The Story of a Successful Authors Camille Saadé Public-Private Partnership Massee Bateman in Central America Diane B. Bendahmane Handwashing for Diarrheal Disease Prevention 33513 United Nations Children's Fund The Story of a Successful Public-Private Partnership in Central America Handwashing for Diarrheal Disease Prevention Authors Camille Saadé Massee Bateman Diane B. Bendahmane The World Bank United Nations Children's Fund Group Recommended Citation Camille Saadé, Massee Bateman, Diane B. Bendahmane. The Story of a Successful Public-Private Partnership in Central America: Handwashing for Diarrheal Disease Prevention. Published by the Basic Support for Child Survival Project (BASICS II), the Environmental Health Project, the United Nations Children's Fund, the United States Agency for International Development, and The World Bank. Arlington, Virginia, September 2001. Credit Photo credits are as follows: Cover photo, page 47, Servicios Estrategicos; page 1, UNICEF/90-0008/ Ellen Tolmie; page 9, UNICEF/94-0948/Nicole Toutounji; page 15, Camille Saadé; pages 21, 29, 35, 55, Colgate Palmolive; page 67, UNICEF/Mainichi/Shinichi Asabe About the Publishers This document was supported by Basic Support for Institutionalizing Child Survival (BASICS II), the Environmental Health Project (EHP), The United Nations Children's Fund (UNICEF), and The World Bank. BASICS II and EHP are sponsored by the U.S. Agency for International Development, Bureau for Global Programs, Office of Health and Nutrition. BASICS II is conducted under the terms of Contract No. HRN-C-00-99-00007-00 by the Partnership for Child Health Care, Inc. Partners are the Academy for Educational Development, John Snow, Inc., and Management Sciences for Health. EHP is conducted under the terms of Contract No. HRN-I-00-99-00011-00 by Camp Dresser & McKee International Inc. and a consortium of specialized subcontractors. The views in this report are entirely those of the authors and do not necessarily reflect those of USAID, UNICEF, or the World Bank. This document may be reproduced if credit is properly given. Office of Health and Nutrition Center for Population, Health, and Nutrition Bureau for Global Programs, Field Support, and Research Website: http://www.usaid.gov/pop_health/ United Nations Children's Fund 1600 Wilson Boulevard, Suite 300 3 United Nations Plaza Arlington, Virginia 22209 USA New York, NY 10017 USA Tel: 703-312-6800 Tel: 212-326-7000 Fax: 703-312-6900 Fax: 212-303-7985 E-mail address: infoctr@basics.org E-mail address: pubdoc@unicef.org Website: www.basics.org Website: www.unicef.org The World Bank Group 1611 N. Kent Street, Suite 300 1818 H Street, NW Arlington, Virginia 22209 USA Washington, DC 20433 USA Tel: 703-247-8730 Tel: 202-477-1234 Fax: 703-243-9004 Fax: 202-477-6391 E-mail: info@ehproject.org E-mail address: books@worldbank.org Website: www.ehproject.org Website: www.worldbank.org Table of Contents Acknowledgments .............................................................................................................vii Acronyms .......................................................................................................................... ix Executive Summary ........................................................................................................... xi Chapter I Introduction: The Story of a Successful Public-Private Partnership ...................................... 1 The Concept ............................................................................................................... 2 The "Nautilus": An Approach to Public-Private Partnerships ........................................... 3 A Promising Opportunity ............................................................................................. 6 The Handwashing Initiative in a Nutshell ....................................................................... 6 Overview of the Document ........................................................................................... 8 Chapter 2 The Public Health Goal: Saving the Lives of Children ......................................................... 9 Diarrhea Morbidity and Mortality in Central America ..................................................... 10 The Burden of Diarrheal Disease ................................................................................ 10 Handwashing and Diarrhea Prevention ........................................................................ 10 Handwashing Not Commonly Practiced ...................................................................... 11 Private Sector Potential ............................................................................................. 12 Chapter 3 The Catalyst: Bringing the Partners Together ................................................................... 15 BASICS Prepares to Play the Role of Catalyst ........................................................... 16 Roles and Responsibilities ......................................................................................... 16 Activities .................................................................................................................. 17 Phase One: Conceptualizing the Initiative ............................................................... 17 Phase Two: Planning and Development ................................................................... 17 Phase Three: Implementation ................................................................................. 19 Phase Four: Assessment and Dissemination .......................................................... 19 Issues and Lessons Learned ..................................................................................... 20 Chapter 4 The Private Sector Partners: Merging Business and Public Health Goals ........................... 21 Commercial and Public Health Goals .............................................................................. 22 Profiles of Participating Producers .................................................................................. 22 A Non-Exclusive Partnership .......................................................................................... 23 Roles and Responsibilities ............................................................................................. 24 Activities of the Private Sector Partners ......................................................................... 25 Phase One: Conceptualizing the Initiative ................................................................... 25 Phase Two: Planning and Development ....................................................................... 25 S Phase Three: Implementation ..................................................................................... 25 T N Phase Four: Assessment and Dissemination .............................................................. 26 E T Issues and Lessons Learned .......................................................................................... 27 N O C F O E L B AT iii Chapter 5 The Public Sector and Other Partners: Joining Hands with the Soap Producers ................. 29 Targeted Groups ....................................................................................................... 30 The Public Relations Blitz .......................................................................................... 30 Activities of the Public Sector and Other Partners ....................................................... 31 The Follow-up Public Relations Event ..................................................................... 32 Issues and Lessons Learned ..................................................................................... 32 Chapter 6 Marketing Strategy Development: From Market Survey to Creative Concept ...................... 35 Consumer Research.................................................................................................. 36 Selecting the Market Research Agency .................................................................. 36 Designing and Testing the Questionnaire and Methodology ....................................... 37 Implementing the Survey ....................................................................................... 37 Results .................................................................................................................... 39 Diarrhea Prevalence and Detailed Analysis of Behaviors .......................................... 39 Overall Stages of Key Behaviors ............................................................................ 40 Key Attitudes and Constraints ................................................................................ 42 Media Usage ........................................................................................................ 42 Implications for the Soap Producers ........................................................................... 42 Advertising Strategy Development ............................................................................. 43 Advertising Brief ................................................................................................... 43 Selecting the Advertising Agency ........................................................................... 43 Developing the Communication Strategy ................................................................. 43 The Design Concepts ............................................................................................ 44 Issues and Lessons Learned ..................................................................................... 44 Chapter 7 The Advertising Campaign: The "How" and the "When"...................................................... 47 Description of the Generic Handwashing Campaign ..................................................... 48 Radio Spots .......................................................................................................... 48 Television Spots .................................................................................................... 48 Posters ................................................................................................................. 49 Strategy for Implementation ....................................................................................... 49 Campaign Activities--March 1998 to April 1999 .......................................................... 50 Activities in Costa Rica ......................................................................................... 50 Activities in El Salvador ........................................................................................ 50 Activities in Guatemala .......................................................................................... 51 Continuing Project Activities ...................................................................................... 52 Issues and Lessons Learned ..................................................................................... 53 Chapter 8 Results: Return on Investments ...................................................................................... 55 S Methods for Assessing Results ................................................................................. 56 T N Follow-up Market Survey with Beneficiaries ............................................................ 56 E T Interviews with Partners ......................................................................................... 56 N O C F O E L B AT iv Results .................................................................................................................... 56 Exposure to the Campaign ..................................................................................... 56 Handwashing Behavior .......................................................................................... 57 Attitudes Toward Handwashing and Soap ................................................................ 57 Public Health Impact in Guatemala ......................................................................... 58 Long-term Effects ................................................................................................. 59 Other Key Findings ................................................................................................ 59 Resources Leveraged................................................................................................ 59 Soap Producers' Evaluation of Results ....................................................................... 61 Sustainable Change Among Partners ......................................................................... 63 Effect on the Private Sector ................................................................................... 63 Effect on the Public Sector and Other Partners ....................................................... 63 Issues and Lessons Learned ..................................................................................... 64 Chapter 9 Key Steps for Replication ............................................................................................... 67 Costs Versus Benefits ............................................................................................... 68 Key Steps for Replication .......................................................................................... 68 Issues ...................................................................................................................... 72 Critical Success Factors ............................................................................................ 73 Boxes Past Experiences with Public-Private Partnerships for Child Health ..................................... 3 Sample Studies of the Effectiveness of Handwashing ...................................................... 11 Task Force Responsibilities of the Soap Producers .......................................................... 24 The Public Relations Brochure ....................................................................................... 31 Advertising Slogan and Logo .......................................................................................... 43 Summary of the Handwashing Initiative Communication Strategy ..................................... 44 Burbujita, the Mascot of the Handwashing Initiative ......................................................... 48 The Generic Poster ........................................................................................................ 49 Protex Handwashing Poster: An Adaptation of the Generic Campaign ................................ 52 Protex Handwashing Promotion: A Program Targeting Schoolchildren ................................ 53 Estimates of the Health Impact of the Handwashing Initiative in Guatemala ...................... 59 Figures Figure 1. The Nautilus .................................................................................................... 5 Figure 2. Handwashing Initiative Time Line ....................................................................... 6 Figure 3. The Effectiveness of Interventions to Prevent Diarrhea ..................................... 11 Figure 4. Diarrhea Prevalence Among Children by Handwashing Behavior Stage of Surveyed Mothers, 1996 (all four countries) ........................................ 41 Figure 5. Moving Families Up the Handwashing Steps .................................................... 42 Figure 6. Generic vs. Branded Campaign Expenditures in 1998 ........................................ 51 Figure 7. Stages of Handwashing Behavior in Guatemala, 1996 and 1999 ........................ 58 Figure 8. Diarrhea Prevalence Among Children by Handwashing Behavior Stage of S T Surveyed Mothers in Guatemala, 1996 and 1999 .............................................. 58 N E T N O C F O E L B AT v Tables Table 1. Socioeconomic Targeting of Soaps .................................................................. 22 Table 2. Products and Markets of Participating Producers .............................................. 23 Table 3. Campaign Activities of Participating Producers ................................................. 26 Table 4. Contributions of Public Sector and Other Partners ............................................ 33 Table 5. Framework for the Market Survey .................................................................... 36 Table 6. Focus of the Market Survey ............................................................................ 38 Table 7. Observed Handwashing Technique: Percentage of Caretakers with Good Reported Practices and Strength of Association with Lack of Diarrhea in Children under Five in the Household, 1996 .................................................. 39 Table 8. Handwashing Occasions: Percentage of Caretakers with Good Reported Practices and Strength of Association with Lack of Diarrhea in Children under Five in the Household, 1996 ................................................................... 39 Table 9. Handwashing Place: Percentage with the Necessary Elements Present at the Usual Place of Handwashing in the Household and Strength of Association with Reduced Prevalence of Diarrhea among Children under Five in the Household, 1996 ................................................................... 40 Table 10. Percentage of those Possessing and Using Soap, Guatemala, 1996 .................. 40 Table 11. Handwashing Behavior Stage of Surveyed Mothers, 1996 (all four countries) ...... 42 Table 12. Exposure to the "Lavo Mis Manos por Salud" Campaign .................................... 57 Table 13. Catalyst Expenditures, 1996-1999 ................................................................... 60 Table 14. Leveraged Resources, 1998-1999 .................................................................... 60 Table 15. Costs and Benefits for Partners in the Handwashing Initiative ............................ 69 Table 16. Key Steps for Replication ................................................................................ 70 Annexes Annex A. The Convenio ................................................................................................. 75 Annex B. Persons Interviewed ....................................................................................... 81 Annex C. Statistical Calculations for Estimates of the Health Impact of the Handwashing Initiative in Guatemala .................................................................................... 83 S T N E T N O C F O E L B AT vi Acknowledgments T he authors gratefully acknowledge the will simply thank their organizations for contributions of the partners in the participating and continuing to use the Initiative and those who further Initiative as a model: Colgate-Palmolive, contributed to the documentation of our FUNDAZUCAR, La Prensa Libre, La Popular/ experience. Documenting the partnership was PROFISA, the ministries of education in itself a partnership among UNICEF, the World Costa Rica and El Salvador, the ministries of Bank, and two USAID Projects--EHP and health in Costa Rica, El Salvador, and BASICS II. Guatemala, NGOs and PVOs such as CARE We wish to express our appreciation first and World Vision, the Office of the First Lady for the individuals who embraced our approach of Costa Rica, Punto Rojo, TCS, Teletica, to building public-private partnerships and television channels 3,7,11, and 13 in who were willing to commit their time and Guatemala, Unisola/Unilever, and USAID and resources to document it and allow its dis- its missions in El Salvador, Costa Rica, and semination to a wider audience: Rita Klees, Honduras. Jennifer Sara, and Joana Godinho from The World Bank and Lizette Burgers and Vanessa About the Authors Tobin from UNICEF. Both organizations pro- Camille Saadé vided support that made this publication Camille Saadé is the public-private partnership possible. We also benefited from the thought- coordinator at the Academy for Educational ful reviews and technical comments of a wide Development (AED), who works with the spectrum of colleagues, including the above- BASICS II and NetMark projects. Mr. Saadé mentioned colleagues from the World Bank has developed and led the implementation of a and UNICEF, Hans Spruijt from UNICEF/ methodology for mobilizing the commercial Nepal, Paul Ickx and Renata Seidel from sector in mutually beneficial partnerships for BASICS II, Lisa Nichols and Frances Tain sustainable interventions, such as the preven- from EHP, and Valerie Curtis from the London tion of malnutrition, malaria and childhood School of Hygiene and Tropical Medicine. illness, promotion of health-enhancing behav- Special thanks go to Karen Steele, who iors, hygiene education, and increasing the conducted post-intervention interviews with supply and demand for appropriate treatments. key players in the Handwashing Initiative from Prior to joining AED, Mr. Saadé spent 20 the public, private, donor, and NGO sectors. years working in the pharmaceutical industry We are especially grateful to Frances Tain in different marketing and management at EHP who cheerfully managed the whole positions in several international operations documentation process, coordinated the with J&J, Upjohn, and Schering-Plough. planning among the four organizations, and Mr. Saadé is the co-author of the kept the authors on schedule. publication Mobilizing the Commercial Sector A warm thank you to our BASICS II for Public Health Objectives. He was the colleagues Kathleen Shears, for her patient editor of the former quarterly Social Marketing copy editing, and Kathy Strauss, for layout Matters and has taught a course on social and design. marketing at Boston University since 1997. S T Finally, we thank all the partners in the N E Central American Handwashing Initiative who Massee Bateman M G created together and contributed to the Massee Bateman is the director of the D E experience reported here. The individuals Environmental Health Project. His career has L W involved are too numerous to mention, so we been dedicated to environmental health, O N K C A vii disease prevention, and child survival issues. obtained a diploma in tropical medicine and He has 18 years of experience in public health hygiene from the Liverpool School of Tropical and medicine; 16 years in international public Medicine and Hygiene. health; and field experience in Antigua and Barbuda, Bangladesh, Bolivia, the Dominican Diane B. Bendahmane Republic, El Salvador, Ghana, Guatemala, Diane B. Bendahmane is a writer and editor Honduras, India, Indonesia, Nicaragua, Peru, with extensive experience in publications on Thailand, Uganda, and Zambia. Before joining development assistance. Previously she was EHP, Dr. Bateman held positions as child technical director for information services for survival advisor on the USAID management the Environmental Health Project (1994­2000) team for the BASICS I child survival project, and for its predecessor, the Water and epidemiologist and acting director, Community Sanitation for Health (WASH) Project (1989­ Health Division, International Center for 1994). She has carried out writing and editing Diarrheal Disease Research, Bangladesh, and assignments for the Inter-American was the associate director for environmental Foundation, the World Bank, the United health in the WASH Project in the early 1990s. Nations Foundation, the Foreign Service Dr. Bateman is the author or co-author of Institute, Appropriate Technology International, 20 some publications on hygiene behavior, and the Carnegie Endowment for International water supply and sanitation, family education, Peace. Her interest in development grew from acute respiratory infections, HIV/AIDS and in- her experiences as a Peace Corps volunteer fectious diseases, nutrition, and reproductive (1966­68) and staff member (1969­1971) in health. He received his degree in medicine Morocco. from the University of California and later S T N E M G D E L W O N K C A viii Acronyms BASICS Basic Support for Child Survival CARE Cooperative for Assistance and Relief Everywhere DHS Demographic Health Surveys EHP Environmental Health Project INE Instituto Nacional de Estadística MOE Ministry of Education MOH Ministry of Health NGO nongovernmental organization ORS oral rehydration salts ORT oral rehydration therapy PAHO Pan American Health Organization PRITECH Primary Health Care Technologies (USAID project) PVO private voluntary organization TCS Telecorporación Salvadoreña UNICEF United Nations Children's Fund USAID United States Agency for International Development S M Y N O R C A ix Executive Summary The Project (principally ministries of health) would find it T he Central American Handwashing mutually beneficial to work in partnership to Initiative aimed to reduce morbidity achieve complementary goals in promoting and mortality among children under handwashing for public health. Soap five through a coordinated communication companies would use new messages and campaign promoting proper handwashing with methods of advertising soap designed to soap to prevent diarrheal disease. The reach groups with low socioeconomic status Initiative was conceived and facilitated by the in rural areas where diarrheal disease rates United States Agency for International were high. These efforts would help each Development (USAID) through two of its company increase sales and enhance its projects: Basic Support for Institutionalizing corporate image. The public sector would Child Survival (or BASICS) and the endorse the promotional campaign, assist in Environmental Health Project (EHP). dissemination, and collaborate in special The Initiative took place from 1996 to interventions--such as distribution of 1999. The facilitator, or "catalyst" (the two handwashing kits. The partnership would projects) contacted soap producers from five provide the public sector with new resources. Central American countries--Guatemala, The Approach Costa Rica, El Salvador, Honduras, and Nicaragua. Four companies eventually The Handwashing Initiative followed a 14-step launched handwashing promotion campaigns approach developed and used by BASICS in in 1998 in the first three countries. Ministries other public-private partnership interventions. of health and education, media companies, These steps fall into four distinct phases: UNICEF, nongovernmental organizations (NGOs), and foundations also joined the s Conceptualization. The catalyst partnership. The campaign consisted of radio organization (usually a donor or NGO) and television advertisements, posters and identifies a public health goal that can be flyers distributed by sales personnel and married with private sector objectives as through mobile units to communities; school, the basis for a public-private partnership. municipal, and health center programs; It also assesses the potential market for distribution of soap samples; promotional the related product or service, tests the events; and print advertisements. interest and capabilities of companies According to a follow-up assessment, ten producing the product, and selects the percent of the women surveyed improved their companies to participate. The companies, handwashing behavior. Based on observed in turn, conduct their own feasibility relationships between handwashing behavior studies before deciding to participate. and diarrhea in these studies and supporting s Planning and development. The scientific literature, one can also estimate that partnership is formalized through a over the course of the intervention there was memorandum of understanding and an overall reduction in diarrheal prevalence of formation of a task force to guide the Y about 4.5 percent among children under five. effort. The companies develop a general R A (See Chapter 8 and Annex C.) marketing plan, which is later fleshed out M based on market research. The research M U S The Concept findings are used to create an advertising E The effort was based on the belief that private and communication strategy. Then the VI T commercial firms and public entities task force reaches out to involve the U C E X E xi public sector and other organizations on the order of 35 percent may be expected (such as media companies, NGOs, (see Chapter 2). Yet in spite of its beneficial donors, and foundations), and this effects, handwashing is not commonly expanded partnership plans the practiced or is ineffective because it is done campaign. without soap or not at the most crucial times. s Implementation. The advertising campaign is launched. As it unfolds, The Catalyst Activities participants monitor implementation and The role of the catalyst was to bring the look for opportunities to expand and partners together, facilitate the work of the improve it. partnership's Task Force, finance a market s Assessment and dissemination. After a survey and development of an advertising specific period of time agreed upon in concept, and provide technical assistance in advance (a year in the case of the designing and implementing the campaign Handwashing Initiative), an assessment strategy. is conducted using essentially the same In the Central American Handwashing instrument used to collect baseline data. Initiative, the catalyst made preliminary visits The analysis is incorporated into the to soap manufacturers in the region to gauge marketing strategy, and results are their interest in the proposed project, brought disseminated to guide continuation or those interested together in an organizational expansion of the campaign and other meeting, and facilitated the writing of a efforts. memorandum of understanding. The catalyst also formed a Task Force and called and led The approach varies depending on periodic meetings. It helped the market circumstances. For example, it may be more research and advertising firms develop a appropriate or even necessary for the catalyst sound advertising strategy, worked with the to involve public sector organizations