Global landscape of locally produced alcohol-based handrub in health care settings: a scoping review

Abstract

Background

Reliable access to alcohol-based handrub (ABHR) is essential for hand hygiene and infection prevention, yet many low- and middle-income countries (LMICs) continue to face supply constraints. A 2011 WHO global assessment demonstrated that WHO-recommended ABHR formulations produced locally at low cost, were well accepted by healthcare workers, but also highlighted persistent barriers, including challenges in procuring ingredients and dispensers and in ensuring adequate quality control. This review aimed to provide an updated global synthesis of evidence on local ABHR production in healthcare settings.

Methods

Following the Joanna Briggs Institute framework and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, we systematically searched Embase, Medline, and CINAHL from inception to 19 March 2025. Two reviewers independently conducted title-abstract screening, full-text screening and data extraction. Primary research articles reporting local ABHR production in healthcare settings in LMICs were eligible for data extraction and descriptive synthesis.

Results

Of 2343 articles screened, 31 studies from 19 countries were included (2006–2023). Over half (n = 18, 58%) were conducted during the COVID-19 pandemic; 22 described health-facility production and 9 described factory-level manufacturing. Of the 22 health-facility production studies, 12 (55%) used WHO Formulation 1 (ethanol-based) or modifications thereof. Pharmacists most commonly led production at the health-facility level. Only 6% (two articles) reported the source of alcohol, and less than half evaluated efficacy or organoleptic properties (13 and 12, respectively). Most funded studies relied on high-income-country (HIC) grants (17 of 24, 71%).

Conclusions

Local ABHR production remains infrequently reported in the literature, although publications increased during the COVID-19 pandemic. Heavy reliance on short-term, HIC-funded initiatives raises concerns about the long-term scalability and sustainability of local ABHR production in LMICs. Strengthening national regulatory capacity, quality-control laboratories, and sustainable financing is critical to maintain safe ABHR access beyond pandemic contexts, for resilient national supply chains and in-country quality control capacity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-026-01757-0.

Background

Alcohol-based handrub (ABHR) is a cornerstone of hand hygiene in health care and is included in the World Health Organization (WHO) Essential Medicines List [1]. In its 2009 Guidelines on Hand Hygiene in Health Care, WHO identified “system change”, ensuring reliable access to essential hand hygiene products and infrastructure, as a key component of the Multimodal Hand Hygiene Improvement strategy [2]. To support this, WHO developed guidance for local ABHR production, recommending two formulations (ethanol-based Formulation 1 and isopropyl alcohol-based Formulation 2) to facilitate affordable, safe, and context-appropriate supply [3].

Despite these efforts, access to safe and reliable hygiene products remains a major barrier in many settings. In 2019, WHO and United Nations Children’s Fund (UNICEF) reported that one in four healthcare facilities globally, and nearly half in sub-Saharan Africa, lacked basic water services [4], jeopardizing progress toward the United Nation’s Sustainable Development Goal (SDG) 6 (Clean Water and Sanitation), and SDG 3 (Good Health and Well-Being) [5]. The COVID-19 pandemic further strained these systems, leading to shortages of safe water and ABHR and the widespread circulation of substandard products [6–8], Water, sanitation and hygiene (WaSH), infection prevention and control (IPC) and universal health coverage (UHC) are closely interdependent, underpinning local resilience, whose priority was highlighted in the post-pandemic context.

In 2011, WHO global assessment of 34 healthcare facilities across 29 countries, including 23 low- and middle-income countries (LMICs) [9], demonstrated that WHO-recommended ABHR formulations could be produced locally at low cost and with good tolerability among healthcare workers, but also identified persistent challenges in procuring ingredients and dispensers and ensuring adequate quality control. More than a decade later, and despite the availability of WHO guidance and early successful pilots, no global synthesis has mapped how and where local ABHR production has been implemented. WHO has recently identified the need to understand approaches that support sustained system change as a high-priority research area for hand hygiene in health care [10, 11].

