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                                SOAP BOX

               The PPP for Handwashing Newsletter

The Handwashing Dream

Despite its strange sounding name, the PPP for HW has a simple aim; to get the
world to wash their hands. Handwashing is a practise that predates history.
Though the Phoenecians and the Ancient Greeks knew that it was healthy to
wash hands, it was left to Semmelweiss in the 1840s to explain why. He showed
that childbed deaths fell dramatically when assisting doctors washed their hands
between patients and he guessed that this was due to preventing the
transmission of `disease particles'. Since then, evidence for handwashing as key
to preventing the transmission of infection has mounted. Today, we know that
washing hands with soap could save perhaps a million live a year. Whilst the
major impact is on the diarrhoeal diseases, the latest research suggests that
handwashing can also cut rates of respiratory infection (1), one of the biggest
killers in the world today.

Since both soap producers and national Governments have an interest in seeing
citizens wash their hands with soap more often, it seems natural that they should
work together. Whilst the idea of getting the public and private sector to work
together sounds simple, like all good ideas, the devil lies in the detail.

Studies and more studies
The LSHTM has been contracted to work with the World Bank and the Water and
Sanitation Programme, the Governments of Ghana and Kerala and partners from
USAID, UNICEF and others to work out how to put the PPP for HW in place in
Ghana and Kerala. Being an academic institution, the LSHTM has proposed to
start with some studies. They have been researching the global soap market,
and the soap market in Kerala. They have also commissioned studies of what
people in Ghana and Kerala do and want concerning soap in their homes, to
understand the consumer perspective. Anne Thomas at the Bank has led a study
of the issues involved in constituting PPPs in the health sector. USAID has
contributed to the process by reviewing the lessons learnt from its work with the
private sector to promote handwashing in Latin America.

PPP study: What have we learnt?
The appeal of Public Private Partnerships in the health sector is rooted in the
fact that by pooling public and private resources, and capitalizing on
complementing skills of each sector (i.e. marketing and product development vs.
basic service delivery in established networks), there is an improvement in the
delivery and affordability of health services as well as positive changes in health

behaviours and programs. Today, PPPs in the health sector are most commonly
being used to 1) promote behaviors to reduce disease occurrence
(gastrointestinal, malaria, stds) 2) facilitate access to vaccines and treatments or
3) improve health services.

The experience of past PPPs for health have shown that key success factors are
governance, strategy, communications and monitoring. Obstacles are ensuring
the public health benefit, transparency and bridging public and private sector
cultures. Furthermore, there are issues of risk sharing, high transaction costs and
market distortion. Despite these challenges, lessons learned tell us that private
and public sector organizations can work together to support disease prevention
programs if they have a perceived mutual benefit, if the strategy employed
maintains an even playing field when promoting public health goods, if the public
sector is not seen to be giving an unfair advantage to one manufacturer and if
issues of supply and demand are dealt with simultaneously.

Global soap market study: What have we learnt?
Five big players dominate the US$88billion world soap and detergent market. In
order of size these are Unilever, Procter and Gamble, Colgate-Palmolive,
Johnson and Johnson, and the Kao Corporation of Japan. The market is
expected to grow by a huge 35% over the next three years as consumer
expectations rise. However, consumers in middle to low-income countries are
demanding cheaper formulations of soap, which is a challenge to all players,
both big and small. The big companies all sponsor social projects. Decision
making about these activities follows the same product category and regional-
head office chain as core business. Releasing substantial funds for the PPP-HW
may thus require contact at the highest level. Once business plans for Ghana
and Kerala are further developed, a global meeting, tentatively set for March
2002, is on the cards.


BASICS and EHP study: What have we learnt?
The following success factors from a joint BASICS and EHP activity, supported
by USAID, contributed to the success of the Central America handwashing
experience:
· Presence of catalyst. BASICS/EHP assumed the role of catalyst and
    brought the partners together.
· Good cause. A strong link between the public health goal ­ the good cause
    ­ and commercial interests.
· Road map. The "nautilus" model developed by BASICS.
· Behavioral research. The advertising strategy was based on the findings of
    market research that included information about the behavior and attitudes of
    the target population vis a vis the product and the key practice ­
    handwashing.
· Public health backing. The Initiative received the enthusiastic support and
    endorsement of ministries of health.

