Good Practice Notes Issue no. 24 June 2012 PERU Clean Hands, Healthy Children A Handwashing Partnership Initiative I n 2004 when this JSDF project was approved, diarrheal diseases were one of the three main causes of morbidity and mortality for children under the age of five in Peru. About 2,000 children died every year due to this disease. Families learned to live with diarrhea. Not surprisingly, 25% of children had symptoms of malnutrition, with the poorest families being the most at risk. Furthermore, the second cause of death – respiratory infections – was also related to bacterial contamination. To address this issue also prevalent in other developing countries, a global Public- Mother washing her hands using the soap dispenser Private Partnership for The Handwashing Handwashing (PPPHW) promoted by the project. (Photo credit: Ana Cecilia Initiative (HWI) Gonzales Vigil) was launched with the presented a feasible participation of, among Development Objectives others, the World Bank, and effective solution UNICEF, USAID, and The development objectives of the project were: to the problem which the London School of (i) to reduce diarrheal disease and consequent had a high economic Hygiene and Tropical malnutrition by 20% in children under five in and social cost. Global Medicine, Centers for the targeted groups, by building capacity to Disease Control (CDC) increase the practice of handwashing utilizing evidence had recently (which participated research-based mass media communication confirmed that an in the design of the campaigns and IPC methodologies; and (ii) to appropriate practice monitoring and evaluation achieve long-term sustainability of handwashing of hand washing with framework that would practices by institutionalizing hygiene promotion measure behavior change programs in the health, education, water and soap, at critical times, and health impact), and sanitation sectors in Peru, and by securing the could reduce diarrheal three multinational soap future continuity of activities by private partners diseases between 47% companies. To join this (2004-05). effort, Peru’s Ministry of and 52%, and up to 50% Health issued a National of respiratory infections Handwashing Decree The Project in children under five in January 2004, to The project had three components: (1) Training promote the practice Partner Staff to Reach the Poor- This component of handwashing. A HW trained staff of Partner Agencies -- mainly Committee for Peru was health, education, and water and sanitation also formed at this time including the Swiss village workers and NGO staff in the project Development Cooperation, USAID, and the areas -- as members of the Peru PPPHW Bank’s Water and Sanitation Program (WSP). initiative. The training focused on behavior change methodology skills for practitioners when working with women and children to ensure they The Japan Social Development Fund (JSDF) was established in June 2000 by the Government of Japan and the World Bank as a mechanism for providing direct assistance to the poorest and most vulnerable groups in eligible World Bank group member countries. The World Bank Key Project Features for Success Box 1- Key Data Wide Range of Partnerships: •• Trust Fund #: TF 054228 Partnership was a key determinant of success for this •• Implementing Agency: PRISMA (Projects in Informa- project. A Public-Private Partnership had been organized tion, Health, Medicine, and Agriculture) with the leadership of the Ministry of Health and the •• Grant Amount: $848,446 participation of USAID, Swiss Development Cooperation, and the Water and Sanitation Program financed by the •• Implementation Period: 02/11/2005-09/09/2008 World Bank. Together they established the National Handwashing Committee (NHWC) that met regularly practice new behaviors, utilizing professionally-designed and had the mandate to draw the vision and develop a messages targeted to the poorest communities; program that would place handwashing as a prominent message in health promotion and hygiene. (2) Materials Development for Interpersonal The partnership included soap companies such as Communication (IPC)- The communication campaigns Colgate-Palmolive and Alicorp, and private media and materials utilized a standardized set of messages companies such as Radio Program of Peru, which had to achieve behavior change such as logos and not previously thought of targeting messages to the communications tools that were costumized to the poor. These private sector companies contributed their needs of the target individuals in local languages, in this knowledge and skill in marketing, communications, and case, Quechua and Aymara. The materials, the delivery consumer behavior to help develop the communications methodologies, and the coordination systems with the strategy. They also showed interest in working with NGOs line sector ministries and private sector partners and and learning to address segments of the markets they NGOs were provided to field workers. Furthermore, were not familiar with. From the government side, the to give backbone to the program, the methodologies Ministry of Health led the public sector commitment were developed in coordination with the Ministry of to this effort. Involvement of the public sector Health, linked to a certification/merit process; (3) facilitated institutionalizing the program for longer term Mass Media Communications- Creative mass media sustainability and scale-up nationally, for example by communication tools were developed for radio and including handwashing in the curriculum for hygiene. The television, adapted to behaviors based on field research, public-private-NGO partnership was innovative for Peru. and included Radio Soap Operas, Radio Talk Shows, and Promotion of Handwashing Contests, among others. Professional Communications Strategy: Delivery was through commercial channels as well as The professional design of the communications strategy private closed networks such as the national banks. included a focus on individual motivation utilizing private