first, producers in each country to enlist the rather than beginning with the private support of additional partners, and maintained companies. In the Handwashing Initiative, liaison with USAID missions in the target where no permissions or licenses--and thus countries. BASICS provided expertise in no government approval--were needed, the marketing and EHP in research and quality private companies preferred to postpone the control of the campaign's health-related involvement of the public sector until a messages. creative concept had been developed. This report is part of the catalyst's assessment and dissemination activities that The Public Health Goal began with a follow-up market survey to Diarrhea is a serious disease among children monitor the effects of the campaign and in developing countries, causing an estimated continued with presentations to many 2.2 million deaths per year among those under organizations to share the results and lessons five, contributing to malnutrition, and learned. The report aims to provide enough increasing the severity of other childhood detail about the experience in Central America diseases. At the time of the intervention, for project managers to understand what might UNICEF's State of the World's Children (1995) be involved in carrying out such an effort. Y R reported that diarrhea was the cause of 45 A M percent of under-five mortality in Guatemala The Private Sector Partners M and 20 percent in El Salvador. The five soap companies that joined the U S Handwashing has been documented as an Initiative were La Popular and the E VI effective means of preventing diarrhea if is it multinational Colgate-Palmolive in Guatemala, T U done properly at appropriate times. Reductions Unisola/Unilever (another multinational) in El C E X E xii Salvador, Punto Rojo in Costa Rica, and which distributed materials in many small Corporación Créssida in Honduras. Four of towns and villages. Colgate-Palmolive initially these companies eventually launched supported the efforts of UNICEF, NGOs, and campaigns. (The Honduran firm had to drop foundations and later organized a public out at the last minute because of financial relations event. Radio, television, and press problems and the effects of Hurricane Mitch. organizations stepped forward and donated The two Nicaraguan soap producers had time and space for advertising. expressed interest but were unable to commit Despite the formal conclusion of the to the Initiative at that time.) BASICS/EHP intervention in 1999, several of Each firm assigned its marketing director the companies continued their own or an official with similar responsibilities to the handwashing promotion. Colgate-Palmolive Initiative's Task Force, which met seven times launched a school program reaching 450,000 and made important decisions about the children regionwide and is using the creative development of the marketing strategy, concepts of the Initiative to advertise its best- selection of the market research firm and selling brand, the antibacterial hand soap advertising agency, scope of the market "Protex." Unisola/Unilever is working with the survey, and design of the campaign. Once the Ministry of Health and BASICS to respond to creative advertising concepts had been the threat of cholera in El Salvador. And at the developed, the companies joined with the public relations event in April 2000, the catalyst in contacting ministries of health, Guatemalan Ministry of Health and media organizations, UNICEF, nongovern- commercial partners in Guatemala presented mental organizations, and others to expand plans for continuing activities through 2003, the partnership. They were able to attract mainly through the MOH National Plan for considerable support for the campaign. Healthy Schools and Municipal Health Which soap to advertise was an issue for Promoters. the producers. It was not financially feasible for any of the companies to develop a hand The Market Survey soap specifically for the campaign. On the The market survey financed by the catalyst other hand, those with multipurpose soaps-- was conducted by Generis Latina, a firm the bola used for laundry as well as personal based in Guatemala. Local surveyors care--did not want to limit the positioning of contacted 4,500 households in lower these products to handwashing. Those socioeconomic strata in the four countries and companies tended to use the basic asked mothers to answer about 50 questions advertisements created by the advertising and give a demonstration of handwashing. agency, simply adding the logo of a brand of Questions covered socioeconomic and laundry soap. The two major multinationals, on household characteristics, water availability the other hand, adapted the handwashing and use, handwashing, soap use, attitudes messages to their existing brand advertising. toward handwashing, and diarrheal The campaigns varied widely. In El prevalence. Salvador, Unisola/Unilever worked with the Times and technique are crucial in Ministry of Health to complement and handwashing for diarrheal disease prevention. strengthen its program for Healthy Schools. In Hands must be washed at a minimum of three Y Costa Rica, Punto Rojo leveraged critical times: (1) before cooking or preparing R A considerable support from the media. Teletica food, (2) before feeding a child or eating, and M (the major television station), matched the (3) after defecation, cleaning a baby, or M U producers' paid advertisements one for one. changing a diaper. The three elements of S E La Popular's efforts in Guatemala were highly proper technique are to use water and soap, VI T integrated with the activities of its sales force, rub one's hands together at least three times, U C E X E xiii and dry them hygienically (e.g., with a clean critical times. The theme was "Manos limpias, towel or by air drying). evitan la diarrhea" (Clean hands prevent The survey showed that only nine percent diarrhea), and the slogan was "Lavo mis of those surveyed were in the "optimal" manos por salud" (I wash my hands for handwashing group. These people health). The basic approach was to present a demonstrated all three elements of proper mother as caretaker of the family and to technique and reported washing at all three describe or illustrate the three critical times critical times. Sixty-five percent were in the and essential aspects of handwashing "inadequate" group. (Their technique was technique. The advertisements were upbeat, inadequate and/or hands were not washed at using popular music and actors in contexts any of the critical times). The remaining 26 familiar to the target population. percent were in the "intermediate" group, reporting adequate technique but at only one The Results or two of the critical times. Because of the The market survey was repeated in importance of correct handwashing behavior, Guatemala a year after the campaign had the goal of the campaign was to move more been launched, with a few additional mothers out of the inadequate group and into questions about exposure to the campaign. In the intermediate and optimal groups. If Costa Rica and El Salvador, smaller follow-up technique is deficient, then handwashing is surveys were used mainly for tracking and to ineffective, no matter how many times a day provide information for further development of hands are "washed." The fact that there was the campaign. room for improvement among 91 percent of mothers surveyed indicated that there was a Key Results in Guatemala wide scope for the campaign (and a s Handwashing behavior improved. Ten significant market potential for the soap percent of mothers moved out of the producers). inadequate handwashing group into either The survey also confirmed the expected the intermediate or optimal group. association between handwashing and s Diarrheal disease can be postulated to diarrheal disease: the better the handwashing have decreased. Based on observed practices of mothers, the lower the rate of relationships between handwashing reported diarrhea among children under five behavior and diarrhea in these studies during the previous two weeks. Diarrhea and supporting scientific literature, one prevalence rates were 7 percent for the can estimate that over the course of the optimal group, 15 percent for the intermediate intervention there was an overall reduction group, and 21 percent for the group with in diarrheal prevalence of about 4.5 inadequate handwashing practices. percent among children under five. (See Chapter 8 and Annex C.) The Creative Communication Concept Regionwide Results The catalyst hired Servicios Estrategicos, an s Catalyst activities leveraged significant advertising agency based in Guatemala, to resources for public health. Together develop the campaign's creative concepts BASICS and EHP allocated Y R based on the survey results and the approximately $389,000 to the A M Initiative's goals, and to prepare generic Handwashing Initiative, which made it M materials for the producers to use or adapt. possible for the soap companies and U S The overall concept was based on the other organizations to carry out E VI "how" and the "when" of handwashing: the promotional activities worth an estimated T U three elements of correct technique and three value of $614,900 during the first year of C E X E xiv the campaign. (It has not been possible to for fear of being left out. An exclusive estimate contributions in subsequent agreement with one company might have years.) prompted a greater effort. s Soap company sales increased. Although s Measuring impact. Because it is the soap companies provided no specific impossible to have a control group, a information, producers implied that sales project operating at the scale of the had increased in areas where project Initiative cannot measure health impact activities had taken place. Producers through an experimental design that were hesitant to share information such allows for ironclad conclusions. The as sales figures with the Task Force involvement of an ever-widening group of because the group was composed participants and more and more varied principally of their competitors. activities also presents challenges for s Sustainable changes achieved among evaluation. partners. Private companies learned new s Feasibility of handwashing intervention. approaches and techniques for soap Environmental constraints, such as promotion and about the potential for limited access to water or affordable working in collaboration with the public soap, may threaten the feasibility of a sector, media, and donor organizations. handwashing campaign. Public sector involvement in the s Sustainability. It is encouraging that campaign led to increased competence of activities inspired by the Initiative personnel in handwashing promotion, continue. Nevertheless, the end of improvements in hygiene programs catalyst involvement has left a void. Time through the contributions of the private will tell whether involved firms will sector, and creation of new associations incorporate elements of the campaign in and networks. their soap advertisements in the long run s Experience disseminated to other and whether ministries of health will countries through the channels of continue their support for the campaign. multinationals. Subsidiaries of multinationals reported the success of the Critical Success Factors intervention to their headquarters, which The following factors proved to be essential to in turn disseminated the news to their the Initiative's success: other subsidiaries, creating opportunities for replication. s Presence of a catalyst. Members of the partnership said that the public and The Outstanding Issues private sectors could not have been More experience with the public-private brought together without the catalyst. In approach used in the Central American addition, the catalyst brought to the table Handwashing Initiative may shed light on the expertise in marketing, public health, and following unresolved issues: behavioral research; financed the all- important market survey and advertising s Collaboration versus an exclusive concepts; and assigned a local agreement. The Initiative invited all coordinator to monitor activities. Y interested soap producers to join, in the s Behavioral research. The market survey R A interest of equity and campaign scope. provided information that was vital to M However, some producers, preferring designing the advertising strategy and a M U exclusivity, were not comfortable working baseline for measuring progress in S E with their competitors. Some later claimed changing behaviors and attitudes and VI T that they participated only "defensively," bringing about health improvements. U C E X E xv s Public health backing. The Initiative to what resources the soap producers received the enthusiastic support and were to provide. A too-specific document endorsement of ministries of health in El would not have been in keeping with the Salvador and Guatemala. This support voluntary nature of the Initiative. reassured the soap producers that they had made a wise decision in participating The success of the Handwashing in the campaign. Initiative has been attributed to the s Road map. The catalyst used a well- enthusiastic support of the concept by the defined approach to public-private soap producers and the availability of flexible, partnership. This gave all partners a clear timely, technical assistance to keep the idea of the sequence of events and project moving along. It is hoped that the helped keep the Initiative on track. experience in Central America will be s Roles, responsibilities, expectations. A replicated in other countries as a component memorandum of understanding set out the of integrated programs to prevent diarrheal roles and responsibilities of the partners, disease and that it can be used as a model the goals, and the expected outcomes. for private sector involvement in other public The document was fairly open-ended as health areas. Y R A M M U S E VI T U C E X E xvi Chapter 1 Introduction The Story of a Successful Public-Private Partnership T his chapter orients the reader to the Handwashing Initiative by... I Explaining the concept behind the Initiative. I Reviewing the approach used to plan, implement, and assess the Initiative. I Telling the story of the Initiative--in abridged form. I Giving a time line of activities. I Describing the contents of the rest of the chapters. 1 T he Central American Handwashing Initiative was a partnership of private and public sector organizations working to promote the use of soap for handwashing to reduce diarrhea-related morbidity and mortality among children. The Initiative was based on the belief that private sector companies can positively influence consumers' health- related behaviors, while at the same time increasing their market share of key products. Private sector involvement in public health can leverage funds to reach those in need, as one component of a comprehensive public health strategy. The effort received funding from the United health-related products and services. But States Agency for International Development these NGOs, in turn, rely on limited funds for (USAID) through two of its projects: BASICS their operations. (Basic Support for Institutionalizing Child Throughout the world, the commercial Survival) and the Environmental Health sector has managed to reach people at all PI Project (EHP). From 1996 to 1999, these socioeconomic levels with a wide array of H S projects served as the catalyst for the products and services through consumer-driven R E Initiative--mobilizing support from private marketing. These manufacturers, distributors, N T soap companies, ministries of health and and marketers work within vibrant distribution R A education, media organizations, donors, and and promotional networks that are effective in P nongovernmental organizations (NGOs). reaching and motivating consumers. Successful E T A This report tells the story of the Initiative, companies also have a highly developed VI documents its successes and challenges, capacity to influence customer behavior in the R P- and offers lessons learned to guide future most cost-effective ways. CI activities in Central America, as well as Normally, the public and the private L B similar programs in other regions. sectors work independently, and donors and U P ministries of health have made only limited L U The Concept efforts to seek partnerships with commercial F S Making a widespread and lasting impact on firms. Public-private partnerships have the S E public health is a challenge for all in the potential to reinforce and expand the C C international health community. In many capabilities of donors and ministries of health U S developing countries, the number of public and to increase the use of essential products A health problems continues to grow, while the in a sustainable and efficient way. F O resources available to address them become For public-private partnerships to work, Y more constrained because of economic they must be mutually beneficial and part of R O crises, changes in public and political an overall strategy to deliver needed products T S priorities, and complex bureaucratic and services. Bringing in the private sector to E H processes. Even when donor funding is help achieve public health objectives does not T : available, recipient governments often lack mean replacing the public sector. A N OI the necessary infrastructure and personnel to coordinated approach helps rationalize T reach at-risk populations efficiently and spending on priority health needs at both the C U effectively. Overextended ministries of health national and the individual levels. For D O may collaborate with NGOs to deliver public example, companies can relieve the burden R T NI 2 Section 1 Past Experiences with Public-Private Partnerships for Child Health The Regional Handwashing Initiative is not the first USAID-funded effort of its kind. In the early 1990s, USAID's PRITECH Project (Technologies for Primary Health Care) developed an approach to engage private sector companies in the prevention and treatment of diarrheal diseases. The approach was tested in Indonesia, where PRITECH involved major soap producers in a coordinated hygiene campaign in partnership with the government, media personnel, and the advertising council. (There was no evaluation of the campaign impact, however.) Several other public-private partnerships focusing on diarrheal disease and the promotion of oral rehydration therapy (ORT) also preceded and informed the Central American Handwashing Initiative: s a partnership among Sterling Beecham, UNICEF, USAID/PRITECH, and the government of Kenya to ensure nationwide availability of oral rehydration salts (ORS) and increase their use for the prevention and treatment of dehydration due to diarrhea; s a collaboration brokered by PRITECH between ORS producers in Pakistan and the Ministry of Health to commercialize ORS and minimize the burden of procurement on the government through (tax-free) low-price, extended distribution to rural areas and promotion in conformity with national policy; s a partnership among two ORS producers in Bolivia, the Pan American Health Organization (PAHO), UNICEF, BASICS, and the Ministry of Health to produce and market ORS in pharmacies and beyond to rural outlets. PI H S R on public sector resources through market governments view public health as a priority. E N segmentation that targets those willing and Regional approaches also require favorable T R able to pay for products and services through regulations and trade agreements. A P private channels. Typically, the private sector E can offer a wider range of choice, higher The "Nautilus": An Approach to T A quality, and convenience. Public-Private Partnerships VI R The coverage of populations with The Central American Handwashing Initiative P- disposable income by the commercial sector followed an approach that BASICS has CI L is obviously not an adequate solution to most developed and applied in various settings to B U public health needs, since populations with promote public-private partnerships. The P L the heaviest health burden are often least able approach is designed for a donor-funded U F to pay. However, public health delivery organization that serves as a catalyst--to S S systems often serve a disproportionate initiate the partnership, provide technical E C number of people who can afford to pay. When assistance and other resources, and keep C U these populations are offered convenient, high things moving. S quality, affordable options through the The sequence of activities may vary A F commercial sector, they are often eager to depending upon the circumstances, O switch, freeing public sector resources for particularly regarding the point at which the Y R those most in need. public sector is brought into the process. O T Public-private collaborations are more Figure 1 depicts the steps followed in the S E successful in countries in which there is a Central American Handwashing Initiative as H T thriving commercial infrastructure and the "chambers" in a nautilus.1 : N OI T C U 1. More details on the approach, and variations of it, may be found in Mobilizing the Commercial Sector for Public Health Objectives, D published jointly by UNICEF and USAID (Slater and Saadé 1996). O R T NI 3 Step 1 State relevant public health objective. years to enable them to make a corporate The health objective identified must lend decision about whether or not to engage itself to private-sector involvement. In in the partnership. Such a study helps the practical terms, this usually means partnership avoid building unrealistic identifying a key health-related behavior expectations. It also forces an internal connected with a health care product company discussion of the pros and cons (e.g., use of ORS to prevent and treat of participation. dehydration from diarrhea and use of Step 6 Finalize partnership. The partnership is iodized salt and other fortified foods to formalized in a memorandum of improve nutrition). understanding outlining the goals, roles Step 2 Assess market potential. Both the size and responsibilities, and contributions of of the current market for a health-related the major partners. There should be ample product as well as the size of the time for decision makers in the untapped potential market should be participating organizations to review and estimated. A dynamic market segment revise the agreement before signing it. attracts competition. Evaluating the The agreement should provide for the market share of each competitor helps formation of a task force made up of identify the dominant forces and representatives from the partner trendsetters. organizations to guide the remaining Step 3 Assess company capabilities. steps in the process. PI Information is gathered on all firms Step 7 Prepare marketing plan. Together the H S manufacturing or distributing the health partners develop a preliminary marketing R E care product. (What is their product? plan based on the public health goal. For N T Where is it sold? How much does it cost? example, the Handwashing Initiative's R A Who buys it? How is it advertised? For plan was to promote the beneficial health P whom is it targeted?) An effective way to effects of handwashing with soap to low- E T A get answers to these and other such income groups with high rates of diarrheal VI questions is to meet with a representative disease, using appropriate communication R P- of each company's top management for channels involving media, community CI an informational interview. This first activities, and interpersonal communica- L B contact also gives the catalyst a chance tion according to the combined and U P to introduce the concept of a public- individual resources of the partners. L U private partnership and gauge the F Step 8 Carry out baseline market research. S company's interest. S Before a marketing strategy can be E Step 4 Select partner companies. Establish developed, the companies must find out C C criteria for involvement and invite the how much consumers know about the U S appropriate company or companies to health problem being addressed and what A F participate. Some partnerships may their related practices and motivations O involve just one company, while others are. Market research techniques, such as Y R will involve several. (An exclusive surveys, focus group discussions, or O T arrangement may be appropriate if the observation, can be used. Such research S E goal is to provide a specific product for can also provide baseline information H T distribution in a public health program.) about knowledge, attitudes, beliefs, and : N Step 5 Request feasibility study. Companies behaviors, so that results can be OI monitored. It is usually advisable to T conduct feasibility studies with well- C contract with a professional market U considered projections of potential D revenue, expenses, and profits over five research agency for this work. O R T NI 4 Step 9 Raise public sector interest. After the and help foster public-private collaboration market survey has been completed and for health goals. the results analyzed, the task force Step 10 Build consensus. Consensus is built meets with public sector organizations to as the partners in the public and private invite their involvement and collaboration. sectors discuss and address public health It is important to contact key public and business concerns in a neutral way health officers, especially those who may and develop a joint work plan with an be enthusiastic about working appropriate time frame and a clear collaboratively with the private sector. In definition of roles and responsibilities. the Handwashing Initiative, the soap Step 11 Finalize marketing strategies. Using companies preferred to postpone the market research data, the partners involvement of the public sector until finalize the marketing plan, including the plans were fairly well developed. However, communication strategy. An advertising the public sector might be involved first, agency develops the creative concepts before private companies have joined the and reviews them with the partners. The effort. In such situations, the public concepts should be tested with the sector might play a role similar to the intended target audience before the catalyst's, reaching out to the private promotional materials are produced. sector. International and regional lending institutions, bilateral aid agencies, Step 12 Launch campaign. An advertising professional associations, and NGOs are launch provides a great opportunity to PI also contacted to expand the partnership solidify the commitment of each partner. H S R E N T Figure 1. The Nautilus R A P E T A Promoting Public/Private Sector VI R Partnerships for Public Health P- CI L B U P L U F S S E C C U S A F O Y R O T S E H T : N OI T C U D O R T NI 5 A well-planned public relations event will its effect on the target population. The project create long-lasting promotional "noise" for essentially began "at scale" because it was the benefit of the campaign. implemented at the national level in three Step 13 Monitor implementation. The catalyst countries. Most handwashing studies in the ensures that the marketing plan is past have been aimed at relatively small implemented according to schedule by populations with levels of external inputs that reviewing the plan regularly, monitoring were not generally sustainable. each partner's activities, marshaling Promoting handwashing is a natural goal resources to solve problems, recognizing for a public-private partnership. The potential contributions, and ensuring that sufficient for combined public health and commercial data are collected to measure impact. benefits promises that initial investments may lead to a partnership that is self sustaining-- Step 14 Evaluate and integrate results. The catalyst and public sector partners are and that will bring lasting benefits. usually responsible for measuring and The Handwashing Initiative documenting the partnership activities in a Nutshell and determining their impact on public health. Commercial firms may collect their BASICS/EHP began work on the Central own data to show the impact of the American Handwashing Initiative in 1996 by partnership activities on their sales. The contacting all soap producers in five countries main purpose of evaluation is to improve (Guatemala, Costa Rica, Honduras, Nicaragua, PI subsequent efforts. Therefore, a and El Salvador) to assess their interest. H mechanism must be in place to document Eventually four companies--including S R results, integrate them into future multinationals as well as regional and national E N activities, and disseminate them to soap producers--joined the collaborative effort. T R stakeholders. A Task Force made up of representatives from A P each company, BASICS, and EHP met E T A Promising Opportunity periodically to guide the Initiative. A VI The project described here was part of The advertising strategy was based on a R P- USAID's attempt to hone an approach to market survey financed by BASICS, with CI public-private partnerships and to document technical assistance from EHP (see Chapter L B U P L U Figure 2. Handwashing Initiative Time Line F S S E C C U Phase One: Conceptualizing The Initiative Phase Two: S A F O Y R O T S Jan 95 ­ Jan 96 Jan 96 Mar 96 Jul 96 E H Nautilus Step #2: Step #3: Step #4: Step #5: Step #6: Step #7: T : Step #1: Assess Assess Select Request Finalize Prepare N State public market company partner feasibility partnership marketing OI T health potential capabilities companies study plan C objective U D O R T NI 6 6). The survey results revealed that fewer than As soon as the creative strategy had ten percent of mothers in low-income rural been developed, the Task Force presented it areas washed their hands in an optimal to ministries of health and education, donor fashion. The project defined this optimal organizations, and NGOs and