72177 Report Enabling Environment Assessment and Baseline for Scaling Up Handwashing Programs: Peru Michael Favin and Doris Alfaro Global Scaling Up Handwashing Project April 2008 This report is one in a series of products of the Water and Sanitation Program’s Scaling Up Handwashing Project funded by the Bill and Melinda Gates Foundation. The aim of the project is to test whether innovative promotional approaches can generate widespread and sustained increases in handwashing with soap at critical times among the poor and vulnerable. This series of reports documents the findings of work in progress about handwashing with soap in order to encourage the exchange of ideas and information and to promote learning. Please send your feedback to: wsp@worldbank.org . The Water and Sanitation Program (WSP) is a multi-donor partnership of the World Bank. For more than 30 years, WSP has helped the poor gain sustained access to improved water supply and sanitation services (WSS). WSP works with governments at the local and national level in 25 countries. For more information, please visit: www.wsp.org . Credits Editorial Support: Hope Steele Production: Paula Carazo This report was reviewed by Rocio Florez, Lene Jensen, and Eduardo Perez. ABOUT THE AUTHORS Michael Favin Michael Favin has over 30 years of experience in international public health in more than 25 countries in Africa, Asia, and Latin America, and has worked periodically in environmental health since his time as a community organizer and health educator for the Peace Corps in Brazil in the early 1970s. Since joining the Manoff Group in 1987, he has served as a senior technical adviser or a consultant to numerous health and nutrition projects. For these projects and others, Mr. Favin facilitated behavior change and communication strategy design, planning, implementation, and evaluation. He has worked in many critical public health areas, including child health and nutrition, school health and nutrition, maternal and neonatal health, and environmental health and has supported innovative tool development in areas such as routine immunization, growth promotion, care-seeking, and community surveillance. Mr. Favin has written or contributed to more than 60 books, manuals and articles. Doris Alfaro Doris Alfaro is a communications specialist with 15 years of experience participating in and managing projects in the fields of hygiene promotion, behavioral change, social mobilization, and advocacy for local development as well as partnership building at the community level. She has coordinated, designed, and implemented communication plans for health and nutrition programs nationwide. She has been a communications consultant for the health sector in Peru, Latin America, and the Caribbean for projects in environmental and public health. She has worked with CEPIS-PAHO/WHO, PAHO, municipalities, and Ministries of Health as well as for NGOs such as CARE and PRISMA. The findings, interpretations, and conclusions expressed in this report are entirely those of the author. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations or those of the Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility whatsoever for any consequence of their use. The boundaries, colors, denominations and other information shown on any map in the document do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. ii Global Scaling Up Handwashing Project TABLE OF CONTENTS LIST OF ACRONYMS AND ABBREVIATIONS ………………………………………………………V SUMMARY........................................................................................................................................1 1. BACKGROUND..............................................................................................................................3 The Global Scaling Up Handwashing Project……………………………………………………..3 The Peru Handwashing Promotion Project………………………………………………………...4 Rationale for Enabling Environment Assessment …………………………………………………5 2. ASSESSMENT METHODOLOGY....................................................................................................6 Dimension Descriptions …………………………………………………………………………...6 The Assessment Process…………………………………………………………………………...7 Feedback on the Assessment Methodology………………………………………………………11 3. MAJOR FINDINGS BY DIMENSION.............................................................................................13 Policy, Strategy, and Direction…………………………………………………………………...13 Partnerships……………………………………………………………………………………….14 Institutional Arrangements………………………………………………………………………..18 Program Methodology……………………………………………………………………………19 Implementation Capacity…………………………………………………………………………20 Availability of Products and Tools……………………………………………………………….21 Financing………………………………………………………………………………………….21 Cost-Effective Implementation…………………………………………………………………...23 Monitoring and Evaluation……………………………………………………………………….23 4. RECOMMENDATIONS BY DIMENSION........................................................................................24 Policy, Strategy, and Direction…………………………………………………………………...24 Partnerships……………………………………………………………………………………….25 Institutional Arrangements………………………………………………………………………..27 Program Methodology……………………………………………………………………………29 Implementation Capacity…………………………………………………………………………29 Availability of Products and Tools……………………………………………………………….30 Financing………………………………………………………………………………………….31 Cost-Effective Implementation…………………………………………………………………...31 Monitoring and Evaluation……………………………………………………………………….32 5. NEXT STEPS...............................................................................................................................33 APPENDIX A: SELECTED DOCUMENTS.........................................................................................34 APPENDIX B: LISTA DE ENTREVISTADOS......................................................................................36 APPENDIX C: RESUMEN DE PUNTOS IMPORTANTES DE LAS ENTREVISTAS..................................42 APPENDIX D: ENCUESTA SOBRE LAS CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN: 10 RESPUESTAS.............................................................................................61 APPENDIX E: LAS CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN. GU�A DE ENTREVISTA ....................................................................................................................69 APPENDIX F: ESTUDIO DE CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN (GU�A DE ENTREVISTA PARA SOCIOS POTENCIALES) ........................................................75 iii Global Scaling Up Handwashing Project APPENDIX G: INFORME DE VIAJE A PIURA...................................................................................83 APPENDIX H: CONDICIONES PARA LA PROMOCIÓN DE LAVADO DE MANOS ................................88 APPENDIX I: SUMMARY OF MAJOR FINDINGS AND RECOMMENDATIONS BY DIMENSION.........93 APPENDIX J: MENÚ DE ACTIVIDADES PARA ALUMNOS (IDEAS PRELIMINARES)..........................97 APPENDIX K: MENÚ DE ACTIVIDADES PARA PROMOTORES DE SALUD (IDEAS PRELIMINARES).99 APPENDIX L: ACTION PLAN TO IMPROVE THE ENVIRONMENT FOR AN EXPANDED HANDWASHING PROJECT IN PERU..............................................................................................101 LIST OF FIGURES Figure 1. Partner Contributions to Interpersonal Communications……………………………...16 Figure 2. Partner Contributions to Mass Media………………………………………………….17 LIST OF TABLES Table 1. Handwashing Targets by Country……………………………………………………….4 Table 2. The Public-Private Partnership for Handwashing in Peru……………………………….4 Table 3. Dimension Addressed by Stakeholder Type …………………………………………….8 Table 4. Persons Interviewed by Organization Type…………………………………………….10 Table 5. Self-Reporting Questionnaire Responses by Organization Type………………………10 Table 6. Calendar of Assessment Team Activities, May–June, 2007…………………………...11 Table 7. Committee Participants…………………………………………………………………27 iv Global Scaling Up Handwashing Project List of Acronyms and Abbreviations CBO Community-based organization COSUDE Swiss aid organization DIRESA Regional health directorate DREA Regional education directorate FBO Faith-based organization HWWS Handwashing with soap M&E Monitoring and evaluation MIMDES Ministry of Women and Social Development MOE Ministry of Education MOH Ministry of Health MOU Memorandum of understanding NGO Nongovernmental organization PAC/SEDAPAL Program in Lima to install/improve small water systems PPPHW Public-Private Partnership for Handwashing PRONASAR National program to install/improve small water systems (Ministry of Housing) UGEL Local educational management unit USAID U.S. Agency for International Development WSP Water and Sanitation Program v Global Scaling Up Handwashing Project SUMMARY To follow up country work supported by the Public-Private Partnership for Handwashing, the World Bank Water and Sanitation Program (WSP) received funding from the Bill & Melinda Gates Foundation to support projects to scale up the promotion of handwashing with soap (HWWS) in Peru, Senegal, Tanzania, and Vietnam. The major project objectives of the Handwashing Initiative are: • inculcate the HWWS habit among millions of mothers and children in these countries, • use a strong monitoring and evaluation (M&E) component to enhance the conceptualizing and management of such programs, • establish sustainable programs that will continue and expand after this four-year grant ends. Enabling environment assessments were carried out in all four countries to assess current conditions for scalability and sustainability and to make recommendations for improving conditions that are not supportive. This report summarizes the study in Peru, which was carried out by an international and a national consultant during three and a half weeks in May 2007. All four county studies are following a similar methodology, developed by WSP, to examine nine dimensions of scalability/sustainability through individual and group in-depth interviews, an electronic survey in which respondents are asked to score various statements, and a review of documents (Appendix A). A partnership of many public and private organizations has supported handwashing promotion in Peru since 2002, achieving impressive results in advocacy, partnership development, tool development, and many other areas. The Initiative supported partnership formation, mass media, and capacity building for on-the-ground promotion in 14 of Peru’s 24 regions. Evaluation of actual impact on knowledge, attitudes, and practice regarding HWWS shows some positive and some inconclusive findings. However, the study team feels that much excellent groundwork for the expanded program in Peru has been solidly laid by efforts to date and that, in combination with strong 1 Global Scaling Up Handwashing Project political will from the national government and a certain level of guaranteed funding, the outlook for effective expansion is very good. Nonetheless, the team has a number of suggestions, many of which expand ideas suggested by persons interviewed. Some of the key recommendations are the following: • Plan and implement a dynamic advocacy strategy that begins immediately and that continues throughout implementation. • Plan and implement a strong project communication strategy directed primarily to partners but also to decision makers at various levels and to the public. Materials, formats, and activities should be directly related to reaching one of the strategy’s objectives (for example, partner motivation, sharing good ideas) and audiences, which should be clearly defined. • Develop and implement an exit strategy that includes steps for dissemination and sustainability of program activities and achievements. • Continue to negotiate and sign more formal agreements on partners’ roles and responsibilities and develop systematic mechanisms to monitor the implementation of the agreements. • Have the key national-level partners, including the implementing organizations (which will be contracted to manage local implementation), dedicate themselves to establishing the conditions and providing the tools and support for successful local implementation. In this decentralized vision, the team expects that key factors for program success will be strong and dedicated partnerships at local levels, with effective tools, methodologies, and support from the national level. • Greater attention should be given to carrying out thorough regional, provincial, and district assessments of organizations, potential champions, resources, programs, and conditions and to establishing and encouraging strong local partnerships. The assessment methodology, findings, and recommendations are documented in this report and its many appendixes (a number of which are in Spanish). 2 Global Scaling Up Handwashing Project 1. BACKGROUND Funded by the Bill & Melinda Gates Foundation, the WSP Global Scaling Up Handwashing Project will follow the basic approach of the Public-Private Partnership for Handwashing (PPPHW), a global initiative established in 2001 to promote handwashing with soap at scale to reduce diarrheal and respiratory infections. 1 This approach draws extensively on lessons learned from two large-scale handwashing promotion programs. Programma Saniya, implemented in Bobo-Dioulasso, Burkina Faso, showed the importance of undertaking careful consumer research at the outset of a handwashing promotion program. The Central American Handwashing for Diarrheal Disease Prevention Program showed that an effective approach to changing hygiene behaviors at large scale was to work with a broad partnership of public and private sector stakeholders that have a mutual interest in increasing handwashing with soap, to focus on the one behavior with largest potential health impact (handwashing with soap), and to promote it with cost-effective, consumer-centered marketing. The Scaling Up Handwashing Project In hopes of facilitating effective replication and scaling-up of future handwashing-with-soap behavior change programs, the new project will carry out a structured learning and dissemination process to develop and share evidence, practical knowledge, and tools. Specific project objectives are to: 1. design and support the implementation of innovative, large-scale, sustainable handwashing programs in four diverse countries (Peru, Senegal, Tanzania, and Vietnam); 2. document and learn about the impact and sustainability of innovative, large-scale handwashing programs; 3. learn about the most effective and sustainable approaches to triggering, scaling-up, and sustaining handwashing behaviors; 4. promote and enable the adoption of effective handwashing programs in other countries and position handwashing as a global public health priority through the translation of results and lessons learned into effective advocacy and applied knowledge and communication products. The project is designed to achieve key targets in each country at the end of two years of implementation. The specific handwashing targets for each country are in Table 1. The target audience is defined as poor women of childbearing age (15–49) and poor children ages 5–9. 1 Global PPPHW partners include the Water and Sanitation Program, USAID, World Bank, UNICEF, London School of Hygiene and Tropical Medicine, Centers for Disease Control, Academy for Educational Development, Water Supply and Sanitation Collaborative Council, Colgate-Palmolive, Procter & Gamble, and Unilever. 3 Global Scaling Up Handwashing Project Table 1. Handwashing Targets by Country Country Target Estimate target population (population) population adopting HWWS at critical (millions) times Peru (28 million) 5.10 1.30 Senegal (11 million) 1.97 0.49 Tanzania (37 million) 5.20 1.30 Vietnam (84 million) 9.20 2.30 Source: World Bank (Water and Sanitation Program). 2007. “Terms of Reference. Enabling Environment Assessment and Baseline to Scale up, Sustain and Replicate Handwashing with Soap Behavior Change Programs.� March 9. The Peru Handwashing Promotion Project As in many countries, diarrhea and respiratory diseases are the leading causes of childhood illness and death in Peru, and malnutrition is a major underlying cause of child mortality. Handwashing with soap can significantly reduce all of these major causes of misery. Attention to hygiene and handwashing got a significant boost in Peru in the 1990s because of the cholera epidemic, but as shown by the Handwashing Initiative’s 2004 baseline, practice levels were still woefully low: 11 percent of mothers and 6 percent of children washed hands with soap before eating, and 17.6 percent of mothers and 12 percent of children after going to the bathroom.2 The public-private partnership for handwashing developed in Peru over several years, as summarized in Table 2. Table 2. The Public-Private Partnership for Handwashing in Peru Year Activity 2003 Advocacy, handwashing practices study, development of a business plan 2004 Efforts to secure funding, funding commitments from the Japanese Fund, USAID, WSP (the Water and Sanitation Program), and COSUDE (Swiss aid) 2005 Selection of communication agencies, design of project strategy and work plan, first campaign and training workshops, monitoring activities, commitment of private sector funds 2006 Training workshops and promotional activities, monitoring, financial management, international advocacy, launching of second campaign, effort to establish local alliances, process evaluation, design of impact evaluation 2007 Financing from the Bill & Melinda Gates Foundation secured, local alliances strengthened, school program, mass media campaign, monitoring and evaluation Source: Flórez P., Rocío. “Iniciativa de Lavado de Manos en el Perú.� 17 de Octubre, 2006 (PPT). 2 AB PRISMA. Estudio de comportamiento de lavador de manos con jabón en zonas periféricas del Perú. Preparado como línea de base para la Iniciativa de Lavado de Manos en el Perú, liderado por PAS-Banco Mundial. Junio 2004. 4 Global Scaling Up Handwashing Project The Peruvian program implemented activities at the national level and developed partnerships and activities in 14 of Peru’s 24 regions. Preliminary monitoring and evaluation showed mixed but promising improvements in knowledge, attitudes, and practices, particularly in handwashing before eating and preparing food. Fostering partnerships at the national, regional, and local levels has been a key project strategy. Although this has been difficult and demanding at times, it has also been a major reason for progress. Both interpersonal communication (in schools and communities) and mass media (mostly print and radio) made important contributions to changing knowledge, attitudes, and practices. M&E studies (these and other references are listed in Appendix A) indicate that all of the communication channels used (mass media broadcasts, print materials, training teachers and students, and training health staff and volunteers) contributed to reaching the target families, and that no one channel predominated. Rationale for Enabling Environment Assessment In each participating country, an Enabling Environment Assessment is being carried out to (1) assess the extent to which the programmatic conditions for scale up and sustainability are in place at the beginning of the project; and (2) on the basis of the assessment findings, recommend what should be done to address the gaps during project implementation. Toward the end of the project period—in about 3.5 years—a final assessment will be carried out to determine whether there is an enabling environment in place in each country that can continue after 2010 without the Gates Foundation/World Bank project assistance. The overall handwashing project is four years in duration with three distinct phases: • Phase I is the 1.5-year start-up period for detailed planning at the global and country level. Several assessments, including a handwashing measures study and the baseline for the impact evaluation, will be carried out during this period. The baseline assessment of enabling elements will be carried out during Phase I. • Phase II is the 2-year implementation period. • Phase III is the 6-month wrap-up phase that will include the final evaluation and dissemination of lessons learned. The final enabling environment assessment will take place during Phase III. 5 Global Scaling Up Handwashing Project 2. ASSESSMENT METHODOLOGY In other to ensure consistency in the assessment findings, WSP constructed a conceptual framework for assessing scalability and sustainability. This framework was developed based on a review of relevant literature and discussions with key individuals. Dimension Descriptions The framework comprises nine dimensions that are considered essential to scaling up a handwashing-with-soap behavior change program. Policy, Strategy, and Direction: Establishing a shared vision and strategy and ensuring the political will to implement them is the starting point for scale up. Without political will and a shared vision and strategy among stakeholders at all levels, scale up will remain an elusive goal. Developing this shared vision and strategy in a collaborative manner is also the foundation for coordination and for creating motivation all levels. Partnerships: This handwashing-with-soap program model is based on a establishing a public- private partnership. A partnership is a relationship where two or more parties, having compatible goals, form an agreement to share the work, share the risk, share the power, and share the results or proceeds. Partnerships need to be built at all levels among public, private, and NGO sectors and between communities and local governments. Institutional Arrangements: Institutions at all levels must clearly understand their roles, responsibilities, and authority. They must also have the resources to carry out their roles. In addition to clear roles and responsibilities, institutional arrangements must include the mechanisms for actors at all levels to coordinate their activities. Program Methodology: Handwashing-with-soap programs have a seven-step program methodology. This methodology, adapted to each country context, should be clear and agreed upon by all key stakeholders. Implementation Capacity: In addition to clearly defined institutional roles and responsibilities, institutions at all levels must have the capacity to carry out their roles and responsibilities. Institutional capacity includes adequate human resources with the full range of skills required to carry out their functions; an “organizational home� within the institution that has the assigned responsibility; mastery of the agreed-upon program methodology, systems, and procedures required for implementation; and the ability to monitor program effectiveness and make adjustments. Availability of Products and Tools: A handwashing-with-soap behavior-change program is predicated on the existence of the soap that responds to consumer preferences and their willingness and ability to pay for them. In addition, handwashing station supplies—that is, plastic basins, towels, and so on—need to be easily available. Financing: This dimension is aimed at assessing the adequacy of arrangements for financing the programmatic costs. These costs include training, staff salaries, transportation, office equipment and supplies, and the development of communication and educational materials as well as programmatic line items in budgets for handwashing-promotion activities. Cost-Effective Implementation: The potentially high costs of promoting handwashing-with- soap behavior at scale make cost-effective implementation a key element. It is essential to understand how the unit costs change as activities are scaled up. Although it will not be possible to assess the cost-effectiveness of the approach and how best to achieve economies of scale until 6 Global Scaling Up Handwashing Project the end of the project, data must still be collected during implementation to make this determination at the end of the project. Therefore, this assessment will try to ensure that information will be collected from the outset and that the capacity to collect the information is in place. Monitoring and Evaluation: A large-scale handwashing-with-soap behavior-change program requires regular monitoring and, perhaps more importantly, the willingness and ability to use the monitoring process to make adjustments in the program. Effective monitoring will identify strengths and weaknesses in the program methodology, implementation arrangements, and cost efficiencies. Overall monitoring responsibility must be at the highest level of the program, but must be based on information collected at the local government or district level. The Assessment Process The primary data sources comprised the main stakeholders/present partners for the in-country program work, including government agencies, international agencies, international NGOs, local NGOs, private sector organizations, and community-based organizations (CBOs) at national, regional, district, and local levels. In Peru, all members of the National Committee were sought for interviews, as well as other partners at the national level and local partners in two of the country’s 24 regions. Piura was visited as an “old� region that had participated in the Handwashing Initiative, and Arequipa as a new region that will be included in the expanded program. In the expanded program, the number of participating regions will increase to approximately 20, depending on the requirements of the M&E plan. Secondary data sources comprised documents and additional potential implementers, such as media and ministries with no direct involvement to date. Appendix A lists the main documents consulted. Table 3 indicates the type of stakeholders interviewed on various dimensions. 