Municipalities were provided with the ads and the soap sector know-how, while NGOs provided extremely opera to be aired locally at their own expense; and valuable experience with direct contact communication (4) Project Management, Monitoring & Evaluation, and methodologies to reach the poorest segments of the Institutionalization- PRISMA, the Grant implementing targeted population. Attention had been given to an agency, reported to the national Peruvian PPPHW experience in Central America, where the private sector Steering Committee. A key activity of the PRISMA had provided its expertise on the design of well targeted team was to promote the institutionalization of the and effective communication campaigns that placed a handwashing process focus on the consumer. into the work of Learning about community-based triggers of motivation programs, especially was essential for among NGOs and line communication efforts sector ministries, thus to have an impact. ensuring sustainability With the support of of the practice. The the CDC in Atlanta, capacity of NGOs field research was and community carried out in Peru institutions to collect to learn about child- baseline health and bearing women’s handwashing practice perceptions and data was strengthened, motivation in health as well as their skills to and hygiene. observe and measure behavior change. Information Standardized global dissemination tools indicators were used to The Handwashing Project Cycle- a partnership for production, distribution, were designed to facilitate cross-country promotion and monitoring of activities that helped achieve results reach the targeted comparisons. audience through personal and mass media communication, developed through field research to ensure cultural sensitivity for 2 http://www.worldbank.org/jsdf the proper content and medium. All field agents had on how to use the kit materials and conduct an event. to acquire the skills to communicate the same effective The kit also included an overview of main messages and messages, and be able to motivate women to adopt the sample scripts for sketches. Radio spots and jingles proposed behavior. Thus, it was crucial to train village further emphasized the power of soap and water through workers to strengthen their communication skills, and at the SJ character which became endearing to children in the same time attempt to standardize quality messages. particular. To bring SJ to life, three 30-second radio spots Furthermore, health promoters who are commonly were developed. The radio spots were also designed to overloaded with tasks, had to be incentivized to deliver remind mothers of the four critical times to handwash the handwashing initiative messages. with soap. Another reinforcement of the message was the slogan developed and broadcast -- Manos Limpias, Intensity of Communications Interventions: Niños Sanos (Clean Hands, Healthy Children). IPC activities targeted two audiences: i) mothers via community-based workers, including health providers and community development volunteers; and ii) primary Results and Lessons school students via teachers. The IPC sessions focused on three key themes to affect behavior for handwashing Vertical or Integrated Initiative for Handwashing - with soap, and improve skills to manage soap and water: Although the HWI started as a free-standing project Motivation, Resources, and Knowledge. Sessions were in 2004, after the first couple of years it became clear delivered through front-line workers who convened that HWI would be integrated into the tasks of field small group meetings or workers because it offered visit mothers at home. value added to other programs. Mothers received two As implemented, HWI was a to three sessions, while catalyst to improve the impact students got three to six of health, education, and IPC sessions – teachers sanitation programs at the delivering IPC to children national level. followed the same content as for mothers but each Validated Standardized Training session was divided in half. Instruments Yield Results A child was considered - One of the most valuable reached if she/he attended project investments was the four of the six sessions. development of a behavioral change methodology to build The messages were capacities and standardize the enhanced through Direct approach by HWI promotion Consumer Contact (DCC) workers to be applied when events focused on the Street theather performers presenting ‘Super Jaboncin’ and the power instructing children and power of soap and water of soap in Piura province (Photo credit: Ana Cecilia Gonzales Vigil). mothers. The program received through the superhero a certification equivalency from character of Super Jaboncin (SJ). Research had revealed the Ministry of Health and validation from the Ministry of lingering misconceptions about HW, mainly the belief Education for instruction in primary schools. The manuals that rinsing hands in water was sufficient. To counter this produced provided a tool for teachers and health and belief, the project developed a communications concept sanitation field workers who rarely benefit from access to for mass media and DCC, featuring Super Jaboncín materials and often produce their own. who gains the power to fight germs by adding soap to water. The Superhero concept formed the basis of DCC Private Partners: Thinking Outside the Box - A events. A SJ handwashing dispenser was also promoted partnership building strategy was a key aspect of the by front-line workers to households and schools in seven project design which brought additional resources to regions, where they have been used by an estimated maximize outreach and knowledge expertise in fields 530,000 women and children. Demand for the dispenser outside the public sector such as marketing to reach in some areas outpaced supply and households began women at home or in their surroundings. Also, to the constructing an artisan “do-it-yourself ” version. Larger project’s advantage, the private sector got involved and DCC events were fairs with simultaneous activities