asked them to behavior as: join the Initiative. The response was very positive: s washing at three key ministries of health endorsed "The main reason for the times (before cooking or the campaign and distributed preparing food, before Handwashing Initiative was to materials to health centers feeding children or eating, and schools; media try to get the best of two and after defecating companies donated time; and--for those with worlds." UNICEF incorporated the babies--after changing messages in its local -- Baudilio Lopez, USAID, Guatemala babies' diapers) programs; and USAID and s with three correct UNICEF enlisted their NGO techniques (using soap, networks in distributing the rubbing hands together at least three handwashing promotional materials. times, and drying with a clean towel). The intervention was carried out in three of the five countries: Guatemala, Costa Rica, The survey also confirmed a correlation and El Salvador. Campaign elements included among survey participants between poorer television and radio advertisements, PI handwashing practices and a higher distribution of posters and brochures, mobile H S prevalence of child diarrhea. units distributing soap samples, and school R E BASICS financed preparation of a programs. N T generic advertising campaign based on the About a year after the launch of the R A market survey to communicate the "three campaign, BASICS financed a follow-up P times/three elements" message. The generic market survey to assess impact. The second E T A campaign could be used as it was or adapted survey, which was essentially a repeat of the VI by the companies in campaigns for their own earlier baseline survey, showed improve- R P- brands of soap. ments in handwashing behaviors and beliefs CI L B U P L U F S S Phase Four: E C Phase Three: Assessment & C Planning & Development Implementation Dissemination U S A Oct 99 ­ F Nov 99 O (some activities Y R Jun 96 ­ Sep 96 ­ May 97 ­ Mar 98 ­ Mar 98 ­ continuing O T Sep 96 Feb 98 Sep 97 Oct 97 Sep 98 Sep 99 to present) S E Step #8: Step #9: Step #10: Step #11: Step #12: Step #13: Step #14: H T Carry out Raise public Build Finalize Launch Monitor Conduct : baseline sector interest consensus marketing campaign implementation evaluation N market strategies, and integrate OI T research test and produce results C U material D O R T NI 7 and attitudes among the target population. s Chapter 3: The Catalyst's roles and Based on observed relationships between responsibilities, activities, and issues and handwashing behavior and diarrhea in these lessons learned. studies and supporting scientific literature, s Chapter 4: The Private Sector Partners' one can also estimate that over the course goals, activities, interactions with the of the intervention there was an overall catalyst and other partners, and issues reduction in diarrheal prevalence of about 4.5 and lessons learned. percent among children under five. (See s Chapter 5: The Public Sector and Other Chapter 8 and Annex C.) At a national level, Partners' activities, and issues and such a reduction would represent a lessons learned. significant impact on public health. A relatively small amount of funds Three chapters describe the ($389,000 over four years) from the donor intervention itself: organization for the catalyst activities leveraged resources for diarrheal disease s Chapter 6: Marketing Strategy prevention from the private sector valued at Development covers the market survey, approximately $614,900 in just the first year development of an advertising strategy, of the campaign. field-testing, the generic campaign, and Figure 2 provides a time line for project issues and lessons learned. activities, related to the steps of the Nautilus. s Chapter 7: The Advertising Campaign describes the launch, breadth, and scope PI H Overview of the Document of the campaign, variations from company S R This report uses the story of a successful to company and country to country, and E N project as the jumping off point to describe the issues and lessons learned. T R replicable elements of a public-private s Chapter 8: Results summarizes what the A P partnership for achieving health goals. In these campaign achieved in terms of behavior E T pages, project planners from donor change, diarrhea prevalence, and A VI organizations, as well as ministry of health institutional changes among the R officials and representatives of commercial partners. P- CI firms, can learn about the essential elements L of public-private partnerships. How are Chapter 9 : Key Points for Replication, B U activities sequenced? Who must be involved-- includes critical success factors, outstanding P L and how deeply? What resources must be issues, obstacles, and recapitulates key U F available? What kind of expertise is needed? steps. S S What results might be expected? What are the E C pitfalls and how can they be avoided? C U Readers should find information to help S them decide whether the approach might A F enhance their programs, and understand the O Y time and resources such an approach would R require. O T Chapter 2: The Public Health Goal: Saving Works Cited S E the Lives of Children, explains the public Slater, S, and C Saadé. 1996. Mobilizing the H T health challenge addressed by the Initiative. Commercial Sector for Public Health : N The next three chapters focus on the Objectives. A Practical Guide. New York and OI T roles of the key players in the partnership: Washington, DC: UNICEF and USAID/BASICS. C U D O R T NI 8 Chapter 2 The Public Health Goal Saving the Lives of Children T his chapter establishes the significance and the appropriateness of the public health goal of the Central American Handwashing Initiative by . . . I Presenting diarrheal disease morbidity and mortality figures for Central America and for developing countries in general. I Discussing handwashing as an effective intervention for diarrheal disease prevention. I Explaining the potential role of the private sector in promoting handwashing. 9 W hen the Central American Handwashing Initiative began, an estimated 11 million children under five years of age were dying each year worldwide. About one-fifth of these--2.2 million childhood deaths--were due to diarrhea (Murray and Lopez 1996). Diarrhea Morbidity and mothers report that a child under five has had Mortality in Central America diarrhea in the two weeks before the survey. In Central America, frequent diarrhea has a Diarrhea--especially frequent and marked impact on the lives of children. prolonged episodes and dysentery--is also According to UNICEF's State of the World's one of the main causes of malnutrition Children (1995), at about the time of the (Martorell et al. 1975 and Alam et al. 2000). Initiative, diarrheal disease was the cause of And even mild malnutrition is associated with 19 percent of under-five mortality in increased risk of death from a variety of Honduras, 23 percent in Nicaragua, 20 common childhood illnesses (Pelletier et al. percent in El Salvador, and 45 percent in 1995). In addition, families face numerous Guatemala. Diarrheal disease is more direct and indirect costs when a young child prevalent among children whose families' has diarrhea: expenses for treatment, lost socioeconomic status and educational levels work and wages for parents, older siblings are low and who live in remote areas. kept out of school to care for the sick child, an additional strain on the resources of The Burden of Diarrheal already overburdened mothers, and so on. Disease Reducing the burden of diarrhea is clearly one Diarrhea-related deaths have been reduced of the most important public health priorities dramatically over the past 25 years thanks to in the developing world today. improved treatment with oral rehydration salts N E (ORS), which prevents dehydration. However, Handwashing and Diarrhea R D diarrhea mortality remains high, and deaths Prevention LI H will not continue to decline solely through the The means by which diarrhea is spread have C use of oral rehydration therapy. Evidence is been generally understood for many years. F O accumulating that many of the children who Minute quantities of fecal matter from a sick S E die with diarrhea today have dysentery, person are ingested by a new host. Hands are VI prolonged diarrhea, or diarrhea combined with an important vehicle in this fecal-oral L E malnutrition (Victora et al. 1993, Bhan et al. transmission route, especially the hands of H T 1996, and Fauveau et al. 1991). A more mothers and other caretakers of children. If a G comprehensive approach to reducing such mother's hands are not free of fecal NI V deaths is needed that also addresses the contamination, the risk of spreading diarrhea to A S source of the problem. the family through water and food is high. : L Diarrhea is the most frequent significant Enteric bacteria can survive on hands for at A O illness of children under five throughout the least three hours and can easily be transferred G to food and to other family members. H world. In some parts of Latin America, T L children under three have an average of ten Likewise, the means to prevent diarrhea A E episodes of diarrhea each year. In have been well documented. Esrey et al. in H Demographic and Health Surveys (DHS) 1991 and Huttly et al. in 1997 reviewed all CI L conducted in many countries throughout the relevant studies on diarrheal disease B U developing world, approximately 20 percent of prevention. Figure 3 summarizes what these P E H T 10 studies revealed about the effectiveness of Figure 3. The Effectiveness of various interventions. One remarkable finding Interventions to Prevent Diarrhea is the effectiveness of improved handwashing to prevent diarrhea--both in developing and developed countries. This should be no surprise, as handwashing has long been understood to be the key to preventing the spread of infection in hospitals--although even in hospitals this practice is poorly implemented (Boyce 1999 and Pittel and Boyce 2001). Most cultures consider handwashing a fundamental aspect of personal cleanliness. The box on this page gives the findings of several representative studies of handwashing. Effective programs to improve handwashing of mothers and other caretakers of children, as well as other hygiene behaviors, compare favorably in cost-benefit to other specific child Source: Esrey et al. 1991; Huttly et al. 1997. health interventions (Varley et al. 1998). wash their hands at certain critical times Handwashing Not Commonly using proper technique. The critical times are Practiced before cooking or preparing food, before In many parts of the world, handwashing is feeding children or eating and, after not well recognized as a means to prevent defecation, or cleaning babies or changing diarrhea and is not commonly practiced. To their diapers. The proper technique is to use prevent diarrhea, at a minimum, people must clean water and soap, to rub hands together N E R D Sample Studies of the Effectiveness of Handwashing LI H C Ten studies of handwashing intervention. In Indonesia, im- was reduced by 30 percent F were included in a review of proved handwashing behavior in urban households where O interventions to prevent diar- by 65 mothers (who received the mother was given soap S E rhea (Huttly et al. 1997). All soap and explanations of the and handwashing education VI reported a positive relation fecal-oral route of diarrhea (Han and Hlaing 1989). L between improved hand- transmission) reduced diarrhea In more recent studies E H washing and diarrheal incidence in their children by 89 not included in the 1997 T prevention, with a median percent (Wilson et al. 1991). review, soap distribution with G reduction of 33 percent Similarly, handwashing and handwashing education was NI V (range 11-89 percent). The hygiene behavior interventions associated with a 33 percent A S finding that improved hand- reduced diarrheal disease by up decrease in childhood diar- : L washing can prevent to 39 percent in rural Thai vil- rhea in urban Bangladesh A diarrhea was remarkably con- lages (Pinfold and Horan 1996). (Shahid et al. 1996) and O G sistent in a variety of settings. Handwashing interventions soap distribution alone was H For example, Black et al. in urban Bangladesh reduced associated with a 27 percent T L (1981) cited reductions of 43 dysentery (shigella) by 35 per- reduction in diarrhea in a A E percent in diarrhea among cent and non-dysenteric refugee camp in Malawi H day-care center children in diarrhea by 37 percent among (Peterson et al. 1998). CI the United States resulting all age groups (Khan 1982). In L B from a simple handwashing Myanmar, childhood diarrhea U P E H T 11 at least three times, and to rinse them well improve handwashing have not been shown and dry them hygienically (Favin et al. 1999). effective. Educational campaigns conducted Under ideal circumstances, additional by the public health sector can be labor- handwashing is advisable; however, the intensive and time-consuming for busy health critical times and techniques care providers, may be provide a great deal of ineffective in terms of protection and are feasible for influencing behaviors, may people whose time and "We genuinely believed in the not reach the most at-risk resources may make campaign and its cause. This populations, and so on. additional handwashing Public education campaigns allowed us to keep in mind at excessively burdensome. for handwashing are Mothers in developing every moment that we were expensive to maintain at the countries often do not use the perhaps saving a life . . . level that may lead to lasting proper technique; the most changes, and may not be well common failing is to wash We started to visualize the true designed in many cases. with water alone--no soap. meaning of this project: The private sector offers Likewise, they do not an under-utilized resource for to save lives." consistently wash at critical transmitting health -- Jorge Mario Lopez, times. Many cultures perceive information by advertising La Popular, Guatemala soap as necessary only for soap and its appropriate use washing clothes, bathing, and as a means to prevent when the hands feel or look diarrhea. Involvement of the soiled. private sector can significantly strengthen and supplement the efforts of the public sector. Private Sector Potential The private sector can provide a valuable While the beneficial health effects of proper public service while developing the market for handwashing with soap have been well inexpensive soap for handwashing and N documented, public health sector efforts to increasing market share. E R D LI H C F O S E VI L E H T G NI V A S : L A O G H T L A E H CI L B U P E H T 12 Works Cited Murray, C, and A Lopez, eds. 1996. Global Health Statistics: Volume 2. World Health Organization, Alam, DS, GC Marks, AH Baqui, M Yunus, and GJ World Bank and Harvard School of Public Fuchs. 2000. Association Between Clinical Health. Type of Diarrhea and Growth of Children under Pelletier, DL, EA Frongillo, Jr., DG Schroeder, and 5 Years in Rural Bangladesh. International JP Habicht. 1995. The Effects of Malnutrition on Journal of Epidemiology 29:916-921. Child Mortality in Developing Countries. Bhan, MK, N Bhandari, S Bhatnagar, and R Bahl. Bulletin of the World Health Organization 1996. Epidemiology and Management of 73(4):443-448. Persistent Diarrhoea in Children of Developing Peterson EA, L Roberts, MJ Toole, DE Peterson. Countries. Indian Journal of Medical Research 1998. The Effect of Soap Distribution on 104:103-114. Diarrhoea: Nyanmithuthu Refugee Camp. Black, RE, AC Dykes, KE Anderson, JG Wells, SP International Journal of Epidemiology Sinclair, GW Gary, Jr., MH Hatch, and EJ 27(3):520-4. Gangarosa. 1981. Handwashing to Prevent Pinfold, JV, and NJ Horan. 1996. Measuring the Diarrhea in Day-Care Centers. American Effect of a Hygiene Behaviour Intervention by Journal of Epidemiology 113(4):445-451. Indicators of Behaviour and Diarrhoeal Boyce, JM. 1999. It is Time for Action: Improving Disease. Transactions of the Royal Society of Hand Hygiene in Hospitals. Annals of Internal Tropical Medicine and Hygiene 90(4): 366-371. Medicine 130:153-155. Pittet, D, and JM Boyce. 2001. Hand Hygiene and Esrey, SA, JB Potash, L Roberts, and C Shiff. Patient Care: Pursuing the Semmelweis 1991. Effects of Improved Water Supply and Legacy. Lancet Infectious Diseases April: 9-20; Sanitation on Ascariasis, Diarrhoea, http://infection.thelancet.com/journal/ Dracunculiasis, Hookworm Infection, review9.html. Schistosomiasis, and Tracoma. Bulletin of the Shahid, NS, WB Greenough 3rd, AR Samadi, MI World Health Organization 69(5):609-621. Huq, N Rahman. 1996. Hand Washing with Fauveau, VM, K Yunus, J Zaman, Chakraborty, Soap Reduces Diarrhoea and Spread of and AM Sarder. 1991. Diarrhoea Mortality in Bacterial Pathogens in a Bangladesh Village. Rural Bangladeshi Children. Journal of Journal of Diarrhoeal Disease Research Tropical Pediatrics 37(1):31-36. 14(2):85-89. Favin, M, M Yacoob, and D Bendahmane. 1999. N State of the World's Children. 1995. New York: E Behavior First: A Minimum Package of R UNICEF. D Environmental Health Behaviors to Improve LI Varley, RC, J Tarvid, DN Chao. 1998. A Child Health. EHP Applied Study No. 10. H Reassessment of the Cost-effectiveness of C Arlington, Virginia: Environmental Health F Water and Sanitation Interventions in O Project. Programmes for Controlling Childhood S Han, AM and T Hlaing. 1989. Prevention of E Diarrhoea. Bulletin of the World Health Diarrhoea and Dysentery by Hand Washing. VI Organization 76(6):617-31. L Transactions of the Royal Society of Tropical E Victora, CG, SR Huttly, SC Fuchs, FC Barros, M H Medicine and Hygiene 83:128-131. T Garenne, O Leroy, O Fontaine, JP Beau, V Huttly, SRA, SS Morris, and V Pisani. 1997. G Fauveau, and H R Chowdhury. 1993. Prevention of Diarrhoea in Young Children in NI International Differences in Clinical Patterns of V Developing Countries. Bulletin of the World A Diarrhoeal Deaths: A Comparison of Children S Health Organization 75:163-174. : from Brazil, Senegal, Bangladesh, and India. L Khan, MU. 1982. Interruption of Shigellosis by A Journal of Diarrheal Disease Research O Hand Washing. Transactions of the Royal G 11(1):25-29. Society of Tropical Medicine and Hygiene H Wilson, JM, GN Chandler, Muslihatun, and T 76:164-168. L Jamiluddin. 1991. Hand-Washing Reduces A Martorell, R, C Yarbrough, A Lechtig, JP Habicht, E Diarrhoea Episodes: A Study in Lombok, H and RE Klein. 1975. Diarrheal Diseases and Indonesia. Transactions of the Royal Society of CI Growth Retardation in Pre-school Guatemalan L Tropical Medicine and Hygiene 85:819-821. B Children. American Journal of Physical U Anthropology 43:341-6. P E H T 13 Chapter 3 The Catalyst Bringing the Partners Together T hree types of organizations are involved in a public-private partnership: catalyst, private sector, and public sector. This chapter takes an in-depth look at the catalyst by... I Enumerating the roles and responsibilities of the catalyst (BASICS/ EHP) as outlined in the memorandum of understanding of the Central American Handwashing Initiative. I Describing the catalyst's contribution to the planning, implementation, and assessment phases of the Initiative. I Providing tips for carrying out the role of catalyst effectively. 15 A successful public-private partnership is often initiated by an intermediary--a bilateral or multilateral donor organization or an NGO. The intermediary brings resources and expertise to the table, but functions mainly to help the public and private sectors work together, using their resources in innovative ways for public health benefits. We call this partner a catalyst because, like a chemical catalyst, it is the "stimulus in bringing about or hastening a result." BASICS Prepares to Play the through environmental improvements and Role of Catalyst behavior change and its specific experience in In 1995, USAID's BASICS Project began to handwashing promotion. EHP's regional explore the potential of the private sector in advisor in Central America was assigned to Central America to assist the public sector in the Initiative. He and the BASICS' private preventing and treating the serious problem of sector specialist visited soap producers and diarrheal disease. The project's private sector USAID officials in Costa Rica, El Salvador, specialist traveled to the Guatemala, Honduras, and region to identify Nicaragua a second time in opportunities for mobilizing 1996 to ask the producers to commercial firms to produce "There is the possibility of join the proposed Initiative. and market products for working together, even among The original idea had preventing and treating been to promote both soap diarrhea. He focused on different institutions, but only if for handwashing and handwashing with soap, there is communication. There household chlorine for water disinfecting water with purification, but the decision must also be an institution that household chlorine, and the was made to focus on soap prevention and treatment of is capable of leading and and then build on that R dehydration with ORS as the experience, perhaps E guiding the process." H most appropriate areas for introducing chlorine later. T -- Jorge Mario Molina, E private-sector involvement. Important considerations that G UNICEF, Guatemala O This preliminary work weighed against including T S revealed that the soap chlorine were that (1) bleach R E companies were very and soap marketing were N T successful in getting their products into every segregated within companies; (2) developing, R A small retail outlet in rural as well as urban promoting, and evaluating bleach use for P E areas. They were intrigued by the idea of water disinfection was more complex; and (3) H T positioning a brand of soap for handwashing. a number of safety issues related to bleach G BASICS concluded that providing the promotion were not relevant for soap NI G companies with evidence of market potential promotion. The single focus of the Initiative NI through a market research study would made it easier to design and evaluate. R B influence their decisions about investing in :T this new market "niche." Roles and Responsibilities S Y L USAID's Environmental Health Project Conceptualizing the public-private partnership A T (EHP) was a natural partner because of its initiative is perhaps the most important A C commitment to preventing childhood disease responsibility of the catalyst. Additional roles E H T 16 and responsibilities were laid out during a The Initiative was originally scheduled to BASICS-EHP meeting in February 1996, agreed begin in January 1996 and end in September upon by the producers in their first meeting in 1998. However, it was completed in 1999 March 1996, and stated in the Convenio, the because of delays along the way. memorandum of agreement that all parties to the Initiative signed (see Annex A). Phase One: Conceptualizing the The three main responsibilities were Initiative (January 1995 ­ January 1996) divided among BASICS and EHP, the two Catalyst activities in the preliminary phase organizations that comprised the catalyst consisted of identifying the problem to be team: addressed and making preliminary visits to the countries to test the feasibility of a public- s Facilitate the work of the Task Force set private partnership. All five countries--Costa up to guide the Initiative; Rica, El Salvador, Guatemala, Honduras, and s Provide technical Nicaragua--shared a thriving assistance in developing commercial infrastructure that the campaign strategy; offered excellent s Finance the market "The catalyst also knew how to opportunities for contributing survey, development of balance the private competing to child survival programs. generic creative Their governments were enterprises so that there was no concepts, and evaluation concerned about diarrheal study. personal interest, but rather only disease. Regulations and trade agreements favored a general interest present." BASICS provided overall regional approach, and most -- Ileana Quiros, leadership and support, successful manufacturers Colgate-Palmolive, Costa Rica technical leadership in already had a regional scope marketing and working with of operations. the private sector, and secretarial and administrative support. EHP's Phase Two: Planning and Development specific responsibilities were in research-- (January 1996 ­ October 1997) design, data analysis, and presentation--and Organizational Meeting. In March 1996, quality control of health-related messages for BASICS called a one-day meeting of the chief R the campaign. About midway into the effort, E executive officers (or other top management H the catalyst team hired a local coordinator to T officials) of the interested soap companies in E facilitate planning and implementation, G the region. Five companies sent O especially in Guatemala, where she was T representatives. S located. Participants agreed on the broad strategy, R E discussed their expectations, reviewed a draft N T Activities memorandum of understanding that set out R A The Initiative was divided into four phases: the goals, roles, and responsibilities of all P E parties and a general strategy. They also H T s Conceptualizing the Initiative (steps 1-3 of made a list of the information that the G the Nautilus); proposed market study should obtain, NI G s Planning and developing the advertising established a task force, and developed a NI campaign (steps 4-11); preliminary work plan. The Task Force R B s Implementing the campaign (steps 12 included the marketing managers of each of :T and 13); S the companies plus the catalyst team. Y L s Assessing the effort and disseminating As a follow-up to this meeting, the A T findings and lessons learned (step 14). companies were sent copies of the A C E H T 17 memorandum of understanding and asked to bids, selecting contractors, and sign. Unlike a formal contract, the supervising the contracts. Since the memorandum provided general guidelines and catalyst paid the fees charged by these allowed flexibility for firms, it had the final word in individual implementation. oversight. However, it would Asking competing "The involvement of have been counterproductive companies to agree to to ignore the wishes of the collaborate when they were international organizations was Task Force. For example, used to working alone (and also very important because it some Task Force members when several of them were insisted that the advertising helped us to sell the campaign quite open about preferring firm selected be one that had to work alone) was a within our own company." no other soap accounts, which sensitive matter, raising -- Jorge Mario Lopez, narrowed the field significantly. fears about confidentiality La Popular, Guatemala This requirement and other and proprietary information. Task Force stipulations caused The agreement had to allow a significant delay in selecting each company to define the specific terms of the advertising agency. its own participation. s Technical assistance for consulting firms. The catalyst team met frequently with key Task Force Meetings. The first meeting of the people in the market research and Task Force took place in June 1996 to review advertising agencies, helping them focus the memorandum of understanding and the on the public health objectives as the plan for the baseline market survey. market survey was designed and Subsequent meetings were held in October conducted and the advertising strategy 1996 (to review the baseline survey results developed. In particular, the catalyst and develop the communication strategy); provided technical assistance to the May 1997 (to present the creative concepts); agencies on health-related data October 1997 (to test and select the final requirements, methods of data collection, concept); July 1998 (to distribute master and analysis. The catalyst also helped copies of the generic campaign); and January both agencies make effective 1999 (to review the status of the campaign R presentations to the Task Force, other launch). By the final Task Force meeting, the E H potential partners, public health officials, T project was in the implementation phase. E and USAID. G Support for Developing and Testing O s Assisting the soap producers individually. T Advertising Concepts. The catalyst provided The soap producers hesitated to share S R technical support in developing the information about company operations in E N advertising campaign to ensure that public Task Force meetings. To respect this T R health goals would be addressed. This support desire for confidentiality, the catalyst A P included selecting and hiring consulting firms, team kept in close individual contact with E H providing technical assistance to those firms, all producers throughout the development T and assisting each of the soap producers. phase and assisted them in using the G NI data from the market research and the G NI s Selecting consulting firms. Using criteria advertising concepts. R and other suggestions from the Task B :T Force, the catalyst team hired a market Public Relations Efforts. One of the jobs of S Y research firm and an advertising agency. the advertising agency was to create a public L A This task included preparing contract relations package that could be used to make T A documents required by USAID, reviewing presentations to additional partners from the C E H T 18 public and nongovernmental sectors. In Except for work on phase four, BASICS' February 1998, the Task Force assisted the role changed from leading to coaching during catalyst team in a blitz public relations tour to 1999 and, during 2000, from coaching to Guatemala, El Salvador, and Honduras to serving as an intermediary on retainer. A key consult with soap producer personnel, the element in this transition was developing and USAID missions, and UNICEF on the best achieving consensus on a plan that specified approach to reaching public sector decision partners' new