7 Global Scaling Up Handwashing Project Table 3. Dimension Addressed by Stakeholder Type Stakeholder Type Dimension International International Local NGOs Government Advocacy NGOs & Bilateral agencies agencies & FBOs projects Private groups Sector Media CBOs FBOs Policy, Strategy, Direction X X X L X – – X X Partnerships X X X X X L X X X Institutional Arrangements X X X X – L X X X Program Methodology X X X X X L – X – Implementation Capacity N,D – X X X L – – – Availability of Products & Tools – – X X X L – – – Financing X – X – – L – – – Cost-Effective Implementation N,D – X – – – – – – Monitoring N,D, – X – X L – – – L Note: Unless otherwise noted, an X means that it is appropriate to discuss this dimension at all levels: national, regional, district, and local; — indicates that this stakeholder type was not questioned on this dimension; N = national, R = regional, D = district, L = local. In addition to reviewing documents on the program, both interviews and self-reporting were used to solicit individuals’ knowledge and opinions. Self-reporting consisted of responding to a grading-scale questionnaire that was e-mailed to approximately 35 potential respondents, some of whom were identified at the end of the interviews with the primary informants. Self-reports allowed the triangulation of information as well as some quantitative analysis that can be easily compared to findings of the repeat of the assessment planned to take place near the end of the implementation phase. Sampling was purposive for all primary data sources. The team strived to interview persons who had participated in the handwashing program for at least six months. They also sought a good representation of decision makers, implementers, and midline supervisors/managers from different levels of organizations involved in the program—that is, national, regional, district, and local (as indicated needed on the interview matrix of Table 3). Targets for the minimum sample size were: • one interview and/or self-report (electronic questionnaire) with each current partnering stakeholder at any level • three interviews in each dimension • two self-reports in each dimension 8 Global Scaling Up Handwashing Project • two interview sets with two different present partnering agencies, within each of these two organizations, one of each work type • one self-report set with two different present partnering agencies, within each of these two organizations, one of each work type • two interview sets with two different present partnering agencies with one representative for each level at three levels minimum—that is, national, district, local • one self-report set with two different present partnering agencies with one representative for each level at three levels minimum—that is, national, district, local • three interviews with three potential partnering organizations (if appropriate). The team conducted 35 interviews in different organizations (Appendix B). The persons interviewed were from the organizations listed in Table 4. 9 Global Scaling Up Handwashing Project Table 4. Persons Interviewed by Organization Type Types of organizations Persons interviewed Government agency 9 Bilateral project 3 Media company 3 Local NGO 4 Private sector 3 International agency 8 International NGO 5 TOTAL 35 Self-reporting questionnaires were sent to representatives of different institutions linked to the Handwashing Initiative, including some from the same institutions where the team interviewed. Table 5 shows the types of organizations that provided the 10 completed questionnaires. Table 5. Self-Reporting Questionnaire Responses by Organization Type Types of organizations Persons responding Government agency 2 Bilateral project 3 Media company 0 Local NGO 1 Private sector 2 International agency 1 International NGO 0 Consultant 1 TOTAL 10 The team carried out a qualitative analysis of the interviews, first by summarizing all respondents’ positive and negative comments by type of organization and dimension and also listing the respondents’ corresponding recommendations. Appendix C documents this step in the process. The team used many, but not all, of the respondents’ recommendations to develop its own recommendations. The major recommendations were then placed in an Action Plan, as required by the team’s terms of reference. The team also did a quantitative analysis of the 10 self-reports received (see Appendix D) but did not attempt a further breakdown by stakeholder type because of the relatively small number of responses. 10 Global Scaling Up Handwashing Project The assessment team was comprised of one international consultant and one local consultant who worked together during the final 3.5 weeks of May 2007. Table 6 summarizes their activities in Peru. Table 6. Calendar of Assessment Team Activities, May–June, 2007 Date Peru In-Country Activities May 8–11 Met with country team manager (CTM) to plan the activity Reviewed the stakeholder list and developed the interview list Scheduled interviews Organized logistics Modified and translated instruments Sent out self-report questionnaires by e-mail Began interviews May 14– Conducted interviews (in Lima, Piura, Arequipa) June 1 Summarized responses Received and tabulated self-reported questionnaires Drafted findings, recommendations, action plan June 4–30 Prepared and gave debriefing to global WSP team and Peru program coordinator Read additional documents Debriefed for global WSP and drafted this assessment report Feedback on the Assessment Methodology The team had to make some adjustments to the general assessment methodology proposed for all four countries, starting with translating all instruments into Spanish. In addition, they found that the standard interview questionnaire contained many single questions that contained multiple issues, so they separated these out. The first few interviews showed that there were too many questions to ask knowledgeable respondents and that there was some redundancy in questions under the different dimensions. The team therefore prepared a shortened version of the interview guide to try to address these concerns. Also, the team was unsure about the degree to which it should seek information from regions that had already participated in the program compared with areas where the program would expand. In the end they visited one region of each type, but they had to prepare another version of the question guide for the new region. (Appendixes D and E contains these question guides in Spanish. Appendixes F and G contain summaries of the visits to Piura and Arequipa.) The persons interviewed varied tremendously by level and nature of their involvement in the program. Although the methodology anticipated some of this challenge, the interviewers still had to make on-the-spot decisions on which questions were relevant to the particular respondent and 11 Global Scaling Up Handwashing Project whether the respondent should focus on the past or the future of handwashing promotion activities. Many of the respondents of the self-reported questionnaires participated in the Initiative as local- level implementers or supervisors, so they were really not in a good position to comment on some of the broader program questions. Nonetheless, there was a fairly strong congruence in scores for the different questions, which gives some confidence regarding general opinions. Since it is planned that this assessment will be repeated near the end of the expansion phase, the team would recommend that different versions of the question guides be prepared for representatives of key national partners, key regional partners, local implementers, and national organizations that implemented promotional activities within their own organizations. 12 Global Scaling Up Handwashing Project 3. MAJOR FINDINGS BY DIMENSION Based on documents, interviews and questionnaires, the team prepared a summary of findings and recommendations in table format (see Appendix I). This section presents a narrative of key findings. Policy, Strategy, and Direction • The National Committee served as a key venue for manifesting high-level national commitment to promotion of HWWS. • Government and other organization officials have a strong, positive political will toward handwashing promotion and child health, although some government officials find it hard to give these areas special attention because of so many other priorities. • The current national administration has embraced the Initiative and seems well disposed to collaborate. • Key partners feel that they understand the approach used in the first phase and feel ownership, but they do not yet have a good understanding of the expanded project (which is still being designed). • There are several politically prominent national initiatives (regarding malnutrition, healthy schools, and water and sanitation) that offer natural links with handwashing. • Although the Ministry of Health (MOH) signed a ministerial decree in 2004 in support of the Handwashing Initiative, its enthusiasm has waxed and waned with frequent changes of officials; current officials appear to be quite supportive. • At the beginning of the Initiative, national Ministry of Education (MOE) involvement was minimal, but now the MOE is actively engaged. There appears to be a strong and positive attitude toward the promotion of handwashing and an appreciation of its link to child health, in part due to the country’s experience with handwashing as an effective way to control cholera. This common perception of handwashing promotion as a key action for improving child health is a major factor favoring program expansion. The current national government has made a public commitment to improving health and education, and in turn to supporting several specific programs to which HWWS can directly contribute. The handwashing program has been successful in promoting the concept that the Initiative is a true partnership of many organizations and not a program of, for example, the World Bank or the MOH alone. There has been a shared vision of the partnership that transcends any particular member, which was no doubt fostered by the National Committee (in particular), as well as the consultative committee and communication committee. At the same time, the interviews strongly indicated the need to strengthen dissemination of results and to maintain clarity regarding roles in the partnership and to nurture partners’ sense of active participation. Important steps have been taken toward institutionalization, but much work remains to be done. The Initiative first focused on identifying and engaging with partners to form a public-private alliance, conducting a study on handwashing practices, and designing a business plan. The MOH issued Ministerial Resolution No. 062-2004 in support of the Handwashing Initiative, and in 2005 the ministry assumed a stronger leadership role with the initiation of the communication activities, providing some resources and a resolution in support of a national program of information dissemination. The MOH also established a sectoral committee comprised of key ministry offices, but its function was limited to receiving information, and it did not evolve into making proposals to strengthen the institutionalization of the Initiative. 13 Global Scaling Up Handwashing Project In some of the regions, there has been progress in institutionalizing handwashing activities into public and private institutions’ work plans (for example, Lambayeque and Ica) and into training curricula (in Cusco, for teachers). Continuing to encourage such steps is a key to sustainability of the Initiative. Although before 2006, the MOE was not linked to the Initiative, MOE offices in various regions, provinces, and districts were active partners, taking advantage of the Initiative’s communication tools and using the training modules with children in their classrooms. Today the MOE is actively engaged in planning for the expanded phase, and it will include handwashing in schools as part of its national Social Mobilization Program. For this purpose, it has assessed and pretested the Initiative’s school materials. The current national MOE support should facilitate strong involvement of local MOE offices. There is good political will at the regional level also, but not as strong or cohesive as the political will at the central level. The regional and provincial levels are in a transition to decentralization, in which authorities are uncertain about their functions, roles, and resources. Local decision making and regional organizations working together on a common objective are new ways of working, and local governmental units are in the process of trying to establish their regional priorities from among a plethora of needs. The regional governments are working on their development plans and documents on regional health priorities. The Initiative and its partners should work to make improving child health and reducing diarrheal diseases prominent in these plans. At all levels, there are additional avenues for the expansion and sustainability of the project by linking it with current national political initiatives such as Reduction of Infant Malnutrition, Healthy Schools, and Water for Everyone, which do or could incorporate handwashing promotion. Despite this positive situation, converting political will into program actions remains a challenge because, as various persons interviewed noted, it is difficult to give special attention to one particular theme such as handwashing because there are so many other public sector priorities. Decrees published by government agencies at national, regional, and local levels are very important since they represent the main door leading to public funding of activities. They also define a period of time in which the strategy and activities will be implemented. So, as several respondents pointed out, although a decree does not guarantee further action (rules, regulations, and activities in work plans and in the field), without them there is no public spending. Following the MOH decree in 2004, the ministry financed a one-month handwashing campaign and direct consumer contact (local promotional events) in 24 regions in 2006. Partnerships • In general this has been a successful and innovative aspect of the program, in particular with private sector partners. • Public and private organizations have generally worked well together, but not without some minor friction. Private partners sometimes become impatient because the public sector tends to be more formal and bureaucratic and to have more changes in personnel. Some local public officials consider private organizations to be too interested in receiving individual credit. • Keeping key government ministries (particularly health, education, and housing) involved is essential, even though this can be difficult at times because of political changes and overburdened officials who are too busy to participate in meetings. 14 Global Scaling Up Handwashing Project • Different partners have played very different roles, from being fully engaged as a member of the national coordinating committee to providing short-term messages on handwashing and co-financing and/or managing local activities. This is fine as long as expectations are clear. The Initiative engaged with diverse organizations and persons, including regional and municipal governments, communication media, and health and education offices and organizations. Many partner organizations were able to insert handwashing promotion into existing strong and efficient networks. In general, the organizational partners were of three types: (1) WSP, donor organizations, and governmental organizations that managed the program (through the national committee); (2) national-level implementation partners—from various types of organizations (public and private), most of which collaborated on the basis of informal agreements and some on the basis of memoranda of understanding or contracts; and (3) regional and local implementing partners, also both public and private, and some with financial or material support from the Initiative. The different roles of partners at the national level that the team identified include: • providing funding (for example, the Japan Social Development Fund) • providing funding and participating in planning and management of the Initiative (for example, COSUDE, USAID) • providing funding and participating in planning, management, and national implementation (for example, the MOH and the MOE, more recently) • implementing communication activities directed to their personnel and customers (for example, Belcorp, CARE) • carrying out M&E activities and playing a major role in preparing training and trainers (as, for example, PRISMA, which worked under contract) • supporting a specific activity, such as dissemination or printing, based on its resources (for example, Banco de Crédito, Transportes Ormeño). At the regional level, the Initiative established strong relationships with various types of organizations, usually via the Regional Health Directorates (DIRESA), that made various contributions. Some examples are: • providing funds and participating in the planning and management of the Initiative (for example, the Regional Government of Lambayeque) • providing funds and participating in local planning, management, and implementation (for example, the DIRESA, Regional Education Directorate [DREA], or MOE’s Local Educational Management Unit [UGEL]) • implementing communication activities directed to their staff and beneficiaries (for example, local NGO offices) • getting involved in a specific activity (for example, dissemination or printing) appropriate to its resources (for example, Radio PROMUDEH in San Martín). Figures 1 and 2 show organizations that have done person-to-person promotion and mass media promotion. 15 Global Scaling Up Handwashing Project Figure 1. Partner Contributions to Interpersonal Communications PUERTA A PUERTA Socios Actividad / Impacto MINSA Promoción de la Salud PAC SEDAPAL Ampliación de cobertura AGAP Asociación de Agricultores + + Programa Mi Desarrollo público local + Barrio + CARE Programa Promoción de la Salud + Belcorp Venta de cosméticos Peace Corps Voluntarios + + Prisma ONG Talleres + Talleres Talleres y réplicas itinerantes Scouts Actividades de Scouts Source: Flórez P., Rocío. “Iniciativa de Lavado de Manos en el Perú.� 17 de Octubre, 2006 [PPT] 16 Global Scaling Up Handwashing Project Figure 2. Partner Contributions to Mass Media MEDIOS MASIVOS Socios Actividad / Impacto RPP Serie Radial, avisos Banco de Circuitos interno de TV220 Crédito agencias Luz del Sur Aviso en recibo de electricidad Expreso Extra Avisos en periódicos de circulación nacional Ormeño Circuito de TV en buses Interbank Circuito interno de TV, 40 agencias Terra Avisos en página Web Radios y TV 25 regiones Local SEDAPAL Aviso en recibo de agua Source: Flórez P., Rocío. “Iniciativa de Lavado de Manos en el Perú.� 17 de Octubre, 2006 [PPT]. The process of participating in such a public-private partnership has allowed government and company staff to learn about other ways of working together for public health, in a participatory way, with support that they could offer with their own resources. The public institutions, the companies, and the NGOs interviewed indicated their interest in continuing their involvement. In the case of NGOs, officials are pleased to collaborate to the extent that their goals and funding address reducing diarrhea and respiratory disease among children. At the central level, the Initiative worked to achieve financing from the Ministry of Women and Social Development (MIMDES) for disseminating broadcast materials in the Clean Hands, Healthy Kids campaign, 15 times a day, mostly in the preferred early morning hours. This dissemination included four regions where the project was active: Ayacucho, Cusco, Lambayeque, and San Martín. In Ayacucho, the Regional Health Council stimulated the formation of a regional Handwashing Initiative by establishing an implementation committee in which the MOH and DIRESA joined the regional government to prepare guidelines for health programs and projects. The objective of the committee is to safeguard the logic and consistency in the implementation of all health programs in the region. The local partners achieved the collaboration of the army for the temporary storage of training materials. In Cusco, the provincial municipality of Canchis participated in inter-institutional agreements with the UGELs of the Ministry of Education of Cusco and Canchis to train local trainers and health promoters. 17 Global Scaling Up Handwashing Project In Lambayeque, the regional government took the initiative to engage other partners, including the DIRESA. In San Martín, a partnership between communications media and the water company was established to support health communication. Many respondents praised the Initiative’s innovative and generally successful partnership of public and private organizations, particularly in regard to support from the private sector. Although all types of partners generally worked well together, some respondents did note that the public sector tended to be more formal and bureaucratic and to have frequent changes of personnel, which delayed approvals of actions and materials. In general, private sector partners are more flexible, comfortable with informal arrangements, and able to act more rapidly. Most private sector companies have had a more focused participation in specific promotional activities and have not been involved in overall planning or management. Private voluntary organizations, particularly at the local level, generally integrated handwashing promotion and/or activities and materials into their existing programs. Most private companies that collaborated in the first phase do not appear to have been motivated by a desire to expand their sales of soap (there was only one company that was a major soap vendor) or other handwashing products. Most collaborating companies have established units for supporting socially beneficial programs—no doubt motivated by both altruism and a desire to maintain a public image of social responsibility. Institutional Arrangements • Many respondents felt that arrangements have been informal yet have worked well based on the basis of personal relations, particularly for NGOs and private organizations. • Arrangements with governmental organizations were more formal: the MOH issued a ministerial decree in 2004, and some regional governments approved ordinances. Beginning in 2006, the Initiative made an effort to sign MOUs with national and local partners. The public sector has a strong need to formalize its relationships and commitments. The MOH did this by issuing a formal ministerial regulation that promoted the Initiative within the MOH and another decree that established an internal sectorial committee charged with coordinating implementation responsibility among the various offices and programs of the MOH. However, interviewees made two common points: (1) that with decentralization, national agreements would not necessarily translate to the regional level and below; and (2) that although formal agreements with government organizations were definitely desirable, they were also insufficient to ensure that the commitments would yield actions and funding in the field. The issuance of ministerial resolutions and directives contribute to the sustainability of handwashing-promotion activities by helping to orient work to a theme, but these resolutions and directives still need to be reflected in work plans, budgets, institutional directives, and actual activities. Initially, informal relations seemed to work quite well for private sector partners and some NGOs, but since 2006 the Initiative has negotiated and signed more formal agreements with public and private partners, a trend that most respondents feel is desirable. For example, there are letter agreements with such groups as Ecoclubes Perú, Asociación de Gremios Agroexportadores del Perú (AGAP), the regional government of Ica, Caritas Piura y Tumbes, Municipality of Surco, and Asociación Civil Pro Ica. More formal agreements are likely to facilitate the sustainability of organizational commitment, so it seems wise for the Initiative to try to make informal agreements more formal over time, appropriate to various organizations’ roles. 