To address these gaps, we conducted a scoping review to provide an up-to-date global assessment of local ABHR production in healthcare settings, describe geographic and temporal trends, and identify factors influencing sustainability and quality assurance.

Methods

This scoping review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews and is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [12, 13]. A scoping review design was selected to map the extent, range, and nature of the evidence on local ABHR production, recognizing the heterogeneity of study designs and implementation contexts.

Eligibility criteria

We included primary research articles reporting the local production of ABHR within healthcare settings in LMICs. Country income levels were determined according to the World Bank classification system applicable at the time of each study’s publication [14]. Local production was defined as ABHR manufactured within the country where it was used, including production at facility, district, or national factory level.

We excluded studies that described ABHR production outside healthcare settings (e.g., community settings), studies conducted exclusively in high-income countries (HICs), and non-original publications (reviews, commentaries, letters), as well as animal studies, and non-English language publications. The review protocol was pre-registered and published in an open-source platform previously (Open Science Registries (OSF), 10.17605/OSF.IO/3KA54) [15].

Information sources

A literature search was conducted in Embase (Elsevier), Medline (Ovid), and CINAHL (EBSCOhost) from database inception to 19 March 2025. Reference lists of included studies and relevant WHO or institutional reports were reviewed to identify additional eligible publications. Grey literature was not systematically searched due to resource constraints and the focus on peer-reviewed evidence.

Search strategy

Search strategies were developed in collaboration with an experienced medical librarian and combined controlled vocabulary (e.g., MeSH, Emtree) with free-text terms related to hand sanitizer, alcohol-based handrub, local production, and manufacturing. No date or study-design limitations were applied. Full search strategies for each database, including record counts, are provided in Appendix 1.

Screening and selection

All records were imported into EndNote 21 for deduplication before being uploaded to Rayyan (https://www.rayyan.ai/) for screening. Two reviewers independently screened titles and abstracts, followed by full-text assessment against the inclusion criteria (HS, ET and JG). Disagreements were resolved through discussion or adjudication by a third reviewer. Full-text articles meeting eligibility criteria were included for data extraction. Reasons for exclusion at the full-text stage were documented. The overall selection process is presented in a PRISMA-ScR flow diagram (Fig. 1).

Fig. 1.

PRISMA flow diagram of a scoping review on local alcohol-based hundrub production

Data charting

Data were extracted independently by two reviewers using a pre-defined and pilot-tested charting form. Extracted variables included: study identifiers (country, year of publication, study period, study design), linkage to the COVID-19 pandemic, ABHR formulation type, production setting (facility-level or factory-level), professional cadres involved in production, evaluation of ABHR characteristics (e.g., efficacy, acceptability/tolerability, organoleptic properties), and funding sources. Any discrepancies in extracted data were resolved through consensus or third-reviewer arbitration. Consistent with JBI guidance, no critical appraisal of study quality was undertaken.

Synthesis of results

Extracted data were synthesized descriptively to map geographical distribution, temporal trends, production modalities, and evaluation practices related to local ABHR production. Frequencies and proportions were calculated using Microsoft Excel, and findings were summarized narratively and in tabular form.

Results

The literature search was conducted on March 19, 2025, yielding 3036 articles identified from the databases. After removing duplicates of 693 articles, a total of 2343 articles were reviewed for title-abstract screening, followed by 90 articles for full-text screening. Subsequently, 31 articles were selected for data extraction and synthesis (Fig. 1).

