The $23 Billion Dilemma: Lessons In Personal Hygiene

Handwashing is the most inexpensive and effective way to maintain good health and hygiene. It is simple, yet paramount, globally recommended, and has found a prominent place in the Sustainable Development Goals (SDGs), also known as the Global Goals, adopted by the UN in 2015. The 17 goals inscribe a universal Call to Action to end poverty, protect the planet, and ensure people enjoy peace and prosperity by 2030.

SDG 6, clean water and sanitation, highlights the importance of equitable sanitation and hygiene and calls for ending open defecation. The concept of hygiene comprises a gamut of behaviours, including improved menstrual hygiene, oral hygiene, environmental hygiene, environmental cleaning and food hygiene in various public institutions, households, health centres, educational institutions and child care centres. Practising hand hygiene is the predominant and most common behaviour, where handwashing with soap and water is quintessential.

Health benefits of handwashing are many, and its role is critical in reducing the transmission of outbreak-related pathogens such as cholera, ebola, shigellosis, SARS and hepatitis E. Handwashing reduces acute respiratory infections by 23 per cent risk of endemic diarrhoea by 30–48 per cent and infant deaths caused by infections by 27 per cent. Undeniably, it is also one of the most prominent Covid Appropriate Behaviours (CAB).

The stress caused by ill-health, a result of poor hand hygiene, has financial costs like medical treatments and indirect ones like out-of-pocket expenditures, which can cause huge economic stress. Other unseen burdens of poor hygiene and handwashing practices are loss of productivity linked to sickness and school abs­ence that have detrimental impact on social and economic well-being.

A study by Townsend et al. 2016 stated that annual net costs to India from not washing hands with soap after contact with faeces were estimated to be $23 billion. Meanwhile, the net returns from national behaviour change programmes aimed at handwashing were estimated at $5.6 billion, at $23 per DALY. The lack of proper handwashing and basic hygiene facilities in public institutions like schools has resulted in greater social exclusions and school dropout rates, especially amongst the female population. Evidence suggests that 43 per cent of missed school days can be averted by providing basic handwashing facilities. Assuring adequate facilities at workplaces will decrease the stress on women by reducing their unpaid and caregiving responsibilities.

Despite the countless benefits, the National Sample Survey 2019 revealed that only 25.3 per cent households in rural India and 56 per cent in urban areas washed hands with soap and detergent before a meal. According to the National Health and Family Survey-5, 2019–2021, 70.8 per cent possessed basic handwashing facilities, wherein 92 per cent had water available and 74.9 per cent had soap in their facility. Just over 26 per cent had limited facilities.

Merely providing a handwashing station is not enough as, despite proven to be the first line of protection against infections, including Covid, many neglect it as an important practice. Simple innovations like the ‘tippy-tappy’ can create a conducive environment for internalizing the behaviour of handwashing that can be adopted organically.

The early stages of the pandemic saw increased handwashing with soap. However, fear-based changes are likely to be short-lived. Therefore, additional motivations are needed. The pandemic has opened up a window of opportunity to sustain behaviour change by addressing a broader array of determinants. Introducing hand hygiene in early education and schools is critical for inculcating a habit among children. Drafting a curriculum which increases knowledge on benefits of using soap can help raise, improve and sustain good handwashing behaviour. Active participation of students can catalyze larger good for communities, as the former can be advocates for HWWS and further mobilize the members of families and communities.

Handwashing programmes seem to be successful when they target multiple delivery channels and engage a myriad of stakeholders. Ideally, programme implementers should consider combining mass media strategies with interpersonal techniques, which reach the target population at the community and household level.

Effective hygiene programmes require long-term investments from governments to strengthen capacity for behaviour change. Led by WHO and UNICEF, the ‘Hand Hygiene for All’ is a global initiative that calls for action to achieve universal access to hand hygiene by supporting the most vulnerable communities with the means to protect their health and environment. It brought together international partners, governments, public and private sector and civil society actors to ensure affordable products and services to the disadvantaged sections to enable a culture of hygiene.

This is in line with the theme of Global Handwashing Day, which calls for governments and stakeholders to ‘Unite for Universal Hand Hygiene’. Fostering behaviour change needs critical partnerships and collaborations across various stages and commitments. Let us come together and unite to spread the message of handwashing for protecting our health and well-being.

UNICEF and WHO have given support to develop a draft hand hygiene roadmap for India that takes along stakeholders  across sectors. It provides operational guidance on the integration of handwash and hygiene into other relevant programmes, further providing a monitoring and evaluation framework. The roadmap aims at facilitating the supply of and demand for hygiene products and services. While doing so, one needs to look at market incentives to promote availability and sale of handwashing products. On Global Handwashing Day, UNICEF and global partners will unite to raise the profile of handwashing with soap and promote actions that enable people to do so at critical times.

(This appeared in the print edition as "The $23 billion Dilemma")

(Views expressed are personal)

Yasumasa Kimura Deputy Representative, Programmes UNICEF India