18 Global Scaling Up Handwashing Project At the regional level, governmental units, including municipal governments, require a formalized participation. Although NGOs and private organizations are willing to be flexible, a move toward more formality and the generation of agreements to govern joint work does facilitate program implementation as well as sustainability. Program Methodology • In general, opinions were positive; people felt that combining diverse partners’ strengths produced an effective approach. • Some respondents mentioned the need to focus more on interpersonal communication, while media representatives felt that mass media could play a larger role. • Many of the persons interviewed pointed out that it has been easier to generate enthusiasm and behavior change among children than among mothers, particularly in rural areas. The Peruvian program has followed the general PPPHW methodology. Findings from formative research formed the basis of a work plan for promoting behavior change. The Peruvian program relies strongly on a participatory training methodology that uses games and activities to build the capacity of change agents (teachers, health staff, and volunteers) and gives them motivations, resources, and information to influence mothers. Interpersonal communication is supported by print materials and complemented by mass media communication. The project managed the design, production, pretesting, and dissemination of all these communication materials. Opinions on the project methodology are quite positive. Most people appreciate the need for diverse communication channels to effectively carry information and motivations. A few interviewees believe that the Initiative has been implemented too much like a short-term campaign and had insufficient supervision and follow-up. The team’s impression is that this was certainly not the general situation, although it did happen in specific locations. Short campaigns, centered on brief public events, are indeed popular in Peru. The strength of supervision and follow-up seemed to depend very much on the normal working methods and resources of the local partner. In some cases this happened; in others it did not. Regarding work at the regional and district levels, various respondents emphasized the need for strong interpersonal communication in order to achieve behavior change. They view mass media as an important but supportive channel for sensitizing people and reinforcing information given person to person. Many respondents recommended that in the expanded program, the field staff of local partner organizations include interpersonal promotion of handwashing in the programs and plans; that is, that institutionalization goes beyond formal acknowledgment in program norms and general guidelines. This refers to the MOH at all levels, to the MOE, to the networks of women’s organizations, NGOs, and others. Some international public health specialists question the feasibility of interpersonal communication on a large scale, but in the opinion of the interviewees and the team, this component can be affordable and feasible as long as the Initiative: • stimulates the formation of strong local partnerships (of popularly respected organizations that manage cadres of change agents), • provides strong training guidance and tools as well as job aids, • contracts with implementing agencies for training teachers and health personnel and for post-training follow-up, and 19 Global Scaling Up Handwashing Project • encourages the MOH and the MOE to award certificates to change agents who satisfactorily complete training on handwashing promotion and who carry out actual counseling on HWWS in their communities and schools. Respondents judge the behavior-change methodology used to have been more effective with schoolchildren than with mothers. It would be interesting in the second phase to see if this impression is valid and, if so, why. (According to the monitoring study, 90 percent of school children talked with their families about handwashing after having sessions in school.) The November 2006 evaluation study found the impact of project activities on actual handwashing behavior to be inconsistent and fairly modest, so it would seem advisable for the Initiative to monitor behavior change periodically during the second phase to see if slow change is occurring or if the methodology needs strengthening in some respects in order to achieve the desired impact on practices. To effectively apply the methodology at the national and regional levels in the expansion phase, implementing agencies must master the methodology and have essential materials. Processes and products need to be standardized, but they also need to be adaptable. Possibly the Initiative can provide standard resources with instructions for adaptation when needed because of such local factors as climate, availability of water, ways of warming water in very cold zones, and cultural factors. For institutionalization of the at-scale program, it will be important that the methodology can serve as a resource that public sector institutions can use at the national and local levels, adopted formally in institutional strategies. The Initiative should meet with the persons responsible for related programs in the MOH, the MOE, and other partners to promote the use of each other’s communication materials where appropriate and possible. The global PPPHW methodology recommends that messages focus exclusively on HWWS. The team feels that such a focused approach could be quite effective in the short run, but it is not likely to be sustainable, because there are so many competing priorities, even within child health. On the other hand, the Initiative should work with the implementing partners to try to ensure that HWWS information is not given at the same time as messages on many other topics, because this is not likely to result in people being sufficiently informed and motivated to change their practices. The best strategy for sustainability is to integrate HWWS into many existing programs (advocate for ministerial decrees, regulations, budget allocations) but at the same time work with these programs to make handwashing promotion more effective and receive more attention. In general, there is NO guarantee of sustainability. However, the more that partners at all levels work well together and the more the public supports these activities, the better the chance of sustainability. Over a period of several years, HWWS at key times could become a social norm in Peru, passed on within families and communities with little or no need for programs to promote it. In the United States, this has begun to happen with such practices as using seat belts, using designated drivers, and smoking in public only in designated areas, but some promotion of the desired practices is still needed. Implementation Capacity • While the skills and systems needed to implement the program well certainly exist at the national level, a few of the persons interviewed at the national level expressed concern about capacity at the local level. 20 Global Scaling Up Handwashing Project A large-scale program requires that central planners in the public sector know enough about implementation conditions to be able to make good compromises between what they would like to do and what is feasible in the field. From the interviews and the team’s analysis, it appears that the national level has capabilities for program design, planning, preparation of norms and supervision of activities, but not perhaps for making needed adaptations at the local level because of varying local conditions. Availability of Products and Tools • Most of the training and communication materials can be used with little or no change in the expanded program. • There is little concern with the availability of soap, although access to water is difficult in some communities. The Initiative generated a variety of tools to support partner organizations in promoting handwashing among poor families. These included a methodology to motivate and teach handwashing through games and activities, modules to build capabilities of teachers and health/development personnel, and communication materials (posters; reminders; a radio soap opera, spots, and mentions; and television spots). These tools were developed on the basis of the baseline behavioral study, and then pretested with their target audiences. Unfortunately an administrative delay during the creative design process left little time for the complete intervention, with all of the communication channels working together. Disseminating all of these tools was a challenge that seems to have been met. Some of the tools were managed and used directly by the Initiative, while others were offered to partner organizations that intended to use them through their own channels. The program monitored the distribution of materials as well as the use of interpersonal materials used in educational sessions. The monitoring study provided useful feedback on the manuals and educational materials. In general these were considered well done and effective, although people did express the need to adapt materials to the zones of the country (coast, mountains, jungle). Problems in the availability of complementary materials were also noted, and the poster picture may need to be changed to focus more on hands. Persons interviewed expressed minimal concern about soap availability in the homes, since the baseline study (covering all regions of the country) found soap that could be used for handwashing available in 98 percent of homes (and usually in several places in the home). A few people in Arequipa, however, did mention that families in isolated mountain communities may have poor access to soap. Respondents considered the provision of plastic washing bowls and pitchers to have been useful in the first phase, and the team observed these being well used in schools. Financing • Many partners made financial and in-kind contributions during the first phase. • The general opinion is that there is potentially sufficient funding in Peru for this activity, but that the partners need to work hard to obtain the funding to support HWWS. • The team believes that some external funding is likely to be needed after 2009, mainly for covering the cost of implementing agencies to support new districts and, at a lower level, to support continued advocacy. However, partner contributions should increase during this phase, so the percentage of funding provided by external sources should decline. 21 Global Scaling Up Handwashing Project As a result of awareness-raising and advocacy activities, various donors agencies such as USAID and COSUDE decided to provide funding to support the Handwashing Initiative. Also, the MOH showed its commitment by making funds available annually for local communication and mass media. In addition, the Initiative received many in-kind contributions from public, private, and civil- society organizations, which facilitated the incorporation of handwashing messages in activities of their networks to reach the public. Some made financial contributions for message dissemination and/or implementation of extra workshops, in addition to those funded by the Japanese Development Fund, thus allowing the expansion of some handwashing promotion to 14 regions. These organizations included: Public Sector • regional governments of Lambayeque and Ica • municipalities: Santiago de Surco (Lima); Pucallpa (Ucayali); Piura, Castilla, and Catacaos (Piura); Trujillo (La Libertad); Santiago (Ica), among others • MOH: Direcciones Regionales de Salud (Nivel Nacional); CLAS (Local Health Administration Committee) • MOE: Dirección Nacional de Educación Comunitaria y Ambiental; Dirección Regional de Educación (Lima) Private Sector • agricultural companies: Asociación de Gremios Agroexportadores del Perú (AGAP), Fundación ProIca; Gremio Pro-Citrus (Huaral), Sunshine Export (Piura) • banks: Banco de Crédito, Interbank, Banco del Trabajo • utilities: Sedapal, Luz del Sur • cosmetics companies: Belcorp NGOs • Healthy Cities (Ucayali, Ica, Piura) • Caritas (Piura, Tumbes) • CARE (Piura, Ayacucho, Huancavelica, Huánuco) • Ecoclubes (Piura, Tacna) In general, there exists potential funding in-country, particularly with the decentralization process, since the regions are gaining autonomy in preparing and budgeting for their development plans. For the expanded handwashing program, it will be essential to identify regional priorities and then lobby (with regional presidents and others) to include handwashing in local plans and programs. In addition, each year the municipal governments allocate funds through a participatory budgeting process that includes discussions with organized citizen groups and local institutions. For sustainability, it would be highly desirable for the Initiative’s implementing agencies to participate in these deliberations, since they could lobby not only for activities to promote HWWS but also for the conditions that would support the sustainability of this and other desirable objectives. The team believes that if the handwashing promotion initiative is to continue to expand to new districts after this second phase, external funding is still likely to be needed after 2009, mainly to cover the cost of implementing agencies that will probably be needed to support new districts 22 Global Scaling Up Handwashing Project and also to support continued advocacy. However, the percentage of program costs contributed by national partners should continue to increase. Cost-Effective Implementation • In the first phase, WSP and its partners collected extensive cost information and some impact information, but there was no attempt to calculate the cost-effectiveness of various activities or strategies. • The capability for collection and analysis does exist in Peru, but technical support and training will be needed for particular partners and local areas. Analysis of cost-effectiveness probably cannot be done until the final year of the expansion phase, but clearly the methodology and data collection systems and procedures need to be designed sooner than that. The partners took full advantage of the materials that were developed. For example, the episodes of the radio soap opera comprise a series, but each can also be used independently to generate discussions in group education sessions. To maximize their use, the print materials were distributed to local radio stations, to some municipal radio stations, and to informal communication channels. Another cost-effective action was drawing on the regional training facilitators themselves to develop training materials for use with the local facilitators. Some local NGOs have the ability to collect and analyze information on cost and impact, but it is still necessary to strengthen existing capabilities and to monitor activities. Monitoring and Evaluation • The persons interviewed generally consider M&E to be very important for project success. • Many of the persons interviewed were not very aware of the Initiative’s monitoring activities or results. • On the electronic survey, respondents scored monitoring lower than any other dimension. With funding from the Japan Social Development Fund, the NGO PRISMA assumed M&E responsibilities. There were formal studies and routine monitoring, and the Initiative did disseminate the findings in annual reports and other summary documents. In the electronic survey, however, M&E scored lower than other dimensions, which seems to indicate that the M&E results were not widely or well disseminated; or it may simply be that most respondents to this survey collaborated at the local level and therefore were less likely to have been exposed to M&E findings. The persons interviewed indicated that M&E should be a key component in the expanded program and that the opportunity to show how well different interventions work in this type of project should not be lost. The team feels that it is going to be a challenge to allow the local implementation flexibility that many respondents recommend while at the same time keeping sufficient uniformity in the program districts to be able to generalize about them in relation to the control districts. In addition, the monitoring team will have to control carefully for the effects of the many existing programs and projects in both intervention and control districts. 23 Global Scaling Up Handwashing Project 4. RECOMMENDATIONS BY DIMENSION The team has a number of suggestions, many of which expand ideas suggested by persons interviewed. (In some cases, the team further developed some general suggestions from the interviewees). This section presents key recommendations by dimension. These are also described in table format in Appendix I. Policy, Strategy, and Direction Although the attitudes of public and private officials toward handwashing are generally very positive, many still lack knowledge of the multiple benefits of HWWS. Moreover, government officials in particular must try to address many different priorities simultaneously. Therefore, the Initiative should develop an advocacy strategy—with arguments and materials for different levels and types of decision makers—that describes the importance of HWWS for reducing diarrhea, respiratory disease, and infant mortality; for preventing malnutrition; and for improving school performance, mothers’ confidence and self-esteem, and the nation’s human capital. Advocacy activities should begin as soon as possible and continue throughout the project period. At the time of this assessment, even key partners lacked information and had differing expectations regarding the expanded handwashing program, although clearly steps were already planned to remedy this situation. Before the selection of implementation districts, the Initiative should hold individual and group meetings with the key partners to clarify their expectations and the project’s intentions and constraints (such meetings have already begun). The Initiative should prepare and disseminate a brief description of the new project that summarizes the proposed strategy and plans, making clear which features are required under the new project. Initial discussions of each partner’s role and responsibilities should also occur during these meetings, leading eventually to MOUs or other types of agreements. A similar process, managed by the implementing agencies, should be repeated at the regional, provincial, and district levels, once the intervention districts have been selected. The National Committee has played a key role in institutionalizing HWWS by making the major programmatic decisions and being viewed by others as the face of the Initiative. It is important in the expansion phase that it continues to play this role and that its decisions are well disseminated to give orientation to regional activities. The first phase of the Handwashing Initiative in Peru has achieved various degrees of integration with such programs as PRONASAR; PAC/SEDAPAL; the MOH’s Healthy Schools program; and, recently, the MOE’s Clean, Safe, and Healthy Schools program. The team (and many of the people interviewed) strongly support efforts to integrate with and strengthen promotion of HWWS in existing programs rather than implementing the handwashing promotion as a vertical program. This makes sense for several reasons: Many national and local programs, some with strong political support, already include hygiene improvement and/or handwashing, so they should be quite open to making this component more effective. For example, there is a strong link between handwashing and infant nutrition, which is a priority of the president, along with other programs such as Together and Water for Everyone that are being implemented by public and private organizations. This strategy of incorporating handwashing promotion into ongoing activities gives the best chance of institutionalization. In addition to existing programs, there is the potential of synergy of handwashing promotion with the rollout of rotavirus vaccine (since both interventions reduce diarrhea) and with planned sanitation marketing programs. 24 Global Scaling Up Handwashing Project Taking a more vertical, campaign-type approach can generate jealousy among other programs that eventually leads to the demise of the vertical program. In general, the team recommends a decentralized structure for this expansion phase. The national level should create supportive policies, standard tools and methods—including strong advocacy, program communication, and M&E activities—and work through the implementing agencies to establish strong coordination and clear responsibility at local levels. The national-level public sector institutions are in the process of taking on a normative role. More and more decisions on priorities and program activities will be taken at the regional level, which will also control the resources to implement them. Given the reality of decentralization, it is important that advocacy activities designed to build and maintain support for HWWS be directed to decision makers at the regional, provincial, and district levels as well as at the national level. In response to the past problem of frequent changes in public sector officials, it is important to promote the inclusion of HWWS in the annual work plans, guidelines, and budgets of the MOE and the MOH. Also, it is recommended to link with the National Health Council, a consultative group of the MOH that is charged with arriving at decisions via consensus and with coordinating the national Coordinated and Decentralized Health Systems. There are similar institutions at the regional level, with active civil society participation. These organizations work on health guidelines but also on implementing regulations and national plans. Partnerships The main recommendations at the national level are to proceed with making the MOE a full national and local partner (already in progress) and also to consider adding to the coordinating committee the Ministry of Housing, as well as at least one private sector partner such as CONFIEF, which represents an array of private companies. The Initiative should engage other old and new partners with national reach through the National (consultative) Committee. It should also assess the interest of potential new partners in joining the Initiative (for example, UNICEF, PAHO, Save the Children). The existence of a certain level of guaranteed funding (from the Gates Foundation), along with concrete products (training and communication materials, handwashing kits) should help build the confidence of old and potential partners. Although selling more soap has not been a strong motivator of private sector participation, the Initiative should meet with companies that produce soap, towels, and plastic containers to see if they would be willing to incorporate HWWS information in their advertising or packaging in the hope of expanding their markets. It can be argued that the Initiative is doing free market expansion, which they should be happy to encourage. To achieve impact and sustainability, the Initiative should focus on establishing and strengthening partnerships at the regional, provincial, and districts levels, where the implementing agencies need to identify existing public and private coordinating groups to take on explicitly the coordination of handwashing-promotion activities. The first choice for a coordinating group should be an existing structure such as the mesa de concertación or regional multisectoral committee. It is also important, at the local level, to identify one or more HWWS champion organization or person that can identify the groups best positioned to engage other partners. Partners at the district level should include the strongest programs and institutions in each district. A strong partner organization is one that has a good reach into communities, has built confidence among the population, and is committed to ongoing follow-up and supervision of promotion 25 Global Scaling Up Handwashing Project activities. Each partner should be asked to commit itself to strengthen or expand attention to handwashing in its objectives and work plans. Organizations to consider include those helping install or improve water and sanitation systems, Vaso de Leche, comedores populares, and NGOs with long histories and good reputations in an area. The WSP, the National Committee, and the implementing agencies should focus on providing guidelines, tools, and strategic technical assistance to local partnerships. To keep local partners motivated and informed, the team also recommends a strong project communication program with a newsletter, Web site, media coverage, and meetings and exchange visits that facilitate the dissemination of achievements and sharing of lessons learned (see Appendix L). As part of the process of consolidating the public-private alliance to promote HWWS, it is recommended that WSP and/or the National Committee lay out clear organizational responsibilities, including a checklist of requirements for implementing person-to-person promotional activities, assigning roles and functions to different actors at the regional level. At the national level, each partner should be invited to join one of the committees listed in Table 7, depending on each organization’s agreed-upon roles. 26 Global Scaling Up Handwashing Project Table 7. Committee Participants Type of Participants Type of Institutions Frequency Committee National One representative each • Those providing funding and Monthly meetings Committee from the MOH, the participating in planning and MOE, from each major management of the initiative (for donor organization, example, COSUDE, USAID). private-sector partners, and civil-society • Those providing funding and partners. participating in planning, management, and national implementation (for example, the MOE and the MOH) Committee of Collaborating • Those implementing Meetings every three Institutional organizations that have communication activities directed months to receive Partners less overall involvement to their personnel and customers information and (in limited geographical (for example, Belcorp, CARE) exchange experiences, or functional areas) plus information • Those involved in a specific exchange via other activity, such as dissemination or communication channels printing, based on their resources (for example, Banco de Crédito, Transportes Ormeño) In the first phase, there does not appear to have been a strong connection between the National Committee and the regional and local partnerships. The Initiative needs to clearly define and follow through on its relationship with the regional coordination committees. The project communication program (newsletter, Web site, and so on) should facilitate two-way communication. Institutional Arrangements Although MOUs and other formal agreements are no guarantee of follow-up, they are essential for working with government agencies since they are needed for budget allocations to occur, and they may limit disruptions caused by changes in personnel. Formal agreements are particularly important with the MOH, which maintains substantial control over its local offices. The Initiative should continue to pursue such formal agreements at the national level and instruct its implementing agencies to do so at local levels. Although it is fine initially to have less formal agreements with private and civil society partners, it the long run negotiating and signing more formal agreements is desirable because such agreements would clarify roles and expectations and support sustainability. All agreements should define roles, responsibilities, and expected contributions. Moreover, the fulfillment of all formal and informal agreements should be reviewed and documented every six months. The WSP and the MOH should be responsible for this monitoring at the national level, and the implementing agencies should have responsibility at other levels. More formal arrangements are also needed at the regional level, not only regarding implementation guidelines but also written commitments on responsibilities and in-kind and monetary contributions. The types of organizational involvement described in the section on major findings on partnerships provide a menu of possible relations with the Initiative. 