roles as BASICS pulled away. makers who could influence the expansion of the campaign. Phase Four: Assessment and Dissemination (October 1999 ­ 2001) Liaison with USAID. The catalyst briefed the The principal activities under Phase Four were USAID missions in each of the four countries an assessment of the Initiative and analysis on every visit. The missions supported the and presentation of the results. Initiative by arranging meetings with key people in the ministries of health and by Follow-up Assessment. The catalyst was facilitating the involvement of NGOs in the responsible for conducting and analyzing the campaign. follow-up survey. The original plan called for an assessment about a year after launch of Phase Three: Implementation the campaign. BASICS solicited a proposal (March 1998 ­ September 1999) from the same firm that had done the baseline The Initiative was designed so that the market survey to conduct a study of catalyst's role would diminish greatly once the households in the same sample clusters and intervention was launched, leaving the compare the results. The second study was producers to continue their handwashing carried out in October and November 1999. campaigns in partnership with public agencies. The goal was to create within the Presentations. The catalyst team presented soap companies a sustainable interest in the results of the Handwashing Initiative in pursuing public health goals congruent with April 2000 at an official event sponsored by the their own sales targets. Ministry of Health in Guatemala. The event, Two Task Force meetings which was covered by the were held for producers to media, was an excellent share their launch opportunity for public recog- R "Both public and private sectors E experiences and ideas for nition of the soap producers, H T enlisting additional partners. brought to the table their own the partnering media, and the E G In addition, the catalyst team funding agencies. Further O experiences and strengths, T met individually with each presentations were given S making the partnership a solid R producer in September 1999 outside the Central American E N to monitor the campaign and team with a common vision." region to various groups: the T R prepare for the evaluation. Global Health Council, the A -- Baudilio Lopez, USAID, Guatemala P To coordinate the Society for International E activities of the increasing Development, the Pan H T number of local partners in American Health Organization, G Guatemala, the local coordinator organized a UNICEF, the World Bank, the World Federation NI G national task force that included the local of Public Health Associations, and USAID. The NI R soap producers, the media, the Ministry of purpose of the presentations was to B Health, USAID, UNICEF, PAHO, and communicate to USAID the results of its :T S representatives of NGOs and foundations. investments and to interest other organizations Y L A (Local task forces were not formally organized in the potential of public-private partnerships T A in the other countries.) for achieving health goals. C E H T 19 Issues and Lessons Learned expectations of all are clearly s A catalyst must offer more than mere articulated and that project processes coordination to attract private sector are transparent. For example, partners. In this case, the catalyst was agreements should be documented and able to put market research and face-to-face meetings held. development of the communication s Technical assistance for the private strategy on the table. The catalyst should sector must retain an entrepreneurial offer expertise and experience in both the spirit to enable the partnership to take commercial sector and public health. advantage of new opportunities and react s From the outset, the catalyst must quickly in times of crisis. For example, in foster a sense that the initiative Guatemala, using a network of relations, belongs to all the partners. If only one the catalyst won the support of the owner partner claims ownership, the effort may of the main television channel, who be stalled. The catalyst is not the owner. donated free time to air the generic s The catalyst should always have a clear campaign for a full year. vision of the project's goals and stay s A local coordinator makes it much focused on those goals. This is a vital easier for the catalyst to play its role part of the conceptualization process. It is effectively and to maximize the much easier to get partners to participate participation of all partners. Nothing can if the goal is clearly understandable, easy take the place of regular personal to articulate, and generally considered contacts and monitoring. Further, a local worthwhile. The catalyst must also present coordinator can follow up after the project a compelling case for the public good (in is officially over to see how sustainable this case, reduced diarrhea and improved the effort has been. The right person for child health) that can be achieved through this job will know the local players in the private sector participation. development field and be familiar with s The catalyst's vision should be based market research and advertising. on a strong model, such as BASICS' s Analyzing and documenting project public-private model (the Nautilus), shared experience and lessons learned will among the partners as a basis for help ensure that innovative approaches R collaboration. are widely replicated. When a project is E H completed, managers often turn toward T s A catalyst's sponsoring organization E must provide steady, flexible support. another assignment, and it is difficult for G O USAID created an environment in which them to carve out time to look back to the T S new approaches could be tried out and lessons learned from the previous project. R E adjustments and corrections could be s A key issue is whether the partnership, N T made as needed. An initiative like the one once established, can continue when R A described here must be flexible because the catalyst draws back. In the Central P E it brings together organizations with American experience, new activities were H T different motivations and priorities. initiated after the catalyst withdrew. The G s The catalyst should ensure that the larger producers integrated handwashing NI G roles, responsibilities, and promotion in their brand advertising. NI R B :T S Y L A T A C E H T 20 Chapter 4 The Private Sector Partners Merging Business and Public Health Goals T his chapter takes an in-depth look at the private sector partners (the soap producers) by . . . I Reviewing the profile of potential partners. I Describing the nature of the partnership. I Enumerating the producers' roles and responsibilities as outlined in the Initiative's memorandum of understanding. I Describing their activities during the planning, implementation, assessment, and follow-on phases of the Initiative. 21 I n preparation for the Handwashing From the outset it was clear that the Initiative, the catalyst team contacted ten Initiative aimed to merge business and public soap manufacturers--virtually all the health goals. As stated succinctly in the producers in the region. Two were memorandum of understanding, the objective of multinationals, two were regional, and the the Initiative was "to promote the habit of remainder were local companies. handwashing with soap" and "increase the market for soap" (see Annex A). Later, an In Costa Rica ­ Punto Rojo (local) explicit connection between handwashing and In El Salvador ­ Unisola/Unilever prevention of diarrhea-related infant mortality (multinational) and Summa (local) was made in the Initiative's mission statement: In Guatemala ­ La Luz (regional), La Popular (local), Productos Finos (local), and The partnership aims to promote the habit Colgate-Palmolive (multinational) of appropriate handwashing with water and soap by means of an intensive, In Honduras ­ Corporación Créssida targeted, educative campaign focused on (regional) lowering the incidence of diarrhea to In Nicaragua ­ Ind. Chamórro (local) and reduce infant mortality among populations Ind. Prégo (local) at risk in Central America. Commercial and Public Health Profiles of the Participating S Goals L Producers A Companies were encouraged by the catalyst O Five of the companies responded by attending G to join the partnership for commercial an organizational meeting at their own expense: H T reasons, such as increased sales volume and L A market share resulting from more frequent E s Punto Rojo from Costa Rica H handwashing. Joining would also demonstrate s Unisola/Unilever from El Salvador CI good corporate citizenship. The key for the L B s Colgate-Palmolive from Guatemala catalyst was to present the public health U P objectives in a way that made the benefits to s Fabrica La Popular from Guatemala D the private sector immediately apparent. N s Corporación Créssida from Honduras A S S E Table 1. Socioeconomic Targeting of Soaps NI S U Laundry Personal care B G Country Company A B C D E A B C D E NI G R Costa Rica Punto Rojo x x x x x x x E M El Salvador Unisola/Unilever x x x : S Summa x x R E Guatemala La Luz x x x N T La Popular x x x R A Productos Finos (PROFISA) x x x P R Colgate-Palmolive x x x O T Honduras Corporación Créssida* x x x x x x x C E Nicaragua Ind. Chamorro x x x S Ind. Prego x x x E T A VI Note: A=Highest; E=Lowest R * Corporación Créssida was acquired by Unisola/Unilever in 2000, expanding Unilever's representation to Honduras and potentially P broadening its marketing to classes D and E. E H T 22 Table 2. Products and Markets of Participating Producers Company Soaps Interest in Initiative Market Punto Rojo Full line Regional collaboration Primarily Costa Rica but Costa Rica interested in expanding regionally. Unisola/Unilever Three personal care Prefers an exclusive Local subsidiary of the El Salvador soaps relationship, but will multinational Unilever group. collaborate regionally. Recently acquired additional companies in Panama and Belize. La Popular La Popular produces Reservations about Wants to position "Jabonito" Guatemala laundry soap and working with companies as a handwashing product (La Popular and detergent; Productos with competing markets. aimed at lower Productos Finos Finos produces socioeconomic groups. are sister personal care soaps. companies with one owner) Colgate- Personal care soaps Interested in an exclusive Multinational corporation; Palmolive relationship only. marketing in all Central Guatemala American countries. S L A Corporación Full line Regional collaboration Primarily oriented toward O Créssida with no reservations. Honduran market but also G Honduras works regionally. H T L A E H The five participating companies Table 2 summarizes the information the CI represented 72 percent of the laundry soap catalyst team obtained about the soap L B market and 71 percent of the personal care producers who joined the Initiative. U P soap market in the region. The personal care D soap was generally not targeted to the groups A Non-Exclusive Partnership N A that the Initiative intended to influence. Initially the two multinational soap producers S S However, lower-income families do use each requested an exclusive arrangement for E "laundry soap"--in bars, cylinders, or more the regional campaign. However, the catalyst NI S commonly, balls (bola)--for laundry, team concluded that public health priorities U B dishwashing, bathing, general housecleaning, would be better served by working G and handwashing. Thus, an important factor in collaboratively with the whole soap industry. NI G preliminary meetings with soap producers was (The companies both participated in the regional R E to find out to whom they marketed their effort in the end, although they didn't commit M : various brands. Companies selling to lower- until just before the organizational meeting.) S R income groups in rural areas were favored. While an arrangement with a single E N Table 1 shows how the producers target multinational soap producer with the know-how T R their markets by socioeconomic levels. The and resources to run the regional promotional A P highlighted columns are the socioeconomic campaign would require less direct technical R groups that the Handwashing Initiative was to assistance, such an arrangement would have O T target. Note that only three of the companies distinct disadvantages. Some of the larger C E marketed personal care soap to the Initiative's multinationals concentrate on higher-income S E target groups. The others did not market either consumers (as shown in Table 1), which were T A type of soap to the target groups, shown as not the target of the Handwashing Initiative. VI R "D" and "E." Also, involving only one company would have P E H T 23 raised issues of equity and coverage. In a Force responsibilities (see box) makes clear collaborative arrangement, the expertise and that the group was to make all the major resources offered by the decisions about the nature of catalyst were available to all the campaign. producers who wished to join. It The Task Force met seven was hoped that participating in "Negative aspects? I could not times from March 1996 to the Initiative would encourage mention any major one, except January 1999. Meetings took producers to make lasting place at critical decision that I was sitting at the same changes in how and to whom points in the process. Task they advertised their soaps. table as my competition. But Force members paid for their From that perspective, the own travel and lodging. The that pales next to the positive more firms involved, the better. catalyst paid for the meeting things that were born of this space and circulated reports Roles and program." on all the meetings. Responsibilities --Ileana Quiros, Adapting the Initiative's The memorandum of Colgate-Palmolive, Costa Rica Advertising Concepts. Once understanding outlined the the generic advertisements roles and responsibilities of had been created by the the soap companies for at advertising agency, the S L least the two-and-a-half years of the Initiative. producers agreed to adapt them to their own A O brands using their own resources for G Participation in the Regional Task Force. H Each producer selected a representative, production and dissemination. T L A preferably the marketing director, to serve on Maintaining Communication. Producers E H the Initiative's Task Force. This group, which pledged to keep in contact with the catalyst CI also included the catalyst team, provided team and the other members of the Task L B guidance for the effort and its members were Force and to share information that would U P the points of contact for both internal and assist in assessing the impact of the D external communications. The list of Task campaign. N A S S Task Force Responsibilities of the Soap Producers E NI S U The memorandum of understanding, or Convenio, outlined the following responsibilities: B s Design the general marketing strategy. G NI s Establish a work plan with dates and responsibilities. G R s Identify the information necessary for the market research study. E M s Review the market survey questionnaire and advise on methodology. : S s R Review and analyze the results of the market research study and translate them into a E communication strategy. N T R s Set criteria for selection and offer advice on the selection of an advertising agency. A P s Review and approve the generic communication strategy. R s Seek to obtain the participation of the local public sector to broaden the reach of the campaign. O T C s Launch the campaign using company resources. E S s Assist in planning the follow-up market survey. E T s Interpret the final results of the communication strategy. A VI s Advise on the dissemination strategy for each market. R P E H T 24 Activities of the Private Sector Honduras canceled its campaign at the last Partners moment because of internal financial The Initiative progressed in the planned constraints and the devastating effects of sequence, but several issues caused delays Hurricane Mitch. that pushed the launch date into the spring of The campaigns varied widely, as shown in 1998--a year later than originally planned. Table 3. (Chapter 7 describes the intervention Even with the delays, the Initiative proceeded in greater detail.) In El Salvador, Unisola/ at a brisk pace. Unilever worked closely with the Ministry of Health to complement and strengthen its Phase One: Conceptualizing the program for Healthy Schools. In Costa Rica, Initiative (January 1995 ­ January 1996) Punto Rojo leveraged considerable support The catalyst used input from the soap from the media: Teletica (the major television producers in designing the Initiative. Their station) matched the producers' paid willingness to meet with the BASICS' advertisements one for one. La Popular's representative and share ideas contributed efforts in Guatemala were highly integrated significantly to the catalyst's assessment of with the activities of its sales force, who the market potential and company distributed samples and materials. Their capabilities. mobile units--pickup trucks equipped with megaphones--reached many small towns and Phase Two: Planning and villages. Colgate-Palmolive focused its initial S L Development efforts on organizing a public relations event A O (January 1996 ­ October 1997) in April 2000 to recognize the support of a G H Producers were involved in wide range of organizations T L planning through their and make a commitment to A E participation in the Task Force. continue with the campaign H "We got the people's good will They worked collaboratively to (see Chapter 5). Since then, CI L identify the elements of a B towards the brand, and this is the company has integrated U market survey, develop criteria handwashing messages into P very important. The media D for selecting a market research the advertising of its best- N A firm and advertising agency, coverage also more than selling soap, "Protex." S formulate an overall strategy, S compensated for our efforts." Implementation Issues. The E and assist in developing the producers addressed the NI --Jorge Mario Lopez, S creative concepts. issue of territorial coverage U B In addition to their work La Popular, Guatemala by agreeing to carry out the G on the Task Force, the campaign in their home NI producers had to carry the G markets. This would focus R Initiative into their firms and integrate it into E their efforts and avoid overlap that could lead M their marketing plans. Interestingly, when Task : to competition. Punto Rojo was to work in S Force members were asked to identify R Costa Rica, Unisola/Unilever in El Salvador, E potential partners that should be the target of N Corporación Créssida in Honduras, and La T a public relations campaign to boost the R Popular and Colgate-Palmolive in Guatemala, A Initiative, they identified their own top P through a segmented approach in which La R management as the initial target. Popular worked mostly in rural areas and O T Colgate-Palmolive in urban areas. C E Phase Three: Implementation In launching their campaigns, producers S (March 1998 ­ September 1999) E had to face the issue of brand equity. T A Campaigns. Four of the five original firms Companies cannot change the positioning of VI R launched a campaign. Corporación Créssida in an established brand unless the change P E H T 25 Table 3. Campaign Activities of Participating Producers Producer Dates Generic/branded Activities Punto Rojo May '98 ­ Used generic Printed posters for distribution through World Costa Rica April `99 advertisements with Vision and the Office of the First Lady of Costa brand name. Rica; advertised on television and radio and in print; and obtained the agreement of a major television station to double its media investment. Unisola/ Sept. `98 Used generic Devoted most of its efforts to collaborating with Unilever advertisements with the Ministry of Health's Healthy Schools Program El Salvador brand name and logos by providing video, audiotapes, banners, posters, of Ministry of Health soap samples, and coloring leaflets. and TV station. Colgate- '99 ­ `00 Generic. Organized public relations event involving Palmolive Ministry of Health and media, donated soap to Guatemala schools, and funded handwashing kit prototype. La Popular Mar. '98 ­ Generic with brand Supported radio advertisements, distributed Guatemala Oct. `99 logos. posters and flyers, and broadcast radio advertisements from mobile units traveling to small towns and villages. S L A O reinforces the brand equity. In other words, was targeted at more affluent socioeconomic G H an established laundry soap cannot groups.) T L immediately be repositioned for handwashing; Another brand issue was related to the A E nor can the image of a personal care way advertising resources are allocated by H CI ("beauty") soap be changed to that of a hand the companies. Funds for the handwashing L soap. Furthermore, creating and building a campaign had to be pegged to a specific B U new brand specifically for handwashing would brand. The catalyst tried to link the campaign P D require a large financial investment and to a best-selling soap, or market leader, to N A considerable lead time. benefit from the substantial resources S Personal-care-only soaps were not sold to allocated to such brands. Integrating the S E the socioeconomic groups that the Initiative handwashing message within the advertising NI S sought to reach. What's more, laundry soap of a major brand with a significant budget (a U B producers that reached the target population market leader) would ensure greater impact G were reluctant to change the positioning of and sustainability. NI their established brands, and producers had G Reaching Out to Additional Partners. R had bad experiences marketing dual-use E Producers were also instrumental in M soaps. Personal care soaps have a closer : encouraging other organizations, both public S connection to handwashing than laundry R and private, to get involved in the campaign. E soaps, which are usually more abrasive. This N T dilemma was not totally resolved. The R Phase Four: Assessment and A producers settled on simply connecting their P Dissemination R brand logos or names to the generic (October 1999 ­ April 2000) O T advertising spots or printed materials, which Using results from the evaluation study, C E communicated the handwashing behavior producers secured internal support from their S message but said nothing about type of soap. E organizations to bolster company support for T A (Colgate-Palmolive used the advertising the campaign. In Guatemala, for example, the VI concepts of the Initiative in a campaign for R two companies co-sponsored a public P "Protex," an antibacterial soap, even though it relations event hosted by the MOH in April E H T 26 2000. At this event, the soap companies and of scale in market research and the MOH presented their collaborative plan for production of campaign materials. In this two programs--"Healthy Schools" and case, the producers were concerned "Healthy Communities"--which will be about working with their competitors, but implemented over three years. they joined in because they were afraid to Follow-on Activities. Colgate-Palmolive be left out. developed and launched in 2001 a regionwide s Encouraging collaboration among educational program for schoolchildren. In firms in fierce competition requires addition, Unisola/Unilever plans to launch a finesse on the part of the catalyst. handwashing campaign in Honduras, based Past a certain point, producers may feel on its acquisition of Corporación Créssida. that to collaborate is to give away trade secrets. Their desire to keep their plans Issues and Lessons Learned confidential may run counter to the desire of the catalyst to encourage s A regional approach was preferred over wider participation and disseminate a lengthy country-by-country approach results. to take advantage of the regional structure of the commercial partners and s Because of the potential for changes in company leadership to cause delays in the economies of scale for the catalyst. A the project, it is best not to base the regional approach also provided better S geographic and socioeconomic coverage. partnership on individual relationships L A but instead to seek broad-based s A key issue that was O acceptance of strategies and G never resolved in the H T Initiative was whether commitments. During the L Initiative, there were frequent A an exclusive agreement E "The support we got from the changes in personnel. In a H would have been CI preferable to a health department gave us great highly competitive industry L such changes are not B collaborative approach. credibility. But I believe that the U unexpected, but they did P A more common model of ones who really benefited were D private sector present difficulties. The new N A people had to be briefed on collaboration in public the people." S the goals and status of the S health would call for one --Gregory Hawener, Unisola/Unilever, E firm to be selected on the Initiative. In one instance, a NI El Salvador S newly assigned marketing basis of well-developed U B director did not know that her criteria to produce and G distribute a certain firm belonged to the Initiative. NI The representative from one of the largest G product for use by a ministry of health-- R producers had to withdraw from the Task E usually a product that is not widely M : available at an affordable price. The Force when he was promoted elsewhere. S There was a long delay in assigning a R purpose of the Handwashing Initiative was E product manager to prepare the campaign N to change the way people use a T R ubiquitous product. The more firms launch. Management changes in two other A companies had similar effects. P involved, the wider the behavior change R and the greater the benefit to all firms in s The potential for a "clash of cultures" O T terms of increased sales. Furthermore, between the different organizations is C E there is synergy in working with a group of ever present. Within the typical catalyst S E producers across a product line. It can organization, decisions are made T A encourage project advancement through through a slow process of developing VI R friendly competition as well as economies consensus, whereas businesses are P E H T 27 more likely to operate through command It must be pointed out, however, that it and control and are able to make was easy to postpone public sector decisions and take action quickly. involvement because the Initiative could Furthermore, in this case the smaller go ahead without licenses or waivers from local soap producers had the flexibility the respective governments. In some to move rapidly, but the multinational countries, it would have been impossible companies had complex approval to take any action without the initial systems, thorough budget planning involvement of the public sector. processes, and acute concerns about s The memorandum of understanding or brand quality and positioning. other document outlining a public- s The timing and sequence for private partnership should not be too involvement of the public and private prescriptive. Some involved in the Initiative partners will differ depending on the thought that there should have been a nature of the partnership and the goals detailed plan that set specific targets for to be achieved. In the Handwashing each producer. The prevailing view was that Initiative, attempts to engage the public the producers might back away from a sector and other organizations were partnership if the document formalizing the postponed until the marketing concepts collaboration appeared too prescriptive. were fully developed. The private sector s The public-private partnership was a S partners believed it would be more tool for implementing desired behavior L A efficient to ask other partners to change among the soap producers. The O G participate in a clearly delineated initiative hope is that advertising the health benefits H T and feared that earlier collaboration would of handwashing will eventually be L A cause delays. One possible source of integrated into the long-term strategy of a E H concern was inherent in the regional specific brand, such as Protex for Colgate- CI design of the partnership, which Palmolive and Gold Pro for Unisola/ L B necessitated involving different public Unilever. Thus, as the partnership evolves, U P sector officials in each country--a the Task Force outlives its usefulness. The D potential cause of delays and a difficult Initiative will likely be continued as N A and cumbersome process. individual company activities. S S E NI S U B G NI G R E M : S R E N T R A P R O T C E S E T A VI R P E H T 28 Chapter 5 The Public Sector and Other Partners Joining Hands with the Soap Producers T his chapter takes an in-depth look at the public sector and other partners by . . . I Describing the public relations efforts to recruit them. I Listing who became involved from governments, media, donors, foundations, and others. I Describing the contributions of these partners to the Initiative. 