Characteristics of the eligible articles in the scoping review

The characteristics of the 31 eligible articles included in the scoping review was summarized in Table 1. The included studies spanned 2006–2023 across 19 countries and six WHO regions: Africa accounted for two thirds (n = 21, 67.7%), followed by Asia (n = 6, 19.4%) (Fig. 2). Nine articles were published before 2020 whereas 22 were published in 2020 or later: eighteen articles (n = 18, 58.1%) were relevant to the COVID-19 pandemic (Fig. 3). Seventeen articles (54.8%) were single-year studies. Approximately half of the articles (n = 16, 51.6%) were non-interventional studies, either cross-sectional design (n = 10) or descriptive nature/institutional report (n = 6), and the rest 15 articles were quasi-experimental studies. ABHR was produced at health-facility level in 22 articles (71.0%) and manufactured at factories in nine articles (29.0%), respectively. Among the articles of ABHR production at health-facility level, the WHO Formulation 1 (ethanol-based) including modifications was most commonly produced (12 out of 22, 54.5%), and pharmacists were the main profession in charge of the production (11 out of 11 articles reporting the profession, 100%), followed by laboratory technicians. The source of alcohol was rarely reported (two out of 31, 6.5%). The majority of the funded studies (17 out of 24 articles, 70.8%) were supported by grants from HICs.

Table 1.

Characteristics of the eligible studies of a scoping review on local alcohol-based handrub production

