costs of hand hygiene for all in household settings estimating the price tag for CORD-Papers-2022-06-02 (Version 1)

Title: Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries
Abstract: INTRODUCTION: Domestic 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 (HWF) 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. METHODS: Our model combines quantities of households with no 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 20212030 and estimated total cost probabilistically using Monte Carlo simulation. RESULTS: An estimated US$12.2US$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 US$334 million (24% of annual total) with a further US$233 million for top-up promotion (17%). Together these promotion costs represent US$0.47 annually per head of LDC population. The annual cost of HWFs a purpose-built drum with tap and stand is US$174 million (13%). The annual cost of soap is US$497 million (36%) and water US$127 million (9%). CONCLUSION: The annual cost of behavioural change promotion to those with no HWF 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 behavioural change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.
Published: 2021-12-16
Journal: BMJ Glob Health
DOI: 10.1136/bmjgh-2021-007361
DOI_URL: http://doi.org/10.1136/bmjgh-2021-007361
Author Name: Ross Ian
Author link: https://covid19-data.nist.gov/pid/rest/local/author/ross_ian
Author Name: Esteves Mills Joanna
Author link: https://covid19-data.nist.gov/pid/rest/local/author/esteves_mills_joanna
Author Name: Slaymaker Tom
Author link: https://covid19-data.nist.gov/pid/rest/local/author/slaymaker_tom
Author Name: Johnston Richard
Author link: https://covid19-data.nist.gov/pid/rest/local/author/johnston_richard
Author Name: Hutton Guy
Author link: https://covid19-data.nist.gov/pid/rest/local/author/hutton_guy
Author Name: Dreibelbis Robert
Author link: https://covid19-data.nist.gov/pid/rest/local/author/dreibelbis_robert
Author Name: Montgomery Maggie
Author link: https://covid19-data.nist.gov/pid/rest/local/author/montgomery_maggie
sha: 94930a8d9619259bc99327f9b08c7a6f44b4db2a
license: cc-by
license_url: https://creativecommons.org/licenses/by/4.0/
source_x: Medline; PMC
source_x_url: https://www.medline.com/https://www.ncbi.nlm.nih.gov/pubmed/
pubmed_id: 34916276
pubmed_id_url: https://www.ncbi.nlm.nih.gov/pubmed/34916276
pmcid: PMC8679104
pmcid_url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8679104
url: https://doi.org/10.1136/bmjgh-2021-007361 https://www.ncbi.nlm.nih.gov/pubmed/34916276/
has_full_text: TRUE
Keywords Extracted from Text Content: Ross I, Esteves Mills J Slaymaker T water basic' water Afghanistan's piped US$ stand/basin WASH LDCs UNICEF LMICs point-of-use water donors C. hygiene-specific roadshows US$7 HWF type(s US$5 HWF @ianrossuk line LDC I$ SDG people WHO/UNICEF Joint purchase/use WHO-led TrackFin Top-up tap HEWs HWFs GDP B Niger participants Ross http:// orcid facilities-no WASHspecific US$12.2-US$15.3 COVID-19 CIs Swachh On-premises -online participants
Extracted Text Content in Record: First 5000 Characters:To cite: Ross I, Esteves Mills J, Slaymaker T, et al. Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries. Hand hygiene reduces transmission of a variety of enteric and respiratory infections. 1 2 Every year, 165 000 deaths from diarrhoeal disease and 370 000 deaths from acute respiratory infections are attributable to inadequate hand hygiene. 3 However, nearly a third of the global population do not have handwashing facilities (HWFs) with soap and water available at home, denoted a 'basic' hygiene service. 4 Many more do not practice handwashing with soap at critical times-for example, only 26% of potential faecal contact What is already known? ► Understanding resource requirements is important for planning, but data on the costs of improving domestic hand hygiene are scarce. ► While 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. What are the new findings? ► The total economic cost over 10 years is US$12.2-US$15.3 billion, of which US$4.9-US$6.6 billion (42%) is for behavioural change promotion interventions. ► The remainder is for facilities and supplies, with soap the biggest cost category (36%), followed by handwashing facilities (13%) and water (9%). ► The 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 US$17 for soap and US$5 for water. What do the new findings imply? ► The annual cost of behavioural change promotion to those with no handwashing facility represents 4.7% of median government health expenditure in least developed countries. ► On 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. ► Promotion 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 behavioural change campaigns where appropriate. BMJ Global Health events globally are followed by handwashing with soap. 5 The COVID-19 pandemic highlighted the need for hand hygiene to reduce transmission across settings, including households, schools, healthcare facilities and public places. 