29 T he Task Force's decision to postpone involvement of the public sector until after the development of the creative concept was not made lightly. The Task Force realized that additional partners might not feel any ownership if they were invited to join too late. On the other hand, if they were invited early, the Task Force would not have enough information to provide concrete ideas about how the public sector and other partners could be involved. After some debate, the Task Force decided that it would be more efficient to await the market research results, develop the communication strategy, and then present the entire package to decision makers and opinion leaders in each country. S R E Once the planning process was completed, · Purpose: To disseminate the generic C U the producers and the catalyst began a campaign as a public service. D O continuous public relations effort to recruit R s Other private companies P other partners to reinforce the advertising P · Examples: toilet paper and soap dish A campaign and attract additional resources. O manufacturers S Recruitment efforts reached out not only to · Purpose: To associate good hygiene E public sector organizations but also to H practices with the use of their T international organizations, NGOs, and other H products. TI businesses, most notably the media. W S The key groups were the ministries of Targeted Groups D health, to officially endorse the campaign, and N A Four groups were targeted in the public radio and television companies, to disseminate H relations effort: G the generic campaign. For the audiences that NI s The public sectors in each country the Initiative intended to reach--lower NI O · Examples: ministries of health and socioeconomic groups in isolated rural areas-- J : education radio was the preferred medium, then S R · Purposes: To provide political support television, and finally newspapers. E N through an official endorsement and to T R disseminate health messages through The Public Relations Blitz A P health workers and teachers. The catalyst team developed a public relations R briefing kit including a briefing paper, the logo E s International organizations and NGOs H of the Initiative, examples of materials, and a T · Examples: USAID, UNICEF, World O Vision, and CARE customized proposal. The kit was used in D N individual contacts with potential partners. · Purposes: To diffuse the campaign A A graphics art firm assisted with the R through their resources and community O development of an eight-page, four-colored T networks and to increase the depth and C brochure (9 inches x 12 inches) with a built-in E coverage of the campaign. S folder for inserting other documents. It was CI s The mass media entitled "Lavo mis manos por salud: una L B · Examples: Radio, television, and iniciativa multisectorial para salvar vidas U P newspapers infantiles" (I wash my hands for health: a E H T 30 multisectoral initiative to save children's lives) The Public Relations Brochure and featured a photo of a mother and child (First Version) with soaped up hands. Topics included diarrheal disease; prevention through handwashing; the mission of the Initiative and its membership; the essential messages of the campaign; results of the marketing study about the correlation between proper handwashing and diarrheal prevalence; a description of the campaign materials; and an invitation to join the Initiative. In February 1998, the catalyst team and Task Force members, each in his or her own country, went on a public relations blitz. With the help of USAID, they contacted company executives and representatives of the media, governmental ministries, and international S R organizations. They made professional E C presentations about the rationale for the U D campaign; showed off the generic materials; O R and left behind the public relations brochure. P P In each country, the ministry of health A O immediately agreed to support the campaign. S The attempt to encourage media participation E H through donation of free media time and T H reproduction of tapes and video materials was TI also quite successful. W s Media. Although the media partners in S Guatemala had not been involved in D Activities of Public Sector and N conceptualizing or planning the A Other Partners H Handwashing Initiative, they were the G Additional major partners joined the Initiative first to step forward to launch the NI just before or during the implementation phase: advertising campaign on radio and NI O television. This campaign is scheduled to J : s Ministries of health. The Ministry of Health continue until at least 2003. In Costa S R was a substantial partner in El Salvador, Rica a large television channel E N where Unisola/Unilever supported the contributed free generic advertisements T R ministry's Healthy Schools Program. In during prime time for a year, matching A P Guatemala the MOH created an Office of Punto Rojo paid advertisements one for R E Hygiene Promotion within its Mother and one. A television station in El Salvador H T Child Division. contributed free airtime for the generic O s UNICEF. In Guatemala and El Salvador advertisement. The Guatemalan daily La D N UNICEF distributed the campaign's Prensa Libre used vignettes about A R generic materials to support its water, handwashing as filler. O T sanitation, and hygiene activities. s Office of the First Lady of Costa Rica. C E s NGOs. In Guatemala CARE disseminated This office was instrumental in seeing S the handwashing messages, using soap that handwashing promotion posters CI L samples and promotional material reached governmental offices all over the B U provided by soap producers. country. P E H T 31 Other partners included PVOs such as Palmolive, La Prensa Libre daily newspaper, World Vision, other businesses, and UNICEF, Camara de Radiodifusion de FUNDAZUCAR, the foundation of the Guatemala, Channel 3, Super Channel, Guatemalan sugar Televisiete (Channel 7), and the Ministry of industry (sugar Health. This second brochure presented the cane growers and results of the follow-up survey as evidence refineries), which "The fundamental of the effectiveness of the campaign's is the country's approach and outlined proposed campaign reason that made the largest employer. activities until 2003. Table 4 lists all Ministry of Health take partners and their an active role in the Issues and Lessons Learned contributions. campaign was its vast s The catalyst has the necessary Several donor credibility to communicate effectively organizations also responsibility as health with ministry of health officials and contributed to the manager. Handwashing, should play an active role in recruiting assessment and public sector organizations. Some S if one looks at it closely, R dissemination producers did not feel comfortable E phase of the C is of vital importance to contacting health ministries without an U Initiative. USAID, D everyone." intermediary. One producer was reluctant O the World Bank, R to interface directly with public sector -- Almeda Aguilar, P and UNICEF have Ministry of Health, Guatemala allies, stating that the government would P A supported be more receptive to a health-related O S publication and agency. BASICS therefore assisted in E distribution of this H meetings with UNICEF, the Ministry of T document and are disseminating the findings Health, and education officials to obtain H TI of the Initiative within their organizations. endorsements of the campaign. W S s The public-private partnership needs to D The Follow-up Public Relations Event N be sold to the public sector as an A public relations event was held in April A integral part H 2000. Organized in Guatemala under the joint G of its national NI sponsorship of Colgate-Palmolive, La Popular, strategy. If the NI and the local task force, it was an opportunity O public sector "Who better to work J to publicly recognize the efforts of the various : perceives S partners in that country. The Ministry of Health with than those who are R private sector E hosted the event, which drew many people responsible for the N interest in T from governmental ministries and agencies, R public health health of that specific A international organizations, foundations and P activities as associations, NGOs, and private sector R country?" an effort to E companies. They were entertained by a choir H -- Ileana Quiros, T usurp its from a nearby school, whose members sang Colgate-Palmolive, Costa Rica O prerogatives, D the campaign jingle and enacted skits about N unnecessary A handwashing before the keynote speech of friction can R the Deputy Minister of Health. O arise, and the partnership may be T A second public relations brochure was C jeopardized. E prepared for this meeting. It carried the logos S s It is not difficult to attract public sector CI of all the partners in Guatemala: USAID, La L Popular (through the logo for "Ambar," its and other partners to a cause that is B U best-selling laundry soap), Colgate- obviously good. The Initiative was P E H T 32 Table 4. Contributions of Public Sector and Other Partners Partner Country Activity Public Sector Office of the First Lady Costa Rica Distributed posters donated by Punto Rojo to health centers, schools, and other state offices and institutions, where they were used in hygiene programs. Ministry of Health El Salvador Distributed educational materials provided by Unisola/ Unilever and used them in the Healthy Schools Program. Ministry of Health Guatemala Created an office of "Hygiene Promotion" within its Mother and Child Division. Media Television, Channel 7 Costa Rica Contributed airtime equivalent to Punto Rojo's budget for (Teletica) television commercials. TCS (channels 2, 4, El Salvador Contributed free airtime during the first month of launch. and 6) S R E Television, channels 3, Guatemala Radio and television stations donated airtime for the C 7, 11, and 13; radio generic advertisement provided by BASICS and daily U D (Central de Radios y newspaper used generic advertisements as filler when O Camara de space allowed. R P Radiodifusion Nacional); P and daily press (La A O Prensa Libre) S E International Organizations and NGOs H T USAID El Salvador Facilitated contacts with governments, collaborating H Guatemala agencies, and NGOs; accessed NGO network as a channel TI Honduras for distributing handwashing materials. W S UNICEF Costa Rica Used generic materials in its rural sanitary educational D N Guatemala programs and soap samples in handwashing kits. A H World Vision Costa Rica Distributed posters donated by Punto Rojo. G CARE Guatemala Distributed leaflets and soap samples. NI NI NGOs Costa Rica Used generic materials in community programs. O J FUNDAZUCAR Guatemala Introduced handwashing kits and handwashing corners in : S schools and health centers. R E N T espoused readily by ministries of health epidemiologist on the catalyst team also R A P and education, media, foundations, and added authority and credibility. He was R NGOs, not to mention the soap able to reassure the producers that the E H producers. Not all health issues would be Initiative was built on a solid public health T O so free of political sensitivity. foundation. However, he was not assigned D full time to the Initiative. Optimally, an N s The importance of public health input A R in a public-private partnership seeking activity of the magnitude of the O to achieve health goals cannot be Handwashing Initiative should have two T C overemphasized. When ministries of full-time or almost full-time people E S health joined in the Handwashing assigned to it: one a private sector CI Initiative, the commitment of the private manager and the other a public health L B sector partners was strengthened. The specialist. U P E H T 33 Chapter 6 Marketing Strategy Development From Market Survey to Creative Concept T his chapter reviews the planning stage of the Central American Handwashing Initiative by. . . I Outlining the process for designing and implementing a marketing survey. I Describing the survey questionnaire. I Presenting the results. I Showing how the results were used to develop an overall communication strategy. 35 T he Task Force's first major task was to develop a regional campaign. This work was carried out in a relatively compressed period, from March 1996 to May 1997, with the active participation of most Task Force members. The goal was to develop a generic market strategy based on solid market research. Consumer Research Selecting the Market Research The foundation of the communication strategy Agency was a market survey. It provided a profile of The producers discussed the information the target consumer and was also intended to needs for the marketing study, characteristics provide baseline information for use in of the study sample, and criteria for selecting evaluating the Initiative. The soap producers the research agency. Their decisions are were no strangers to market surveys. summarized in Table 5. However, the type of survey envisioned for Guided by the producers' criteria, the the Initiative was different from those usually catalyst selected a market research T P conducted by the private sector (which agency through USAID's competitive E C typically include trade audits, store checks, process. Bids were solicited from five N O quantitative research, and focus groups). The companies. The agency selected was C producers saw in-depth behavioral research Generis Latina, a company based in E VI as an opportunity to learn about consumers' Guatemala with a solid track record in the T A attitudes and behaviors regarding a then- region and the ability to respond effectively E R neglected use of their product: handwashing. to the client's needs. C O T Y Table 5: Framework for the Market Survey E V R Decision Areas Specific Requirements U S Information needs s Demographics T E s Socioeconomic status K s Living conditions (including type of water and sanitation R A systems) M s Behavior and attitudes toward handwashing M O s Type of soap used R F s Sources of information about handwashing : T s Diarrheal disease prevalence among children under five N E Characteristics of the study sample s Mothers of children under ten years of age M P s Drawn from all four countries O L s Stratified urban and rural E s Socioeconomic status of class "D" or "E" V E s School-age children in household D Y Selection criteria for market s Demonstrated capability of performing a study in all G research agency countries E T s High quality sample and information collection methods A R s Ability to conduct study in a timely, expeditious manner T S s Previous experiences in similar studies G s Reasonable cost NI T s Availability of additional data that could be incorporated E in the study at no additional cost K R A M 36 Section 1 Designing and Testing the analysis by urban and rural strata and by the Questionnaire and Methodology main geographic regions of the country with a Four main categories of information were margin of error of five percent. sought through the study: The sample was drawn based on clusters selected from updated census tracks s Information the Task Force and categorized as D and E (the lowest advertising agency needed about the socioeconomic levels). Within the clusters, target audience profile to develop a interviewers selected households where there marketing campaign. was at least one child age ten years or s Baseline information on handwashing younger and applied standard criteria to practices for subsequent evaluation of the eliminate households that displayed campaign. characteristics of a higher socioeconomic s Information on the observed relationships level. In Guatemala, each of the four main between handwashing behaviors and Mayan language groups was to be sampled, diarrhea among children for the public in addition to the Spanish-speaking health partners to use in advocacy populations. Ten households were randomly activities and to ensure that key risk selected from each rural cluster and five factors for diarrhea were addressed in the households from each urban cluster. All T campaign. interviews and observations were performed P E s Information about water sources, in the house or yard with the mother (or other C availability, storage, and handling that adult female family member in a small N O could be used in a future campaign to number of cases), the male head of C E address household water risks for household, and children ages five to 10, VI T diarrhea, and, specifically, household when available. A E water chlorination. Supervisors for each survey were trained R C in Guatemala. They, in turn, trained a group of O The Task Force reviewed the initial draft interviewers and local supervisors in each of T Y questionnaire and methodology presented by the four survey countries. The training E V Generis Latina. In the next two weeks, the included conducting pilot interviews before R U questionnaire was revised, field tested in actual data collection began. The catalyst S T Guatemala, and revised again based on team assisted in the training and field testing E K findings from the field test. Interviewers were in Guatemala and Honduras. R A trained. Within two months, the fieldwork for The questionnaire consisted of about 50 M the survey had been completed in four items. Interviewees were also asked to M O countries. demonstrate how they washed their hands R F and were scored in a structured observation. : T Implementing the Survey At the request of the soap producers, children N E A total of 4,500 households were surveyed: ages five to ten present in the household at M P 1,000 each from Costa Rica, El Salvador, and the time for the survey were also asked to O L Honduras and 1,500 from Guatemala. A larger demonstrate how they washed their hands E V sample size was used in Guatemala because and to answer questions about when they had E D of its relatively greater ethnic and geographic washed their hands in the past 24 hours. Table Y diversity. In all cases, the sample size was 6 provides some details about the questions G E sufficient to provide a summary descriptive asked.1 T A R T S G 1. A complete copy of the questionnaire can be found on the CD-ROM, The Story of a Successful Public-Private Partnership in NI T Central America: A Compendium of Resources. To obtain a copy of the CD-ROM or to find out how to access it through the E Internet, contact the EHP Information Center, 1611 North Kent Street #300, Arlington, Virginia 22209, USA. K R A M 37 Table 6. Focus of the Market Survey Section Type of Questions Socioeconomic and s Language household s Education levels of mother and father characteristics s Occupations s Number, relationship, and age of persons in household s Presence of electricity, radio, television, refrigerator Water availability Nature of water supply (household connection, community standpipe, and usage well or cistern, etc.) For households without piped water. . . s Who collects, how often, with what s Usage (drinking, washing dishes, washing clothes, handwashing, etc.) For households with piped water. . . s Hours of availability, outages, scarcity s Usage (drinking, washing dishes, washing clothes, handwashing, etc.) For all households. . . s Location in house where washing activities take place (sink, barrel, wash basin, etc.) T P Sanitation s Type of sanitation system (toilet, latrine, no system) E s Who uses C N Handwashing s A 24-hour handwashing history was taken--from mothers and fathers O C and children (five to ten years old)--to determine on what occasions E (typically before or after some recognizable event) and how many times VI T they had washed their hands during the previous 24 hours A E s Handwashing demonstration: elements of technique observed--one or R two hands, cleansing material (soap or ash), number of times rubbed, C O how dried, cleanliness of drying material (towel or rag)--for mothers T and children present at the time of the interview Y E s Presence of a handwashing place, defined as soap and water V R available at a "usual" handwashing place where there is a basin or U other arrangement for handwashing water S T Soap Usage s Use or nonuse (if nonuse, why) E K s Types (laundry bar, laundry powder, and hand soap) R A s What used for M s If not used for handwashing, why not M O s Where purchased R F s Who in the household makes purchasing decisions : s Brands used T N E Attitudes toward Interviewee responds true or false to a number of statements, M handwashing for example. . . P O s "Most times, handwashing with water alone is sufficient." L E s "It is impossible to see that children wash their hands after going to the V bathroom unless one is watching them all the time." E D Diarrhea prevalence s Presence or absence of diarrhea within the previous 14 days as Y G reported by the mother for each child under five in the household E T Communication profile A s Literacy (tested) R s Exposure to radio, television, print media T S s Preferred programs, times of listening, viewing G NI T E K R A M 38 Table 7. Observed Handwashing Technique: Percentage of Caretakers with Good Reported Practices and Strength of Association with Lack of Diarrhea in Children under Five in the Household, 1996 Guatemala Honduras El Salvador Costa Rica Total Both hands 99* 99 99 99 99 Uses soap 82 90 91 96 89 Rubs at least 3 times 85** 99 88* 88 90* Dries with a clean towel 28*** 37*** 40* 69*** 42*** *P<.10 **P<.05 ***P<.01 Results association with reduced risk of diarrhea in a Diarrhea Prevalence and Detailed child under five in the household. Analysis of Behaviors Drying hands with a clean towel had the Diarrhea prevalence in the last two weeks strongest association with reduced risk of among children under five was calculated diarrhea of all of the handwashing elements based on 2,983 surveyed households (in all observed (Table 7). At the same time, this T countries) with a child under five. Overall, 19.3 was the least prevalent of the three "correct P E percent of households reported that at least techniques." The low rates of practice brought C N one child in the household had had at least down overall rates of both "good practices" O C one day of diarrhea in the two weeks prior to and "optimal handwashing." E the survey. Prevalence figures varied from The association between washing one's VI T country to country: Guatemala ­ 22.5 percent; hands at critical times and reduced risk of A E Honduras ­ 24.9 percent; El Salvador ­ 19.5 diarrhea in children was confirmed, as shown R C percent; and Costa Rica ­ 7.9 percent. (The in Table 8. O T survey was conducted during the rainy The findings in tables 7 and 8 were further Y season when children are most prone to suffer examined using logistic regression analysis to E V R from diarrhea.) control for potential confounding factors U The percentages in tables 7­9 indicate (country of residence, urban/rural residence, S T the proportion of those surveyed who reported location of source of water, use of sanitary E K or demonstrated each of the critical elements latrine or toilet by all family members, tested R A of proper handwashing. The number of ability of the mother to read, and number of M asterisks (*) indicates the strength of the children in the household) and to confirm M O R F : T Table 8. Handwashing Occasions: Percentage of Caretakers with Good Reported N E Practices and Strength of Association with Lack of Diarrhea in Children under M P Five in the Household, 1996 O L E Guatemala Honduras El Salvador Costa Rica Total V E D Before eating/feeding 50* 77* 64* 56* 61* Y Before cooking/food G E preparation 68** 63 67* 61* 65** T A R After defecation 65 74* 75 91** 75* T S After changing or G cleaning baby 29 18* 17 44* 26* NI T E *P<.10 **P<.05 K R A M 39 Table 9. Handwashing Place: Percentage with the Necessary Elements Present at the Usual Place of Handwashing in the Household and Strength of Association with Reduced Prevalence of Diarrhea among Children under Five in the Household, 1996 Element Guatemala Honduras El Salvador Costa Rica Total Water 98 99 99 99 99 Soap 86 94 97* 98* 93* Basin or place for water to fall 94 89 99* 97 94* All three elements 82 84* 96** 95** 88** *P<.10 **P<.05 which of these elements was most commonly factors (Cousens et al. 1996). The importance linked with reduced risk of diarrhea. In short, of using soap to clean hands of observed hand drying with a clean towel and microbiological contamination and its T reported handwashing before eating and association with reduced risk of diarrhea have P E preparing food were confirmed to have the been demonstrated consistently in the past. C N strongest and most significant relationships The importance of rubbing hands O C with reduced risk of diarrhea. sufficiently (Hoque et al. 1995, Bateman et al. E Interestingly it appears that a dedicated 1995) was confirmed. The importance of VI T handwashing place is necessary to support handwashing at times commonly found to A E the practice of appropriate handwashing at contribute to reducing diarrhea risk was also R C critical times. In three countries and overall, confirmed in these settings, although the O T the presence of all three elements at a associations were not strong. Y handwashing place--water, soap, and a basin The results clearly indicated that the E V or place for water to fall--are more important communication strategy should address both R U than any one element, including soap alone correct technique and critical handwashing S T (Table 9). times. The results also suggested that the role E K The use of soap was not found to have a of a dedicated handwashing place in a R A strong association with reduced risk of household should be explored further. M diarrhea in this survey. The reason for this M O finding cannot be determined, but it could be Overall Stages of Key Behaviors R F due to changes in behavior under observation Of the 4,497 families surveyed in four : T (resulting in an over calculation of those who countries, almost all regularly used and could N E actually use soap) or any number of other demonstrate possession of some sort of soap M P O L E V Table 10. Percentage of those Possessing and Using Soap, Guatemala, 1996 E D Y Laundry Soap Laundry Soap G Hand Soap (Bar) (Powder) E T A Have used in the past month (reported) 90 100 93 R T S Used for handwashing (reported) 85 55 9 G NI Had at the time of the interview 76 93 69 T (demonstrated) E K N= 1500 R A M 40 at the time of the interview. Table 10 presents hands correctly eight times or more during the the data for Guatemala, where soap was least day, compared to a prevalence of 23 percent available. among those whose mothers never washed Ideal handwashing behavior was defined their hands correctly at critical times (see in the survey as: Figure 4 and Table 11). The finding of a strong association s washing at three key times (before between handwashing and the risk of diarrhea cooking or preparing food, before feeding was confirmed by a logistic regression children or eating, and after defecating or analysis that controlled for variables that had changing babies' diapers) and an independent association with diarrhea. As s with three correct techniques (using soap, listed above, these variables were country of rubbing hands together at least three residence, urban/rural residence, location of times, and drying with a clean towel). source of water, use of a sanitary latrine or toilet by all family members, tested ability of The research segmented the target the mother to read, and number of children in audience according to three behavior change the household. stages: In the analysis shown in Table 11, for example, caretakers at the intermediate step T s Inadequate practice--technique is had a 1.5 risk (odds ratio 1.46, 95% confidence P E inadequate and/or hands are not washed interval: 1.15-1.86) of having a child with C at any of the critical times. diarrhea within the past two weeks. Caretakers N O C s Intermediate practice--technique is at the inadequate step had a 2.1 risk (odds ratio E adequate and hands are washed at one or 2.14, 95% confidence interval: 1.71-2.68) VI T two of the critical times. compared to families at the optimal stage. A E s Optimal practice--technique is adequate R C and hands are washed at all three critical O times. Figure 4. Diarrhea Prevalence Among T Y Children by Handwashing Behavior E V Only 9 percent of the mothers surveyed in Stage of Surveyed Mothers, 1996 R U the four countries were in the optimal group. (all four countries) S T (There were marked regional differences: more E K mothers in Guatemala were in the inadequate Diarrheal disease prevalence R A group and more mothers in Costa Rica were in (percent) M the optimal group.) Regionwide, there was room 25 M O for improvement in the handwashing behavior of R F about 91 percent of mothers surveyed. Two- : 20 T thirds of mothers demonstrated poor technique N E or reported that they had not washed their M P hands at any one of the three critical times on 15 O L the previous day--or both. Technique appeared E V to be less of a problem than timing. E 10 D Perhaps the most striking finding was the Y direct correlation between the number of G E correct handwashing times and the 5 T A prevalence of diarrhea among children R T S younger than five. For example, diarrhea 0 G prevalence was less than 10 percent among Inadequate Intermediate Optimal NI T young children whose mothers washed their E K R A M 41 Table 11. Handwashing Behavior Stage of Surveyed Mothers, 1996 (all four countries) Average daily % of children Description occurrence of under age 5 % of those correct having Stage Technique Critical times interviewed handwashing diarrhea Inadequate Incorrect and/or ¿ 0 65 0 23.1 Intermediate Good 1 or 2 26 4.5 13.1 Optimal Good 3 9 8 9.8 N= 4497 Key Attitudes and Constraints Implications for the Soap The market survey sought to learn about both Producers positive associations with handwashing and To the soap producers, the results of the T P the primary constraints to good handwashing market survey highlighted the potential market E C practices. for soap. People in the optimal group washed N O Specifically, the survey looked at the their hands an average of eight times per day. C connection of handwashing to water The remaining 91 percent washed their hands E VI availability; mothers' perceptions of their own zero to five times per day. If the campaign T A ability to influence children's handwashing were successful, these people would increase E R behaviors; and perceived connections their handwashing by three to five times per C between handwashing and health. day, thus increasing consumption of soap. O T Caretakers believed in an association The strategy adopted was to attempt to move Y E between handwashing and good health, but did families up the "handwashing steps," V R not think handwashing was sufficient