· Roles, responsibilities, expectations. A memorandum of understanding
    set out the roles and responsibilities of the partners to the Initiative, the goals
    of the effort, and the expected outcomes.
· Decision-making. Critical decisions were made jointly so that all partners
    felt ownership for the project.
· Timing and sequence. Soap producers were approached first, involved, and
    rapidly moved through the planning stage

Several unresolved issues that further experiences will help to shed light on:
· Dynamics of competition. Not all producers were happy with the
    arrangement to work with a group of producers vs. exclusively with one.
· Role of Task Force. Participation in the Task Force was good at the
    beginning of the Initiative but fell off precipitously at the beginning of the
    implementation phase.
· Measuring Impact. Measuring results for a project operating at the scale of
    this initiative was challenging.
· Sustainability. It will be interesting to see if the effort will survive the
    transition as BASICS/EHP withdraws from an active leadership role.

Rapid soap study
Jane Anderson, who is an MSc student at the LSHTM, spent the summer in
Kerala looking into soap use by families for her dissertation. In 100 families in
four regions, none had no soap at all, in fact most had two soaps and some
three. People almost always had a toilet soap for body washing and a bar of
detergent soap for clothes washing. Some had a third bar for washing dishes.
Though hand washing was infrequent, the toilet soap was the one reserved for
this. She calculated that current average per capita consumption of toilet soap
was 108g per month at a cost of 11.4Rs ($0.20) and the average per capita
consumption of clothes and dishwashing soap was 425 g, costing 19Rs or $0.40.
The average household size was 4.3 persons, giving a total average monthly
soap spend of 566Rs or about $11.00. In the rural areas men were the buyers of
soap, and bought the bars one-by-one as they were needed. Only in richer urban
areas did women buy the soap, often in larger quantities.

Activities and Progress:

Kerala: Soap Suds and Soap Stars
The idea of the PPP for handwashing has been welcomed by all and sundry in
Kerala. The Chief Minister is keen to make it the focus of his month of activities in
honour of Ghandi's birthday, the Secretary for Irrigation has offered his
unequivocal support (and his show business contacts). We realised that if
celebrities were involved this would have the important effect of attracting people
to, and motivating those involved in the initiative, even if it didn't directly get
people washing their hands! The Department of Health was planning a
handwashing programme in schools and now wants to set up a joint effort. A
steering committee has been formed, linking industry, via the Indian Soap and

Toiletry Manufacturers, and Government. They have agreed to the appointment
of a Project Manager to be funded jointly.

The Indian Market Research bureau (IMRB) made an excellent presentation on
how they would execute the consumer research and were appointed in
competition with two other agencies. Key staff were trained in July and the study
is about to go to the field.

Ghana: quick, quick, slow
Activities in Ghana progress at a slower rate. Terms of reference for the market
and consumer studies have been sent out to tender. A steering committee has
been formed and will meet in September. Progress is expected to accelerate with
the imminent appointment of a consultant Project Manager.

Globally, more work is still needed to constitute an effective steering committee
and to ensure better communication between partners.

Next Steps: from Commitment to Action
The work of generating enthusiasm and commitment has borne fruit over the first
six months of this project. There has been an astonishing level of support from all
and sundry: colleagues, individuals and institutions both public and private, both
in country and internationally. The next steps are to convert this enthusiasm into
real progress on the ground. Though the results of the studies are not all yet
available, work has begun on a business plan for the intervention in Kerala. The
programme will be designed to combine the mass media skills and channels of
industry coupled with the resources of Government. Learning from the pulse
polio programme, which achieved 98% coverage, we will craft a programme
which uses the skills, reach and resources of all sectors in Kerala.

The PPP for handwashing approach is likely to be extended to other countries.
BASICS is planning a programme in Senegal and UNICEF in Nepal. Other
countries that might join the initiative could include Yemen, Guatemala, Burkina
Faso and the UK.



(1) Ryan MAK, Christian RS, Wohlrabe J. Handwashing and respiratory illness among young
adults in military training American Journal Of Preventive Medicine 21: (2) 79-83 Aug 2001