taking over 60 private institutions supported the project in place, including games for children, live theater, and different regions of Peru. One that stands out is Belcorp, kiosks where demonstrations and advice on where to a Peruvian and Latin American cosmetics firm with about place soap and how to set up a handwashing station was 120,000 field agents in Peru alone. Each agent had 20 shared with mothers. clients that she/he visits every month. An agreement To facilitate implementation by various street theatre with Belcorp resulted in that all of their well trained door groups, a SJ kit was developed, which included: i) a to door agents, promoted handwashing with soap among superhero costume; ii) three games with large props low-income women they would visit every month, during to engage audience participation; iii) support materials a three month campaign period. It is estimated they (such as posters and comic strips featuring the reached nearly 2 million women. superhero) to distribute to the audience; and iv) a guide 3 The challenge of measuring impact while targeting sustainability - One important factor to keep in mind is that once the project is integrated into a bigger program, it is quite difficult to attribute direct impact. In Peru, while the project’s analysis of impact evaluation data was scheduled for the beginning of 2012, authorities at local and regional level had already attributed diarrhea reduction indicators to the HWI. Even when the data is gathered through monitoring mechanisms to determine project results, the public sector will rely on their own statistics to make policy decisions. Going to Scale and Sustainability Looking back, the HWI evolved early into a full scale program as it reached 24 regions after 2007. The initial stage set a strong platform of a strategy that was developed for full implementation. In 2007 a second Handwashing Day Celebration -Raising awareness of the practice phase of the HWI started thanks to additional funding and value of handwashing (Photo credit: Mariana Basso) received from the Bill and Melinda Gates Foundation. Altogether, the HWI has lasted 8 years, sliding through community development workers, and teachers. a learning continuum that took it from a pilot project to a component of nutrition, health promotion, and Ensuring Sustainability Through Handwashing Stations environmental and education programs being financed by – The project facilitated the creation and distribution the public and private sectors either at national or sub- of handwashing stations that would help sustain national levels in Peru. behavior change after the project ends. Over 57,000 Super Jaboncín soap dispensers were distributed free At the country level, an Enabling Environment was of charge throughout the country, with both public and designed to develop and strengthen the institutional private partners covering transportation, distribution, and and policy/strategy environment in which handwashing monitoring costs. These dispensers continue to be used with soap programs can be scaled up and sustained. in households, schools, health clinics, and private sector There were ten dimensions to facilitate sustainability: firms to increase easy access to soap and water and policy; strategy and direction; institutional arrangements; are, thereby, reducing a major access barrier to washing program methodology; implementation capacity; hands with soap. availability of products and tools; financing; cost- effective implementation; monitoring and evaluation; and partnership. These factors were monitored and reported Follow-on Project on once a year using a spider diagram. The project The Water and Sanitation Program from the World Bank fully completed the desired results under partnerships, has incorporated the program in sector projects, and will institutional arrangements, and the availability of continue to play a critical role in supporting national and products and tools. The Partnership for Handwashing is local efforts to promote handwashing at scale, through now operating at the national level with clear roles and operations in nutrition, health, and water and sanitation. responsibilities. In 2007 with the Bill and Melinda Gates funding, the HWI scaled up to 24 regions in Peru. Also in 2007, the HW Institutionalizing Approaches in the Ministry of project was started in Tanzania, Senegal and Vietnam. Education and Regional Governments - As designed, the project planned full integration of HWI messages and methodologies as part of the school curriculum. The Resources project strengthened the enabling environment conditions to sustain interventions beyond the end of the project. To know more about the WSP administered by the The facilitating agencies and regional coordinators played World Bank and its partners, go to: www.wsp.org/wsp a pivotal role in the intervention execution. They engaged and visit: www.globalhandwashing.org to have more partners to broaden the reach of the project and share information about PPPHW. tools that contribute to consistent messaging. They also trained master trainers, who in turn trained the IPC front- line workers—principally health care providers, local The Japan Social Development Fund -- JSDF Good Practice Notes seek to share achievements, knowledge and lessons learned from the implementation of JSDF projects over the past decade. The JSDF is a partnership between the Government of Japan and the World Bank to support innovative social programs that directly meet the needs of the poorest and most vulnerable groups in developing countries. JSDF projects meet four basic requirements: Innovative, introducing new approaches to development; Responsive to the needy, by directly meeting the needs of vulnerable, marginalized, and disadvantaged groups; Rapid response activities that deliver short-term results and benefits to targeted beneficiaries; and Community capacity building activities that empower local governments, NGOs, and disenfranchised groups, while promoting stakeholders participation and ownership.