Author	Country	Study year	Impact of COVID-19	Study design	ABHR formulation	ABHR format	Efficacy evaluation	Organoleptic evaluation	Organoleptic characteristics	Health Facility produced vs Factory manufactured	Professions of the staff producing ABHR	Funding
Nigro et. al. [28]	Brazil	2020	Yes	Descriptive report of institutional experience	ABHR containing 70% ethanol concentration, according to the Brazilian Pharmacopeia National Form	Rinse, Gel	Yes	Yes	Appearance, Texture	Facility	Pharmacists, Pharmacy technicians	no specific funds
Müller et. al. [29]	Côte d'Ivoire	2018–2020	Yes	Quasi-experimental	WHO formulation 1	Rinse	Yes	No	n/a	Facility	Pharmacists, Laboratory technicians, Hygiene experts	Governmental (HIC)
Caniza et. al. [30]	El Salvador	2007	No	Quasi-experimental	ABHR following the local standard procedure (62% ethanol concentration, citrus aroma added)	Gel	No	Yes	Smell, Texture	Facility	Pharmacist	Philanthropic (HIC)
Pfäfflin et. al. [31]	Ethiopia	2016	No	Quasi-experimental	WHO formulations (details unknown)	not specified	No	Yes	Skin tolerability	Facility	not specified	Governmental (HIC)
Gebremicael et. al. [32]	Ethiopia	2018–2019	No	Quasi-experimental	WHO formulation 1	not specified	Yes	No	n/a	Facility	not specified	Governmental (HIC), Philanthropic (HIC)
Manaye et. al. [33]	Ethiopia	2020	Yes	Cross-sectional	Various types of ABHR from local vendors tested for efficacy (mostly ethanol based)	not specified	Yes	No	n/a	Factory	n/a (Commercial entities)	Academia (LIC)
Selam et. al. [34]	Ethiopia	2020	Yes	Cross-sectional	not specified	not specified	No	No	n/a	Facility	not specified	Governmental (LIC)
Selam et. al. [35]	Ethiopia	2020	Yes	Cross-sectional	not specified	not specified	No	No	n/a	Facility	not specified	no specific funds
Selam et. al. [23]	Ethiopia	2022	Yes	Cross-sectional	Various types of ABHR in market tested for content and efficacy	not specified	Yes	Yes	Appearance, Smell	Factory	n/a (Commercial entities)	Academia (LIC)
Müller et. al. [36]	Guinea	2017–2019	No	Quasi-experimental	WHO formulations 1	not specified	Yes	Yes	Appearance, Skin tolerability, Acceptance among HCWs	Facility	Pharmacists	Governmental (HIC)
Müller et. al. [37]	Guinea	2017–2019	No	Quasi-experimental	not specified	not specified	No	No	n/a	Facility	Pharmacists	Governmental (HIC)
Sharma et. al. [38]	India	2009–2011	No	Quasi-experimental	Modified WHO formulation: 95% ethanol (lower by 1% compared to WHO formulation 1), 3% hydrogen peroxide, glycerol, water, and rose extract	not specified	Yes	Yes	Appearance, Skin tolerability	Facility	not specified	Governmental (HIC)
Khurana et. al. [39]	India	2020	Yes	Descriptive report of institutional experience	WHO formulations 1 and 2 (isopropyl alcohol)	not specified	Yes	No	n/a	Facility	not specified	not reported
Tulsawani et. al. [40]	India	not specified	Yes	Descriptive report of institutional experience	73% isopropyl alcohol-based, herbal extracts (Aloe vera, Azadirachta indica, Citrus limon, Zingiber officinale/Ocimum sanctum)	not specified	Yes	No	n/a	Facility	not specified	Governmental (MIC)
Putri et. al. [41]	Indonesia	2014	No	Cross-sectional	WHO formulation 1	not specified	Yes	No	n/a	Facility	not specified	no specific funds
Rafizadeh et. al. [42]	Iran	2020	Yes	Cross-sectional	Various types of ABHR in market tested to meet standards by WHO and Food and Drug Administration guidelines	not specified	No	No	n/a	Factory	n/a (Commercial entities)	Academia (MIC)
Ndegwa et. al. [43]	Kenya	2012–2014	No	Quasi-experimental	ABHR with 75% alcohol concentration, using 99.8% isopropyl alcohol, 6% hydrogen peroxide, and 99% glycerol	not specified	No	Yes	Smell, Skin tolerability, Feeling on skin	Facility	Pharmacists	Governmental (HIC, MIC)
Ochwoto et. al. [44]	Kenya	2015	No	Cross-sectional	Various types of ABHR in market and hospitals tested for efficacy (mostly ethanol or isopropyl alcohol based)	Rinse, Gel	Yes	Yes	Appearance, Feeling on skin, Ease of use	Factory	n/a (Commercial entities)	Governmental (HIC, MIC)
Saab et. al. [24]	Lebanon	2021–2022	Yes	Cross-sectional	Various types of ABHR in market tested for content and quality	Gel, Spray	No	No	n/a	Factory	n/a (Commercial entities)	Academia (MIC)
Bausch et. al. [45]	Liberia, Guinea	2014–2016	No	Descriptive report of institutional experience	WHO formulation 1 (ethanol purchased from a local commercial entity)	not specified	No	No	n/a	Facility	Pharmacists, Laboratory technicians	Academia (HIC), Governmental (HIC)
Kachingwe et. al. [46]	Malawi	2020	Yes	Descriptive report of institutional experience	Modified WHO formulation 1	Gel	Yes	Yes	Texture, Skin tolerability, Feeling on skin	Facility	Pharmacists	not reported
Lee et. al. [47]	Malaysia	2021	Yes	Descriptive report of institutional experience	three ABHRs, ethanol-based (70–83% ethanol)	Gel	No	Yes	Appearance, Smell, Texture, Skin tolerability, Drying effect, Speed of drying	Factory	n/a (Commercial entities)	no specific funds
Allegranzi et. al. [18]	Mali	2006–2008	No	Quasi-experimental	WHO formulation 1 (ethanol produced in Mali from sugar cane)	not specified	No	Yes	Appearance, Smell, Skin tolerability	Facility	Pharmacists	UN agency, Academia (HIC), Governmental (HIC)
Fofanah et. al. [48]	Sierra Leone	2022–2023	Yes	Quasi-experimental	WHO formulation 1	not specified	No	Yes	Appearance, Smell, Texture, Skin tolerability, Feeling on skin, Ease of use, Drying effect, Speed of drying	Facility	Pharmacists, Physicians, Nurses	Governmental (HIC)
de Bruin et. al. [49]	South Africa	2020	Yes	Cross-sectional	Various types of ABHR in market tested for content, quality and safety (ethanol-based, propanol-based, or both)	Rinse, Gel	No	No	n/a	Factory	n/a (Commercial entities)	UN agencies
Berkkan et. al. [25]	Turkey	2020	Yes	Cross-sectional	Various types of ABHR in market tested for alcohol content (colognes containing ethanol 37.9% to 98.9% w/w)	Rinse	No	No	n/a	Factory	n/a (Commercial entities)	not reported
Ishida et. al. [21]	Uganda	2018–2022	Yes	Quasi-experimental	not specified	not specified	No	No	n/a	Facility	not specified	Governmental (HIC)
Saito et. al. [19]	Uganda	2014–2015	No	Quasi-experimental	ABHR locally made by a commercial entity, meeting international standards (Good Manufacturing Practice) (76.9 to 81.4 vol% ethanol, made from sugar care)	Rinse	No	No	n/a	Factory	n/a (Commercial entity)	Commercial
Tusabe et. al. [50]	Uganda	2019–2020	Yes	Quasi-experimental	WHO formulations 1 and 2 (isopropyl alcohol)	Rinse	No	No	n/a	Facility	Pharmacists, Laboratory technicians	Governmental (HIC)
Tusabe et. al. [22]	Uganda	2018–2023	Yes	Quasi-experimental	not specified	not specified	No	No	n/a	Facility	not specified	Governmental (HIC)
Gudza-Mugabe et. al. [51]	Zimbabwe	2015	No	Quasi-experimental	WHO formulation 1	not specified	Yes	No	n/a	Facility	not specified	Governmental (HIC)