6 The greatest deficit is in least developed countries (LDCs), where 6 in 10 people are without a basic hygiene service, of which about half have a HWF but no soap and/or water. 4 However, promotion of handwashing behaviours is required in all countries and settings. For example, it is estimated that in high-income countries, where over 99% of the population have water accessible on premises, 4 only 51% of faecal contacts are followed by handwashing with soap. 5 Hand hygiene is best facilitated by an on-premises water supply, 7 but 60% of the LDC population do not have such a service, 4 instead hauling water from off-premises sources. Reviews of factors for success in scaling up public health interventions in low-income and middle-income countries (LMICs) frequently identify costing and economic analysis of interventions in the top three success factors. 8 9 For hand hygiene, such cost figures are scarce. A 2016 study costing the Sustainable Development Goal (SDG) targets for drinking water, sanitation and hygiene (WASH) in 140 countries by Hutton and Varughese identified only five peer-reviewed studies providing data on the costs of handwashing promotion, alongside seven from grey literature. 10 11 The absence of robust cost data for handwashing programmes makes financial planning and resource allocation difficult. 12 Hutton and Varughese reported an annual capital cost of US$2.0 billion over 15 years for 140 LMICs to achieve basic hand hygiene in domestic settings. 10 11 This figure includes HWFs and promotion only. Limitations of these cost estimates include: (1) not reporting hygiene-specific estimates of recurrent or total costs, only incorporating them into totals for WASH; (2) no description of the assumed hygiene promotion 'software' or the assumed HWF type(s); (3) inconsistent approach to HWF useful life, with 10 years applied for rural areas in all countries, but 2.5 or 5 years for urban areas in 86% of countries; (4) no sensitivity analysis specific to hygiene assumptions. The costs of activities promoting hand hygiene in LDCs are typically borne by governments and donors as a public health investment. However, only 16% of the 115 countries responding to a WHO-led survey could report the size of hygiene budgets or expenditures, compared with 53% for sanitation and/or water supply. 13 Of the 16 countries providing expenditure data, 8 indicated only one source of funding (government, households or dono
Keywords Extracted from PMC Text: COVID-19 pandemic.6 strategy.34 limitations,62 On-premises safely-managed' criteria.4 adherence.20 57 C. WHO/UNICEF Joint WASH rural.66 basis20 Afghanistan's on-premises water practice.40 beneficial.45 guidance.12 37 setting.21 country,4 Swachh COVID-19 people purchase/use I$ components,64 65 households.14 LDCs CIs roadshows effectively.54–56 US$5 service,4 hygiene.3 difficult.12 HWFs participants tap LDCs.4 interventions.12 cholera B sanitation.53 HWF SDG capita),42 practice'12 inflation.38 's literature.10 11 HWF type(s hygiene,3 hygiene-specific water UNICEF capita).43 line HWF'.4 conversion.39 WHO-led realities.41 LMICs US$ donors study10 LDC US$7 Survey17 interventions,35 point-of-use water year.10 TrackFin Niger GDP stand/basin costing.63 required.47 piped 2019.44