27 Global Scaling Up Handwashing Project Program Methodology The study team feels that the expanded project can follow a very similar methodology that combines forming partnerships at every level, advocacy and institutionalization activities, and strategic communication activities that combine mass media and several channels for interpersonal communication. It should be possible to scale up interpersonal communication training and activities, since this will be done by implementing agencies, each of which will be responsible for three to five regions and selected districts within each region. A key to success will be the supervision and follow-up of the training by the local partners themselves. The team has made small suggestions for improving the methodology (for example, by suggesting handwashing-promotion activities that students and promoters can do in homes and communities, and preparing modified materials for each of the three zones in the country—see Appendixes J and K) but has not suggested major changes. Three general suggestions from various respondents were to: (1) focus on supporting the local levels, (2) allow local partners flexibility in implementing the general strategy, and (3) urge local partners to avoid a focus on short campaigns with no clear follow-up. Such campaigns seem to be very popular in Peru, but their impact is questionable. In the start-up period, the Initiative should develop a standard methodology and instruments for assessment visits at the provincial and district levels to identify existing activities in which handwashing promotion could be added or strengthened, and to identify the strongest partner organizations and potential HWWS champions. Most respondents recommended that implementation emphasize interpersonal communication, but all saw a continued role for mass media. The team favors a focus on local radio in local languages and interactive formats (call-in shows, radio listening groups, and so on). It is important to ensure better coordination between mass media promotion and on-the-ground activities, so they are mutually reinforcing. The team recommends encouraging and facilitating local partners to create opportunities for individual and group dialogue between change agents (teachers, students, health staff, health volunteers) and mothers, to give ample opportunity to explain and discuss the desired behavior changes and to jointly problem solve if there are barriers to action. Mass media should continue to support interpersonal communication by generating interest in and reminders of handwashing with soap. What is ideal, but only possible in one-on-one or group communication, is for the change agents to ask a few assessment questions to learn what the mother or group is currently doing regarding HWWS. So, for example, if the mother is already washing her hands at key times but not using soap, the focus of the conversation would be on the importance of using soap and how this can be done by this particular mother. If the mother is washing with soap but only before preparing food, then the importance of washing of other key times would be the focus. If feasible, it would be desirable to develop separate communication materials for the coast, mountains, and jungle areas of Peru. If this is not possible, the Initiative should encourage regions to modify materials to incorporate more appropriate images, language, and local conditions, such as limited water or cold temperatures, and counsel families on how to overcome them. For both effectiveness and sustainability, the Initiative should encourage strengthening of handwashing promotion within existing programs such as health promotion by the MOH, Escuelas Saludables, Viviendas Saludables, Municipios Saludables, PRONASAR (new water 28 Global Scaling Up Handwashing Project and sanitation systems), PRONOEI (preschool program), initiatives directed at malnutrition, JAAS (water and sanitation boards), NGOs doing health promotion, and so on. Although moving away from a single focus on handwashing contradicts the general PPPHW strategy, the team feels that this is the most appropriate approach for Peru as well as the one mostly likely to be sustainable. On the other hand, any particular educational opportunity should have a specific focus (on handwashing or some other topic) and be as interactive as possible, so as not to overwhelm people with too many messages and too much information all at once. To try to build and maintain a positive program image, to motivate partners and supporters, and to share useful technical and strategic information, the Initiative needs a strong project communication program directed at both collaborating organizations and the outside world (political leaders, donors, the public). At a minimum there should be an electronic newsletter, a section on the WSP/Peru and MOH Web sites (with links to partners’ sites), and specific efforts to obtain radio and press coverage of accomplishments and activities. These communication spaces should include basic information on the program, descriptions of particularly effective/innovative strategies or activities; updates on achievements and impact; and exchanges on lessons learned. (This recommendation combines respondent and team ideas.) The “implementing organizations� that the Initiative intends to contract to manage the program in several regions should collaborate in preparing an operational guide for the district level. The guide should propose implementation steps in a way that encourages each district to select those that are likely to be most feasible and effective. The program should take advantage of children’s enthusiasm by suggesting activities for students to promote HWWS at home and in their communities. The Initiative should work with students, health promoters, and local organizations (soliciting and testing their ideas) to develop new activities and materials. In addition, the workshop methodology and supplementary materials should add coverage of how change agents can work with individual mothers on solving problems, such as (perceptions of) limited water, soap, or time. Lack of compensation for transportation and food costs are said to be barriers to promoters making more home visits. Where other partners are willing to share the cost, the Initiative should contribute to the costs of such compensation at the local level. Finally, the key partners should develop an exit strategy that addresses both sustainability and expansion issues. This might include steps to institutionalize support (funding and commitment) for HWWS in government and partner organizations, plans to expand the program into some control districts as soon as the final measurements have been completed, intensified efforts to get handwashing benefits and promotion in curricula and pre-service training, and local and national presentations on the project’s lessons learned and impact on health and malnutrition. Implementation Capacity Considering implementation capabilities of national public sector organizations, and looking at the institutionalization of the process and human capabilities, the team recommends that the Initiative link not only with the directorate level of each ministry but also with higher levels such as ministers and vice ministers, who can instruct the ministry’s various directorates and programs to be involved. The Initiative is already working on such contacts. All needed capacities exist in Peru, so the challenge in the expanded program is to build capacity at decentralized levels. Although regional and district levels have resources of institutions such as NGOs and some public sector units, it is evident that the large-scale program, mainly through the implementing agencies, must work intensively to strengthen local capabilities both before 29 Global Scaling Up Handwashing Project and during implementation. Although training is the main approach, provision of materials (manuals, a district implementation guide, a newsletter, and so on), technical assistance by implementing agencies, mentoring, and exchange visits are also important. More intense support should be given to regions, provinces, districts, and municipalities where the local assessments show particular weaknesses. WSP and other National Committee members should train key staff in the implementing agencies, who in turn should train and support persons and organizations in the regions. Training should be participatory and capacity-based and should include as much practice of skills and exercises to draw out attitudes as possible. WSP should ensure that the MOH, the MOE, and implementing organizations receive information on the most outstanding people who were trained in the first phase, since they are an excellent resource to support implementation in the regions. The local partners should be responsible for monitoring the implementation of training skills a few months after training and then every six months after that. They should also monitor if significant numbers trained teachers or promoters have left their positions, so additional training sessions may be planned and implemented. After their assessment of each region, province, and district where this phase will be active, the implementing agencies need to identify key leaders or “champions� who can serve as spokespersons, as well as persons who are already trained and informed about the Initiative and who can support expansion. For example, these could include the group of regional facilitators who trained many others to give training in the first phase. Most of them are regional health or education staff who have leadership capabilities. The Initiative should encourage and facilitate the existing trend for regional partner organizations to integrate HWWS into preservice training curricula and, in addition, explore at the national level adding or strengthening coverage of the benefits of HWWS and promotion of handwashing in professional training institutions. Availability of Products and Tools It is important that the products and tools are appropriate to the local reality at the regional and district levels—for example, illustrations should reflect coast, mountains, or jungle. If it is not possible to prepare completely different sets of materials for each geographical zone, the Initiative should support regional efforts to devise their own appropriate activities and local materials. Except in isolated rural communities, soap availability is not a problem, but change agents in those particular communities should be trained to offer alternatives to soap, such as ash, sand, or quinoa oil (their acceptability and feasibility should be investigated first; as well as the efficacy of quinoa oil). Difficult access to water is a problem in some communities, schools, and homes. Three potential solutions are to: (1) link handwashing promotion to existing initiatives that install or improve water systems; (2) train change agents to promote water-saving technologies such as Tippy Taps, and (3) delay working in schools and communities with poor access to water. Some persons interviewed suggested that the Initiative support encourage municipal governments to support infrastructure such as construction of water faucets near kitchens and latrines and simple systems for disposal of used water. This seems like a logical idea, as many interviewees’ suggested that handwashing stations near the kitchen and bathroom would facilitate consistent handwashing at key times. 30 Global Scaling Up Handwashing Project Materials to support training and communication on HWWS (for the hygiene corners in schools and the training modules) should be given out in the training workshops for local facilitators and promoters, as was done in most workshops in Phase I, so that they can have the needed tools to effectively carry out their tasks related to HWWS. Although the team favors the continued provision of plastic bowls and pitchers, with an eye to sustainability, this should be made a district responsibility rather than a national one. District partners could devise a plan to have these materials donated to schools and to some or all families. The Initiative can continue to use the existing behavior-change materials, which were prepared and approved with great effort. However, as mentioned, the team has recommended a few supplementary materials, and the widespread call for more locally appropriate versions needs to be addressed. The Initiative or its local partners should consider producing reminder materials that families can place at handwashing stations. It is important to identify and measure the storage capacity in each intervention area because of the considerable volume of materials. Because of the ongoing changes related to decentralization, this issue needs to be followed carefully. Financing Aiming toward sustainability, the Initiative should continue to focus during this phase on getting national and local partners to finance increasing portions of handwashing-promotion costs. To the extent possible, commitments should be included in signed MOUs whose implementation should be monitored. In order to expand into new districts at the end of this phase, it is likely that some funding from external donors will still be needed—mainly to support advocacy, program communication, implementing partners, and M&E—but the percentage of external funds should be significantly less than for the current phase. The team recommends preparation and implementation of an exit strategy so that ideally there can be a smooth transition to the following phase of handwashing promotion in Peru. Other, specific ideas include: • Continue to explore a co-financing agreement by the Fund of the Americas (FONDAM), which has expressed interest in supporting HWWS in Peru. • Obtain information on USAID’s small grants program and then decide if it wants to share this with local partners. • Lobby at all levels of government for budgetary funds directed toward handwashing or hygiene education. • Continue to seek donated air time and publicly acknowledge the donation of free air time by private media companies. Cost-Effective Implementation In the first phase in Peru, the Initiative collected extensive cost information. This should continue. The second phase will focus on M&E, so the Initiative should be able to combine findings on costs and on effectiveness to help formulate recommendations on adding, dropping, or changing certain program inputs. Although calculating the cost-effectiveness of certain inputs or strategies requires both art and science, making programmatic decisions on the basis of cost-effectiveness should also factor in sustainability and non-monetary costs, such as WSP time to coordinate. In the interest of holding down costs, the use of national radio and television should be modest and directed more toward decision makers (advocacy). Local radio should be used to reinforce interpersonal activities at the local level. As much as possible, the local partners should try to 31 Global Scaling Up Handwashing Project negotiate the inclusion of information, discussions, or contests on HWWS in existing programs, at little or no cost to the Initiative. The Initiative’s materials appear to have been used effectively and efficiently. For example, chapters of the radio soap opera could be used independently and as a stimulus to discussions in group educational sessions. Other audiovisual materials were given to local radio stations, some municipal radios, and informal communication channels. For sustainability and replicability, the Initiative should continue to look for and utilize such opportunities to maximize human and material resources. Monitoring and Evaluation A key to maintaining partner and public motivation is the timely dissemination of achievements and results. There was quite thorough project monitoring, but it came at the end of the first implementation phase and the findings apparently were not well disseminated—many of the persons interviewed felt that monitoring was one of the weaker aspects of the program. For the expanded program, interviewees suggested better communication of achievements, a suggestion that the team expanded into a recommendation for a strong communication program that updates partners at regular intervals on major activities, resources, innovations, and achievements, as well as on the dimensions of scalability and sustainability that this study has used. There will be a thorough M&E program in this phase, standardized across the four countries. The team recommends that M&E be managed by a person or group connected to but separate from those managing implementation, and that findings be used to modify to program. No information should be collected unless it potentially can be used to modify the program in an important way. In general the focus should be on changes in practice and their determinants, not on changes in knowledge. Findings from M&E should be appropriately packaged and well disseminated to partners, decision makers, and the public. 32 Global Scaling Up Handwashing Project 5. NEXT STEPS Steps recommended by the study team to support program expansion and sustainability are found in Appendix L. In some cases additional detail may be found in Appendix I. Among the principal recommendations are: • Plan and implement a dynamic advocacy strategy that begins immediately and that continues throughout implementation. • Plan and implement a strong project communication strategy directed primarily to partners but also to decision makers at various levels and to the public. Materials, formats, and activities should be directly related to reaching one of the strategy’s objectives (for example, partner motivation, sharing good ideas) and audiences, which should be clearly defined. • Develop and implement an exit strategy that includes steps for dissemination and sustainability of program activities and achievements. • Continue to negotiate and sign more formal agreements on partners’ roles and responsibilities and develop systematic mechanisms to monitor the implementation of the agreements. • Have the key national-level partners, including the implementing organizations; dedicate themselves to establishing the conditions and providing the tools and support for successful local implementation. In this decentralized vision, the team expects that key factors for program success will be strong and dedicated partnerships at local levels, with effective tools and methodologies and support from the national level. • Great attention should be given to carrying out thorough regional, provincial, and district assessments of organizations, potential champions, resources, programs, and conditions and to establishing and supporting strong local partnerships. Although Appendix L contains some elements of a work plan, these ideas should be considered to be no more than recommendations to the Peru country coordinator, for her to consider in consultation with in-country partners and WSP staff in Peru and Washington. 33 Global Scaling Up Handwashing Project APPENDIX A: SELECTED DOCUMENTS AB PRISMA. 2004. Estudio de comportamiento de lavador de manos con jabón en zonas periféricas del Perú. Preparado como línea de base para la Iniciativa de Lavado de Manos en el Perú, liderado por PAS-Banco Mundial. June, Cogswell, Lynne. 2007. “Revised PROTOCOL. Enabling Environment Assessment of HW and TSSM Programs.� World Bank (Water and Sanitation Program). April 19. COSUDE. Brochure institucional. Cuerpo de Paz. Brochure institucional. Flórez P., Rocío. 2007. Informe de Implementación 2006-2007. May. Flórez P., Rocío. 2006. “Iniciativa de Lavado de Manos en el Perú.� October 17 (PPT). Flórez P., Rocío. 2006. “Sistematización. Período 2003-2005.� February. Iniciativa de Lavado de Manos. 2006. Proyecto de fortalecimiento de capacidades para el cambio de comportamiento: reducción de diarrea en niños de escasos. Informe de monitoreo. November. Iniciativa de Lavado de Manos. 2006. Proyecto de Fortalecimiento de capacidades para el cambio de comportamiento: reducción de diarrea en niños de escasos. Informe de Evaluación de Efecto. November. Iniciativa de Lavado de Manos. No date. Módulo para facilitadotes – promotores de salud y desarrollo. Iniciativa de Lavado de Manos. No date. Módulo para docentes del nivel inicial y primaria. Jensen, Lene. 2007. “Quick Backgrounder on the PPPHW Approach to Handwashing Promotion.� Water and Sanitation Program/Handwashing Secretariat. April 12. Ministerio de Vivienda, Construcción y Saneamiento, PRONASAR. 2006. Proyecto Piloto de Agua y Saneamiento en Pequeñas Ciudades. “Cuidar el Agua: La escuela en acción.� July. Ministerio de Educación, Viceministerio de Gestión Pedagógica, Programa de Educación Ambiental. Brochure Educación Ambiental. Ministerio de Educación, Viceministerio de Gestión Pedagógica, Programa de Educación Ambiental. “Guía instructiva de la Campaña nacional Escuelas Limpias y Saludables 2005 al 2014.� Programa Nacional de Agua y Saneamiento Rural (PRONASAR). 2007. “Documento de Sistematización del Proyecto Piloto de Agua y Saneamiento en Pequeñas Ciudades.� January. SEDAPAL. 2005. “Guía metodológica para la intervención técnico social en la elaboración y ejecución de proyectos condominiales de agua potable y alcantarillado.� November. 34 Global Scaling Up Handwashing Project Sub Región de Salud Luciano Castillo Colona, Sullana. 2007. Informe de Lavado de Manos. World Bank (Water and Sanitation Program). 2006. Grant Proposal: Scaling Up Handwashing Behavior Change. September 25. World Bank (Water and Sanitation Program). 2007. “Terms of Reference. Enabling Environment Assessment and Baseline to Scale up, Sustain and Replicate Handwashing with Soap Behavior Change Programs.� March 9. World Bank, BNWP, WSP Water and Sanitation Program. 2005. The Handwashing Handbook: A guide for developing a hygiene promotion program to increase handwashing with soap. 35 Global Scaling Up Handwashing Project APPENDIX B: LISTA DE ENTREVISTADOS LISTA DE ENTREVISTADOS NACIONAL INSTITUCION PERSONA CARGO DIRECCION TELEFONO FECHA HORA Ministerio de Coordinadora Salud Beatriz Ugás Comisión Nac 3156600 Jueves 31 3 p.m. Director Nacional Van de Velde Dirección 160, San Nacional de Borja Educación Pabellón A, 2155800 Ministerio de Armando Sanitaria y Tercer Piso, 2155830 Educación Barrantes Ambiental Of. 305 (1139) Martes 22 9 a.m. Consultor Van de Velde Dirección 160, San Nacional Borja Educaciòn Pabellón A, 2155800 Ministerio de Jorge Sanitaria y Tercer Piso, 2155830 Educación Chumpitaz Ambiental Of. 305 (1139) Jueves 24 11 a.m. Paseo de la Ministerio de República Vivienda/PRON Especialista 3361, San 4226608 ASAR Rosa Meza técnico UGP Isidro 99271760 Jueves 31 9:30 a.m. Paseo de la Ministerio de República Vivienda/PRON Gabriela 3361, San 4226608 ASAR Flores Isidro 4226585 Viernes 01 9:30 a.m. 36 Global Scaling Up Handwashing Project REGIONAL INSTITUCION PERSONA CARGO DIRECCION TELEFONO FECHA HORA Gerente Biblioteca Municipalidad Giovanna Educación, Municipal de 073-302525 Piura Bisso Cultura Piura 9687691 Jueves 17 8 a.m. Jefe de Oficina 073-307775 Omar de Población, Municipalidad / 073- Palacios Salud e Higiene de Piura 9961239 Viernes 18 11 a.m. Presidente de la Comision de Salud, Municipalidad Salubridad y Municipalidad Catacaos Deisy Chero Saneamiento de Catacaos 073-370239 Viernes 18 3 p.m. Dr. Carlos 073-342424 DIRESA Piura Bayona Sub director DIRESA Piura 341563 Jueves 17 12 m. Red de salud Jenny Relaciones Red de Salud Sullana Portocarrero Públicas Sullana Viernes 18 9 a.m. Dirección Especialista Regional Gestión Educación Germán Educativa y Ronda Recoleta 054-270975 Arequipa Robles Ambiental s/n 054-252391 Lunes 28 9 a.m. Calle Alvarez Tomas 304, Altos (Altos Biblioteca Municipalidad Sonia Gerente Gestión Municipal 054-229240 de Arequipa Sánchez Social Arequipa) 9862105 Lunes 28 8 a.m. Autoridad Calle Unión Gobierno Regional de 100, Urb. Cèsar Regional Dr. Aníbal Medio Vallejo, Dist. 054-463165 Arequipa Díaz Ambiente Paucarpata 054461319 Martes 29 8 a.m. Av. Alcides Haydé Rodas Carrión - Hospital DIRESA / Mariela Promoción de la General Honorio Arequipa Díaz Salud Delgado 235155 Martes 29 11 a.m. 37 Global Scaling Up Handwashing Project LISTA DE ENTREVISTADOS Bilateral Projects INSTITUCION PERSONA CARGO DIRECCION TELEFONO FECHA HORA Gonzales Prada 350 USAID/Comuni Miraflores dades (frente teatro Saludables Edgar Medina Director MSH Marsano) 2429800 Miércoles 16 3 p.m. Comunicación Eliana López MSH Miércoles 16 4 p.m. Av. Nicolás Ayllón 2309, Piso 4, Ate. (Por la Clínica San PAC Javier Acosta Especialista Juan de 3261182 SEDAPAL Sotomayor social Dios). 99176790 Miércoles 23 10 a.m. LISTA DE ENTREVISTADOS Media INSTITUCION PERSONA CARGO DIRECCION TELEFONO FECHA HORA Paseo de la República 3866, San Isidro (altura Paseo de la Frida República y RPP Delgado Directora Aramburú) 215-0200 Martes 22 11:45 a.m. Centro Comercial Oswaldo Director de Cayma Of. PERUTV Vizcarra Prensa R2 054-252525 Martes 29 2:00 p.m. Gerente de César Portillo Producción 38 Global Scaling Up Handwashing Project LISTA DE ENTREVISTADOS Local NGOs INSTITUCION PERSONA CARGO DIRECCION TELEFONO FECHA HORA Carlos Gonzales Delia Directora 251, San PRISMA Haustein Ejecutiva Miguel 6165500 Viernes 11 11 a.m. Especialista en Ruth Pérez comunicación Viernes 11 12 m Av. Jorge Ciudad Basadre 255 421-5163 Saludable Albina Ruiz Directora Of. 401 S.I. 92759213 Calle Paz Coordinador Soldán 307, 054-272883 ONG Labor Jorge Béjar Arequipa Yanahuara 256740 Lunes 28 3:30 p.m. 992 2496 997 8788 Calle Málaga ONG DESCO - Grenet 678, Arequipa Oscar Toro Coordinador Umacollo 054-257043 Lunes 28 5 p.m. LISTA DE ENTREVISTADOS Private Sector INSTITUCION PERSONA CARGO DIRECCION TELEFONO FECHA HORA Gerente Av. Canaval corporativo y Moreyra Daniela responsabilidad 480 San 2113300 Martes Belcorp Barbieri social Isidro (1466) 15 11 a.m. Av. Camino Real 456, María Sonia Torre Real PROICA Arenas Gerente Piso 11 98382401 Lunes 21 11:30 a.m. Cámara de Comercio e Calle Industria de Martín Quezada 104, 054-253920 Arequipa Cotrina Gerente Yanahuara 254188 Lunes 28 8 a.m. 39 Global Scaling Up Handwashing Project LISTA DE ENTREVISTADOS International Agencies INSTITUCION PERSONA CARGO DIRECCION TELEFONO FECHA HORA Cesarina OFICIAL DE Av. Salaverry Miércole COSUDE Quintana PROGRAMA 3242, S.I. 2645001 s 23 3 p.m. Calle Vía Láctea 132, Urb. Los Emilia Directora de Granados, 617-2200 / Martes Cuerpo de Paz Villanueva Programas Surco. 