ABHR, alcohol-based handrub; HIC, high-income country; LIC, low-income country; MIC, middle-income country; UN, United Nations; WHO, World Health Organization

Fig. 2.

Countries reporting local alcohol-based hundrub production

Fig. 3.

Number of publications by year of the eligible articles, categorized by the COVID-19 pandemic related vs not

Efficacy evaluation was reported for 13 articles (41.9%): of these, three (23.1%) explicitly mentioned attaining or overcoming the recommended threshold of a 5-log reduction in bacterial load, for bacterial agents commonly found as human colonizers or pathogens (Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, and/or Enterococcus hirae) [16]. Seven (53.8%) reported a significant reduction in bacterial load for pathogens belonging to Enterobacterales, Staphylococci and/or Micrococci, while the remaining three articles (23.1%) simply declared the efficacy of the locally produced formulation without reporting precise figures.

Organoleptic evaluation was conducted in 12/31 articles (38.7%): among these, the vast majority assessed skin tolerability/feeling on skin (9/12, 75.0%) and appearance (8/12, 66.7%) of the ABHR produced, around half of the studies evaluated smell (6/12, 50.0%) and texture (5/12, 41.7%), while only 2 studies (16.7%) assessed additional parameters such as ease of use and drying speed.

Discussions

The scoping review provides a global synthesis in more than a decade of local ABHR production within healthcare settings in LMICs. Thirty-one studies from 19 countries were identified, with more than half published during the COVID-19 pandemic. Although both facility-level production and factory-level manufacturing were reported, the overall volume of evidence remains limited relative to global need. This suggests that sustained access to ABHR, an essential IPC imperative, likely continues to pose challenges in many LMICs. The marked increase in production during the COVID-19 pandemic, reflects both the adaptive capacity of local systems under crisis conditions and the vulnerability of supply chains dependent on emergency-driven responses given the fact that the increase was only observed in response to the pandemic rather than during normal times.

Since ABHR was found to be effective in improving hand hygiene in health care [17], WHO has been advocating to improve “system change,” the first element of multi-modal improvement strategy, including local ABHR production at health-facility level. ABHR enables hand hygiene to be performed at point of care in healthcare setting, and has been shown to be effective in resource limited settings where access to soap and water is limited [18, 19], Therefore, access to ABHR is a key to successful hand hygiene promotion in LMICs. Historically, the needs for ABHR also surged during outbreaks, such as Ebola virus diseases in West Africa [20]. This scoping review has revealed that ABHR is now manufactured at factory level, using locally available ingredients, in addition to previously reported local ABHR production mainly led by pharmacists at health-facility level. Both types of local ABHR production were likely promoted during the COVID-19 pandemic, as studies relevant to the COVID-19 pandemic accounted for more than half of the articles included in this review.