to prevent incrementally improving handwashing practice U S diarrhea. In Guatemala, 51 percent of mothers and decreasing risk of diarrhea in children T E said "One gets sick even though we wash our (see Figure 5). K R hands often." A basic belief in the importance of A M handwashing was prevalent in all countries, M however. For example, 94 percent said, "People Figure 5. Moving Families Up the O Handwashing Steps R at home always told me I should wash my F : hands." T N E M Media Usage P O The survey also looked at media use and L E influence. Eight out of ten mothers surveyed V E listened to the radio daily--especially in the D Y morning. Television was most common in G E urban areas, particularly after 6 p.m. T A Newspapers played a minor role in influencing R T the target group. Other studies have shown S the importance of interpersonal G NI communication to reinforce messages T E delivered by the mass media. K R A M 42 Advertising Strategy the mission statement, and summarized the Development results of the market research. Like the market survey, the advertising strategy was developed by a professional Selecting the Advertising Agency agency hired by the catalyst. Task Force BASICS issued requests for proposals to five members made decisions on the general Central American advertising agencies, thrust and extent of the campaign--deciding following USAID's contracting procedures. The to focus advertising on the "how" and "when" Task Force set the following criteria for and to target those with "inadequate" selecting the agency: handwashing behavior (the largest group). They also agreed to focus on healthy s Strong creative capability children--and specifically prevention of s Regional scope in Central America diarrhea--as a positive campaign theme. s Neutral, i.e., no accounts with any Task (Some diarrhea campaigns have used fear or Force member or competitor, to avoid a other negative motivators as a basic strategy potential conflict of interest for promoting changes in practices.) s Affiliation with a multinational advertising agency to benefit from sophisticated Advertising Brief technical support T After analyzing in detail the findings of the P E market survey, the Task Force developed a The third criterion eliminated many top-ranked C preliminary marketing strategy, which formed agencies that might have wished to bid, N O the basis for an advertising brief. The purpose because of their handling of a soap company C E of this brief was to guide the advertising portfolio. VI T agency in developing messages and concepts. The scope of work also specified that the A E It analyzed the public health problem that the agency chosen would develop the creative R C Initiative was to address, described the strategy but would not place the O partnership that had been formed, presented advertisements. Ad placement was to be T Y handled by the in-house publicity departments E V of the soap companies. This arrangement was R Advertising Slogan and Logo U unattractive to the advertising agencies, S T which usually derive substantial commissions E K from ad placement. This delayed the R A submission of an adequate number of bids. M Eventually, three companies did submit bids M O and a Guatemala-based firm, Servicios R F Estrategicos, was selected. : T The original schedule called for selection of N E an advertising agency by mid-December 1996 M P for approval by USAID in mid-January 1997. The O L contract was finally awarded in April 1997. E V E D Developing the Communication Y Strategy G E The catalyst team met with Servicios T A Estrategicos in late April to develop a R T S communication strategy. The strategy formed G the basis for developing materials and NI T ensuring consistency of the message. E K R A M 43 Summary of the Handwashing Initiative Communication Strategy Purpose: Develop the habit of handwashing with soap and water at critical times using correct technique among mothers of children ages five and under. Desired Consumer Response: "I should always wash my hands with water and soap at critical times, such as after coming in contact with fecal matter and before eating, to prevent illnesses, such as diarrhea, which can cause the death of my children." Benefits: Preventing diarrhea. Rationale:The market research study showed that, among the target population, the risk of diarrheal disease was inversely associated with the frequency of appropriate handwashing. Target Groups:Primary group: Mothers with a low level of education and socioeconomic status who have children under five, principally in the interior of the country. Secondary group: Elementary schoolchildren living under the same conditions. Tone: Project an image that is positive, cheerful, memorable, direct, and natural. The Design Concepts Issues and Lessons Learned T Servicios Estrategicos developed rough s A well-conducted market survey is P E design concepts and presented them to the essential for an initiative of this kind. It C N Task Force. The package consisted of a serves two purposes: as formative O campaign logo and two versions of a research to develop a profile of the C E campaign, each consisting of a radio spot, a potential customers and to create a VI T storyboard for a television spot, and a poster. baseline for measuring the impact of the A E Version one centered on handwashing intervention on behaviors. Without such a R C behavior technique and critical times. It survey, an advertising campaign cannot O featured a young mother in a rural setting--a be designed or evaluated. T Y typical representative of the primary target s The catalyst must be prepared to E V audience. Version two conveyed the same provide technical backstopping to the R U message but showed young children washing market research and advertising firms. S T their hands correctly at appropriate times, as Working with a good local market E K instructed by their mother. Servicios research firm can be a very efficient way R A Estrategicos also suggested alternative to get a high-quality product. However, M communication channels, including market research firms are unlikely to have M O community activities at fairs or markets, and experience and personnel with prior R F school activities. training in the behavioral aspects of the : T The Task Force approved both design research required. Examples include N E concepts as complementary. The "mother" handwashing demonstrations, questions M P version would be used for the introductory about diarrhea, or just about anything to O L campaign and the "children" version in a do with children (from selecting E V follow-up round. It agreed to pretest the radio households based on the presence of E D spot and poster in Guatemala and Costa children to enumerating the children in a Y Rica--two countries at opposite ends of the G household and their ages). Specific E region's socioeconomic range. Approval of the T technical backstopping on the training of A R creative concept marked the end of the all- survey personnel is essential to ensure a T S important planning phase. The next chapter uniform approach and high-quality results. G discusses implementation, beginning with a These firms also may be unfamiliar with NI T more detailed description of the advertising public-private partnerships and may, for E K campaign. example, need help presenting R A M 44 information in a way that will be Works Cited convincing to all partners. Another Bateman OM, RA Jahan, S Brahman, S Zeitlyn, challenge of working with a market SL Laston. 1995. Prevention of Diarrhea research firm is the compressed time Through Improving Hygiene Behaviors. schedule typically allowed for such a ICDDR, B Special Publication No. 42, Dhaka, survey. Technical assistance and quality Bangladesh: International Centre for Diarrheal control input from the catalyst requires Research, Bangladesh. intensive commitment of resources during Cousens S, B Kanki, S Toure, I Diallo, V Curtis. the planning phase. 1996. Reactivity and Repeatability of Hygiene Behavior: Structured Observations from s It is important to establish the Burkina Faso. Social Science and Medicine communication strategy as the 43(9):1299-308. reference document for all advertising Hoque BA, D Mahalanabis, MJ Alam, MS Islam. designs and media. Adhering to the 1995. Post-defecation Handwashing in communication strategy ensures that Bangladesh: Practice and Efficiency clear, consistent messages are conveyed Perspectives. Public Health 109(1):15-24. to consumers. Shahid NS, WB Greenough 3rd, AR Samadi, MI Huq, N Rahman. 1996. Hand Washing with Soap Reduces Diarrhoea and Spread of T P Bacterial Pathogens in a Bangladesh Village. E C Journal of Diarrhoeal Disease Research N 14(2):85-9. O C E VI T A E R C O T Y E V R U S T E K R A M M O R F : T N E M P O L E V E D Y G E T A R T S G NI T E K R A M 45 Chapter 7 The Advertising Campaign The "How" and the "When" T his chapter reviews the implementation phase of the Central American Handwashing Initiative by. . . I Describing the promotional materials (radio and television spots and posters). I Recounting how the campaign was implemented in each country. I Highlighting ongoing activities. I Reviewing future plans for continuing the campaign. 47 T he implementation phase of the Handwashing Initiative began in October 1997, when all producers in the Task Force received master copies of the campaign materials created by Servicios Estrategicos. The plan was to launch all of the country campaigns simultaneously (in February 1998) for maximum impact. In actuality, launch dates were staggered from March to September 1998. Description of the Generic known by all family members. The first was Handwashing Campaign aimed at mothers and the second at children. The campaign theme was "Manos limpias, Only the first spot was produced in ready-for- evitan la diarrhea" (Clean hands prevent broadcast format. The second was created in diarrhea), and its slogan was "Lavo mis non-final prototype format, intended for a manos por salud" (I wash my hands for follow-up campaign. The spots were as health). Servicios Estrategicos also designed follows: a campaign logo (shown in Chapter 6) and a mascot, "La Burbujita." s Version 1 (finalized): "Uno, dos, y tres" (One, two, and three)--a 30-second spot Radio Spots to the tune of "Cielito Lindo" (a very Based on information from the market survey popular old song transmitted through about media usage, radio was identified as generations). The mother sings a song the primary medium for reaching the target telling happily why it is important to wash audience. Servicios Estrategicos created two one's hands at critical times. "Uno, dos, y spots with easy-to-remember lyrics set to the tres" refers to the three critical times (after " music of traditional songs that would be going to the bathroom, after changing a N E baby, and before preparing food) and the H three critical techniques (use soap and W" Burbujita, the Mascot of the water, rub hands three times, and dry in E Handwashing Initiative H the air or on a clean towel). T D s Version 2 (prototype): "Dice mi mama" (My N mama says)--a 15-second spot with A " variations to the tune of "Tengo una W O muneca vestida de azul" (another popular H" song). The child sings about what his E H mother has told him. There are three T : variations: wash before eating, wash after N GI going to the bathroom, and my mama A washes after cleaning my little sister. The P M three aspects of correct technique are A C also included. G NI SI Television Spots T Television was the secondary medium. Again, R E two spots were created. Both were short and V D upbeat, using actors and contexts the target A E H T 48 population could identify with to portray good The Generic Poster health, and featuring the same popular tunes as the radio spots. s Version 1 (finished master copy): "Uno, dos, y tres," a 30-second spot--similar to version one of the radio spot, presenting the cheerful mother as the authority for maintaining the health of the family as she demonstrates the proper handwashing technique at critical times during the day. s Version 2 (prototype storyboard): "Dice mi mama," a 15-second spot with three variations, similar to the second version of the radio spot. Posters Posters were created to support and reinforce the radio and television campaign. They were to be displayed in public places such as schools, health centers, stores, and pharmacies. One version depicted the cheerful mother carrying out all of the campaign behaviors (the three "techniques" at the three "times"). The poster carried the logo and slogan as well as the main message: "Manos limpias evitan la diarrea." adding the trademark and logo of the product " N Task Force members had thoroughly to the materials or (2) incorporating the E discussed the design elements of the H messages and graphics into a company's own W" campaign. Hand soap producers wanted a advertisements for a specific brand. The basic E scene showing a modern bathroom sink, while implementation strategy of the Handwashing H T laundry soap producers insisted on a rural Initiative was to launch a two-pronged D setting, showing the pila (laundry tub) with campaign in each country: a generic N A laundry hanging on a line in the background. campaign on radio and television (presumably " W The poster Servicios Estrategicos designed with time donated by media organizations), O represented the best compromise, targeting followed or accompanied by the individual H" E the primary audience of rural mothers in company's brand advertising through mass H T socioeconomic categories D and E. media, educational activities, and point-of- : sale promotion. N GI Strategy for Implementation The local coordinator prepared a generic A P Servicios Estrategicos gave each of the media plan detailing the radio-television mix, M A producers in the Task Force master copies of the number of radio stations, programs, and C the advertising materials. These materials spots, date of launch, and duration of the G could be used as they were for promoting NI campaign for each country, and presented it SI handwashing with no brand identification (a to the Task Force. For the producers, T R generic campaign). Or producers could acceptance of this plan raised issues of E V associate the campaign with a product by (1) ownership, budget, confidentiality, and brand D A E H T 49 positioning adaptation. Most of them was one of the country's most active soap developed their own media plans instead of advertising campaigns. Thanks to the adapting the generic plan. agreement with Teletica, the campaign outspent even the big names, such as Campaign Activities-- "Palmolive," "Bactex," "Lux," "Dove," and "Gold March 1998 to April 1999 Pro" soaps, in television advertising. Activities in Costa Rica The Office of the First Lady of Costa Rica Punto Rojo set aside approximately $114,900 also contributed to the campaign by providing to spend on media for the Handwashing a total of 3,500 posters to all government Initiative (about $82,400 on television and ministries and directorates for distribution to $26,000 on radio). The company contacted health centers, post offices, and the like. Channel 7 (Teletica), the television station with Punto Rojo printed a special batch of posters the widest national coverage (90 percent) carrying the logo of the Office of the First broadcasting the most popular programs for Lady along with the "Fortuna" brand logo. housewives. Teletica was so enthusiastic about the campaign that, for every paid Activities in El Salvador announcement, they offered at least one free The Directorate of Social Programs of the announcement during prime time. Ministry of Health, which had introduced the For the generic campaign, television concept of Escuelas Saludables (Healthy spots were run on Channel 7, and printed Schools) several years before, expressed materials and tapes of the radio spots or the interest in the Handwashing Initiative as poster were distributed to soon as its director heard NGOs with direct reach to about it. Unisola/Unilever had communities (for example, been seeking Ministry of World Vision). The branded "We joined the campaign Health endorsement of the campaign consisted of because it involved the handwashing advertising television and radio campaign and agreed to put company in a social outreach " commercials of the "Fortuna" its full effort into a joint N E brand--an inexpensive toilet program, something we had not arrangement with the H soap with high distribution in ministry. Under the W" participated in before, and to rural areas--and agreement, "Plan de E H merchandising through the decrease the number of children cooperación `Lavo mis T D distributor sales force. who die due to disease." Manos por Salud,' " Unisola/ N Punto Rojo did not renew Unilever developed A --Arnoldo del Valle, " the agreement with Teletica La Popular, Guatemala handwashing materials to be W O when it ended in April 1999. used in schools, health H" The producer felt that the centers, prisons, and E H spot was targeted more to the markets. The school T : poorer Central American neighboring countries program, which reached 3,500 schools, N GI and that it did not adequately reflect the Costa consisted of educational modules on A Rican setting. The producer agreed with the handwashing for schoolchildren and P M message but preferred a more upscale model distribution of "Gold Pro" soap samples, A C in a more urban setting--more in keeping with educational posters, banners, and leaflets. G the local population. Within the health centers, the TV spot was NI SI Despite Punto Rojo's reservations, shown as a video in waiting rooms, T independent media audits indicated that the accompanied by posters and leaflets. The R E company's advertising campaign for "Fortuna" soap company mass-produced materials for V D in connection with the Handwashing Initiative distribution to selected schools and health A E H T 50 posts. USAID and UNICEF also distributed Figure 6. Generic vs. Branded materials through NGO networks. Campaign Expenditures in 1998 Following the positive collaborative experience with Unisola/Unilever, the Ministry of Health reached out to ask Colgate- Palmolive to supply additional soap samples for the school program and to Helsal, a major towel manufacturer. Unisola/Unilever, with the Ministry of Health and the major Salvadoran television broadcasting corporation (TCS--Channels 2, 4, and 6), cosponsored free broadcasting of the generic spot, though only for a limited time. The "Gold Pro" brand advertising on television was preceded and followed by the handwashing message and logo, reinforcing the link between the generic campaign and the brand advertising. Activities in Guatemala The campaign was launched in Guatemala in March 1998 with airtime for the generic "Uno, dos y tres" television and radio spots donated 2001, the advertising agencies of Colgate- by the largest media company and the radio Palmolive had developed and begun association. The television spot has been disseminating handwashing kits in schools. aired mostly on Channel 6, the station with La Popular launched its activities in May the largest audience, and the radio spots have 1998. The company wavered between been broadcast in several areas of the associating the handwashing campaign with " N country. In addition, La Prensa Libre, the its line of personal care soaps or its line of E largest daily newspaper in the country, agreed H laundry soaps. The original position was to W" to run generic advertisements with launch the campaign along with the laundry E handwashing vignettes as filler. The soaps, where La Popular, with its four brands, H T newspaper is also considering other ways to holds more than 50 percent of the market. La D participate, such as reporting on handwashing Popular ultimately followed the BASICS N A through interviews of experts in the field and private sector advisor's recommendation to " W featuring handwashing as a topic in the stick with that position because the primary O Sunday children's section. The local target for the Initiative uses laundry, not hand, H" E coordinator was responsible for contacting the soap. La Popular's laundry brands are H T media companies and persuading them to identified with the campaign--for example, : participate in the Initiative. their logos are on the posters--but the N GI Two producers, La Popular and Colgate- messages of the Initiative have not been A P Palmolive, shared responsibility for the integrated into the company's advertising. M A campaign in Guatemala. Colgate-Palmolive (One "Ambar" advertisement touted the soap's C was not able to launch its branded campaign thorough cleaning of clothes but gentleness G during the first year of the Initiative, mainly NI on hands. Beyond this mild mention, the SI because of the delay in assigning a new company did not wish to include dedicated T R representative when the company's Task messages on handwashing in its E V Force member was promoted. As of August advertisements.) D A E H T 51 La Popular carried out field activities Protex Handwashing Poster: through its mobile units, playing the radio spot An Adaptation of the Generic on a loudspeaker, distributing soap samples Campaign and leaflets, and displaying posters around the country. And to celebrate the fiftieth anniversary of "Ambar," the country's leading laundry soap, the company provided 14,000 samples of the soap for handwashing kits for programs in 400 schools--a program also supported by UNICEF. FUNDAZUCAR, an organization fostering education, health, housing, and municipal development for those working in the sugar cane plantations and plants, introduced handwashing kits and handwashing corners in the schools and centers it sponsors. Figure 6 compares the implementation of the campaign in the three countries. Continuing Project Activities Since the follow-up market survey at the end of 1999, which marked the official conclusion of the BASICS/EHP intervention, producers and other partners have carried out additional activities. These activities are not officially part of the campaign, but grew out of the activities of the partnership and are evidence " of sustainability. N E s CARE/Guatemala continued to distribute H s In the aftermath of the earthquake in El leaflets and place posters in strategic W" Salvador in January 2001, Unisola/Unilever locations. E H worked with BASICS and the Ministry of s Colgate-Palmolive has donated soap and T D Health to launch a promotional campaign to promotional material to the ministries of N address the high risk of diarrheal disease in health in Guatemala, Nicaragua, El A " communities damaged or destroyed by the Salvador, and Honduras. W O earthquake. Through press, radio, posters, s Colgate-Palmolive is using the messages H" calendars, and stickers, the partners of the handwashing campaign to E H conveyed three important messages: advertise its antibacterial soap, "Protex," T : disinfect drinking water, wash hands with to the general public. N GI water and soap at three key times, and s Colgate-Palmolive has also developed a new A wash fruits and vegetables. USAID financed regionwide campaign targeting elementary P M the production of materials, and Unisola/ school children in Guatemala, El Salvador, A C Unilever provided bars of soap and tablets Panama, and Costa Rica. Materials G for disinfecting water. The strategy was developed for the school program include a NI SI launched at the community level through handwashing story told by Manolo, a cartoon T the Department of Health. The company octopus character, a board game about when R E has proposed repeating the campaign but to wash one's hands, a poster for V D focusing exclusively on handwashing. classrooms with accompanying notes for A E H T 52 teachers, and a take-home calendar ­ handwashing clinics in markets, students can use to keep a daily record of ­ handwashing kits for health when they wash their hands. centers and schools, s At the April 2000 public relations event, ­ a "Handwashing Week." the partnership announced that it had drawn up plans to continue the campaign Colgate-Palmolive pledged a donation of in Guatemala through 2003. Two types of 20,000 soap samples and 10,000 posters activities were anticipated: and stated that it would lead the effort in · Educate the population about the coordination with the Ministry of Health critical times and techniques for and other partners. handwashing through television, radio, Other future plans are discussed in press, mobile units in local markets, Chapter 8 in the section on sustainability. and posters in health centers, hospitals, and schools. Issues and Lessons Learned · Integrate the "Lavo Mis Manos Por s The diversity of implementation Salud" program with the Ministry of methods underlines the importance of Health's National Plan for Healthy flexibility on the part of the catalyst. Schools and Municipal Health However, if the methods diverge too Promoters through: sharply, the campaign materials may not Protex Handwashing Promotion: A Program Targeting Schoolchildren " N E H W" E H T D N A " W O H" E H T : N GI A P M A C G NI SI T R E V D A E H T 53 be completely appropriate. In the case of implementation and ruled out a El Salvador, for example, a school simultaneous launch, which would have program was adopted, yet the generic generated regional and local momentum. materials were clearly addressed to Competitive factors also explain the mothers, not children. The constant in all failure to launch the campaign in a implementation approaches was that the coordinated manner. The smaller firms soap companies financed or leveraged wanted to wait for the larger firms to funds for the campaign without donor launch to benefit from the "tempo" the financial support. large firms would create. There was also s Internal issues of the soap producers an element of defensive competition: "I and competitive stresses among them won't launch until the others launch." And can have a significant impact on the regional leaders were afraid of losing their implementation of a regional edge: "If I launch in one country, I cannot advertising campaign. For example, replicate regionwide because the local management and personnel changes at firms have the market." There was no two companies slowed down campaign leveraging of regional capabilities. " N E H W" E H T D N A " W O H" E H T : N GI A P M A C G NI SI T R E V D A E H T 54 Chapter 8 Results Return on Investments T his chapter reviews the assessment phase of the Central American Handwashing Initiative by. . . I Describing the assessment efforts--including the follow-up marketing survey. I Detailing positive results in three categories: public health, resources leveraged, and sustainable change among partners. I Reviewing the Initiative's results from the soap producers' point of view. 55 T he Central American Handwashing Initiative yielded three kinds of results. Foremost were the public health results--including changes in attitudes and actual handwashing behaviors known to prevent diarrheal disease. To some extent it is also possible to estimate changes in the burden of diarrheal disease itself. Second, the Initiative leveraged considerable resources for handwashing promotion, not only from producers but also from other partners. Finally, the Initiative had a positive and--the evidence suggests-- sustainable effect on the organizations that participated in it. Methods for Assessing Results surveys (Evaluación del Impacto Campana Follow-up Market Survey with Lavo, 2000). Key features of this analysis are Beneficiaries presented below.1 Public health results were assessed by Interviews with Partners means of a second survey conducted by Generis Latina. The questionnaire was Partners in the Initiative were also contacted identical to the one used in 1996, with the to assess the collaboration. In April 2001, the addition of questions to capture campaign local coordinator interviewed ten people who exposure. Due to funding limitations, this had been involved in the Initiative in follow-up survey was carried out only in Guatemala, Costa Rica, and El Salvador (see Guatemala. There, a total sample of 1,500 Annex B). She questioned them on their households was once again selected within reasons for involvement, expectations, the same clusters that were sampled in the impressions of the partnership, benefits to baseline survey. The supervisors and, to the their organization, problems and issues, and extent possible, survey team members, were continuing related activities. the same as those who performed the Results baseline survey. The second survey was conducted in November 1999, a little more Exposure to the Campaign than a year after the launch. Smaller tracking The campaign most effectively reached capital- surveys of 500 mothers were conducted in dwelling, non-indigenous populations with urban areas of Costa Rica and El Salvador to access to television, but also reached rural and S T provide information for further development of indigenous populations--albeit at a lower rate N E the campaign in those countries. These (see Table 12). In Guatemala, about 25 percent M T surveys were not designed for strict of the total population recalled campaign S E comparison to the baseline, and they differ messages on the radio--a key element of the V NI significantly from the baseline in terms of strategy for reaching rural indigenous N sample design and implementation. populations via Mayan-language radio stations. O Generis Latina prepared a report The survey also looked at exposure to N R comparing the results of the baseline and final "any" messages about handwashing during the U T E R : S TL 1. The complete report, Impacto del Campana Lavo Mis Manos por Salud: Reporte Final, is also available in the CD-ROM, The Story U of a Successful Public-Private Partnership in Central America: A Compendium of Resources. S E R 56 campaign period. Because the Initiative critical times. As in the first market study in encouraged soap companies to promote 1996, the follow-up survey categorized handwashing but did not dictate exactly how interviewees as being in one of three stages (or even whether) the graphics specifically vis a vis good handwashing practice: optimal prepared for the campaign practices, intermediate were to be used, it is helpful practices, and inadequate to look at broader exposure to practices (see Chapter 6). "At a local level, the campaign handwashing messages as Figure 7 compares the first well. For example, in had a great impact; people and second survey results in Guatemala, exposure to any were even saying, `I wash my terms of handwashing behavior messages about in Guatemala. Considerable handwashing during this hands for my health.'" progress was made: ten period was mentioned by 42 -- Almeda Aguilar, percent moved from the Ministry of Health, Guatemala percent of those surveyed; in inadequate to the intermediate El Salvador, by 49 percent, or optimal stages. and in Costa Rica, by 74 percent. The distribution of those exposed Attitudes Toward Handwashing (urban vs. rural, indigenous vs. non- and Soap indigenous) was similar to the exposure A number of important attitudes improved patterns for the campaign-specific messages. following the campaign. In Guatemala, for example, the proportion of mothers who said, Handwashing Behavior "One still gets ill even with regular The behavioral objectives of the Initiative handwashing," fell from 51 percent to 37 were to improve handwashing techniques and percent. The percentage of mothers who increase the frequency of handwashing at agreed with the statement, "We should wash Table 12. Exposure to the "Lavo Mis Manos por Salud" Campaign Recall "Lavo Mis Manos por Salud" Guatemala El Salvador Costa Rica Campaign (urban & rural) (urban) (urban) Prompted and unprompted recall of campaign: All interviewees 18% 23% 65% Urban 24% 23% 65% Rural 14% S T Capital 30% 26% 68% N E Rest of Country 15% (rural and urban) 20% (urban only) 63% (urban only) M T Indigenous 10% S E Nonindigenous 22% V NI Medium recalled: N O TV 70% 81% 97% N Radio 25% 4% 7% R U Newspaper 6% 3% 1% T E R Flyers and Posters 20% 18% 2% : S N (Guatemala) = 1500; N (El Salvador) = 500; N (Costa Rica) = 500 TL U S E R 57 second survey conducted in Guatemala, this Figure 7. Stages of Handwashing association was still marked (see Figure 8). Behavior in Guatemala, 1996 The final survey was conducted during a and 1999 season when diarrhea rates are normally lower. As one would expect, optimal Handwashing behavior change after 12-month campaign in Guatemala handwashing behaviors were associated with (1500 mothers) a stable, low prevalence of diarrhea. And, given the reduced risk of diarrhea during this Percent season, intermediate and inadequate 90 78 behaviors were associated with about half the 80 68 1996 risk of diarrhea seen in the baseline, which 70 1999 was conducted in the high-diarrhea season. 