Costs of hand hygiene for all in household settings - estimating the price tag for the 46 least developed countries

IntroductionDomestic hand hygiene could prevent over 500,000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs. MethodsOur model combines quantities of households with no handwashing facility (HWF) and prices of promotion campaigns, HWFs, soap, and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021-2030, and estimated total cost probabilistically using Monte Carlo simulation. ResultsAn estimated US$ 12.2 - 15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is $334 million (24% of annual total), with a further $233 million for top-up promotion (17%). Together, these promotion costs represent $0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is $174 million (13%). The annual cost of soap is $497 million (36%), and water $127 million (9%). ConclusionThe annual cost of behaviour change promotion to those with no handwashing facility represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behaviour change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households. Summary boxO_ST_ABSWhat is already known?C_ST_ABSO_LIUnderstanding resource requirements is important for planning, but data on the costs of improving domestic hand hygiene are scarce. C_LIO_LIWhile a 2016 study estimated the global cost of drinking water, sanitation and hygiene, it did not report hygiene-specific estimates of recurrent or total cost, nor did it describe the assumed promotion intervention and handwashing facility or consider alternatives to them. C_LI What are the new findings?O_LIThe total economic cost over 10 years is US$ 12.2 - 15.3 billion, of which $4.9 - 6.6 billion (42%) is for behaviour change promotion interventions. C_LIO_LIThe remainder is for facilities and supplies, with soap the biggest cost category (36%) followed by handwashing facilities (13%) and water (9%). C_LIO_LIThe facility and supply costs per household comprise an initial investment in a handwashing facility (lasting 5 years) at a median of US$ 17, accompanied by an annual cost of $17 for soap and $5 for water (Figure 1). C_LI O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=86 SRC="FIGDIR/small/21262011v1_fig1.gif" ALT="Figure 1"> View larger version (12K): org.highwire.dtl.DTLVardef@62af1org.highwire.dtl.DTLVardef@ed72cdorg.highwire.dtl.DTLVardef@10c06bforg.highwire.dtl.DTLVardef@8f0c17_HPS_FORMAT_FIGEXP M_FIG O_FLOATNOFigure 1:C_FLOATNO Distribution of key input price variables in international dollars (I$) * The base case promotion intervention includes one-to-one activities, group activities and mass media. The alternative case excludes one-to-one activities. This figure presents results in I$ - the median US$ prices per household after converting to local purchasing power are $33.9 for base case promotion, $16.6 for HWF, $17.1 for soap expenditure, and $17.2 for alternative case promotion. Median annual expenditure per household on water for handwashing was $5.7 in rural areas and $4.0 in urban areas. The US$ median for the home-made HWF considered under sensitivity analysis was $1.2. C_FIG What do the new findings imply?O_LIThe annual cost of behaviour change promotion to those with no handwashing facility represents 4.7% of median government health expenditure in LDCs. C_LIO_LIOn top of this, investments in infrastructure and supplies are required. Soap in particular is a substantial and recurrent cost, which may be unaffordable for the poorest households. C_LIO_LIPromotion costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behaviour change campaigns where appropriate. C_LI