Hands4health – Piloting and upscaling a systemic approach to hand hygiene, water quality and sanitation in primary health care facilities and schools not connected to functional water supply systems

Introduction and Objectives: The hands4health project (phase 1: 2021–2025; phase 2: 2026–2027) addresses water, sanitation and hygiene (WASH) in schools in Nigeria and Palestine and primary health care facilities in Burkina Faso and Mali, all lacking functional water supply systems. A systemic approach combines infrastructure improvements, management and monitoring, behaviour change, and stakeholder involvement to promote hand hygiene, water quality and sanitation. Methodology: Project phase 1 developed and piloted intervention along all 3 areas: WASH infrastructure: Regular handwashing stations and innovative gravity-driven membrane handwashing stations were installed and tested. Management and monitoring: Institutional involvement was strengthened through WASH FIT committees in health care facilities and Hygiene Clubs in schools, supporting chlorination, infrastructure maintenance and sanitation management. Behaviour change: Activities promoting handwashing for schoolchildren and health care staff were developed using the RANAS approach. Governmental stakeholders were identified from the onset of the project and continuously involved. Intervention effects on hand hygiene were assessed with a cluster-randomized control trial. Results and Discussion: Phase 1 achieved progress in infrastructure maintenance, water quality monitoring, institutional management and hand hygiene. Regular chlorination measurements continue in all four countries Palestine introduced a digital monitoring platform while Mali adapted its national “WASH in health care facilities guideline” with chlorination protocols. In Nigerian schools, regular preventive maintenance kept installed infrastructure functional beyond project end. Hygiene clubs now manage maintenance and cleaning of sanitation facilities in 26 project schools. In Palestine, water quality measurement and monitoring became a priority for local authorities. WASH FIT, a risk-based management and improvement framework became established in 48 project health care facilities in Mali and Burkina Faso. Handwashing with soap improved significantly among Nigerian schoolchildren while health care staff showed strengthened motivations and intentions, but structural obstacles persisted for performing handwashing at all recommended times. Phase 2 of the project consequently focuses on further strengthening stakeholder involvement and local ownership with the goal of having scalable models for other regions and countries. Nominated school hygiene club members in schools in Maiduguri and Jere are trained in preventive maintenance, chlorination and handwashing promotion and cascade their training to fellow teachers to cover entire schools with the activities. Monitoring and visualization tools of infrastructure needs and water quality are developed based on the needs and processes of local authorities. With the support of national WASH actors (Ministry of Health, WASH cluster), the “WASH in health care facilities national guideline” is rolled out in Mali. Integration with the ministry-led infection prevention and control trainings is the goal for Burkina Faso and Mali. Palestinian researchers are testing and piloting chlorination protocols for school water tanks and develop the respective lines in close coordination with Hebron directorate authorities. Conclusions: The underlying systemic approach proved to be an effective framework, and specific activities were successfully tested while greatly varying across the four countries. Flexibility here was key to success: different contexts required very different foci and national or local preconditions and needs must be known and met.