617-2210 15 PAS 9 a.m. Plaza de Cuerpos de Paz Armas de Jueves (Catacaos) Ana Turves Voluntaria Catacaos (073) 9628939 17 10 a.m. Av. La Encalada Oficina de cdra. 17 Viernes USAID Jaime Chang Salud Monterrico 11 9 a.m. Av. La Encalada Especialista en cdra. 17 6181225 Mabe Arce comunicaciones Monterrico 6181350 Lunes 14 4:30 p.m. Alvarez Coordinadora Calderón 185, Lunes 14 PAS Rocío Flórez Iniciativa LM Piso 9 615-0685 mayo 10 a.m. Alvarez Iris Coordinadora Calderón 185, Martes WSP/PPL Marmanillo Perú PAS/BM Piso 9 615-0685 15 mayo 4 p.m. Especialista Alvarez Mercedes comunicación Calderón 185, Lunes 14 Zevallos PPL Piso 9 615-0685 mayo 3 p.m. 40 Global Scaling Up Handwashing Project International NGOs INSTITUCION PERSONA CARGO DIRECCION TELEFONO FECHA HORA ESPECIALIST A EN Gral Santa Lourdes CAPACITACI Cruz 659 CARE Perú Mindreau ÒN Jesús María 4317430 Lunes 21 4 p.m. Urb. 4 de Carolina CAPACITADO Enero Mz E Jueves CARE Piura Aguilar RA Lote 3 073-304675 17 5:00 p.m. Av. Javier Prado Este 5318 La Molina (alt. Alvaro de la cruce Los FONDAM Romaña ASESOR Frutales) 4372727 Martes 22 3 p.m. Juan Manuel Secretario Calle Cusco Viernes Cáritas Piura Cendra General 179 Piura 073-311203 18 9:00 a.m. Federico Barreto 146, Frente Cáritas Pablo Secretario mercado Martes Arequipa Manrique General Palomar 054-608800 29 9 a.m. 41 Global Scaling Up Handwashing Project APPENDIX C: RESUMEN DE PUNTOS IMPORTANTES DE LAS ENTREVISTAS Política, estrategia y dirección Tipo de Fortalezas Debilidades Recomendaciones institución Gobierno ►Desde la Dirección Nacional de ►Promover la voluntad desde las Regiones vinculando a la Educación Comunitaria y Dirección Regional de Educación, �rea gestión pedagógica. Ambiental (DINECA) existe una ►Para la sostenibilidad de la intervención, sería necesario que voluntad política de participar y de se haga una sensibilización inicial a las autoridades que harían vincularse a otras iniciativas. seguimiento al programa (Municipalidad Piura). ►Las ordenanzas que se emitieron ►Revisar la decisión política en los Planes Regionales desde el nivel central generó un Concertados de Salud (DIRESA Piura). interés de salud en el nivel local. ►Chequear disponibilidad de agua primero para que el tema ►Existe voluntad política de tenga más impacto. (Gerencia medio ambiente, Arequipa). trabajar lavado de manos desde Ministerio de Vivienda ►Considerar las zonas que se están identificando para el (PRONASAR). concurso del próximo año en PRONASAR, componente 1 (rural con 2,000 habitantes a menos) y 2 (pequeñas ciudades ►La nueva gestión del MINSA 2,001 a 30,000 habitantes). tiene un marcado interés en seguir participando en la Iniciativa. ►El MINSA considera necesario trabajar un proceso muy participativo en el diseño de la segunda fase. ►Es interesante ver cómo las empresas privadas han estado ►La Iniciativa coincide con la priorización de los cuatro temas participando en temas de salud. de esta nueva gestión MINSA: descentralización, seguridad ciudadana, nutrición y maternidad saludable. Agencia ►Existe una marcada voluntad ►Faltó involucrar mayor participación ►El nivel central tiene que cumplir su labor de facilitador con internacional política de la agencia. La iniciativa de otras instituciones como UNICEF, herramientas o guías específicas para una ejecución más tiene una buena identidad que se OPS, las que podrían constituir alianza eficiente. traduce en la existencia de un logo. de soporte y no nuclear. ►Esta segunda etapa no debiera constituirse en un modelo de Se identifica que la Iniciativa no es ►Falta presentar lo que se está intervención rígido. Se requiere uniformidad, pero debe ser percibida como exclusivamente de avanzando. Es posible que la actuación flexible como para permitir seguir involucrando otros socios y una organización, sino de socios del MINSA no esté tan bien descrita. otros aportes. igualitarios. ►La voluntad política ha sido variable ►Se debe hacer más diseminación de los avances y actividades ►(USAID) Se ha tomado la dentro del MINSA porque todavía no se decisión de apoyar anualmente con 42 Global Scaling Up Handwashing Project Tipo de Fortalezas Debilidades Recomendaciones institución fondos exclusivamente para lavado ha consolidado una institucionalización de reconocimiento sociales al sector público y privado. de manos. de LM. Esto depende completamente de ►Se debiera tender a que los instrumentos se conviertan en los líderes actuales y su opinión. ►Ha tenido un estilo de trabajo parte de las propias instituciones. informal y abierto a las ►La voluntad política ha variado ►Se requeriría trabajar un plan de abogacía para involucrar instituciones. mucho con los cambios de líderes en el otros actores. MINSA. ►La Iniciativa podría ser más Existe un marcado de interés de fuerte con el sector público. ►Es muy importante institucionalizar lavado de manos en el verlos como procesos: como MINSA, debido a que lo tiene más explícito en el plan mecanismo de Iniciativa y como ►Un obstáculo es que el personal de sectorial. También es muy importante tener una relación más alianza público privada. MINSA tiene demasiadas prioridades y formal entre MINSA y MINED. en ese sentido tienen que estar bien ►Forma parte de un componente convencidos sobre el valor de LM antes ►La Iniciativa debiera estar integrada a programas de agua y de los programas con la comunidad, hacer algo. saneamiento para que pueda asegurar su sostenibilidad. que ellos financian. ►La estrategia no funcionó tan bien con ►Teniendo en cuenta el momento político, la Iniciativa debiera ►Se ha logrado una visión el sector público – es más difícil por los unirse a la Alianza contra la desnutrición crónica. El gobierno compartida, de tal manera que se cambios frecuentes en personal y la está muy comprometido a reducir en un 5% la desnutrición privilegia la Iniciativa más allá de abundancia de prioridades para ellos. antes de 2011. la presencia institucional. ►Muchas áreas del MINSA ►El LM ha sido una excelente actividad inicial para ayudar a ►La estrategia funcionó muy bien participaron en las discusiones de nuevos Voluntarios del Cuerpo de Paz integrarse en sus con el sector privado. estrategia. comunidades y ganar la confianza del pueblo. ►Se identificó una fuerte voluntad ►Muchos políticos han cambiado con ►Su ejecución ha sido muy importante para el auto-estima de política en Lambayeque. las elecciones recientes, lo que genera mujeres rurales. Se puede usar estas resultados positivos para ►Los alcaldes han mostrado una necesidad de orientación sobre LM. motivar a otros a unirse al programa. mucho interés por la relación de ►A nivel nacional falta una estrategia ►Asegurar el vínculo con programas como Agua para Todos lavado de manos con desnutrición y intersectorial que pone LM dentro de (programa paraguas de PRONASAR). la falta de capacidad humana. muchos programas e iniciativas grandes del gobierno (salud, educación, ►Es muy importante afinar los roles y involucrar otros socios ►La visión ha sido desarrollado en que trabajan con agua y saneamiento y/o salud infantil. Se una manera muy participativa. vivienda). podría hacer un matriz con todos los roles y responsabilidades ►Las responsabilidades del nivel de salud, educación y vivienda a cada nivel. central y regional están en un claro proceso de descentralización, lo que crea ►Sería muy importante ganar el apoyo del Presidente de la confusión. República, relacionándolo con la contribución a alcanzar los objetivos del Milenio. ►Para revisar la visión y estrategia los líderes gubernamentales tienen poco tiempo para participar, pero las agencias cooperadoras pueden ayudar desarrollar estrategias y métodos a usar en todos niveles. 43 Global Scaling Up Handwashing Project Tipo de Fortalezas Debilidades Recomendaciones institución ►Sería útil revisar los planes de transferencia de los programas a nivel regional y local. ONG ►Existe voluntad política e interés ►Se siente el impacto de la Iniciativa ►Sería bueno que el programa de lavado de manos se por parte de CARE, sobre todo si se Lavado de Manos en el nivel central, desarrolle junto con otro como es ahorro de agua para asegurar internacional vincula al actual proyecto que aunque todavía no es suficientemente su buen uso. maneja con PRONASAR. fuerte (CARE). ►Es bueno aprovechar el contexto que es totalmente ►Falta un soporte comunicacional que favorable: hay inversión de infraestructura, hay indicadores en permita que la Iniciativa sea identificada lavado de manos en proyectos como PRONASAR, vinculado a por todos. un cambio de comportamiento. ►Se requiere mantener informadas a las autoridades locales para mantener la voluntad política. ►Teniendo en cuenta que las municipalidades muchas veces no cuentan con personal capacitado, se debiera realizar sesiones de capacitación, por ejemplo al responsable de la Comisión de Salud, a los equipos que trabajan saneamiento y al equipo de promoción comunitaria. ONG local ►En el nivel operativo se ha visto ►Consolidar la voluntad política en instrumentos operativos, que el compromiso y la voluntad como mejora en la currícula escolar local. son muy importantes (PRISMA). Sector privado ►Se evidencia una voluntad ►El apoyo del Presidente Regional es esencial, pues tiene política muy fuerte dentro de la redes para llegar a los líderes comunitarios. (incluye compañía. Hay el sentido que medios) ►Tener reuniones para asegurar que los socios principales mucha gente está unida en la entiendan y apoyen la misma visión. Iniciativa. ►Prestar atención a los planes políticos, aunque la ►La video conferencia en que implementación sea lo prioritario. participó algunos actores del sector privado ayudó a explicar la visión y estrategia común. ►Fuertes compromisos de líderes en Ica. Una muestra es que el nuevo presidente regional envió una carta a la Iniciativa confirmando su compromiso. Proyecto ►En PAC SEDAPAL existe la ►La falta de lavado de manos es un problema de desarrollo y voluntad política de trabajar el 44 Global Scaling Up Handwashing Project Tipo de Fortalezas Debilidades Recomendaciones institución bilateral tema, que se traduce en la debe ser atacado desde ese enfoque. existencia de este tema en la línea ►La Iniciativa puede tener más éxito y sostenibilidad si está de base. implementada como un programa de desarrollo local, enfocando en un estilo de vida saludable; no como un programa sectorial de salud. ►Se debe trabajar mirando a las Regiones, pero enfocando en los distritos y comunidades. ►Usar las Juntas Vecinales Comunales, ahora formalizadas en la ley de descentralización, como la unidad de implementación local. Alianzas Tipo de Fortalezas Debilidades Recomendaciones institución Gobierno ►El programa Escuelas ►Colaborar con el programa de Vivienda Saludable, un ataque Saludables se plantea contar con integral a agua e higiene, incluyendo cocinas mejoradas. 12,000 escuelas en 2007, por lo ►Generar el compromiso de MINSA es esencial para aspectos que se identifica muchas técnicos y normativos. posibilidades de colaboración. ►Es importante trabajar con “champions� al nivel técnico ►La participación de las porque el nivel político siempre cambia. empresas privadas ha sido muy importante, porque están ►Promover alianzas estratégicas con especialistas de asumiendo un nuevo rol en la PRONASAR para incluir metodología lavado de manos como salud de la población. condición a sus operadores. ►Para fortalecer las alianzas se debiera presentar lo que se ha venido trabajando, como experiencia previa y las lecciones aprendidas para tener una retroalimentación de los socios. Agencia ►La generación de alianzas se ha ►Todavía se depende demasiado del ►La Iniciativa debe identificar un actor comprometido que internacional dado de manera intuitiva, equipo nacional. asuma la formación de la iniciativa regional, o en todo caso una lográndose el involucramiento de institución local que lo asuma. Alguien debe apoyar, teniendo en ►Los frecuentes cambios de personal en el actores. cuenta que usualmente las personas ya están trabajando a tiempo sector público generan retrasos en la completo. ►Existía alguna confusión en las marcha del proceso o hace que sea más relaciones de agencias públicas y lenta. ►Desarrollar guías con los pasos para trabajar la iniciativa a privadas. El sector público está 45 Global Scaling Up Handwashing Project acostumbrado a tomar dirección, ►El problema era que muchas de las nivel regional, como alianza público privada. pero son los otros socios que contribuciones han sido muy puntuales, ►Para el nuevo programa se debiera pensar en alianzas como en tienen los fondos. solamente para una campaña corta, y federaciones en que la nacional involucra a las regionales, pero muchas organizaciones no mantuvieron su ►Es una excelente modelo, muy éstas también son autónomas. participación activa. flexible. ►Se debe ordenar el uso de herramientas para formar alianzas ►Es importante notar qua hay varios tipos ►La iniciativa es �un éxito� que de este tipo. de socios que juegan varios roles. Algunos muestra un esfuerzo unificado solamente hacen su contribución puntual ►Para la segunda fase la exploración de los actores para la para el desarrollo. en coordinación con la Alianza. alianza podría ser algo planificada. ►En el MINSA se identificó ►El MINSA no se siente cómodo con las ►El paso mas importante es demostrar el impacto de la mucho entusiasmo; ha tomado relaciones informales. Iniciativa en diarrea y desnutrición; los socios necesitan esto para algún liderazgo pero aún no es mantenerse motivados. suficiente. ►La comunicación con algunos socios ha sido difícil. As veces la Iniciativa tenía ►Muchísimas organizaciones puede compartir la meta de niños que continuar llamando a MINSA para sanos y hacer varios tipos de contribuciones. recibir una respuesta. ►Existe más potencial en socios del sector privado que les ►La Iniciativa no ha involucrado los interesan en contribuciones sociales, por ejemplo compañías ministerios de Educación y Vivienda mineras. suficientemente. ►Teniendo en cuenta el marco de la descentralización, es muy importante involucrar los gobiernos regionales – promover LM en sus planes de desarrollo, de salud, de educación. Así se puede ganar más aporte de los medios. ►Trabajar con Escuelas Saludables. ►Se debería involucrar a los líderes comunitarios, quienes tienen “total credibilidad.� ►Las Juntas Administradoras de Agua y Saneamiento (JAAS) seria una buena estructura a involucrar. ►Los líderes al nivel nacional y regional estarían interesados en saber como lavado de manos contribuye a las metas de Desarrollo del Milenio. ►Para mantener las alianzas hay que monitorear y evaluar mejor. También los socios tienen que entender que el cambio de comportamiento lleva tiempo y tiene que ser mantenido. ►Es importante vincularlo con programas que mejoran acceso a agua. ►Usar una figura famosa como portavoz en radio y televisión. ►Es necesario vincular el tema con salud, nutrición, capital 46 Global Scaling Up Handwashing Project humano, infecciones respiratorias. ►Al nivel regional, es esencial identificar “champions�, pues crear propiedad es crítico para firmar compromisos; planear juntos y capacitar. ►La Iniciativa debe dejar que espacio para que cada región desarrolle sus propios métodos. ►Es necesario identificar socios regionales y locales que ya tengan sus programas que llegan directamente al público. ►La Iniciativa tiene que comunicarse mejor con sus miembros, tanto como con el público, por ejemplo una página Web interactiva, estado de ejecución, indicadores de progreso, historias de éxito, lecciones aprendidas, entre otras. ►Además de tener un impacto en diarrea e infecciones respiratorias, considerar que tiene un impacto en desnutrición crónica. Eso puede implicar mirar otros aliados. ONG ►Colaborar estrechamente con Agua Para Todos, que ya tiene buenos indicadores, incluyendo la práctica de LM, que la internacional Iniciativa puede compartir. ►Los ministerios tienen que tener voluntad de compartir el crédito. ►Todas las organizaciones tienen que sentir que la Iniciativa es de ellas. ONG local ►El rol y responsabilidad de los ►No se identificó al Ministerio de la ►La búsqueda de alianzas debiera ser un poco más sistemática. miembros de la Iniciativa es muy Mujer y el Desarrollo Social (MIMDES), ►La Mesa de Concertación de Lucha contra la Pobreza puede clara. con el Programa Juntos, que tiene una ser en algunos lugares una plataforma para la construcción de la intervención en 210 distritos, cuyo objetivo ►Las alianzas son difíciles pero Iniciativa de Lavado de Manos. es disminuir la desnutrición crónica, siendo son importantes para la lavado de manos un componente. ►Sería importante trabajar con el MIMDES [otras personas sostenibilidad. dicen que no, porque ha sido demasiado politizado]. ►Se puso de relieve el asocio, pero todavía es muy nuevo para las Regiones. ►Identificar una estrategia que oriente la decisión de trabajar en alianzas hacia algo más corporativo que de personas. Sector ►PROICA ya es una alianza de 4 ►La alianza en ICA no incluye a ONGs, ►Hacer contacto con las muchas organizaciones que ya tienen privado empresas y trabaja en alianza con pero PROICA misma se convierte en programas dirigidos a niños, diarrea, desnutrición. varios gobiernos locales. ONG. Quieren hacer alianzas con medios ►Hacer más alianzas con compañías privadas y ONGs. masivos locales. ►Ha sido una experiencia muy 47 Global Scaling Up Handwashing Project interesante pues ha permitido la ►Fortalecer los equipos de trabajo en Ica (PROICA y otros participación del sector público y socios) para hacer mejor seguimiento; formar una comisión sobre privado desde su propio aporte, Lavado de manos. sin condicionar la participación. ►Ganar el apoyo del MINSA es esencial, aunque las autoridades ►PERUTV ha estado cambian frecuentemente. acostumbrado a apoyar y ►Existe un espacio que la Iniciativa debiera buscar vinculado a participar en alianzas con otras los espacios regionales, como la Coordinadora de Presidentes instituciones. Regionales (RPP). ►Así también se podría buscar a la empresa privada agrupada, con el Grupo Empresarios por la Educación que CONFIEP está fomentando y mapeando. Proyecto ►La generación de alianzas locales se hace más fuerte cuando bilateral existe una obra de infraestructura y una distribución de roles muy clara (PAC). Acuerdos institucionales Tipo de Fortalezas Debilidades Recomendaciones institución Gobierno ►La Dirección Nacional de ►A partir de los lineamientos de ►Los acuerdos locales deben partir del análisis de los Planes Educación Comunitaria y Promoción de Salud se utilizan las láminas Regionales de Salud o de las prioridades identificadas por el Ambiental está abierta a realizar de salud e higiene, que responde también a Consejo Regional de Salud (municipalidad Piura). una directiva que describe su la incidencia de la Iniciativa, pero lo ►Establecer acuerdos formales con Ministerio de Vivienda y los colaboración con la Iniciativa. utilizan sin criterio de uso (lo usan también programas de agua y saneamiento, vinculándolo a la Iniciativa de en escuelas que no cuentan con servicio de Lavado de Manos. agua y desagüe). ►Trabajar acuerdos con municipalidades para que prioricen ►No se ha informado a las instituciones de agua y saneamiento en escuelas (PROMSA Arequipa). lo logrado, para lograr reiterar los acuerdos. ►Evaluar si el Comité Regional Multisectorial podría ser la instancia de apoyo a la Iniciativa en la Región Arequipa. ►El MINSA está pensando en comités descentralizados por Regiones o Macro Regiones, que tengan autonomía y legitimidad. ►En el Comité Nacional también debiera participar el sector privado. Agencia ►Se ha manejado bien. No ha ►Con excepción del sector público, los ►Podría trabajarse un mapa de relaciones más visual que internacional sido tan formal y ha permitido que socios trajeron sus propios recursos. establezca dónde está ubicado cada actor en el sistema y qué 48 Global Scaling Up Handwashing Project los procesos sean más fluidos. ►Existió confusión durante el proceso produce cada alianza. porque el MINSA insistió en acuerdos más ►Hay capacidad de adaptación a ►Con el Cuerpo de Paz se llegó a acuerdo y ahora debería formales. las necesidades de cada firmarse. institución. Si se necesita más ►Aunque muchos gobiernos regionales ►Para mantener el entusiasmo hay que medir y divulgar los formalidad (DISAS, tienen fondos, no saben bien como resultados, de modo que la gente puedan tener confianza que sus municipalidades) se ha trabajado gastarlos eficientemente (el gobierno ha esfuerzos hacen una diferencia. en ese sentido. gastado 12% de sus asignaciones este año). ►Es importante tener un compromiso institucional escrito, ►Al nivel local, fueron acuerdos ►En muchos casos la participación activa especialmente para socios donde el personal cambia tácitos y funcionaron bien sin muy de una institución no es tanto por las metas frecuentemente. ayuda de fuera. de la institución, sino por el interés fuerte de una o dos personas de influencia (factor ►Establecer comités regionales que pueden coordinar lavado de ►Ha sido un enfoque desde el clave es mas personalista). manos en su región y también dirigirse a otras iniciativas a largo inicio. Por eso la Iniciativa no es plazo. percibida como programa del BM ►Faltaría involucrar educación y vivienda sino como una iniciativa del Perú. al nivel nacional. ►Hay campo para más involucramiento de empresas privadas en las regiones y de ONGs. ►La nueva administración ►Los acuerdos institucionales podrían ser gubernamental ha aceptado la más claros. Por ejemplo cuando las ►Construir una plataforma de discusión para compartir Iniciativa, y hay un interés mucho campañas de comunicación comenzaron, lecciones aprendidas sobre agua y saneamiento, así como más fuerte del MINEDU. varias organizaciones se sintieron celosas promoción de higiene. que no eran parte. ►Más socios tienen interés en mejorar la calidad de vida de familias pobres, algunas específicamente en reducir la diarrea. ►El MINSA ha tenido una participación adecuada. ONG ►Los acuerdos nacionales no son importantes si las alianzas no funcionan al nivel local. internacional ONG Local ►Se necesitan procedimientos claros, un paso por paso. ►Aprovechar el potencial que tienen los convenios salud- educación regional. ►Para la siguiente fase promover acuerdos con una serie de instancias como Consejo Nacional de Salud, FOROSALUD, donde se identifiquen a colectivos que trabajan por salud. ►Se recomienda que los acuerdos con las municipalidades sean independientes, de manera que le dé valoración al acuerdo. ►Tener cuidado con algunas instituciones u ONGs locales que participen, porque pueden estar en conflicto con el sector 49 Global Scaling Up Handwashing Project privado. Sector ►En Ica han trabajado bien ►En Ica cree importante para sostenibilidad formalizar los Privado informalmente. compromisos de varias unidades gubernamentales. ►Sería útil orientar a los funcionarios claves sobre sus roles y funciones en relación a lavado de manos. Proyecto ►Las organizaciones no ►Las alianzas son necesarias e ►Formar alianzas más amplias en el nivel nacional, regional y bilateral gubernamentales hacen lo que importantes pero los socios tienen que distrital. Cada socio nacional puede involucrar sus redes locales. prometen. contribuir más que palabras lindas. ►Hacer todo lo posible para que los Presidentes Regionales ►Todavía las autoridades regionales faltan asuman su responsabilidad hacia lavado de manos y otros un buen entendimiento de la importancia aspectos de una vida saludable. de lavado de manos. ►Participar en un gran esfuerzo nacional de mejorar el estilo de vida de familias. Metodología del programa Tipo de Fortalezas Debilidades Recomendaciones Respond. Gobierno ►El MINSA considera que los ►Se sintió que algunas actividades se ►Es importante trabajar el nivel regional desde un principio, productos de la Iniciativa fueron trabajaron en función a la demanda. desde la sensibilización, para que en las regiones se sientan “parte buenos, pero siempre de�. considerando el aspecto de ►Sugiere que se realicen diagnósticos participativos locales, distribución. vinculando a desarrollo humano, calidad de vida. Poner en evidencia que esta Iniciativa contribuye a la nutrición infantil, a la descentralización y a tener familias saludables. ►No es recomendable promover lavado de manos donde mucha gente no tiene buen acceso a agua. El impacto será limitado en estas áreas. ►Se debiera contar con un ejército de supervisores que aseguren que las actividades se realicen para que salud y educación lo hagan. Es al principio, luego ya se convierte en una práctica. ►Incentivar a la gente con visitas o viajes de intercambio de experiencias. ►Evaluar la experiencia PRONASAR en el área rural: es más fácil promover la práctica en la costa que en zonas más arriba de 50 Global Scaling Up Handwashing Project los 3,500 msnm, debido al clima. Hay que pensar en tecnologías alternativas que faciliten subir la temperatura del agua. ►Sugiere trabajar con los actores locales claves y público objetivo, más que a los socios. Agencia ►Funcionó bien, aunque un poco ►Faltó articulación entre la difusión ►Estandarizar más la metodología con procesos y productos más internacional lento. masiva y el enganche con las acciones estandarizados. Que exista un menú de posibles actividades que interpersonales. facilite la decisión de los nuevos aliados y su inclusión en una ►En general los comités matriz de monitoreo. funcionaron muy bien; ganaron varios tipos de pericia y muchos ►Se requiere considerar equipos de trabajo descentralizados para contactos de valor. Los miembros el programa. aprendieron uno del otro. ►Medios masivos pueden ser más agresivos en ofrecer tiempo en ►La metodología ha funcionado radio y televisión. bien. ►La comunicación interpersonal debiera estar unida a iniciativas y herramientas existentes, por ejemplo, Municipios Saludables, Escuelas Saludables. ►Una estrategia importante es capacitación de líderes locales como alcaldes porque la población sigue sus consejos. Los niños también pueden ser agentes de cambio efectivos. ►Se necesita una fase de sensibilización en todas las regiones nuevas. Hay que sentarse con los directores de salud y mostrar cifras sobre como pueden reducir la diarrea. Posiblemente preparar un video o documento con testimonios de líderes de las regiones ya trabajadas. ►Los fondos de Gates deben ir a los operadores las agencias ejecutoras, incluyendo la encargada de monitoreo y evaluación, no al MINSA y los socios. ►Se debiera dar más énfasis en comunicación interpersonal; diseñar otras actividades para fortalecer actividades interpersonales. ►Todos los socios principales tienen que tener la oportunidad de entender, hacer sugerencias y aceptar la metodología para la nueva fase. ►Las actividades han sido muy puntuales. Se necesita una revisión estratégica de la Iniciativa para pensar más al largo plazo y en términos de institucionalización. ONG ►Aborda bien los aspectos ►Se necesita ajustar las expectativas para áreas con diferencias en básicos y tiene una manera simple 51 Global Scaling Up Handwashing Project internacional de hacer entender los mensajes, lo altura, temperatura, cultura. que lo hace muy replicable. ►Se necesita hacer más visible el tema con espacios en televisión. ►Para obtener apoyo y participación gratuita de otras instituciones, es necesario identificar sus prioridades y engancharlas a lavado de manos. Por ejemplo Cáritas Piura lo enganchó con su eje ahorro del agua. ►En zonas donde no hay facilitad de contar con agua, se puede trabajar adicionalmente el uso que se puede dar al agua jabonosa después de lavarse las manos, como echarla al suelo para que no levante polvo. ONG Local ►Los incentivos que podrían apoyar la implementación del programa son: costo reuniones de sensibilización, certificación oficial para operadores coordinando con educación y salud, logos institucionales en los materiales y premiación a los actores que han logrado mejores resultados. ►En las comunidades identificar al líder, que muchas veces es el médico, para que ejecute la práctica con las mismas personas. La práctica misma con ellos les genera una sensación de autoestima. (Labor de Arequipa). Sector ►Muy participativa y motivadora. ►Se debe dar más apoyo en monitoreo. privado Apropiada para la cultura, pues ►Usar RPP para alcanzar todas partes del programa; es un fuente fue muy visual y verbal. muy confiable y salud y nutrición son de mucha interés popular. ►El éxito de la Iniciativa es que ►También se propone trabajar lo masivo con un mensaje simple y ha logrado cosas concretas: la profundización de contenidos se trabaje desde programas como investigaciones, manuales, consultorios diferentes a diferentes públicos, urbano marginal, actividades en manuales, material otro rural en que se podría poner a hablar a los promotores. audiovisual. ►Para sensibilización se puede abordar desde programas TV como espacio “cabildo abierto� que población puede hacer reclamos y preguntas y el fin de semana va el alcalde a dar respuesta a inquietudes. Proyecto ►Muy buena relaciones ►Los líderes regionales dan apoyo ►Trabajar mucho más por comunicación interpersonal, bilateral informales. verbal pero no lo sigue con acción. especialmente el tipo que estimula a la comunidad a reflejar sobre sus problemas y proponer e implementar soluciones. No depende ►En Ayacucho hubo avances en en medios masivos. conocimiento y actitudes pero poco en prácticas. ►Cada región debe elaborar su propio plan de comunicación y materiales. 