60 The improvement in mothers' 50 handwashing behavior in Guatemala between 40 the baseline and follow-up surveys was 30 25 apparently small, but on a population basis it 19 20 may have translated into an important public 7 10 3 health impact. According to the National 0 Statistics Institute in Guatemala, the total Inadequate Intermediate Optimal population of under-five year olds in the year 2000 was 1,845,317, and about 85 percent of them lived under the lowest socioeconomic our hands before eating only if our hands appear dirty," decreased from 43 percent to 32 percent. There was also a 10 percent drop in Figure 8. Diarrhea Prevalence the percentage who agreed that "Most times, Among Children by Handwashing washing hands with water is sufficient." At the Behavior Stage of Surveyed Mothers same time, the number of mothers agreeing in Guatemala, 1996 and 1999 with the statement: "When I don't use soap, I feel that I am not clean" rose from 78 percent to 88 percent. Mothers perceiving the multipurpose use of the bola soap increased from 39 percent to 50 percent, reflecting the intensive efforts of laundry soap producers to link their brands with the handwashing campaign. S At the same time, changes in attitude were T N not uniformly positive. For example, in E M Guatemala there was no reduction in the T S percentage of mothers who said it was difficult E V to get their children to wash their hands after NI going to the bathroom or before eating. N O N Public Health Impact in Guatemala R U As discussed in Chapter 6, diarrheal disease T E prevalence among children under five was R : closely associated in the first survey with S TL mothers' handwashing practices. In the U N =1500 S E R 58 conditions (INE 2000). That means that the Estimates of the Health Impact of the changes in handwashing behavior and the Handwashing Initiative in Guatemala2 corresponding 4.5 percent overall reduction in diarrhea risk2 had an effect on a large After one year of the campaign in Guatemala population of under-five year olds--about among the 1,572,395 children under five 1.57 million children. What does this mean in nationwide in the two lowest socioeconomic terms of reducing the burden of diarrheal strata, there were: diseases? Some estimates of this impact are s 14,500 fewer children with diarrhea presented in the box on this page. during any two-week period during the rainy (high diarrhea) season Long-term Effects s 7,000 fewer children with diarrhea during The campaign fostered proper handwashing any two-week period during the dry (low behavior now and with a promise into the diarrhea) season future. Mothers modified their behavior to s 322,000 fewer cases of diarrhea a year reduce the current rate of diarrheal disease. And as schoolchildren targeted by the s 1,287,000 fewer days of diarrhea a year campaign become parents, another seed for proper handwashing techniques among future generations will already have been laid. (A similar long-term vision has been realized in consistent increase in reported frequency Sri Lanka, where an oral hygiene program for of handwashing on critical occasions children begun 20 years ago by Unilever has among all three groups. been associated with the highest oral hygiene s Handwashing Technique: Observed rate in the region--and a strong market for handwashing technique improved toothpaste companies as well.) significantly among both mothers and children in Guatemala, but there were no Other Key Findings such improvements in El Salvador or Additional findings on exposure to the Costa Rica. campaign, changes in attitudes, and other s Soap Usage: Reported soap use and factors emerged from the market survey. demonstrated presence of soap in the Differences in findings among countries are household at the time of the interview difficult to interpret because the sample remained very high and unchanged in all design and implementation of the final three countries. surveys in Costa Rica and El Salvador s Movement up the Handwashing Steps: differed from those of the baseline in those Overall improvement in handwashing-- countries and from both surveys in movement up the handwashing steps Guatemala. (Figure 7)--was significant in both urban S T and rural Guatemala, but with much N E s Handwashing on Critical Occasions: In greater improvements in urban settings. M T Guatemala and urban Costa Rica, there S E was little change in reported handwashing Resources Leveraged V on critical occasions among the mothers, A relatively modest level of effort on the part NI N fathers, and children five to ten years of of USAID, through funding to BASICS and O age, whereas in El Salvador, there was a EHP, prompted soap companies and media to N R U T E 2. See Annex C for calculations used to produce these estimates. These estimates were calculated using information in Figures 7 R and 8 and population estimates from the National Institute of Statistics of Guatemala (INE 2000), assuming a mean of 4.5 cases : S of diarrhea per year, with a mean duration of four days per incident case, for children under five in socioeconomic strata D and E TL in Guatemala. U S E R 59 Table 13. Catalyst Expenditures, 1996-1999 Item Description Cost Technical assistance Three technical experts (meet with soap producers and $177,000 other partners, keep USAID apprised of status of the Initiative, attend Task Force meetings, analyze data, etc.) Approximate level of effort: 70 person days for EHP and 260 person days for BASICS. Travel and per diem $20,000 Task Force meetings Facilitators, meeting room rental, refreshments, etc., for $6,000 seven Task Force meetings. Marketing studies: Contract with Generis Latina $153,000 baseline and follow-up Advertising design Contract with Servicios Estrategicos $33,000 concept TOTAL $389,000 Table 14. Leveraged Resources, 1998-1999 Item Description Amount Guatemala Radio Donated commercials, May to December 1998, 6,336 spots $110,000 (Central de Radios y (198 per week), Guatemala City and the Altiplano y Camara de Radiodifusion Nacional) Television Donated commercials, May to December 1998, 589 spots, $200,000 (Channels 3, 7 18 per week, national coverage 11, 13) Print media Vignettes in black and white and color, April to December 1999 $5,000 (La Prensa Libre) Colgate-Palmolive Reprinted 10,000 posters for distribution through UNICEF and $4,000 NGOs, August 1998 Developed protocols for handwashing kits and school program $10,000 materials (coloring books, flyers), April to August 1998 S Donated soap samples $3,000 T N La Popular Radio commercials, October 1998, in Guatemala City and September $9,500 E 1998 to October 1999, mobile unit promotion in the interior of the country M T S Printing and distribution of 5,000 posters in markets, October 1998 $2,000 E V Distribution of banners in markets, September 1998 to October 1999 $1,500 NI Donation of 3,000 bars of soap for handwashing kits distributed $1,400 N in Quiche O N Printing and national distribution of 10,000 flyers through the mobile units $2,000 R U FUNDAZUCAR Introduced handwashing kits and handwashing corners in schools $3,500 T E and health centers R : UNICEF Radio commercial, August to October 1998, in the Altiplano $8,000 S TL Printing and distribution of posters and handwashing kits in the $2,000 U Altiplano, July 1998 S E R 60 spend resources that would not otherwise Soap Producers' have been spent on handwashing promotion. Evaluation of Results BASICS/EHP expenditures for the Key executives from three of the four soap Handwashing Initiative totaled $389,000 for companies involved in the Initiative were technical assistance, travel and per diem, interviewed. Their overall impression of the development of the marketing strategy, and campaign was positive, and two of the market research (baseline and follow-up) from producers are involved in activities that grew January 1996 to December 1999. Table 13 out of the handwashing campaign. itemizes these expenditures. In the producers' view, the Initiative had This investment by USAID leveraged an numerous pluses: estimated $614,900 for public health in the three countries in just the first year of the s Helping people. Most often mentioned campaign. Table 14 itemizes the leveraged was the satisfaction of being involved in a resources and puts a dollar value on them. campaign designed to help people. The The information in Table 14 does not representative from Colgate-Palmolive provide the whole picture because it presents said that the company views helping only the total for one year and does not include communities and governments improve ongoing handwashing promotional efforts that the health conditions of populations as a began after the official end of the Initiative. corporate responsibility. The producers Table 14. Leveraged Resources, 1998-1999 (cont'd) Item Description Amount Work groups distributing handwashing kits in rural communities and schools in the Altiplano, March 1998 to the present $5,000 Total for Guatemala $366,900 Costa Rica Television - Teletica Matched Punto Rojo advertisements on TV7, May to December 1998 $82,400 Punto Rojo Radio commercial, May to December 1998, national coverage $26,000 Print advertisements, May to December 1998, national coverage $3,500 Printing and distribution (through World Vision and the Office of the First Lady of Costa Rica) of 6,600 posters $3,000 Television commercials, May 1998 to April 1999, national coverage $82,400 Distribution of soap samples at events $2,000 Total for Costa Rica $199,300 El Salvador S Unisola/Unilever Distribution of television advertisement via videocassette, Healthy $600 T N Schools Program (3,500 schools) E M Distribution of radio commercial via audiocassette to 31 health posts $100 T S Distribution of banners to 150 health fairs $1,000 E V Printing and distribution of 30,000 posters, Healthy Schools Program, $22,000 NI health posts, and Healthy Markets, and various NGOs N O Donation of 25,000 soap samples, Healthy Schools Program, Healthy $15,000 N Markets, and health posts R U Television (TCS) Aired commercial during initial launch $10,000 T E Total for El Salvador $48,700 R : Grand Total $614,900 S TL U S E R 61 also named the public as the major in areas where project activities had taken beneficiary of the campaign. Said one: place. While public-private partnerships are "We genuinely believed in the campaign built on the assumption that involvement and its cause. This allowed us to keep in will benefit the bottom line for commercial mind at every moment that we were firms, it may be a challenge to document perhaps saving a life." the increases because of the sensitivity of s Advantages of working with the public such information. sector and international organizations. Producers appreciated the value of The producers also raised issues and teamwork and the involvement of the problems: public sector and international organizations. They gave high marks to s Competition. The difficulty of working with the level of communication among competitors--even for a good cause-- partners. All remarked that the was recognized. Throughout the Initiative involvement of ministries of health and certain producers never wavered in their organizations such as UNICEF and CARE contention that an exclusive arrangement gave the advertising campaign more would have been better. credibility--not only with the public but s Tight resources. Lack of funds for public also within their own companies to "sell service efforts was identified as a participation in the campaign." "When we problem. Apparently, not all top managers say, `GoldPro recommends you wash your were willing to allocate resources to the hands,' it doesn't have the same weight campaign unless it was compatible with as when the Health Department, USAID, the positioning of their brands. and BASICS say, `Wash your hands for s Lack of follow-up after the formal the sake of your health,'" noted the campaign. When BASICS/EHP reduced Unisola/Unilever representative. "We need the level of catalyst involvement, the a partner that can give us some authority partners were left without a formal so that people will believe what we say." coordinator and raised the question of In a similar vein, the Colgate-Palmolive who would step forward to lead the effort. representative said, "What is better than Colgate-Palmolive expressed the desire to to have the country's health department keep its national Task Force going with itself next to you?" monthly meetings. ("We have enough s The catalyst role. BASICS/EHP's role as momentum to keep communicating this a catalyst was highly appreciated, simple message in hopes of improving particularly the ability of the catalyst team children's health.") Some criticized the to be neutral toward competing government for not remaining more S companies and a variety of organizations involved or supporting the companies T N and to react quickly to changing more, with compensation through tax E M circumstances. The companies breaks, for example. T S recognized that BASICS, in particular, is s Creative concept. The generic E V very interested in private sector advertisement was criticized for not being NI collaboration. culturally appropriate in all countries. One N O s Increased sales. The producers made producer said, "A Costa Rican woman may N reference to sales but only to say that it is not identify with a commercial showing a R U very difficult to tease out what effect the Guatemalan mother worrying about her T E relatively modest advertising campaign of son's diarrhea." Another producer felt the R : the Handwashing Initiative had. Two generic advertisement was "too heavy with S TL producers implied that sales had increased information" and would have been better U S E R 62 with a simpler message. It was mentioned campaign with the "Lavos mis manos por that radio could have been used to better salud" diarrheal disease prevention campaign. advantage. However, the producers felt Colgate-Palmolive planned to invest $150,000 that the campaign was generally well in this program. targeted to the people in need. Unfortunately, the catalyst has no mechanism for following ongoing activities Sustainable Change Among from a public health point of view. The Partners companies continually monitor their Effect on the Private Sector commercial activities in terms of return on One of the major benefits of the Handwashing investment but are unlikely to assess public Initiative was building awareness among the health impact. private sector that public health objectives are compatible with business opportunities. The Effect on the Public Sector and Other Partners soap producers learned that soap could be advertised in ways to promote its correct use Representatives from the public sector and to achieve health benefits. They also gained other organizations were also interviewed and valuable experience in reaching out to the reported that participating in the Handwashing media, ministries of health, and other partners. Initiative had a positive effect on their A vivid example of this new awareness organizations. was Unisola/Unilever's response to a devastating earthquake in El Salvador in early s Increased competence of personnel. 2001. Within a week the company was able to Involvement with the Initiative helped put together an advertising campaign to health workers learn to speak easily and address the emergency, in partnership with clearly about handwashing. BASICS and the Ministry of Health. The s Improvements in hygiene programs. advertisements focused on handwashing with UNICEF Guatemala mentioned that the soap at key times in addition to other experience with the handwashing messages for cholera campaign materials was helping the prevention. organization to revise the Colgate-Palmolive is messages in its sanitary and launching a regional environmental education "I insist that this campaign be a campaign with elements programs. "The campaign had lasting one, not something that based "100 percent" a single message," the (according to a company ends abruptly, because through UNICEF official said, "not a representative) on the volley of messages. `One, the soap campaign, we are Handwashing Initiative. The two, and three' is very easy plans include a school promoting a health change in for people to remember and S T program in Guatemala, El apply. It is a handwashing N people's habits." E Salvador, Costa Rica, and message stressing practical M -- Lucrecia Mendez, CARE, Guatemala T Panama to teach children the results." The representative S E correct technique, timing, and from CARE/ Guatemala said V NI frequency of handwashing. involvement in the campaign N The program planned to reach 450,000 school had strengthened its program by helping O N children in 2000-2001 and will be extended to CARE unify its efforts, enabling the R U Honduras and Nicaragua the following year. organization to respond to one of the T E The motivation is to replicate the company's Health Department's top priorities, and R : experience of the highly successful, 20-year, fortifying work done by its Maternal and S "Bright smiles, bright futures" oral hygiene Infant Health Program. TL U S E R 63 s Creation of new associations and s Even a small improvement on a large networks. Involvement as a partner in the scale translates into a big impact, but Initiative opened up new channels of greater impact may be achieved collaboration that can be used in other through broader partnerships. In efforts. For example, it appears that Guatemala alone, the national campaign Unisola/Unilever, the Salvadoran MOH, potentially benefited over 1.5 million and BASICS/El Salvador are poised to children, and handwashing improvements collaborate in a sustained way to address were seen at a national scale. The largest child health problems. previously documented handwashing improvement intervention had a target Several issues were identified by the population of about 60,000 children, and public sector and other partners that may most documented experiences had much have limited the success of the Initiative in smaller populations. bringing about sustainable change: s Public-private sector partnership can be routinely considered among public s Length of the campaign. As one health tools. This experience shows how interviewee remarked, "To talk impact, we such a partnership can work. On the other have to talk years." The campaign was too hand, the reduction in diarrhea rates short, and BASICS and EHP should have estimated here are much less than those been involved longer. Now, with the two seen in many reported studies. However, projects playing a very limited role, the this activity does not represent a ministries and international organizations comprehensive approach either to have to find ways to continue and extend diarrhea prevention or to handwashing the campaign on their own. Lack of behavior change. What has been resources may make that difficult. demonstrated here is that public-private CARE's representative said that the sector partnerships can play a useful role campaign should be a lasting one, not in promoting handwashing. something that ends abruptly. Opportunities for expanding the s Community involvement. The partnership and achieving greater impact Handwashing Initiative did not include a include more participation of NGOs and community participation component. PVOs (with community-level interventions There is room for involving key people in and more opportunities for interpersonal the community and people who could communication), integration with serve as models to reinforce handwashing infrastructure programs, assessment of behavior change. barriers to handwashing, and inclusion of partners to address those barriers. S Issues and Lessons Learned T Additional partnerships can be key to N s The most salient feature of a private E influencing the most affected and difficult- M sector initiative for public health T to-reach populations. S objectives is that financial and technical E V support rests with the companies s There are many obstacles to assessing NI themselves, and continued activities are public health impact where the N O not predicated on continued injections of intervention happens at the scale seen N funds and technical assistance. here. R U · Other interventions that may affect the T s Subsidiaries communicate successful E target behavior must be monitored. If R experiences to their headquarters, : S which in turn spread messages to the rest they exist to any significant degree, TL of a global network. then any evaluation will be difficult. U S E R 64 Likewise, the effects of an intervention consistently throughout the process if can be difficult to distinguish from a an evaluation of public health secular trend and behavior improvements is contemplated. As improvements. noted in Chapter 6, the design and · It is impossible to have a control group implementation of surveys often with national-level campaigns, so the moves rapidly when one is working question of whether any effects on with private sector partners. The public behavior can be attributed to the sector and/or catalyst team needs to intervention can never be fully be prepared to invest resources resolved. intensively for a short period of time at · Comparing two surveys with randomly the outset to assure that the critical selected populations presents limitations aspects of evaluation design and when the real interest is finding out what implementation are sufficiently happened to individuals or families. In addressed. Likewise, sufficient support the Handwashing Initiative, the real will be needed throughout for the interest was evaluating specifically monitoring and final information whether individual families moved from collection and analysis. one step to the next in improving s Private companies were unable or handwashing behavior and then trying unwilling to share information about to discover whether the movement was how their participation in the related to exposure to the intervention. advertising campaign affected sales. The latter issue implies that a cohort Thus, it was difficult to document the full design, perhaps with periodic monitoring impact of the Initiative. of a smaller number of families and a s The Initiative tried to integrate time series analysis, should be handwashing promotion into the considered for the survey. In any event, budget of a winning brand (market survey design will present difficulties leader). If handwashing promotion is not and tradeoffs. The design used in this part of the promotional program of a activity was chosen because it balanced market leader, it will not be sustained. If it market research and evaluation needs, is integrated into the promotion of a minor could be applied within the available brand (with a small budget) it will not have budget by a local firm with limited an impact. external assistance, and could be presented to the private sector partners in a format to which they are accustomed. · While the relationship between S T handwashing and risk of diarrhea is N E well documented, demonstrating Works Cited M T behavior change alone may not be S Evaluación del Impacto Campana Lavo Mis E sufficient for the needs of some V Manos Por Salud: Reporte Final. 2000. partners. The more difficult task of NI Prepared for Generis Latina de Grupo de N estimating health impact may be Servicios de Información, Guatemala, O necessary for both continued support Guatemala, CA, Febrero. N R and advocacy. U Encuesta de Ingresos y Gastos (1998-1999) and T · Sufficient support from the public E Population Projections. 2000. Instituto Nacional R health interests in the partnership : de Estadística (INE), Guatemala, Guatemala, S must be provided early and CA TL U S E R 65 Chapter 9 Key Steps for Replication T his chapter identifies the key elements of the Central American Handwashing Initiative for organizations that may wish to replicate a similar effort by . . . I Examining overall costs and benefits for the participants. I Describing the critical path and key actions for replication. I Identifying "red flag" issues. 