Background

Hand hygiene is a cost-effective preventive measure to reduce transmission of infectious diseases.1 Alongside water and sanitation, hand hygiene protects community health and contributes to resilient health systems.1 However, a quarter of the global population lack access to even a basic handwashing facility2 and sustained hand hygiene practice everywhere is low.3

Following the COVID-19 pandemic, and in response to government demand, WHO and UNICEF are now developing guidelines on hand hygiene in community settings.4 These guidelines will provide evidence-based recommendations to governments on actions to improve coverage and practice of hand hygiene in non-healthcare settings that include households, public spaces and institutional settings. The recommendations will be informed by synthesis of scientific and grey literature5 and developed through a consensus-based process involving independent experts, guideline end-users and representatives of beneficiaries.6

The guidelines will also provide guidance on how to implement the recommendations. Detailed implementation plans are necessary for governments to act on global recommendations but guidance on effective implementation approaches has been lacking and has historically hindered progress.7 To address this, end-user consultation has been integrated into this guideline development process, and as part of this, WHO and UNICEF convened a meeting to discuss how forthcoming recommendations might be implemented. The meeting, held in May 2023, included representatives from government, UN agencies, international financial institutions, development partners, civil society and the private sector from 18 low-income, middle-income and high-income countries. Below, we share the five key points of consensus that emerged from the meeting.

Recommendations proposed for the forthcoming WHO and UNICEF guidelines on hand hygiene in community settings are necessary and feasible to implement

Government action on hand hygiene in community settings is constrained by a lack of consistent, evidence-based and internationally agreed upon global guidance.8 Forthcoming global guidelines will provide evidence-based recommendations on when, how and with what hand hygiene should be practised in community settings for effective protection against infectious diseases. Recommendations will describe the essential elements of effective service delivery, and define the roles and responsibilities of diverse actors, with particular focus on the role of government.

There was firm commitment from government representatives to prioritise hand hygiene in community settings to protect health and several examples of strong government action were shared. The forthcoming guidelines were welcomed, and government-led implementation across multiple settings deemed necessary and feasible.

Progress on hand hygiene in community settings requires moving beyond emergency-led responses, to building sustainable and resilient national systems

The COVID-19 pandemic highlighted deficits in access to hand hygiene services and led to various national and global initiatives to accelerate progress on hand hygiene.9 However, efforts focused more on short-term delivery, rather than addressing the underlying reasons for low access. Future efforts must move beyond emergency response, to building the systems that can deliver sustainable and equitable services.

A system comprises inter-related functions enabling effective service delivery, and includes the institutions and actors that fulfil these functions, and the interactions among functions, institutions and actors.10 In the case of hand hygiene, effective and sustainable service delivery means the reliable provision, operation and maintenance of handwashing facilities with water and soap or alcohol-based hand rub and ongoing behaviour change programming for sustained adoption. Systems require strong national policies, financed strategies, institutional structures, monitoring systems and a skilled workforce to be sustainable, resilient and accountable.

Hand hygiene system-strengthening plans should be underpinned by a comprehensive situational analysis and needs assessment, and monitored on an ongoing basis for course correction where necessary

Effective system-strengthening plans are risk-based and context-specific; plans should be based on comprehensive situational analyses and prioritisation of needs, be regularly monitored and evaluated, and reviewed on an ongoing basis.

The following elements were identified as critical to development of an effective system-strengthening plan:

• Evidence-based national norms and standards.

• Setting-specific and context-specific assessment tools.

• Decentralised governance mechanisms for local implementation plans.

• Multisector participation in the development of system-strengthening plans (As non-exhaustive examples, the following sectors were identified during the discussion: education, occupational health and safety, nutrition, cholera).

• Government-led partnerships with public, private or civil society actors.

• An incremental approach in resource-constrained contexts.

Execution of system-strengthening plans should be integrated with existing programmes

Given long-standing lack of prioritisation of this critical public health intervention, hand hygiene merits attention as a standalone policy issue. However, implementation of government-led hand hygiene system-strengthening plans should be integrated with existing programmes across sectors. Where hand hygiene affects the target outcomes of existing programmes, such as child health or cholera, there is a clear rationale for programmatic integration. In addition, embedding hand hygiene within national development plans and programmes benefitting from higher-profile commitments enables leveraging of political leadership and financing.

There was consensus on the need for:

• Strong leadership for hand hygiene within other sectors.

• Costing and financing of hand hygiene components across multiple sectors.

• Alignment of hand hygiene indicators of interest with existing monitoring frameworks (eg, for school settings, the WHO and UNICEF Joint Monitoring Programme has developed a simple school-level self-assessment form for integration into national education management information systems).

• Setting-specific guidance to local government.

Health sector leadership is required to drive this agenda

Strong political leadership is essential in public health. Leadership includes setting out an inspirational vision of hand hygiene as a key driver of economic progress and a plan for achieving it, and providing ongoing support to the implementation agenda, including the creation of course-correction mechanisms that enable rapid identification and remediation of identified implementation obstacles.

Inevitably, a strong single ministerial lead is required to sustain progress. Broadly, in all countries, the ministry of health has the mandate to protect and improve the health of people and their communities, and hand hygiene is central to this. While the ministry of health will never deliver all functions, their mandate empowers them to lead the development of a roadmap for adoption of hand hygiene recommendations, and coordinate its implementation across various ministries.

Beyond health ministry leadership and coordination, a ministerial lead for each community setting should be identified to implement hand hygiene recommendations within their area of focus. For example, in schools, education ministries are responsible for ensuring that hand hygiene is accessible and practised in schools, as part of a healthy school environment.