However, more than half of the included articles were single-year studies, mainly cross-sectional studies, and most funded studies were supported by grants from HICs, risking the sustainability of local ABHR production, particularly given the post-COVID-19 pandemic period. The scoping review also reaffirms that pharmacists remain as a focal point for health-facility level production, and though some reported district-level approach, engaging multiple sites [21, 22]. the scalability and task-shifting may be a challenge. The predominance of pharmacist-led production confirms that existing pharmaceutical infrastructure remains central to implementation, yet scaling beyond institutional pilots is limited.

Quality control emerged as a persistent and critical gap. The 2011 WHO global assessment identified quality control as a major barrier [9], and this review reconfirms that challenge. Although a diversity of formulations and formats is now being produced, fewer than half of the studies conducted efficacy or organoleptic evaluations. Among those that did, reporting was often incomplete and rarely benchmarked against international standards. Concerns regarding the quality of ABHR available on the market, particularly during the COVID-19 pandemic, further highlight the need for robust, standardized quality assurance mechanisms [23–25]. Strengthening regulatory capacity, establishing national or regional quality-control laboratories, and implementing routine monitoring frameworks are essential to safeguard product quality, protect patient safety, and support national IPC programme goals. Improved reporting of local production efforts would also facilitate benchmarking, guide targeted investment, and ensure alignment with global action plans for hand hygiene [26, 27].

This review has limitations. First, only English-language, peer-reviewed studies were included; relevant evidence in the grey literature or in other languages may have been missed. Nevertheless, the systematic search across major databases supports the robustness of the evidence identified. Second, authors of primary studies were not contacted, and some details, particularly concerning production processes, cost, and quality-control approaches may be incomplete. Further research, ideally using global or regional surveys of IPC practitioners and ABHR producers, is warranted to capture operational realities, including financial structures such as external grant funding and domestic health finance, sustainability and scalability considerations, and organizational models at facility, district, and national levels.

Conclusions

Local ABHR production has expanded, particularly during the COVID-19 pandemic, yet remains inconsistently documented and largely dependent on short-term, externally funded initiatives. This scoping review highlights persistent challenges related to sustainability, scalability, and quality assurance, including limited reporting of efficacy testing and reliance on facility-based pharmacist-led production. Strengthening long-term, in-country capacity for quality-controlled ABHR production will require integration into national IPC programmes, incorporation into essential-medicine and supply-chain systems, establishment of robust monitoring and reporting mechanisms, and sustained regulatory oversight to ensure product safety and reliability.

Abbreviations

ABHR

Alcohol-based handrub

HICs

High-income-countries

IPC

Infection prevention and control

JBI

Joanna Briggs Institute

LMICs

Low- and middle-income countries

PRISMA-ScR

Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews

SDGs

Sustainable development goals

UHC

Universal health coverage

UNICEF

United Nations Children’s Fund

WaSH

Water, sanitation and hygiene

WHO

World Health Organization

Author contributions

HS designed the study. HS, ET, and JG performed literature screening, study selection and data extraction of the scoping review. HS conducted the descriptive analysis. HS drafted the first manuscript. All authors (HS, ET, JG, DP and BA) revised the manuscript for important intellectual content.

Funding

World Health Organization provided the funding.

Data availability

All data and materials generated during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The protocol of the scoping review was pre-registered at https://osf.io/3ka54. Ethics approval was not indicated as this study was a review of published articles.

Competing interests

HS previously received a research fund provided by Saraya East Africa Co. Ltd. An article funded by them was identified and included in the scoping review. ET and DP are Editors on the journal.