Extracted PMC Text Content in Record: First 5000 Characters:Hand hygiene reduces transmission of a variety of enteric and respiratory infections.1 2 Every year, 165 000 deaths from diarrhoeal disease and 370 000 deaths from acute respiratory infections are attributable to inadequate hand hygiene.3 However, nearly a third of the global population do not have handwashing facilities (HWFs) with soap and water available at home, denoted a 'basic' hygiene service.4 Many more do not practice handwashing with soap at critical times—for example, only 26% of potential faecal contact events globally are followed by handwashing with soap.5 The COVID-19 pandemic highlighted the need for hand hygiene to reduce transmission across settings, including households, schools, healthcare facilities and public places.6 The greatest deficit is in least developed countries (LDCs), where 6 in 10 people are without a basic hygiene service, of which about half have a HWF but no soap and/or water.4 However, promotion of handwashing behaviours is required in all countries and settings. For example, it is estimated that in high-income countries, where over 99% of the population have water accessible on premises,4 only 51% of faecal contacts are followed by handwashing with soap.5 Hand hygiene is best facilitated by an on-premises water supply,7 but 60% of the LDC population do not have such a service,4 instead hauling water from off-premises sources. Reviews of factors for success in scaling up public health interventions in low-income and middle-income countries (LMICs) frequently identify costing and economic analysis of interventions in the top three success factors.8 9 For hand hygiene, such cost figures are scarce. A 2016 study costing the Sustainable Development Goal (SDG) targets for drinking water, sanitation and hygiene (WASH) in 140 countries by Hutton and Varughese identified only five peer-reviewed studies providing data on the costs of handwashing promotion, alongside seven from grey literature.10 11 The absence of robust cost data for handwashing programmes makes financial planning and resource allocation difficult.12 Hutton and Varughese reported an annual capital cost of US$2.0 billion over 15 years for 140 LMICs to achieve basic hand hygiene in domestic settings.10 11 This figure includes HWFs and promotion only. Limitations of these cost estimates include: (1) not reporting hygiene-specific estimates of recurrent or total costs, only incorporating them into totals for WASH; (2) no description of the assumed hygiene promotion 'software' or the assumed HWF type(s); (3) inconsistent approach to HWF useful life, with 10 years applied for rural areas in all countries, but 2.5 or 5 years for urban areas in 86% of countries; (4) no sensitivity analysis specific to hygiene assumptions. The costs of activities promoting hand hygiene in LDCs are typically borne by governments and donors as a public health investment. However, only 16% of the 115 countries responding to a WHO-led survey could report the size of hygiene budgets or expenditures, compared with 53% for sanitation and/or water supply.13 Of the 16 countries providing expenditure data, 8 indicated only one source of funding (government, households or donors), indicating that the data are not comprehensive.13 While the costs of HWFs, soap and water are borne by households in the majority of cases, they can also be subsidised directly or indirectly (eg, specific subsidies, cash transfers or humanitarian response). Affordability is a concern, and survey data suggest a strong socio-economic gradient in soap availability within households.14 In this study, we aim to estimate the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs. Underlying objectives were to facilitate discussions and plans at the national and global levels, especially in light of the ongoing COVID-19 pandemic, and evaluate the size of the cost in relation to other investment priorities. We estimated economic costs from a societal perspective, and address who might bear those costs in the discussion section. We model straight-line scale-up of a hand hygiene promotion intervention (described below) over a 10-year horizon (2021–2030), whereby 10 equal cohorts of unserved households per country receive the intervention per year. Each cohort starts incurring recurrent costs in the year they receive the intervention. The scope of costed inputs comprised all activities contributing to behavioural change and purchase/use of a HWF over its useful life. We analysed quantities and prices per country for the 46 LDCs, separately for urban/rural areas. We then aggregated to an LDC total. Following norms in resource requirement estimation, we estimate the cost of reaching all target households, and do not incorporate the effectiveness of interventions.12 We retrieved hygiene service level estimates for the 46 LDCs from the WHO/UNICEF Joint Monitoring Programme (JMP).16 For countries missing JMP estimates for 2020 (online supplement
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