only half of health centres worldwide have handwashing facilities with soap and water and just 53% of schools in developing countries provide basic handwashing facilities for students. There is a huge disparity between low- and high-income settings, and between urban and rural locations. Without facilities, people cannot hope to practise proper hygiene and their health and wellbeing are at risk.
  • Handwashing with soap offers wide public health and social benefits.

    It prevents and reduces the disease burden, improves school performance, increases workplace productivity, reduces infections, can prevent the spread of diseases and can help control current and future pandemics. And without hygiene behaviour change programmes embedded at the heart of any water, sanitation and hygiene (WASH), health or education programme, their progress will be compromised.
  • Hand hygiene is cost effective and offers significant economic benefits.

    Handwashing with soap is one of the most cost-effective public health interventions in reducing the global infectious disease burden, costing just US$3 per disability-adjusted life year averted. And investment can bring large economic gains. However, although hygiene interventions are cost effective in the long run, an estimated $12.2–15.3 billion over ten years is needed to achieve universal hand hygiene by 2030 in households alone in 46 LEDCs, of which $4.9–6.6 billion (42%) is for behaviour change promotion interventions and the remainder is for facilities and supplies. However, this equates to less than $1 per person per year (PDF) in these 46 countries.
Prince (4) washes his hands after using the toilet at his house in Shyama Prasad Mukherjee Camp, New Delhi, India.
Prince (4) washes his hands after using the toilet at his house in Shyama Prasad Mukherjee Camp, New Delhi, India. 13 March 2020
Image: WaterAid/ Srishti Bhardwaj

Where should we focus to increase progress?

It's simple – we can only reach our universal hand hygiene goal if all stakeholders work together. We must start with government leadership and ownership; leaders must work with communities and all stakeholders, including donors, academia, NGOs, civil society and the private sector, to give them the space to collaborate and deliver programmes. And these programmes must be comprehensive, evidence-based, have proof of concept for their effectiveness and have behaviour change woven throughout. Creative and unified methods are required, and it is paramount that stakeholders take the following three actions.

  1. Unite for strategies/roadmaps and planning.

    Having a fully costed national strategy or roadmap for hand hygiene that brings together sectors and stakeholders is vital to provide strategic direction for hand hygiene interventions, ensure institutional mechanisms are clear and functioning, deepen sectoral coordination, strengthen systems and improve quality programming and monitoring.

    As a positive example of collective leadership, around 2021’s Global Handwashing Day, more than 30 countries made a public commitment to develop costed hand hygiene roadmaps. Yet just some have put these into action (including Bangladesh, Pakistan, Nigeria, Ethiopia, Nepal, Ghana) and a few are slowly developing their strategy/roadmap.

    In another example, 16 member states of the Southern African Development Community (SADC) united to develop a hygiene strategy, supported by WaterAid and UNICEF and launched in August 2022.

    In 2021 countries’ efforts centred on developing national costed roadmaps or strategies for hand hygiene in several low- and middle-income countries. This effort should be continued where there has not yet been progress and accelerated where there has. Wider engagement in developing strategies – under government leadership – is vital, including with technical agencies and the private sector.

  2. Unite for sustainable financing.

    The cost of ensuring universal hand hygiene must come jointly from governments, donors and households, and discussion of financing national strategies or roadmaps should go alongside their development. One-off investments are not enough because facilities must remain functional and people continuously reminded to practise hand hygiene. In 2020 UN-Water GLAAS reported that only 60% of national plans for hygiene had been costed and, of those, only 9% had sufficient financial resources to implement plans. If global leaders are to deliver on their sustainable development plans and promises, financing for hygiene must be significantly increased at all levels, long term and coordinated between everyone including households, donors and governments.

    Investing in hygiene is a transformative and critical economic stimulus that every country must include in its efforts to build back better from the COVID-19 pandemic. Hygiene is a no-regrets, smart investment that will increase productivity, reduce health costs and decrease time poverty for the poorest and most marginalised, especially women and girls.

  3. Unite for implementation at scale.

    Achieving sustainable hand hygiene for all requires a big improvement in transformative and inclusive behaviour change programmes at scale. Designing, implementing and evaluating hygiene behaviour change programmes effectively demands a multi-disciplinary approach. Achieving this at scale requires harmonised efforts from governments, donors, NGOs, community-based organisations, the private sector, academia and civil society.

    Global, regional and national-scale implementation must be united; this has been clear throughout the COVID-19 pandemic. Governments should not wait for another public health emergency to invest. Making evidence-based and effective hygiene behaviour change programmes part of wider development programmes is vital to achieving good, cost-effective results on multiple development agendas.

Handwashing facilities at the Basic Education High School (8), Hlaingtharya Township, Yangon, Myanmar.
Handwashing facilities at the Basic Education High School, Hlaingtharya Township, Yangon, Myanmar.
Image: WaterAid Myanmar

How WaterAid is contributing to these focus areas

We champion transformative behaviour change programming, embracing behaviour-centred design approaches to attain sustained behaviour change. We support governments to develop strategies; increase governments’ and partners’ capacities to design and implement hygiene programmes; and allocate and advocate funding for sustainable hygiene behaviour change interventions, showing how effective such interventions can be.

We also work with governments to integrate hygiene behaviour change into sectoral programmes such as health (e.g. immunisation and child health), nutrition and education, and help build or strengthen monitoring and evaluation systems. We create innovative products and facilities with behavioural cues and nudges, working with key partners, including in the private sector.

We emphasise behaviour change rather than just improving knowledge. We are currently supporting 17 behaviour change campaigns across South Asia and Africa, most of which have been altered since March 2020 to include COVID-19 sensitive behaviours.

Through our hygiene campaigns with governments in response to COVID-19 we reached 181 million people during 2020–21, distributed 1.8 million hygiene products and installed 2,700 large-scale innovative handwashing facilities in key public places. In 2022 we are aiming to reach 50 million more people across nine countries with our COVID-19 hygiene response.

We supported the 16 members of SADC region to develop a hygiene strategy and have been helping dozens of countries to develop national hand hygiene roadmaps, supporting a few to cost them. We are a core partner of the Hand Hygiene for All initiative, are a member of the Global Handwashing Partnership, lead the SuSanA Behaviour Change Group and are part of the UK Foreign Commonwealth and Development Office-led C-19 Behaviour Change Group. We have also contributed to various initiatives and sectoral coordination mechanisms through WASH and health clusters. We have produced a range of evaluative documents such as a learning report from our global hygiene response to COVID-19, guides, case studies and blogs. We are also advocating the need for national strategies, sustainable financing and implementation of hygiene behaviour change programmes at scale in many countries.  

We are committed to continuing to support global unity and collaboration on hand hygiene, to prioritising hygiene as a core focus and to advocating united action for sustained behaviour change.

Om Prasad Gautam is Senior WASH Manager – Hygiene at WaterAid UK. Sophie Hickling is Senior Policy Analyst – Hygiene at WaterAid UK.

Top image: Addisae, 14, using a tap stand built by WaterAid in her community in Wundiye, Burie, West Gojjam, Ethiopia.