PT - JOURNAL ARTICLE AU - Ian Ross AU - Joanna Esteves Mills AU - Tom Slaymaker AU - Richard Johnston AU - Guy Hutton AU - Robert Dreibelbis AU - Maggie Montgomery TI - Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries AID - 10.1136/bmjgh-2021-007361 DP - 2021 Dec 01 TA - BMJ Global Health PG - e007361 VI - 6 IP - 12 4099 - http://gh.bmj.com/content/6/12/e007361.short 4100 - http://gh.bmj.com/content/6/12/e007361.full SO - BMJ Global Health2021 Dec 01; 6 AB - 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 2021–2030, and estimated total cost probabilistically using Monte Carlo simulation.Results An estimated US$12.2–US$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.Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as online supplemental information. Quantity data are derived from public domain resources (https://washdata.org/). Price data are derived from published studies referenced in the manuscript. Unit prices are tabulated in online supplemental material.