67 T he success of the Central American Handwashing Initiative suggests the potential inherent in partnerships that bring the public and private sectors together to achieve complementary goals. Similar efforts in other countries or regions would multiply the resources available to fight diarrheal disease--and many other diseases. The Initiative also suggests that the private sector's techniques for getting messages out can be marshaled to change behavior. Costs Versus Benefits increases in handwashing. However, such an An attractive feature of the public-private increase would be difficult to track, given the partnership described in this report is its low size of the companies and their varied cost and high benefits. For reasons product lines. Also, companies may not wish described below, it is not possible to put a to divulge information about sales increases. dollar value on all costs and benefits; (When interviewed, two producers implied however, Table 15 indicates the extent and that their sales had increased as a result of kind of resources required and the type of the campaign.) benefits obtained. The investment of the producers, media, The catalyst organization underwrote the international organizations, and others costs of encouraging and facilitating the (estimated at $614,900 in the first year of the participation of the private firms and of campaign alone) may not be large in absolute carrying out essential planning activities--the terms. But it is very large from the point of market study and creative design. The view of the catalyst and the public sector, estimated value of the catalyst's contribution which have limited funds to spend on diarrhea here was $389,000 over four years. This is not prevention. It is not known whether the an insignificant amount, but, considering the companies allocated additional resources for child health benefits--both estimated short- the Initiative or simply reassigned resources term and potential long-term benefits--it is from their regular advertising budgets. actually a modest investment.1 The principal benefit of the Initiative is the Costs and benefits from the soap estimated decrease in diarrheal disease producers' perspective are difficult to prevalence at the end of 1999. However, the estimate. The concept behind the project was campaign has continued since then and will to encourage the private sector partners to continue through 2003--and perhaps beyond. spend resources that they would spend The documented contribution of the Initiative N anyway to advertise soap in a different way likely understates its true benefits. OI T (to promote correct handwashing) and A CI expand and open up new markets. The Key Steps for Replication L P assumption is that the soap producers sold Table 16 (pp. 70­72) presents the key steps E R more soap during the Handwashing for replicating a public-private partnership for R Initiative--based on the documented public health. It is aimed mainly at catalyst O F S P E T 1. See Varley et al. 1998 for a discussion of the cost-effectiveness of hygiene activities ­ including handwashing promotion ­ com- S pared with other diarrhea prevention and treatment interventions. Y E K 68 Table 15. Costs and Benefits for Partners in the Handwashing Initiative Partner Costs Benefits Catalyst s Facilitates the partnership. s Leverages resources to achieve s Provides technical assistance. organizational goals. s Guides development of s Brings about sustainable changes in private advertising strategy and design sector's advertising messages and concept. approaches. s Demonstrates to other potential catalysts and public sector partners, such as ministries of health, the benefits of public- private collaboration. s Provides an approach that other organizations can use. Private Sector s Assigns personnel to s Increases soap sales. participate in the Task Force s Receives kudos/media recognition for and guide the effort. public service in good cause. s Implements the advertising s Creates new alliances with the public sector strategy (this could be an and other organizations. additional cost or part of the s Learns new methods of marketing research normal advertising budget). and advertising for behavior change. s Carries out some pro bono activities to spread generic message. Public Sector Lowers diarrheal disease prevalence. s Assigns personnel to work with s private sector. s Learns about the potential of public-private s Assists in distributing partnerships for public health. advertising messages/ s Learns new techniques for social marketing. materials. s Improves school hygiene programs. s Motivates involvement at local level (e.g., public schools). NGOs s Assists in distributing s Reinforces healthy behavior at household advertising messages and and community level. materials. s Improves and strengthens its own s Organizes activities at programs. community level. organizations as initiators and facilitators of The Initiative was supposed to have been the process. The steps reflect the actual a two-and-a-half year effort, and that is a experience of the Handwashing Initiative. reasonable pace for such a project. The The first column of Table 16 shows the planning phase was to take about a year, critical path of steps and indicates who is followed by a year for implementing the N OI responsible for carrying them out. The second campaign, and then six months for T A column adds detail by listing key decisions or assessment. Delays over the selection of the CI L actions for each step. The third column lists advertising agency and a lag in the launch P E issues to be considered when taking the schedule of the producers postponed the R actions or making the decisions. campaign launch about a year. R O F S P E T S Y E K 69 Table 16. Key Steps for Replication Critical Path Key Decisions/Actions Issues CONCEPTUALIZATION PHASE (Nautilus steps 1-3) Catalyst ³ Selects relevant public health Public health need should be met in part conceptualizes need from epidemiological data, through private sector activities. project locally or regionally. ³ Contacts firms; gauges their Companies should be willing to work interest. collaboratively, if that is the plan. All companies should be invited to participate. ³ Assesses competitive market. There should be room for substantial growth in the market so that companies have an incentive to participate. PLANNING PHASE (Nautilus steps 4-11) Catalyst ³ Selects companies according to Companies selected should have the capacity selects firm(s) transparent and clear criteria. to produce and distribute the product to participate. economically. ³ Holds organizational meeting, Transparent participatory meeting norms should sets goals and overall approach. be established. Catalyst and ³ Sign agreement or memorandum Agreement should be flexible enough to private of understanding. accommodate variations in company styles/ partners goals/resources but specific enough to provide formalize the clear direction and focus. partnership. ³ Establish task force. The roles and responsibilities and expectations of the partners should be clearly spelled out. ³ Develop work plan. Work should be completed in a compressed time frame to keep up momentum and interest. Catalyst ³ Selects market research firm. The task force should help set selection criteria. conducts ³ Reviews draft survey, with Task Survey must address need for both market market Force. research and baseline for evaluation and must research. be kept to a manageable size to maintain data quality. Market research objectives require more input from the agency and private sector partners; the evaluation objectives are primarily the responsibility of the catalyst. ³ Approves survey for Intense technical support from the catalyst is implementation. needed. Additional technical resources may have to be N brought in at significant cost to the catalyst. OI ³ Assists market research agency Intense technical support from the catalyst T A to implement, analyze, interpret, needed to assure the quality of the data and the CI L and present results. usefulness of the analysis and presentation to P serve both sets of objectives. E R Results should be presented in a way that is R O understandable to non-specialists. F S ³ Develops general marketing plan P on basis of research, with Task E T Force. S Y E K 70 Table 16. Key Steps for Replication (cont'd) Critical Path Key Decisions/Actions Issues Catalyst ³ Writes advertising brief, with Task develops Force participation. creative ³ Selects advertising agency. Task Force should help set selection criteria. concept. ³ Provides technical assistance to The creative concept should be consistent with agency during development of public health principles and the findings of the creative concept and promotional research. (The importance of this point cannot materials. be overemphasized if the campaign is to achieve public health goals.) A close relationship between the public health specialist and the task force and private sector partners is needed. Cultural issues should be considered. ³ Approves creative concept, with Decisions should be made on use of creative Task Force. concept for generic and branded advertising. Catalyst and ³ Develop strategy for seeking Strategy should be based on comparative Private Sector collaboration of additional partners advantages of the catalyst and the private firms. expand the from the public sector and other partnership. organizations. ³ Design promotional materials or a presentation to use in recruiting other partners. ³ Recruit public sector and other Private sector partners should be offered partners: media, international support in dealing with ministries of health and organizations, foundations, NGOs. other governmental agencies. ³ Carry out a public relations event Decisions should be made on when (or to recognize partners and publicize whether) to hold an event: before the campaign the project. begins or after the campaign has been completed so that results can be shown? IMPLEMENTATION PHASE (Nautilus steps 12-13) Private and ³ Plan for a coordinated launch for Internal or external events that might make a Other maximum impact and media coordinated launch impossible should be Partners saturation. identified. implement the Ways should be found to keep private campaign. companies involved in spite of personnel changes and shifts in company priorities and strategies. Catalyst The catalyst should make every attempt to have monitors a local presence during the monitoring phase. implementation. The functions of the catalyst are to: s Monitor the campaign activities and level of resources expended by the partners (for N OI evaluation and advocacy). T A s Monitor and support expansion of the CI partnership. L P s Monitor the content of new activities that spin E off from the original campaign (to ensure that R R the content is consistent with the campaign). O s Stay in close contact with the partners to F S assist in identifying and solving P implementation problems, including the need E T for internal advocacy within a company. S Y E K 71 Table 16. Key Steps for Replication (cont'd) Critical Path Key Decisions/Actions Issues ASSESSMENT PHASE (Nautilus step 14) Catalyst ³ Carries out follow-up marketing Follow-up survey should replicate the baseline conducts survey to evaluate impact. (sample and instrument design and assessment implementation), with additional questions activities. related to campaign exposure. Follow-up survey should not be carried out until at least a year after the launch of the campaign (optimally after two years of consistent campaign activity). ³ Assists market research firm to Results should be targeted to decision makers, analyze, interpret, and present who include: results. s Current and potential new partners--to advocate for engaging in a public-private partnership, s Potential catalysts, s Task force members and marketing managers of each private sector partner--to assist them in adjusting their marketing strategies. ³ Identifies opportunities and Diverse private and public sector audiences designs materials for presenting may require a variety of presentations in order results to organizations that could for these to be effective. serve the catalyst role in the future. ³ Designs mechanisms for incorporating assessment results into development of the model and planning for future activities. Issues s Role of Task Force. Participation in the At the conclusion of the Handwashing Task Force was good at the beginning of Initiative, several issues were still unresolved. the Initiative but fell off precipitously as Additional experience with partnerships like implementation began. This meant that the Initiative will shed more light on these the catalyst had to travel directly to the issues. firms to get their input and to keep them engaged--a fairly time-consuming s Dynamics of competition. While the process. There are several possible decision was made to work with a group explanations for the drop-off in interest: N OI of producers rather than to enter into an simple lack of time, lack of interest in T A exclusive arrangement with one company, sharing information about the campaign CI not all producers were happy with this with competitors, changes in personnel L P arrangement. However, even those who that brought less engaged members to E R were unhappy did participate. With an the Task Force, and loss of momentum R O exclusive agreement, a producer might due to delays. F feel that there was more to be gained in s Measuring Impact. A project operating at S P increased sales and might put forth a the scale of this Initiative cannot measure E T S greater effort. health impact through an experimental Y E K 72 design that allows for ironclad Critical Success Factors conclusions on the impact of the The catalyst team, with the help of other campaign. Where the partnership model is partners, has identified several factors that highly successful, more and more were critical to the success of the partners get involved over time and bring Handwashing Initiative: an ever more diverse set of activities under the broadest umbrella of the s Presence of catalyst. Partners agreed initiative. For example, in the Central that the public and private sectors could American Handwashing Initiative, school not have been brought together to programs were not anticipated to be a achieve complementary goals unless primary intervention and thus the survey BASICS/EHP had assumed the role of was not well designed to catalyst. The catalyst also evaluate the effort in El brought to the table Salvador, which was expertise in marketing, almost completely "We got the people's good will public health, and behavioral oriented to toward the brand, and this is research and was able to schoolchildren. Diversity maintain an on-the-ground in campaigns presents very important. The media presence for providing additional challenges, coverage also more than technical assistance, such as ensuring monitoring, and follow-up. consistency with the compensated for our efforts. I Hiring a local coordinator is content of the campaign believe that if we communicated a crucial element in and public health goals, to the rural areas of the country successful public-private describing the numerous initiatives. Flexible, activities, and carrying that handwashing was a way to consistent support for the out the follow-up survey. prevent diarrhea, and if this Initiative was the key. In a dynamic and saved a life, we are more than s Good cause. There was a seemingly organic natural link between the process of burgeoning satisfied." public health goal and partnerships, over time --Jorge Mario Lopez, commercial interests. the limits of an initiative La Popular, Guatemala Because the link was strong, can become difficult to both halves of the partnership define with precision. saw benefits for themselves. s Sustainability. Plans are This perception of mutual benefits is the afoot to continue the handwashing linchpin of private sector participation. campaign in Guatemala until 2003. Media, foundations, and NGOs needed However, it will be interesting to see little encouragement to rally around the whether the effort will survive the public health benefits of the Initiative. transition as the catalyst team withdraws s Road map. The catalyst used a clear, from an active leadership role. The N tested approach as a road map for OI producers may or may not have a long- implementing the Initiative (the "Nautilus" T A term commitment to reorienting some of model). Thus, all concerned knew how the CI L their advertising dollars for diarrhea partnership would evolve. The Initiative P E prevention or to working with the public kept going partly because all partners had R sector. That may depend upon how R a clear understanding of the main O successful the campaign ultimately was F elements and logical progression of S in increasing their sales. steps. P E T S Y E K 73 s Market research. The advertising strategy private organizations are to be expected, was based on the findings of market given their different orientations. Joint research that included information not decision making was facilitated by only about the actual and potential market transparent processes, clear for the product but also about the communication, documentation of behavior and attitudes of the target agreements, and effective face-to-face population toward the product and the key meetings. practice. The research in turn was s Timing and sequence. The Handwashing designed with an understanding of the Initiative got off to a good start because epidemiology of diarrheal disease and the the catalyst approached the soap role of specific behaviors producers first, got them in its prevention. With involved, and rapidly moved solid information in hand, through the planning stage. "What we got in return was that it was possible to develop The effort started small and advertising messages people are now aware that we strategic, later involving that led to behavior are not only a commercial additional partners as change and greater use necessary and useful. company, but that we care for of the product. s Public health backing. the health of the people of El The success of the The Initiative received the handwashing campaign in Salvador. The support we got enthusiastic support and Central America has been endorsement of ministries from the health department also attributed to the enthusiastic of health in all four gave us great credibility. But I support of the soap producers countries, and in El and the availability of flexible, believe that the ones who really Salvador the ministries of timely technical assistance by health and education benefited were the people." the catalyst team to keep the were highly involved in --Gregory Hawener, process moving along. Given the campaign. This Unisola/Unilever, El Salvador the potential impact of a public- support from public private partnership like the one health officials gave the described here, donor Initiative credibility and organizations should make reassured the producers that they had every attempt to work with the private sector in made a wise decision. the cause of proper handwashing in countries s Roles, responsibilities, expectations. where diarrheal disease continues to be a The memorandum of understanding serious problem, as well as in other areas of ensured that partners' expectations were common interest and public health need. realistic. It did not specify precisely what resources the producers would provide but was open-ended, making it possible N for the producers to take advantage of OI T opportunities as they emerged. A CI s Decision making. Critical decisions were Works Cited L P made jointly so that all partners felt E Varley, RCG, J Tarvid, and DNW Chao. 1998. A R ownership of the project. Some of the Reassessment of the Cost-Effectiveness of R group's decisions caused delays, but had O Water and Sanitation Interventions in F the catalyst overruled them, it could have Programmes for Controlling Childhood S P destroyed the whole Initiative. Strong Diarrhoea. Bulletin of the World Health E T differences of opinion between public and Organization 76(6):617-631. S Y E K 74 Annex A Annex A. The Convenio Agreement Between Private Producers of Hand Soap and BASICS/EHP We, the undersigned, meeting in Guatemala statement of Reference Terms, which is City, on the first day of March of nineteen included in Appendix No. 1. ninety-six, have studied the health situation Also, we have determined that in order to in our countries and the project carry out the project, we shall use the "PROMOTION OF HANDWASHING WITH elements of the General Marketing Strategy, SOAP IN CENTRAL AMERICA" promoted which is detailed in Appendix No. 2, "General by BASICS/EHP and concluded that this Marketing Strategy." helps improve health conditions and has an acceptable design. Finally, we have established a Task Force. The names of its members and their Based on our study, WE DECLARE our assigned tasks are shown in Appendix No. 3, commitment to participate in the project in a "Task Force." joint and collaborative manner. We have agreed to work for at least 2 years and 6 In confirmation of our discussions and months (Phase I, Initiation of the Self- decisions, we sign this document, formalizing sustainable process) beginning on this date. our commitment to participate. Our participation shall be limited to the Appendix 1 of the Agreement Rules of the Game or Reference Terms Who should participate in the project? All institutions whose representative[s] attended the Seminar-Workshop for the Promotion of Handwashing with Soap in Central America project (March 1), plus the representative of Industria Chamorro de Nicaragua, subject to their reconfirmation. Agreements on the tasks to be carried out jointly: s Planning and development of the market study s Planning and development of generic promotional campaign 1. We agree to develop a generic promotional campaign (institutional) for handwashing with soap that does not benefit one specific brand. 2. We agree to seek funding (public and private) for production and dissemination of a campaign. 3. We agree that each company should use the concepts of the generic campaign through the sponsorship of the campaign by product. 4. We agree to jointly conduct a market study funded by BASICS/EHP. 5. We agree to disseminate the experience and follow up the Initiative. 6. The cost for the companies mainly involves launching the campaign (February 1997). It is expected that the cost of the campaign will be reasonable in terms of each company's normal investment in advertising. A X E N N A 75 Roles and Responsibilities 1. Companies s Name one representative to the Task Force (commitment to participate, communication link with his company). s Respect the agreements/rules of the game. s Share with BASICS/EHP information to help measure the impact of the campaign in a confidential manner. s Commitment to continue the project in accordance with the general design (2 years and 6 months). 2. BASICS/EHP Technical role s Plan, coordinate, and facilitate the activities carried out jointly (including the Task Force). s Carry out specific technical responsibilities for conducting studies and for the generic communication strategy. Role with respect to funding s Market studies s Development of the generic creative strategy s Costs of the representatives of BASICS/EHP s Contribution to the costs of meetings Support for establishing contacts with the public sector and eventually sources of funding with the objective of reinforcing execution of the generic campaign. 3. Task Force General role s Provide guidance, review, and follow-up of the activities that are carried out jointly. Specific role s Design the general marketing strategy. s Establish the work plan. s Identify the information needed for market studies. s Review the questionnaire / suggestions on methodology. s Review / analyze the results of the market study and transfer the results to the communication strategy. s Establish selection criteria and advise on the research and advertising agencies. s Review and approve the generic communication strategy. s Review and approve the generic creative concepts. s Establish the strategy for involving the public sector. s Design and review market study no. 2 (similar to no. 1). s Interpret results in terms of the communication strategy. s Advise on the dissemination strategy (and active participation). A X E N N A 76 Methods of carrying out the process: s Maintain constant communication between BASICS/EHP and other Task Force members via fax and Internet. s Hold Task Force meetings at critical times (to make decisions) on the work plan. s The Task Force members are the points of contact for internal and external communication. Appendix 2 of the Agreement General Marketing Strategy Objective s To encourage the habit of washing hands with soap. s To expand the market for soap use. Strategy/direction s Principal segment socioeconomic level D and below s All members of the family (men, women, and children) s Investigate behavior in connection with handwashing with soap Critical path 1) Written confirmation of the agreement March 15, 1996 2) Market research No. 1 March ­ July 1996 3) Evaluation of study results August 1996 4) Determination of communication strategy Presentation of other participants September ­ December 1996 5) Execution ­ production of campaign material January 1997 6) Launch February 1997 7) Market research No. 2 March 1998 8) Evaluation of results June 1998 9) Determination of long-term strategy July 1998 Geographic dimension All countries in Central America can participate in a coordinated manner. Coordinating companies by country GUATEMALA ­ Colgate Palmolive / La Popular EL SALVADOR ­ Unisola / Unilever HONDURAS ­ Corporación Créssida NICARAGUA ­ (Chamorro) / Colgate Palmolive COSTA RICA ­ Punto Rojo Total time of the process March 1996 ­ July 1998 Method s It is preferable to conduct the market research with a company that has regional coverage in Central America. A X s The launching of the campaign will be simultaneous. E N N A 77 Appendix 3 of the Agreement Task Force in Connection with the Agreement Composition One representative of each company, one representative of BASICS, and one representative of EHP Who constitutes the task force? Ricardo Mejía-Aoun/ Colgate Palmolive ­ Guatemala Arnoldo del Valle / Fábrica La Popular ­ Guatemala Rafael Chinchilla / Corporación Créssida ­ Honduras Viviane Dechamps / Unisola ­ El Salvador Federico Quezada / Punto Rojo - Costa Rica (Representative of Industria Chamorro ­ Nicaragua) Massee Bateman / EHP Camille Saadé / BASICS Coordinators Massee Bateman and Camille Saadé Meetings at critical points 1. Approval of market study questionnaire: The meeting will be held in May or June of 1996. The questionnaire should be sent out before the meeting. The next meeting will be held in Honduras (Tegucigalpa). 2. Evaluation of results: August 1996 3. Establishment of objectives and creative strategy: October 1996 4. Approval of messages, material, and coordination of launch, development of meeting plan for 1997-98: November 1996 Preferred time for meetings: Friday, first two weeks of the month. Provide (at least) two weeks notice. Draft Information for Marketing Research Objectives 1. Establish the profile of the target consumer for a campaign in connection with handwashing with soap. 2. Establish a reference point for handwashing behaviors in the target population. A X E N N A 78 Characteristics of the sample to be chosen s Country-wide, in each of the five Central American countries (there may be a regional level under each country) s Urban and rural s Class D and below s Families with small and school-age children Required Information 1. Socio-demographic characteristics s Family structure s Level of income s Education/children in school s Occupation of husband and wife s Language spoken at home 2. Living conditions s Availability of water (inside or outside the house and how far away) s Source of water s Storage of water and type of container s Electricity s Radio or television s Latrines or places for defecation 3. Behavior and attitudes towards handwashing s Perceived relationship between cleanliness and health s Handwashing techniques: ­ Demonstration of six elements: use of water, two hands, soap or other material, rinsing, washing, drying ­ Availability of soap: type, kind ­ Place for handwashing ­ Specific uses of soap s Frequency of handwashing ­ Number of times per day ­ At critical times s Handwashing behavior of other family members ­ Demonstration with children ­ Number of times ­ Reasons for washing hands ­ Reasons for not washing hands ­ Which other family members wash their hands with soap s Impact ­ Presence of diarrhea in children under five in the last two weeks (total number of days) A X E N N A 79 4. Soap for any use s Source for obtaining soap s Kind of soap used s Where to buy soap s Decision-making for buying soap: who buys the soap, who decides s Weekly usage of soap s Cost s Obstacles to obtaining soap 5. Soap for handwashing s Preferences with respect to soap for handwashing: size, color, appearance, cost, presentation s Reasons for not using soap 6. Information on handwashing s Source of information s Preferred methods s Influences A X E N N A 80 Annex B Annex B. Persons Interviewed Name of the Contact Company Date of the Interview Soap Companies Ileana Quiros Colgate-Palmolive, Costa Rica 04-06-01 Arnoldo Del Valle La Popular, Guatemala 04-06-01 Jorge Mario Lopez La Popular, Guatemala 04-04-01 Gregory Hawener Unisola/Unilever, El Salvador 05-02-01 Public Sector Lcda. Almeda Aguilar Ministerio Salud, Guatemala 04-06-01 International Organizations Jorge Mario Molina UNICEF, Guatemala 04-17-01 Stan Terrell USAID, Guatemala 03-27-01 Dra. Patricia Quinteros BASICS II, El Salvador 04-17-01 Baudilio López USAID, Guatemala 04-17-01 Dra. Lucrecia Mendez CARE, Guatemala 04-05-01 B X E N N A 81 Annex C. Statistical Calculations for Estimates Annex C of the Health Impact of the Handwashing Initiative in Guatemala Code Formula Total No. Children under five in Guatemala, 2000 1,845,317 Proportion of Children under five in SE levels D and E 0.8521 Total No. Children under 5 in Guatemala in SE Level D and E NUM 1,572,395 Proportion with Diarrhea by Step 1996 (Figure 8) 1996 Inadequate 96DD1 0.21 1996 Intermediate 96DD2 0.15 1996 Optimal 96DD3 0.07 Proportion with Diarrhea by Step 1999 (Figure 8) 1999 Inadequate 99DD1 0.11 1999 Intermediate 99DD2 0.07 1999 Optimal 99DD3 0.06 Population Proportion by Step 1996 (Figure 7) 1996 Inadequate 96POP1 0.78 1996 Intermediate 96POP2 0.19 1996 Optimal 96POP3 0.03 Population Proportion by Step 1999 (Figure 7) 1999 Inadequate 99POP1 0.68 1999 Intermediate 99POP2 0.25 1999 Optimal 99POP3 0.07 Total No. DD cases, 2 weeks, Hi season, A NUM((96DD1*96POP1)+ 1996 POP proportions (96DD2*96POP2)+(96DD3*96POP3)) 305,674 Total No. DD cases, 2 weeks, Hi season, B NUM((96DD1*99POP1)+ 1999 POP proportions (96DD2*99POP2)+(96DD3*99POP3)) 291,207 Total No. DD cases, 2 weeks, Low season, A' NUM((99DD1*96POP1)+ 1996 POP proportions (99DD2*96POP2)+(99DD3*96POP3)) 158,655 Total No. DD cases, 2 weeks, Low season, B' NUM((99DD1*99POP1)+ 1999 POP proportions (99DD2*99POP2)+(99DD3*99POP3)) 151,736 Total No. Diarrhea cases avoided 2 weeks, (A-B) 14,466 Hi season Total No. Diarrhea cases avoided 2 weeks, (A'-B') 6,919 Low season Proportion of Diarrhea cases avoided (A-B)/A 0.0473 2 weeks, High season Proportion of Diarrhea cases avoided (A'-B')/A' 0.0436 2 weeks, Low season Mean proportion of Diarrhea Cases PREVENT ((A-B)/A)+(A'-B'/A'))/2 0.0455 prevented, High and Low Seasons Total No. Cases per year (@ 4.5 per child NUM*4.5 7,075,776 under five years of age, SE D&E) Total No. of days of Diarrhea days per year (NUM*4.5)*4 28,303,103 (@ mean 4 days per incident case) Reduction in number of cases per year (NUM*4.5)*PREVENT 321,709 Reduction in number of days of diarrhea ((NUM*4.5)*4)*PREVENT 1,286,838 per year Note: The model for calculating the effect of changes in handwashing behavior on diarrhea rates was developed specifically for this activity. It is based on changes in population proportions along behavioral steps and the proportion of children with diarrhea at each C step. As the population moves up the "handwashing steps" from baseline to final survey, a higher proportion of the population is in the steps associated with lower rates of diarrhea. These translate into an estimated 4.365 reduction in diarrhea using the 1999 associations X between diarrhea prevalence and handwashing steps (low diarrhea season) and a 4.73 percent reduction in diarrhea using the 1996 E N associations between diarrhea prevalence and handwashing steps (high diarrhea season) for an overall average of a 4.5 percent N reduction in diarrhea from 1996 to 1999. A 83 United Nations Children's Fund