52 Global Scaling Up Handwashing Project ►Más allá de los convenios, se necesita buena voluntad. ►Dar más responsabilidad de planificar e implementar a las organizaciones y estructuras locales. Trabajar mucho más con los gobiernos distritales, que tienen mayor contacto con familias. ►Combinar la promoción de lavado de manos con programas que mejoran la infraestructura de agua y saneamiento. ►El público tiene más confianza en las organizaciones que dan promoción porque ya han ayudado con infraestructura. ►Trabajar con los niños, que tienen entusiasmo y que son más abiertos a cambiar. Usar música, drama, y otras tradiciones para crear interés. Capacidad de ejecución Tipo de Fortalezas Debilidades Recomendaciones Respond. Gobierno ►El Ministerio de Vivienda a ►Hubiera sido necesario más acciones ►Considerar a los operadores de PRONASAR como posibles través de sus programas de supervisión y monitoreo. aliados en los comités regionales o distritales. PRONASAR en zonas rurales y ►Es bueno que para esta segunda fase se contemple medición de pequeñas ciudades tiene impacto, además de resultados. asegurado fondos hasta el 2008 y se está planificando la convocatoria para el siguiente año. ►Desde el MINSA se identifica que hubo capacidad de ejecutar las acciones de la Iniciativa, lográndose elaborar materiales y productos comunicacionales, talleres realizados y personal capacitado. Agencia ►El MINSA es muy jerárquico, pues el ►Es necesario trabajar en el nivel local, pero tiene una tremenda internacional personal necesita órdenes de arriba antes necesidad de fortalecer sus capacidades y por ellos quizás sea de actuar. necesario empezar por ahí. ►Falta confirmar que todos los actores ►La estrategia es identificar y contratar varias organizaciones que estén integrando sus actividades. pueden, cada una, manejar la implementación en 3 a 5 regiones. ►Todavía no se ha logrado que los ►El aspecto clave es mantener el entusiasmo de los socios; con gobiernos regionales publiquen las eso van a proveer los fondos y otros recursos como el tiempo de 53 Global Scaling Up Handwashing Project ordenanzas sobre lavado de manos. Esto sus profesionales. es un decreto sobre la Iniciativa que se ►Es posible que tiene que adecuarse al ritmo del sector público necesita para tener fondos dirigidos a (más lento). lavado manos en el presupuesto regional. ►Las capacidades existen pero la Iniciativa no ha aprovechado de muchos oportunidades de involucrar lavado de manos en los planes de trabajo de varios programas. No ganara mucha atención en agencias gubernamentales como una cosa extra. ONG ►Es interesante evaluar la capacidad de convocatoria que puede tener una institución, más allá de la firma de un contrato. Algunas, internacional tal como Cáritas, pueden movilizar líderes catequistas. ONG local ►Existió capacidad de la ►La vinculación de quienes operan con ►Enfatizar el programa en el nivel regional y local, más que en el institución para diseñar las las alianzas regionales fue muy básica. nacional. Este último puede estar vinculado o muy cercano al estrategias, metodologías y aspecto político. aplicarlas. ►Además de la alianza público privada que orienta este trabajo, se deberían identificar grupos de soporte o especializados que apoyen las actividades y le den sostenibilidad (PRISMA). ►La vinculación del MINSA debe estar comprometido más allá de Promoción de la Salud, para lograr como las campañas de vacunación en que se dedican a eso por uno o dos meses. Sector privado Proyecto ►Si el programa se ejecuta en Lima, se puede trabajar en bilateral colaboración con los consorcios ya formados por PAC Sedapal. 54 Global Scaling Up Handwashing Project Disponibilidad de productos y herramientas Tipo de Fortalezas Debilidades Recomendaciones Respond. Gobierno ►Se está evaluando la propuesta ►Los promotores muchas veces se ►Promover la participación de promotores de salud con la técnica de acercar una zona de cansan de apoyar porque no reciben entrega de incentivos como chalecos, materiales y gorros. lavado a las letrinas que incentivos. (PROMSA Arequipa) ►En proyectos que consideren infraestructura, acercar la zona de PRONASAR promovería. ►La disponibilidad de zonas de lavado y lavado y no sólo el jabón a la letrina y otro a la cocina para ►El jabón no constituye un de agua sí puede constituir un problema facilitar la adopción de la práctica. problema ni en las zonas rurales, para la promoción de la práctica. pues siempre existe. Agencia ►Mas de 90% de las familias se ►Alrededor de 1/3 de familias no tiene ►Se puede solicitar donaciones de jabón de los hoteles en las internacional disponen de jabón que puede ser fácil acceso al agua. ciudades más grandes para ser donados a las familias más pobres. usado para lavado de manos. ►Se puede promover que las familias con difícil acceso preparen ►Pfizer ha donado jabón a los y usen Tippy Taps para poder lavar las manos con poca agua. Voluntarios de Cuerpos de Paz. ►Desarrollar estrategias distintas para costa, sierra, selva, así como manuales sobre lavado de manos para profesionales de salud. ONG ►Se requiere elementos de monitoreo que facilite a las instituciones que apoyan cómo medir las capacitaciones internacional efectuadas y su calidad (Cáritas Piura). ONG ►Para el nuevo programa se debiera asegurar la entrega de materiales con la ejecución de las actividades de comunicación y local fortalecimiento de capacidades. Sector ►Usar más radio y menos material impreso. privado ►Se necesita agregar nuevas mensajes e información para mantener el cambio de comportamiento y facilitarlo donde existan barreras. Por ejemplo, estrategias cuando falta agua. ►Se necesita adaptar los materiales para la región (idioma e imágenes). ►No debe ser una barrera si la gente usa su creatividad; como vincular lavado de manos con temas como agua segura y abastecimiento de agua. Proyecto bilateral 55 Global Scaling Up Handwashing Project Financiamiento Tipo de Fortalezas Debilidades Recomendaciones Respond. Gobierno ►FONDAM tiene 4 tipos de ►El MINSA considera que la fuerza está en los gobiernos financiamiento para programas regionales, con el proceso de descentralización, pues ahora como lavado de manos: disponen de fondos y debieran priorizar este tema. concursos, co-financiamiento, ►Explorar mayor financiamiento para este programa. proyectos especiales (chicos), y proyectos de desarrollo ►Identificar el financiamiento de proyectos de agua y innovadores. Tienen sus saneamiento para poder vincularlos. prioridades geográficas y técnicas. Agencia ►Aún cuando tiene los fondos las ►Más fondos deben estar disponibles del sector privado y de internacional entidades gubernamentales tienen que agencias internacionales como UNICEF y SAVE que trabajan a pasar por procesos burocráticos pesados favor de los niños. para gastarlos. ►USAID tiene un programa de donaciones pequeñas (small grants) que puede apoyar proyectos comunitarios con hasta $2,000. ►Debe existir suficientes fondos en los gobiernos regionales donde reciben canon del las empresas mineras. Para las otras regiones seria bueno hacer abogacía con el Presidente Regional para disponer de algunos recursos. ONG internacional ONG local ►Para que haya decisión de apoyar inclusive financieramente se requiere entrar por la nueva Gerencia Regional de Educación, que está muy cercana a orientar la voluntad política del gobierno regional. (Labor) ►Cuando el proyecto se presente a la Región se debe solicitar que sea un proyecto especial y que tenga autonomía en el manejo presupuestal, organizacional e institucional. Sector privado Proyecto 56 Global Scaling Up Handwashing Project bilateral Costo eficiencia de la ejecución Tipo de Fortalezas Debilidades Recomendaciones Respond. Gobierno Agencia ►El proceso ha sido bien ►Es la responsabilidad del equipo de monitoreo y evaluación. internacional documentado en términos de costos e impacto; pero no específicamente en términos de costo-efectividad de varias actividades, materiales, etc. ONG internacional ONG Local Sector privado Proyecto bilateral Monitoreo Tipo de Fortalezas Debilidades Recomendaciones Respond. Gobierno ►Escuelas Saludables ha ►Es importante que esté desarrollada desde el diseño del desarrollado una tabla de proyecto, con instrumentos precisos y presentados a los socios. indicadores que está en el proceso de aprobación final. 57 Global Scaling Up Handwashing Project Agencia ►La línea de base y su repetición ►Muchas actividades no han sido ►Promover el monitoreo y la evaluación de las actividades, internacional fueron bien hechos, lo que evaluadas. capacitando a los socios en este aspecto y dotando de constituye un aspecto herramientas simples de monitoreo. ►Ha sido un poco ausente pero ha sobresaliente del programa. mejorado recientemente. ►Usar indicadores más sensibles, simplificar los instrumentos, ►PRISMA realizo informes no recoger tantos datos y hacer más observaciones. periódicos; los socios monitorean ►Publicar la evaluación. sus actividades; las instituciones que replican talleres envían ►Hay que preparar un plan de monitoreo que explique bien su informes (RPP, CARE, etc.) relación con la evaluación de impacto. Hay que incluir requerimientos de informes en los contratos con agencias implementadotes. ►Se necesita mayor monitoreo y medición de resultados. ONG ►Debiera promoverse la participación de la población a través de un monitoreo participativo muy visual que permita medir las internacional condiciones generales y las críticas. La escuela debiera ser un espacio de medición necesario. ONG local Sector privado ►No se ha realizado monitoreo ►El proceso de revisión de indicadores de monitoreo y de las actividades de Belcorp. evaluación podría ser elaborado y/o revisado conjuntamente (RPP). ►Los resultados del monitoreo y evaluación deben ser trabajados y compartidos con todos los socios de la Iniciativa. Proyecto bilateral 58 Global Scaling Up Handwashing Project Factores más importantes para las condiciones de éxito GOBIERNO La construcción conjunta de la propuesta facilitaría que los actores nacionales y regionales se apropien de la propuesta, poniendo en evidencia que son parte del problema y de la respuesta. Asegurar que las zonas de lavado como infraestructura existan o se promueva su construcción para facilitar la práctica. Revisar las condiciones de lavado en zonas de altura, mayor a 3,500 msnm Tener en evaluación que cuando existe caño facilita más la práctica, que entregando lavatorios y jarras. PROGRAMA INTER-GUBERNAMENTAL Focalizar; asegurar que las áreas del programa tiene acceso a agua. Antes de implementar, dar la oportunidad para los beneficiaros explicar sus vidas, esperanzas, deseos. Ajustar los productos o servicios para responder; usar radio local, teatro popular, títeres para los niños, no TV. Emitir en horas para el lugar (5/6 a.m. en el campo) con productos adecuados a los padrones culturales de cada región. AGENCIA INTERNACIONAL Mejor definición de una estrategia que coloca lavado de manos dentro de muchas otras iniciativas relacionado con agua y saneamiento y salud infantil a todos niveles. Planificación participativa en todos niveles. Institucionalizar la promoción de lavado de manos. No tener una intervención aislada—hacer como parte de un paquete de intervenciones para disminuir la diarrea. No se crea hábitos nuevos solamente con campañas—necesita una intervención sostenida. Hacer alianzas a partir de iniciativas existentes; uniéndolo con el interés en disminuir la desnutrición. Monitoreo y evaluación es sumamente importante. La Alianza debe apoyar los socios en esto, dando herramientas y ayuda técnica. Por ello se necesita coordinar mejor la hora de las acciones de muchos socios para que se apoyen mejor una a otra. Realizar un buen esfuerza de crear voluntad política; difusión de resultados; usar muchas canales con los mismos mensajes. Incluir el mensaje de poner jabón en todos lugares donde se lavan las manos; usar la repetición de mensajes persona a persona. Se necesita un buen diseño para una ejecución realista. Se necesita una buena comunicación entre los muchos socios, con un comité nacional que trabaja bien y puede resolver problemas. Identificar 3 a 5 organizaciones que puedan manejar la implementación en las regiones. Hacer buenos asesoramientos regionales para identificar los socios, programas y estructuras mejores. Tener flexibilidad ajustar el programa a las realidades en el campo y no tener que seguir la metodología global cuando no funciona bien aquí; no 59 Global Scaling Up Handwashing Project dejar los requerimientos de monitoreo y evaluación condicionen la ejecución. ONG INTERNACIONAL Simplicidad; claridad de roles; mecanismos de reconocimiento; retroalimentación oportuna. Pensar no en una campaña sino en actividades continuas. Se necesita buenas alianzas, financiamiento, recursos humanos, un símbolo unificador. La Iniciativa tiene que general opinión publica favorable. Buscar la relación con las16 mineras que están orientando sus acciones de responsabilidad social, a través de la creación de Fundaciones. ONG LOCAL La alianza público/privada es esencial porque el sector público solo no puede tener los resultados. Trabajar lo más posible al nivel local. Explorar las mesas de concertación como alianzas locales que ya existan. Tener un enfoque más amplio hacia desnutrición y pobreza. SECTOR PRIVADO Proveer evidencia que los cambios de comportamiento están aconteciendo. Trabajar más con comunicación alternativa como pasacalle, teatro, títeres. Hacer una línea de base. Ayudar a todos con monitoreo. PROYECTO BILATERAL La Iniciativa tiene que hacer muchos esfuerzos a crear compromisos y colaboración al nivel regional y distrital por muchos socios de varios sectores. Tiene que ajustar la promoción dependiendo en el acceso a agua que las familias tienen. Juntar promoción de lavado de manos con programas de infraestructura de agua y saneamiento puede ser muy efectivo porque los mejoramientos físicos crean confianza de la población a la organización ejecutora. Source: Summary of the team’s interviews in Peru. 60 Global Scaling Up Handwashing Project APPENDIX D: ENCUESTA SOBRE LAS CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN: 10 RESPUESTAS Nombre de la organización: Fecha Hace cuánto tiempo está involucrado en este programa? __2__Entre 6 meses y un año __2__ entre 1 y 2 años ___5__ Más de 1 año Cuál es su papel en su organización? __5_ tomador de decisiones ___3_ejecutor __3__supervisor/gerente ____3_________ otro A qué nivel se ha vinculado con el programa? __1_ nacional __3_regional ___3_ provincial __6__ distrital __4_ local _____1________ otro Instrucciones: Maque con "X" el numero que mejor refleja su respuesta a cada pregunta o frase. I. POL�TICA, ESTRATEGIA, Y DIRECCIÓN Se necesita Excelente mejorar en esta La iniciativa de lavado de manos, incluyendo el programa: mucho área 1 0 1 1 6 2 Tiene una meta y objetivos claros y entendibles en todos 61 Global Scaling Up Handwashing Project los niveles 2 Ha establecido un visión y estrategia compartidas 0 0 3 7 0 3 Establece hitos y alianzas que apoyan sus objetivos 0 1 1 4 4 4 Ha trabajado en pro de establecer políticas favorables 0 1 2 5 2 5 Tiene un plan completo formulado 0 0 3 5 2 Tiene miembros que entienden su estrategia de larzo 6 plazo 0 1 0 7 2 7 Tiene un plan formulado para guiar sus esfuerzos. 0 0 3 5 2 Tiene políticas y procedimientos que hace posible 8 cambiar la manera cómo se hacían las cosas 0 1 2 4 3 9 Tiene una visión que es comprendida en todos los niveles 0 0 4 5 1 Se destacan los esfuerzos exitosos que pueden ayudar a 10 reforzar la visión 0 1 2 5 2 11 Tiene líneas de autoridad claras 0 1 1 6 2 12 Puede implementar su visión de manera efectiva 0 0 3 4 3 13 Puede llevar su visión a sus miembros y sus comunidades 0 0 2 6 2 II. ALIANZAS Muy Algo Está satisfecho con que el programa, porque … Insatisfecho insatisfecho Neutral Satisfecho satisfecho Tiene la capacidad de ofrecer el apoyo requerido por sus 1 miembros para implementar el programa? 0 1 1 5 3 62 Global Scaling Up Handwashing Project 2 Cuenta con la cooperación y apoyo de sus miembros? 0 1 1 6 2 Tiene amplios contactos que puede motivar a ayudar la 3 iniciativa, p.e. adogados, banqueros, etc.? 0 2 5 0 3 4 Tiene varios contactos fuertes en la empresa privada? 0 3 2 2 3 Tiene varios contactos fuertes con ONGs, grupos 5 sociales? 1 1 1 3 4 Tiene varios contactos fuertes en el sector 6 gubernamental? 0 1 3 2 4 Busca activamente conseguir nuevos contactos en el 7 transcurso del tiempo? 1 0 3 4 2 8 Utiliza sus contactos y relaciones? 1 0 3 3 3 9 Actúa en una manera abierta e inclusiva? 0 1 2 5 2 10 Es eficiente y productivo, enfocado en resultados? 0 1 2 5 2 Se asegura que se disponga de suficientes recursos para 11 que los miembros alcancen sus objetivos? 0 1 1 5 3 12 Brinda suficiente orientación a sus miembros? 0 1 2 5 2 Totalmente En Fuertemente en des- En este programa, acuerdo desacuerdo Neutral De acuerdo de acuerdo La colaboración y el sentido de equipo juegan un papel 13 important en el desarrollo del programa. 0 0 1 4 5 Los miembros están involucrados en encontrar soluciones 14 a los desafios del programa. 0 0 3 4 3 El aprendizaje es parte del trabajo y luego se convierten 15 en tareas de rutina 0 0 3 4 3 63 Global Scaling Up Handwashing Project Se fomenta equipos con representación de varios 16 sectores. 0 0 1 6 3 Los miembros están involucrados en encontrar soluciones 17 a los desafios del programa. 0 0 2 5 2 18 Se comparte el crédito del éxito 0 0 2 3 5 19 Los socios se benefican con la colaboración. 0 0 1 5 4 III. ACUERDOS INSTITUCIONALES Totalmente en En Fuertemente El programa: desacuerdo desacuerdo Neutral De acuerdo de acuerdo Incluye la retroalimentación de los clientes en la 1 generación de nuevas ideas 0 1 2 5 2 Continuamente busca entender las necesidades de sus 2 miembros con encuestas y entrevistas. 0 1 2 5 2 Fomenta que todos los miembros propongan soluciones a 3 problemas. 0 0 3 6 1 tiene disponible información presupuestario actual para 4 avaluar gastos del proyecto. 0 1 4 2 3 Tiene la costumbre de proveer las herramientas/recusos 5 necesarios para apoyar iniciativas. 0 0 2 5 3 6 Tiene la costumbre de comunicarse con todos los niveles. 0 2 2 3 3 7 tiene una historica de identificar y resolver problemas. 0 1 4 5 0 Sigue un proceso claro de toma de decisiones para nuevas 8 iniciativas. 0 1 2 6 1 64 Global Scaling Up Handwashing Project 9 Tiene las personas apropiadas a cada cargo y tarea. 0 0 3 6 1 IV. CAPACIDAD DE IMPLEMENTACIÓN A. Tecnología Se necesita Excelente El programa: Mejorar mucho en esta área Usa technología para mejorar la eficiencia de sus 1 actividades 0 1 3 4 2 Cuenta con un conjunto de tecnología informática para 2 sus necesidades, ej. Base de datos, programas, etc. 0 1 4 3 2 Entiende la importancia de la tecnología informática como una herramiento estrategica y para mejorar el 3 programa 0 0 4 3 3 Se necesita Excelente B. Capacitación mejorar en esta El programa: mucho área 4 Apoya la capacitación de sus miembros. 0 0 0 6 4 5 Brinda oportunidades a asistir capacitaciones. 0 0 3 3 4 Se necesita Excelente C. Destrezas/Capacidades mejorar en esta El programa: mucho área Realiza una evaluación de destrezas como parte del 6 proceso de planificación. 0 1 5 4 0 65 Global Scaling Up Handwashing Project Tiene suficientes recursos dedicados a proveer 7 oportunidades regulares para desarrollar destrezas. 0 2 2 5 1 Puede contratar a pesonas con las destrezas que se 8 necesitan. 0 3 1 4 2 Es capaz de desarrollar las destrezas necesarias en sus 9 miembros actuales. 0 1 2 5 1 Provee a los miembros con habilidades y recursos para 10 que logren sus resultados 0 0 2 6 1 V. MONITOREO Se necesita Ya excelente mejorar en esta Este programa: mucho área Se esfuerza continuamente a avaluar las necesidades de los beneficiarios a través de encuestas cortas y 1 entrevistas. 0 1 4 4 0 Ha desarrollado métodos para recoger y usar 2 retroalimentación sobre las actividades del programa. 0 1 3 5 0 Tiene un plan y método para recoger lecciones claves y 3 divulgarlas a sus miembros y otras personas interesadas de manera continua 0 1 4 3 1 Tiene actividades que estado conectadas a los esfuerzos 4 por capturar lecciones. 0 2 3 3 0 5 Hace seguimiento de los resultados 0 2 1 3 3 Determina lo que cada unidad operativa contribuye al 6 valor del programa 66 Global Scaling Up Handwashing Project y lo comunica a los miembros. 1 1 2 5 0 Utliza las redes de las empresas para informar y divulgar 7 los resultados logrados 1 2 3 2 1 8 Revista sus metas cada año y espera ver mejoras cada año 0 1 3 4 1 Tiene un sistema de información que está alimentado por 9 los resulados en los beneficiarios 0 2 3 2 2 Mide la satisfacción de los beneficiarios al menos 10 trimestralmente 1 1 3 4 0 Adapta los servicios y actividades a la retroalimentación 11 de los beneficiarios 2 1 1 5 0 Ha establecido indicadores para medir la satisfacción de 12 los beneficiarios 1 1 3 3 1 13 Vincula sus procesos internos al impacto programático 1 1 3 4 0 Desarrolla métodos simples de recolección de 14 información para uso de los beneficiarios 1 1 2 5 0 15 Tiene un plan comprensible de monitoreo y evaluación 1 1 3 3 1 Se necesita Ya excelente mejorar en esta Para lo siguiente, favor indicar si lo tiene. En caso sea positivo, evaluarlo. mucho área Tiene escritas las medidas e indicadores de desempeño 16 del programa. Sí No 4 1 0 0 3 0 Mide el impacto de sus servicios y actividades en sus 17 beneficiarios. Sí No 2 0 0 0 5 0 67 Global Scaling Up Handwashing Project Ha establecido un medidas e indicadores de procesos. Sí 18 No 3 0 0 1 4 0 Ha establecido medidas e indicadores de resultados. Sí 19 No 3 0 0 1 2 2 Ha probado y adaptado herramientas para medir 20 ressultados. Sí No 3 0 0 1 2 1 Ha probado y adaptado herramientas para medir el 21 desempeño del programa. Sí No 4 0 0 1 1 1 Ha probado y adaptado herramientas para medir procesos 22 de implementación. Sí No 3 0 0 1 2 1 Ha probado y adaptado herramientas para medir el 23 impacto del programa. Sí No 5 0 0 1 1 1 68 Global Scaling Up Handwashing Project APPENDIX E: LAS CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN. GU�A DE ENTREVISTA Fecha de la entrevista ____________________________________________________ Nombre del entrevistador _________________________________________________ Nombre del entrevistado __________________________________________________ Cargo __________________________________________________________________ Rol del entrevistado (tomador de decisión, ejecutor, supervisor) ________________________________________________________________________ Tipo de organización (sector público, privado, ONG) __________________________ Alcance de la organización (nacional, varias regiones, regional, distrital, comunal) ________________________________________________________________________ Introducción (5 minutos) Introducción Agradecimiento por el tiempo otorgado Propósito de la entrevista Explicación de la confidencialidad de la entrevista, no se usará el nombre u otro dato de identificación Información de la existencia de preguntas. Apertura (10 minutos) Solicitar información acerca de la importancia de lavado de manos Solicitar información acerca de la institución a la que pertenece, lo que hace en relación a lavado de manos y los planes que tienen respecto a este tema. 69 Global Scaling Up Handwashing Project Nota importante: Aclare si la pregunta se refiere al nivel nacional, regional, o local o a varios niveles. Política, estrategia y dirección (Gobierno, Agencia Int., ONG Int., ONG Local, Sec. Privado, Proj. Bilat.) ►Qué tan sólida ha sido la voluntad política (nacional, regional, local) para promover el lavado de manos? ► Qué sugerencias tendría para mejorarla en un programa a escala ampliada? ►¿En su opinión cuánto ha dispuesto la Iniciativa de una visión y estrategia compartida que asegure la voluntad política? Explique. ►¿Tiene Ud. sugerencias sobre cómo este aspecto podría ser fortalecido en el programa expandido? ►Esta visión y estrategia fue desarrollado de una manera participativa? ►¿Tiene Ud. sugerencias sobre como este aspecto puede ser fortalecido en el programa expandido? Alianzas (Gobierno, Agencia Int., ONG Int., ONG Local, Sec. Privado, CBOs, Media, Proj. Bilat.) ►¿Cuán efectivas han sido las alianzas público privadas al nivel nacional y regional? ►¿Cree Ud. que los miembros de la alianza han tenido metas complementarias y cómo han funcionado? ►¿Cree Ud. que los miembros han compartido los riesgos, el poder, así como los resultados o procesos? 70 Global Scaling Up Handwashing Project ►¿Las alianzas han sido construidas en todos los niveles entre los sectores público, privado y ONGs? ►¿Tiene Ud. sugerencias sobre como estas alianzas pueden ser fortalecido en el programa expandido? 3. Acuerdos institucionales (Gobierno, Agencia Int., ONG Int., ONG Local, CBOs, Media, Proj. Bilat.) ►¿Cree que las instituciones que participan en la Iniciativa de Lavado de Manos en todos los niveles claramente entienden sus roles, responsabilidades y autoridad? ►¿Cree que los socios contaron con los recursos para llevar a cabo sus roles? ►Cree que los socios para un programa a escala ampliada podrían contar con los recursos necesarios? ►¿Tiene Ud. sugerencias sobre cómo se puede disponer de mas recursos para complementar el financiamiento de Gates en el programa a escala ampliada? ►¿Cuán adecuados han sido los acuerdos institucionales en definir los mecanismos o procedimientos para los actores coordinar sus actividades? ►¿Tiene Ud. sugerencias sobre cómo este aspecto puede ser fortalecido en el programa a escala ampliada? Metodología del programa (Gobierno, Agencia Int., ONG Int., ONG Local, CBOs, Media) La metodología del programa consiste en las reglas del programa, actividades específicas y su secuencia y cronograma. 71 Global Scaling Up Handwashing Project ► ¿Qué opina sobre la metodología de trabajo de la Iniciativa? ►¿Tiene Ud. sugerencias sobre cómo mejorar la metodología en el programa a escala ampliada? ►¿Cree Ud. que la metodología ha sido clara y acordada por los socios? ►¿Tiene Ud. sugerencias sobre como tener certeza que la metodología es clara y acordada por los socios en el programa a escala ampliada? Capacidad de ejecución (Gobierno, ONG Int., ONG Local, Sec. Privado, CBOs) En la capacidad institucional se considera aspectos como recursos humanos con las capacidades y habilidades requeridas para ejecutar sus funciones, una estructura organizacional dentro de la institución, un manejo de la metodología acordada, sistemas y procedimientos requeridos para su implementación y la habilidad para monitorear el programa y hacer los ajustes oportunos. ►¿Cree Ud. que al nivel nacional los socios de la Iniciativa han tenido la capacidad institucional para llevar a cabo sus roles y responsabilidades? ►¿Cree Ud. que al nivel regional los socios de la Iniciativa han tenido la capacidad institucional para llevar a cabo sus roles y responsabilidades? ►¿En el programa a escala ampliada, cree Ud. que hay uno o más aspectos de capacidad institucional que se necesita fortalecer en cualquier nivel? ►[Si sí] ¿qué sugerencias tendría al respeto? 6. Disponibilidad de productos y herramientas (ONG Int., ONG Local, Sec. Privado, CBOs) ►¿Cree Ud. que la Iniciativa ha provisto de los productos y herramientas que respondan a las preferencias del público objetivo y su decisión y habilidad para pagar por ellos? 72 Global Scaling Up Handwashing Project ►¿En el programa a escala ampliada, cree Ud. que hay uno o más aspectos de productos apropiados que se necesitará fortalecer en cualquier nivel? ►[Si sí] ¿qué sugerencias tendría al respeto? Financiamiento (Gobierno, ONG Int., CBOs) ►¿Han sido suficientes los acuerdos para el financiamiento de los costos del programa? ►¿Tiene Ud. sugerencias sobre como se puede disponer de mas recursos para complementar el financiamiento de Gates en el programa expandido? Costo eficiencia de la ejecución (Gobierno, ONG Int.) ►¿Los socios han tenido los sistemas y procedimientos para recoger y analizar la información requerida para un análisis de costo eficiencia? ►¿Tiene Ud. sugerencias sobre cómo se puede fortalecer esta capacidad en el programa a escala ampliada? Monitoreo (Gobierno, ONG Int., Sec. Privado, CBOs) Un monitoreo eficiente permite identificar las fortalezas y debilidades en la metodología del programa, su ejecución y costo-eficiencia. ►¿Cómo ha sido el proceso de monitoreo en la Iniciativa? ►¿La responsabilidad ha sido clara? ►¿Tiene Ud. sugerencias sobre cómo se puede fortalecer esta capacidad en el programa a escala ampliada? 73 Global Scaling Up Handwashing Project ►¿Tiene Ud. sugerencias sobre como se puede tener suficiente capacidad de recoger información recogida en el nivel comunitario o distrital? Cierre (5 minutos) ¿Cuál sería el factor más importante que permitiría que el proyecto logre sus objetivos? ¿Cuál sería el aspecto clave que debiera realizarse con el fin de generar las condiciones para que el proyecto tenga éxito y se pueda trabajar a escala ampliada? ¿Hay una o dos otras personas en [la organización] que pudieran responder a unas preguntas sobre el tema por correo electrónico? Ellos pueden hacerlo en 10 a 15 minutos. Podría darme sus direcciones de correo electrónico? Nombre Cargo Correo electrónico Gracias por su tiempo. 74 Global Scaling Up Handwashing Project APPENDIX F: ESTUDIO DE CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN (GU�A DE ENTREVISTA PARA SOCIOS POTENCIALES) Primera versión en español Este cuestionario ha sido creado para ser usado por el equipo del estudio de condiciones para la expansión de lavado de manos con jabón. Fecha de la entrevista ____________________________________________________ Nombre del entrevistador _____________________________________________________ Nombre del entrevistado _____________________________________________________ Cargo ______________________________________________________ Rol del entrevistado (tomador de decisión, ejecutor, supervisor) ______________________________________________________ Tipo de organización (sector público, privado, ONG) ______________________________________________________ Alcance de la organización (nacional, varias regiones, regional, distrital, comunal) ______________________________________________________ Introducción (5 minutos) Introducción Agradecimiento por el tiempo otorgado 75 Global Scaling Up Handwashing Project Propósito de la entrevista Explicación de la confidencialidad de la entrevista, no se usará el nombre u otro dato de identificación Información de la existencia de preguntas. Apertura (10 minutos) Solicitar información acerca de la importancia de lavado de manos Solicitar información acerca de la institución a la que pertenece, lo que hace en relación a lavado de manos y los planes que tienen respecto a este tema. Dimensiones de la entrevista (50 – 60 minutos) Usar el cuestionario anexo. Encuestas (10 -15 minutes) Usar en la medida de las posibilidades de los actores. Política, estrategia y dirección (Gobierno, Agencia Int., ONG Int., ONG Local, Sec. Privado, Proj. Bilat.) ¿Qué tan conscientes están los tomadores de decisión sobre la importancia del lavado de manos con jabón en reducir la diarrea y las infecciones respiratorias agudas? ¿Sabe qué dicen los resultados de los estudios de lavado de manos con jabón? En caso sea así, qué recuerda? (Si no sabe, explíqueselo). ¿En qué medida existe una voluntad política para promover el lavado de manos con jabón (en el nivel apropiado al entrevistado)? ¿Conoce usted algún decreto o política o norma que el gobierno o las organizaciones privadas hayan efectuado para promover lavado de manos en esta región. Si no es así, piensa que estas políticas serían posibles de efectuarse? ¿Su organización ha participado en programas de salud infantil en esta Región? 76 Global Scaling Up Handwashing Project ¿Su organización ha participado en la promoción de lavado de manos en esta región? Si es así, por favor descríbalo y explique qué tan exitoso ha sido. ¿Qué tan importante es la promoción de lavado de manos en su organización, comparado con otras iniciativas de salud? Si varias organizaciones se reunirían en una iniciativa de promoción de lavado de manos, ¿quiénes serían los decidores y de quién se requeriría apoyo? Agradeceríamos nos indique qué organizaciones, individuos o agencias podrían actuar como catalizadores o líderes de la promoción de lavado de manos en la región. Voy a mencionar varios tipos de organizaciones. Para cada tipo, mencione cuáles piensa podrían ser las más interesadas y con recursos para contribuir a la promoción de lavado de manos. Actividades o contribución Tipo de recurso que podría dar en financiera actual a lavado de apoyo a la iniciativa manos Sector público ONGs Sector privado 77 Global Scaling Up Handwashing Project Actividades o contribución Tipo de recurso que podría dar en financiera actual a lavado de apoyo a la iniciativa manos Medios de comunicación Otros proyectos de agua y salud Organizaciones de base Alianzas (Gobierno, Agencia Int., ONG Int., ONG local, Sector privado, medios de comunicación, proyectos bilaterales). ¿Existen diferentes tipos de organización en la Región que estén interesados y tengan las capacidades para trabajar como socios en programas que beneficien a las madres y los niños? Dé ejemplos. 78 Global Scaling Up Handwashing Project ¿Cómo describiría la calidad de las alianzas entre los gobiernos locales y las ONGs? ¿Cómo podría mejorarse? ¿En qué medida los roles, responsabilidades y expectativas están claras y acordadas en estas alianzas? ¿Cómo describiría las relaciones que se establecen entre las ONGs y las comunidades en que trabajan? ¿Cómo podrían mejorarse? ¿Qué alianzas en esta Región supo utilizar el potencial de las alianzas estratégicas entre el sector público, privado, las ONGs y las organizaciones en el nivel local y nacional? Si es así, ¿cómo se llegó a realizar? ¿Qué necesitaría ser explorado? Acuerdos institucionales (Gobierno, Agencia internacional, ONG internacional, ONG local, organizaciones de base, medios de comunicación, proyectos bilaterales) ¿Hay ejemplos de alianzas establecidas con objetivos en salud? Si es así, ¿qué tan bien los diferentes grupos trabajaron en…. Planificación Ejecución Capacitación Monitoreo y evaluación? ¿En qué medida los acuerdos estuvieron claramente definidos? ¿Tiene mecanismos establecidos para coordinación entre los socios más importantes? Si es así, ¿cómo están trabajando estos mecanismos? ¿Cómo podrían mejorarse? ¿Tiene idea en cómo establecer o mejorar los mecanismos de coordinación entre las diferentes organizaciones y niveles de ejecución para un programa de lavado de manos a escala ampliada? 79 Global Scaling Up Handwashing Project Capacidad de ejecución (Gobierno, ONG internacional, ONG local, sector privado, organizaciones de base) ¿Qué habilidades, métodos, herramientas y recursos humanos piensa que podría requerirse para ejecutar un programa de lavado de manos en esta Región? ¿Qué recursos ya existen localmente, de manera que pueda apoyar la capacidad requerida? Qué está faltando? Financiero Bienes Humanos Capacitación Tecnología Otro ¿En qué medida existe una adecuada capacidad para planificar y ejecutar promoción de la higiene el sector público? ¿Y entre las ONGs? ¿Entre otros grupos o socios? Por favor describa un programa de promoción de higiene o salud en esta Región que considere exitoso? ¿Qué lo hizo exitoso? ¿Cómo se involucró al sector privado (agencias de publicidad, etc.) en el programa de salud o higiene? 80 Global Scaling Up Handwashing Project Para usar SOLO en caso que se necesite continuar con la entrevista: ¿Hay capacidad desarrollada en el nivel local para abordar la ejecución del programa y monitorear los cambios a nivel de los hogares y comunidad? Si es así, describa. ¿En qué medida existe una adecuada capacidad en el sector privado para otorgar bienes y servicios y responder a las preferencias de los consumidores? ¿Será el sector privado capaz de responder a la demanda creciente en tanto el programa de lavado de manos se desarrolle en gran escala? Disponibilidad de productos y herramientas (ONG internacionales, ONG locales, sector privado, organizaciones de base) ¿En qué medida las siguientes dimensiones de mercadeo de lavado de manos necesitarían ser fortalecidas? Producto: ¿Qué productos que lavado de manos con jabón están disponibles, dónde y cómo? Se consideran productos al jabón, recipientes para almacenar agua, elementos para tener agua segura. ¿En qué medida siente que esos productos ofrecidos responden a la demanda del consumidor? Precio: ¿En qué medida la gente de menores recursos tiene dinero para comprar productos para lavarse las manos con jabón? ¿El costo de los productos corresponden a la capacidad y deseo de pago del público? Ubicación: ¿Qué tan disponibles están los elementos esenciales cerca de las comunidades pobres? ¿Qué cadenas de producción han sido establecidas para responder a la demanda de los hogares? ¿Existen planes en la actualidad que puedan fortalecer las dimensiones de producto, precio y ubicación? 81 Global Scaling Up Handwashing Project ¿En qué medida es común la preparación de jabón en algunas áreas? ¿Existen programas que promuevan el uso de este tipo de jabón para lavado de manos? Financiamiento (Gobierno, ONG internacionales, organizaciones de base) ¿Qué organizaciones posiblemente podrían contribuir al financiamiento de los costos programáticos de implementar un programa de lavado de manos a escala ampliada? (Costos como salario de personal, capacitación, transporte, etc.) ¿En qué medida las actividades de promoción ya están incluidas en los presupuestos regionales, provinciales y distritales? ¿Cómo han contribuido los socios del sector privado a las campañas públicas de salud?, ¿con dinero en efectivo o en servicios? Monitoreo (Gobierno, ONG internacional, sector privado, organizaciones de base) ¿Existen en la actualidad programas en esta región que tengan un buen proceso de monitoreo para medir la efectividad de los programas y sus resultados? Si es así, ¿cómo lo hacen? ¿Qué instituciones del sector público, privado y las ONGs están presentes para conducir varios tipos de estudios (cualitativo, cuantitativo, etc.), y cuál es su capacidad (en términos de habilidades técnicas que podrían están disponibles para lavado de manos con jabón? ¿Qué mejoras técnicas, administrativas o financieras son necesarias para asegurar que los actuales sistemas de monitoreo son adecuados para apoyar un programa a gran escala? ¿Cuáles serían los costos de estas mejoras? ¿Qué incentivos se requieren para lograr el enganche y la diseminación de los resultados de las actividades de monitoreo? ¿Qué podría fortalecer la valoración del monitoreo? 82 Global Scaling Up Handwashing Project APPENDIX G: INFORME DE VIAJE A PIURA Fecha 17 y 18 de mayo del 2007 Realizado por Mike Favin Consultor internacional Doris Alfaro Consultora local Instituciones entrevistadas Giovanna Bisso Gerente de Educación y Cultura Municipalidad de Piura Teodora Miranda Coordinadora de PRONOEI Ana Turves Participante Cuerpos de Paz en Catacaos Omar Palacios Jefe de la Oficina de Población, Salud e Higiene Municipalidad de Piura Dr. Carlos Bayona Sub Director DIRESA Piura Carolina Aguilar Encargada área social CARE Piura Juan Manuel Cendra 83 Global Scaling Up Handwashing Project Secretario General Cáritas Piura Deysi Cheros Presidente Comisión salud, salubridad y saneamiento Municipalidad distrital de Catacaos Eleuteria Cruz Jefa Asuntos comunales y sociales Municipalidad distrital de Catacaos Jenny Portocarrero Relaciones Públicas Sub Región Salud Sullana Principales hallazgos por tipo de institución Sector salud Existe un marcado interés por participar en acciones vinculadas a la Iniciativa de Lavado de Manos. No ha sido evidente un involucramiento directo de la DIRESA con la Iniciativa, aunque sí conoce de la realización de actividades que sí se han realizado en la Región. Existe un nicho interesante a partir de Escuelas Saludables y dentro de las campañas de promoción de la salud en las escuelas. Se puso en evidencia la necesidad de dar incentivos (como capacitación, certificados o movilidad) a los promotores de salud para asegurar la llegada continua a la población. No es difícil asegurar la voluntad política para lavado de manos. El Presidente Regional apoya muchas iniciativas de salud y existen ordenanzas relacionadas a disminuir la desnutrición crónica o a mejorar la gestión del Vaso de Leche. Las autoridades recuerdan mucho la importancia del lavado de manos durante la epidemia del cólera. 84 Global Scaling Up Handwashing Project Sería importante buscar involucramiento con MINED y con el Programa Juntos que trabaja en regiones de extrema pobreza y está apoyando en solventar un profesional en cada establecimiento de salud (54 profesionales), con fondos de la Presidencia de Consejo de Ministros. La elaboración y aprobación del Plan Regional Concertado de Salud constituye una oportunidad para que el tema sea asumido por todas las instituciones de la Región. Están empezando a trabajar este proceso. Gobierno municipal provincial Existe una marcada diferencia entre el involucramiento de la Municipalidad de Piura de la Oficina de Salud, Población y Ambiente, frente a la Gerente de Educación y Cultura. En el primer caso se realizó una capacitación al personal de la municipalidad, pero no se realizó seguimiento posterior. Se señaló que no existiría ningún problema en involucrar al alcalde. Les pareció muy adecuada la dinámica y el enfoque participativo del taller. Se sugirió trabajar una coordinación posterior a través del programa de Municipios Saludables. En el segundo caso, ha sido muy interesante el trabajo en capacitación con los PRONOEI, llegando a 1,273 niños menores 5 años. La metodología fue muy aceptada por las promotoras de los PRONOEI y han trabajado las seis sesiones, aunque señalan que requerirían un refuerzo. Los salones de los PRONOEI tienen sus rincones de aseo instalados. Sugieren que al inicio se considere siempre una sensibilización a las personas que serían las encargadas de realizar el seguimiento. Sugieren que se trabajen campañas agresivas, en que el mensaje llegue por todos lados y de manera muy lúdica, como canciones. Gobierno municipal distrital Trabajó de manera consensuada con las líderes del Vaso de Leche (cada uno entre 30 – 50 miembros), a quienes se les encargó la capacitación, así como el monitoreo en cada grupo y comedor popular. Acostumbran trabajar en alianzas con el sector público y privado en el distrito. 85 Global Scaling Up Handwashing Project Refuerzan la práctica con el lavado de manos antes de comer en los comedores y antes de recibir los alimentos en las reuniones del Vaso de Leche. Han trabajado con incentivos como entrega de ropa a madres. Sugieren que se establezcan fichas y guías para saber cómo hacer un monitoreo más cercano y eficiente. Encuentran que puede ser más interesante trabajar con niños, quienes pueden asumir muchos comportamientos. Agencia internacional A partir de una capacitación de pocas horas se abocó a trabajar con las familias de una comunidad en Catacaos. Funcionó lavado de manos cuando lo vinculó a un proyecto concreto, como de cocinas mejoradas. Para recibir la cocina la familia debía saber los momentos críticos de lavado de manos. Encontró más entusiasmo y posibilidad de trabajar este tema con los niños y las profesoras. Sugeriría capacitar a los que trabajan con población qué aspectos o respuestas dar para motivar más. ONG Internacional La supervisión del proyecto que realizan con PRONASAR muestra que alrededor del 30% de las familias saben los 5 momentos críticos, frente a un 0% inicial, y el 35% aplica la técnica correcta de lavado de manos, a través de la observación (agua a chorro, lavado con jabón, secado con toalla). Se ha podido definir roles y planes de trabajo con los establecimientos de salud y escuelas. Un aspecto a considerar que han sabido mantener a las municipalidades totalmente informadas de los avances. Contar con un equipo de capacitadores pagados por el proyecto facilita la promoción de la práctica en las familias (1 x 300 familias). Se consideró necesario incluir el secado con toalla como un tema adicional (por la existencia de mucho polvo en la zona). Sugieren que los videos sean más cercanos a la realidad socio cultural de las zonas. Indican que debiera trabajarse un material que quede en las familias. 86 Global Scaling Up Handwashing Project Recomienda que primero se fortalezcan las capacidades de las personas que trabajarán lavado de manos con la población. 87 Global Scaling Up Handwashing Project APPENDIX H: CONDICIONES PARA LA PROMOCIÓN DE LAVADO DE MANOS Informe de viaje a Arequipa Fecha 28 y 29 de Mayo del 2007 Realizado por Mike Favin Consultor internacional Doris Alfaro Consultora local Instituciones entrevistadas Germán Robles Especialista Gestión Educativa y Ambiental Dirección Regional Educación Arequipa Sonia Sánchez Gerente Gestión Social Municipalidad de Arequipa Aníbal Díaz Autoridad Regional de Medio Ambiente Gobierno Regional de Arequipa Haydee Rodas Mariela Díaz Lourdes Benavides Zula Carpio Mary Ann Zeballón Promoción de la Salud DIRESA Arequipa Oswaldo Vizcarra Director de Prensa 88 Global Scaling Up Handwashing Project César Portillo Gerente de Producción Jorge Béjar Coordinador Arequipa ONG Labor Oscar Toro Coordinador Arequipa ONG DESCO Martín Cotrina Gerente Cámara de Comercio e Industria de Arequipa Pablo Manrique Secretario General Cáritas Arequipa Resumen El viaje se realizó en un momento clave de la reorganización del gobierno regional y por ende de las instituciones de salud y educación. En el marco de la descentralización, Arequipa es la primera Región que ha decidido eliminar la gerencia de desarrollo social para convertir la DIRESA en Gerencia de Salud y la DREA en Gerencia de Educación. La intención es evitar duplicidades de funciones y áreas y tener más posibilidad de implementar programas, con menos carga burocrática. Un aspecto a considerar es que el 80% de la población de la Región se encuentra en Arequipa, con facilidades de accesibilidad y el 20% restante está en las otras 7 provincias, siendo algunas muy lejanas. Sin embargo, existen comunidades andinas distantes que requieren con urgencia programas de desarrollo social y económico. La recomendación sería que la Iniciativa trabaje en ambos tipos de áreas. En las rurales sería interesante que se enganche a programas u ONG existentes. Respecto al interés por participar en la Iniciativa Lavado de Manos, es muy positiva la reacción de los representantes de las instituciones aunque el conocimiento sobre los beneficios sea todavía 89 Global Scaling Up Handwashing Project muy limitado. Todos creen que la Iniciativa podría ser incluida en actividades existentes como proceso, sin pensar en campaña, lo cual es alentador. Ninguno de los entrevistados pudo brindar un ejemplo de un programa efectivo de cambio de comportamiento en la Región. Un tema de discusión con varios de los entrevistas fue respecto a la existencia de un grupo de coordinación interinstitucional que pudiera asumir la coordinación de lavado de manos. El CIIMSA (Comité inter institucional de mejoramiento de la salud ambiental) es una posibilidad, aunque el liderazgo y la promoción está a cargo de una ONG. Es posible que sea mejor trabajar con un comité liderado por el Gobierno Regional, sobre todo vinculado a las gerencias de salud o educación. Nos indicaron que por norma existen comités multisectoriales regionales, provinciales y distritales, aunque sus intereses son muy generales. Los programas de Cáritas y la actitud empresarial de su director regional causaron buena impresión. En todo caso, se recomienda que la Iniciativa evalúe su participación en esta Región y posiblemente en otras donde tenga programas fuertes. La empresa de televisión regional que está llegando a todo el país vía satélite es Perú TV, quienes señalaron su voluntad de colaborar con un presupuesto razonable. La programación podría estar dirigida a tomadores de decisión, además de involucrar lavado de manos en sus programas existentes. Si bien no se pudo conseguir una entrevista con funcionarios de la minera Cerro Verde, ellos han establecido un contacto vía correo electrónico y se les ha pedido una cita cuando vengan a Lima. Principales hallazgos por tipo de institución Salud Lavado de manos es uno de los temas que forma parte del programa de salud e higiene en Escuelas Saludables, trabajando con 322 en Arequipa. Cuentan con un convenio entre DIRESA y la DREA. Utilizan el juego de láminas que ha elaborado Promoción de Salud desde el nivel central (10 láminas sobre cada uno de los 6 temas), siendo uno de los temas higiene y ambiente, entregándose un juego para cada una de las escuelas. Señalan que el problema es que muchas de las escuelas no cuentan con agua o servicios higiénicos porque dependen de las municipalidades para dotarlos de servicios (este hecho pone en evidencia la necesidad de vincularse con socios que faciliten estos servicios). Cuentan con un Comité Multisectorial Regional (salud, educación, agricultura, vivienda, policía), en que cada institución señala lo que puede trabajar en función a un tema específico, pero no hay cultura de trabajo estableciendo sinergias en las mismas actividades. En las provincias y distritos debieran tener comités similares. 90 Global Scaling Up Handwashing Project En todo Arequipa cuentan con 2,800 promotores, los que necesitan incentivos y materiales para seguir trabajando y evitar la deserción. Los materiales tendrían que servir para su identificación como chaleco, sombrero, material educativo. Sugieren que se trabajen materiales como rotafolio, que se enseñe por televisión y que se promueva el intercambio de experiencias. Educación Abordan las áreas de prevención como violencia, drogas, prácticas de salud incluyendo lavado de manos. Algunas aulas cuentan con rincón de aseo, pero no son muchas. Su programa tiene una hora de tutoría semanal en cada aula y cuenta con un documento oficial que define su trabajo, incluyendo salud corporal y mental. Las asociaciones de padres de familia (APAFA) funcionan bien en algunas escuelas, pero en otras han generado conflicto con las administraciones. Las APAFA funcionan mejor en escuelas privadas. Colaboran bien con la DIRESA en el marco del Programa Escuelas Saludables. Gobierno municipal La Gerencia de Gestión Social se orienta a trabajar con las poblaciones más pobres, especialmente las de zonas urbano marginales y rurales, en áreas como alimentación, capacitación, organización de asociaciones culturales y recreativas. Cuentan con un centro de atención médica en el mercado, pero no desarrolla actividades específicas de promoción de la salud. Identifica que los mejores espacios para hacer acciones de lavado de manos podrían ser los 309 comedores populares que benefician a más de 15,400 beneficiarios. Autoridad Regional de Medio ambiente Consideran que la falta de servicios de agua puede ser una barrera para lavado de manos en áreas rurales y es por ello podría ser que el Programa de Escuelas Saludables se circunscriba a la provincia de Arequipa, donde se ubica al 80% de 1´170,000 personas, de la cual el 50% es urbano marginal. Su oficina podría promover lavado de manos en restaurantes y en la industria alimentaria. Señaló la existencia de un Comité Regional de Salud en que se invitan a instituciones relacionadas, como educación, municipalidades, instituciones de enseñanza médica, Cruz Roja, entre otros. Asimismo, existe un comité equivalente para educación. Sugiere que con el personal de salud se realicen charlas en las salas de espera de los hospitales y se aproveche la movilización de vacunación en su llegada casa a casa para promover lavado de manos. 91 Global Scaling Up Handwashing Project Puso de relieve la necesidad de que se cuenten con fondos para contratar un contingente de supervisores que aseguren que las personas que sean capacitadas cumplan con sus tareas en los hogares. ONGs Las ONG tienen vinculación con los sectores, en función del objetivo del proyecto, aunque no es siempre fácil por la burocracia existente, perdiendo muchas veces su sentido técnico por el político. Se recalcó la necesidad de promover una voluntad política manifiesta desde el gobierno regional, debido a los índices de diarrea en la Región y los gastos que se generan para su tratamiento. Sugirieron orientar el programa hacia las escuelas y los clubes de madres, pues algunos de estos últimos son fuertes. Estiman importante conversar con las empresas mineras, teniendo en cuenta la tendencia a la formación de Fundaciones para derivar fondos para desarrollo social. Medio de comunicación Buscan ser una propuesta alternativa al enfoque nacional de los medios que se emiten desde Lima, priorizando un enfoque regional. Trabajan noticieros, programas de análisis político, de entretenimiento, magazines incluyendo consultorio médicos y de concurso con feedback masivo a través de cartas o teléfono. Cuenta con un programa interesante (Cabildo Abierto) que promueve la participación de la población durante una semana y el fin de semana las autoridades municipales van al programa y responden a las preguntas planteadas por la población. 92 Global Scaling Up Handwashing Project APPENDIX I: SUMMARY OF MAJOR FINDINGS AND RECOMMENDATIONS BY DIMENSION The following table summarizes major findings and recommendations. Readers interested in more detail should also consult Appendix C, which contains all of the recommendations (in Spanish) made by persons interviewed. Although the team agrees with the most of those recommendations, for this document it selected the ones it considered the most important. While virtually all of the recommendations listed in this document were made by the persons interviewed, those ideas that the study team developed further are marked with an asterisk. Dimensions Major Findings Major Recommendations Policy, ►There is generally strong, positive political will toward ►Although the attitudes of public and private officials towa Strategy, and handwashing promotion and child health among very positive, many still lack knowledge of the multiple ben Direction organizations and government officials, although some government officials in particular must try to simultaneousl government officials find it hard to give it much attention priorities. Therefore, the Initiative should develop an advoc because of so many other priorities. and materials for different levels of decision makers, that de HWWS for reducing diarrhea, respiratory disease, and infan ►The new national administration has accepted the malnutrition; and for improving school performance, mothe Initiative and seems well disposed to collaborate. and the nation’s human capital. Advocacy activities should ►Key partners feel that they understand the approach and continue throughout the project period. used in the first phase and feel ownership, but they do not ►In addition, it appears that even key partners lack informa yet have a good understanding of the expanded project expectations regarding the expanded handwashing program (which is still being designed). that, before the selection of districts and implementation, th ►There are several politically prominent national group meetings with the key partners to clarify their expecta initiatives (re: malnutrition, healthy schools, water and intentions and constraints. In preparation for these meetings sanitation) that offer natural links with handwashing. and disseminate a brief description on the new project that s strategy and plans, making clear which features are required ►Although the MOH signed a ministerial decree in discussions of each partner’s role and responsibilities shoul support of the Handwashing Initiative, its enthusiasm has meetings, leading eventually to MOUs or similar agreement waxed and waned with frequent changes of officials; current officials appear to be quite supportive. ►A similar process, managed by the implementing agencie regional, provincial, and district levels once the intervention ►At the beginning of the Initiative, national MOE involvement was minimal, but now the MOE is actively engaged. ►Many officials remember the role of handwashing during the cholera epidemic and are therefore well disposed to support the Initiative. Partnerships ►In general this has been a successful and innovative ►Consideration should be given to inviting the MOE's env aspect of the program, in particular with private sector the MOH’s PRONASAR (small water systems) program to partners. Committee. (The MOE already has been invited.) It would a private sector partner such as the CONFIEF, an association ►The process of public and private organizations working together has not always gone smoothly. The ►Assess the interest of potential new partners in joining th public sector tends to be more formal and bureaucratic UNICEF, PAHO, Save the Children, and so on). and to have more changes in personnel. ► WSP, the National Committee, and the implementing ag ►Different partners play very different roles, from being providing guidelines, tools, and strategic technical assistanc fully engaged as a member of the coordinating committee ►To achieve impact and sustainability, work hard to establ 93 Global Scaling Up Handwashing Project to providing short-term messages on handwashing and district level. co-financing or managing local activities. This is fine as ►Partners at the district level should include the strongest p long as expectations are clear. district. A strong partner organization is one that has good r ►Keeping key government ministries (particularly built confidence among the population, and is committed to health, education, and housing) involved is essential, supervision of promotion activities. Each partner should be even though this can be difficult at times because of strengthen/expand attention to handwashing in its objective political changes and overburdened officials who are too to consider include those helping install or improve water an busy to participate in meetings. Leche, comedores populares, and NGOs with long histories area. ►The Initiative and implementing agencies should work at district levels to have an existing public-private coordinatio the handwashing activities, such as the mesa de concertació committee. Institutional ►Many respondents felt that arrangements have been ►Although MOUs and other formal agreements are no gua Arrange-ments informal yet have worked well based on personal essential for working with government agencies, since they relations, particularly for NGOs and private allocations to occur, and they may limit disruptions caused organizations. Formal agreements are particularly important with the MOH control over its local offices. The Initiative should continue ►Arrangements with governmental organizations were agreements at the national level and require its implementin more formal: the MOH issued a ministerial decree in levels.* 2004, and some regional governments approved ordinances. Beginning in 2006, the Initiative made an ►Although it is fine initially to work less formally with pri effort to sign MOUs with key national and local partners. it the long run negotiating and signing more formal agreeme agreements would clarify roles and expectations and suppor ► WSP and the implementing agencies should periodically these agreements.* Program ► In general, opinions were positive; people felt that ►Three general suggestions from various respondents were Methodology combining diverse partners’ strengths produced an local levels, (2) to allow local partners flexibility in implem effective approach. (3) to urge local partners to avoid a focus on short campaign campaigns seem to be very popular in Peru, but their impac ►Some mentioned that the Initiative took too much of a campaign approach, without follow-up in some places, ►Develop a standard methodology and instruments for ass and with insufficient concern for institutionalization. and district levels to identify existing activities in which han added or strengthened and to identify the strongest partner o ►Some respondents mentioned the need to focus more HWWS champions.* on interpersonal communication, while media representatives felt that mass media could play a larger ►Most respondents recommended that implementation emp role. communication. Use mass media when possible, emphasizin and interactive formats* (call-in shows, radio listening grou ►Several of the persons interviewed pointed out that it possible to ensure that there is good coordination between m has been much easier to generate enthusiasm and the-field activities so they are mutually reinforcing. behavior change among children than among mothers, particularly in rural areas. ►If possible, develop separate communication materials fo jungle areas of Peru. Encourage regions to modify materials appropriate images, language, and so on. Recognize local b cold temperatures, and counsel families* on how to overcom ►For both effectiveness and sustainability, the Initiative sh of handwashing promotion within existing programs such a MOH, Escuelas Saludables, Viviendas Saludables, Municip (new water and sanitation systems), PRONOEI (preschool), malnutrition, JAAS (water and sanitation boards), NGOs do on. Although moving away from a single focus on handwas PPPHW strategy, the team feels that this is the most approp as the one mostly likely to be sustainable. On the other hand 94 Global Scaling Up Handwashing Project opportunity should be as focused and interactive as possible ►To try to build and maintain a positive program image, to supporters, and to share useful technical and strategic inform strong project communication program directed at both coll outside world (political leaders, donors, and the public). At electronic newsletter, a section on the WSP/Peru and MOH partners’ sites), and specific efforts to obtain radio and pres and activities. These communication spaces should include program, descriptions of particularly effective or innovative on achievements and impact; and exchanges on lessons lear combines respondent and team opinions.) ►The Initiative intends to contract several “implementing o the program in several regions. These organizations should operational guide for the district level. The guide should pro way that encourages each district to select those that are like effective. ►The program should take advantage of children’s enthusi students to promote HWWS at home and in their communit develop such materials with suggestions for students and he partners to invent additional ideas. In addition, the worksho supplementary materials should put a greater emphasis on h with individual mothers on solving problems, such as (perce or time.* ►Lack of compensation for transportation and food costs a promoters making more home visits. Where other partners a Initiative should contribute to the costs of such compensatio ►The key partners should develop an exit strategy that add expansion issues. This might include steps to institutionaliz commitment) for HWWS in government and partner organi program into some control districts as soon as the final mea completed, and local and national presentations on the proje on health and malnutrition. Implementa- ►Although the skills and systems needed to implement ►Develop implementation guidelines and tools to support i tion Capacity the program well certainly exist at the national level, and district levels. there was some concern about capacity at the local level. ►Where the local assessments show particular weaknesses agency should provide training, mentoring and exchange vi technical assistance. Availability of ►There is little concern with the availability of soap, ►Ideas mentioned were to collect soap bars from hotels in Products and although access to water is difficult in some the poorest communities; promote Tippy Taps and similar w Tools communities. needed; promote hand-drying on clean cloths or towels in d would not be recommended); and promote use of ash, sand, ►Respondents considered the provision of plastic available. washing bowls and pitchers to have been useful in the first phase. ►Local change agents should be prepared to counsel famili and, where needed, local partners should address shortages. ►Partners at the district level should consider purchasing a and even soap to the poorest families. The national level mi these items in order to obtain lower prices.* Financing ►Many partners made financial and in-kind ►Continue to explore a co-financing agreement by the Fun contributions during the first phase. which has expressed interest in supporting HWWS in Peru. 95 Global Scaling Up Handwashing Project ►The general opinion is that there is potentially ►Obtain information on USAID’s small grants program an sufficient funding in Peru for this activity but that the partners. partners need to work hard to actually obtain the funding ►Lobby national and regional government officials for bud to support HWWS. handwashing or hygiene education. ►The team believes that external funding is likely to still ►Continue to seek donated air time and publicly acknowle be needed at the end of this phase, mainly for covering by private media companies. the cost of implementing agencies supporting new districts and, at a much lower level, to support continued advocacy. However, partner contributions should increase in this phase, so the percentage of funding provided by external sources should decline.* Cost-Effective ►The first phase collected extensive cost information ►The Initiative needs to identify its needs and contract indi Implementa- and some impact information, but there was no attempt to meet them.* tion calculate the cost-effectiveness of various activities or strategies. ►The capability for collection and analysis does exist in Peru, but technical support and training will be needed for particular partners and local areas. Monitoring ►Persons interviewed generally consider M&E to be ►The M&E functions are very important in this program, b and Evaluation very important; many are not very aware of monitoring the responsibility of persons outside of the central managem activities or results. interfere with their ability to manage implementation.* ►On the electronic survey, respondents scored ►A key to maintaining partner and public motivation is the monitoring lower than any other dimension. achievements and results (see suggestions for project comm ►It is going to be a challenge to allow the local implementation flexibility that many respondents recommend while at the same time keeping sufficient uniformity in the program districts to be able to generalize about them in relation to the control districts. The monitoring team will have to carefully control for the effects of the many existing programs and projects in both intervention and control districts.* 96 Global Scaling Up Handwashing Project APPENDIX J: MENÚ DE ACTIVIDADES PARA ALUMNOS (IDEAS PRELIMINARES) En casa: 1) Aplique una encuesta en casa sobre las condiciones para LM con jabón en momentos críticos: Hay jabón para lavar? Hay agua para lavar? Hay toallas o trapos para secar las manos? Hay lugares con agua, jabón, toalla o trapo limpio cerca de donde ir al baño y donde prepara la comida? Producto: Las preguntas y respuestas. Note: Si falta buenas condiciones se debe repetir la encuesta una semana después. 2) Dé una clase a su familia sobre como lavar las manos bien (con agua corriente o echado; jabón, cenizas, o óleo de quinua; frotando los dedos muy bien; secando en una toalla o trapo limpio (o no aire libre se es una zona de poco polvo). El día después, dar un “examen� a su madre y hermanos de 5 a 9 años para ver si saben lavar correctamente. Si no, explique como puede mejorar. Producto: Un pequeño informe sobre la experiencia. 3) Dé una clase a su madre sobre los momentos críticos para lavar: después de ir al baño, después de cambiar el pañal o tener cualquier contacto con heces; antes de preparar la comida. El día después de la “clase� dar un examen a su madre para ver cuantos momentos críticos ella recuerda. Si ella no sabe todos, explique lo que falta. Producto: Un pequeño informe sobre la experiencia. 4) Construye un aparato simple que se deja lavar las manos sin gastar mucha agua. Puede usar su propio diseño o uno de los siguientes diseños (véa los dibujos abajo): Tome una lata o recipiente de plástico con forma similar a una lata. Hace un hueco pequeño al fundo del lado de la lata. Ligar una cuerda al parte superior de la lata para poder colgarla en un lugar apropiado para lavar manos. Para usar el aparato, hay solo que echar un poco de agua en la lata, y puede usar el agua que sale por el hueco para lavar las manos con jabón. Un otro diseño usa una calabaza o botella plástico con pico. Ligar una cuerda para poder colgar la vasija de un árbol o la casa. Llénela con agua, y cuando quiere lavar las manos simplemente derríbela una vez para lavar y una segunda vez para echar los burbujas y sucio. 97 Global Scaling Up Handwashing Project Producto: El aparto pronto para ligar y usar. Source: Salubritas 9: 4 (December 1986) (left); M. Ponga for SANRU (middle and right). En la comunidad: La próxima vez que haya alguna fiesta o evento publico en su comunidad, 5 a 10 estudiantes pueden organizar una esquina educativa sobre lavado de manos con jabón. Pueden cantar las canciones que aprendieron en clase. Pueden demostrar la técnica correcta de lavar. Un estudiante puede explicar los beneficios para la salud (proteger contra diarrea, infecciones respiratorias, y desnutrición). Otro puede explicar los momentos críticos. Si quiere, pueden preparar afiches u otros materiales. Producto: Un pequeño informe sobre la experiencia, incluyendo el número de personas que asistieron, lo que los estudiantes hicieron, y la respuesta de la comunidad. 98 Global Scaling Up Handwashing Project APPENDIX K: MENÚ DE ACTIVIDADES PARA PROMOTORES DE SALUD (IDEAS PRELIMINARES) Estas ideas son para un promotor en su comunidad o para un grupo de promotores en una comunidad. Puede combinar varias ideas si quiere, por ejemplo, 2 y 3, o 2, 3, y 4. 1) Aplique una encuesta en las casas sobre las condiciones para LM con jabón en momentos críticos: Hay jabón para lavar? Hay agua para lavar? Hay toallas o trapos para secar las manos? Hay lugares con agua, jabón, toalla o trapo limpio cerca de donde ir al baño y donde prepara la comida? Primero, haga una pregunta. Entonces, pregunte si puede mirar (el jabón etc.). Después de hacer las preguntas, explique sobre los beneficios de lavado de manos (proteger contra diarrea, infecciones respiratorias, y desnutrición). Al terminar todas las familias, haga un análisis si puede. Cuántas familias hay y cuántas tienen jabón, etc. Aplique la encuesta de nuevo un mes o mas después y comparar los resultados. 2) Enseñe a una familia o a un grupo de madres y otros familiares sobre como lavar las manos correctamente (con agua corriente o echado; jabón, cenizas, o óleo de quinua; frotando los dedos muy bien; secando en una toalla o trapo limpio (o no aire libre se es una zona de poco polvo). Después de explicar y demostrar la técnica correcta, pida a cada participante mostrar la técnica correcta. Después de cada vez, pregunte al grupo para sugerencias sobre como la persona puede mejor su técnica. 3) Enseñe a una familia o a un grupo de madres y otros familiares sobre los momentos críticos para lavar: después de ir al baño, después de cambiar el pañal o tener cualquier contacto con heces; antes de preparar la comida. Pida el grupo que repita los momentos, y después pida cada individuo. 4) Ayude a las familias que carecen de agua construir un aparato simple que se deja lavar las manos sin gastar mucha agua. Puede usar su propio diseño o uno de los siguientes diseños (véa los dibujos abajo): Tome una lata o recipiente de plástico con forma similar a una lata. Hace un hueco pequeño al fundo del lado de la lata. Ligar una cuerda al parte superior de la lata para poder colgarla en un 99 Global Scaling Up Handwashing Project lugar apropiado para lavar manos. Para usar el aparato, hay solo que echar un poco de agua en la lata, y puede usar el agua que sale por el hueco para lavar las manos con jabón. Un otro diseño usa una calabaza o botella plástico con pico. Ligar una cuerda para poder colgar la vasija de un árbol o la casa. Llénela con agua, y cuando quiere lavar las manos simplemente derríbela una vez para lavar y una segunda vez para echar los burbujas y sucio. Source: Salubritas 9: 4 (December 1986) (left); M. Ponga for SANRU (middle and right). 5) La próxima vez que haya alguna fiesta o evento publico en su comunidad, organice una esquina educativa sobre lavado de manos con jabón. Puede demostrar la técnica correcta de lavar; explicar los beneficios para la salud (proteger contra diarrea, infecciones respiratorias, y desnutrición); y explicar los momentos críticos. Si quiere, pueden preparar afiches u otros materiales. 100 Global Scaling Up Handwashing Project APPENDIX L: ACTION PLAN TO IMPROVE THE ENVIRONMENT FOR AN EXPANDED HANDWASHING PROJECT IN PERU Current Situation Objective Strategy Recommended Steps and Timing Expected Implementation Skills and Challenges Expertise Phase I: 12/06–8/07, Phase II: 9/07– 8/08, Phase III: 9–12/08 Political support Build decision Prepare and implement an ►Draft an advocacy strategy (Phase I). Two main challenges are to ►Ability to makers’ support advocacy strategy directed (1) develop and implement a develop and The attitudes of for HWWS as a to officials at the national, ►Send draft to partners for comments; strategy that appropriately manage a complex, public and private long-term regional, provincial, and meet with national partners to discuss addresses the diversity of multilevel officials toward priority as district levels. The strategy (Phase I). leaders of different types of advocacy activity. handwashing are shown by their: should disseminate organizations working at ►Ability to generally very arguments and materials for ►Draft, pretest, and finalize materials; different levels, and (2) to periodically insert positive (many ►devoting time different levels of decision make printing, broadcasting, convince leaders to give fresh ideas, recall how to handwashing makers that show the disseminating arrangements; identify sufficient support to HWWS materials, and important plans and importance of HWWS for advocacy champions during regional/ at the same time that they activities over handwashing was programs, reducing diarrhea, provincial/district assessments (Phase are being pressured to attend time; this is an in the control of ►committing to respiratory disease, and I/early Phase II). to many other development ongoing activity, cholera), but handwashing infant mortality; preventing priorities. not just a short- many still lack promotion in malnutrition; and improving ►Monitor to ensure that the national term campaign. knowledge of the official school performance, and regional coordination committees ►Ability to multiple benefits documents, mothers’ confidence and are giving attention to advocacy negotiate and of HWWS. ►allocating self-esteem, and the (Phases II and III). manage mass Moreover, funds, nation’s human capital. media government Materials and interpersonal ►Intense implementation (including contributions. officials in ►including communication should trying to add HWWS to broader ►Ability to particular are HWWS show how HWWS can advocacy events). Give special focus to periodically under pressure to activities in easily fit into existing regional presidents (early Phase II). monitor and make address numerous work plans. objectives and plans. Try to appropriate priorities. The obtain free donated mass ►Less intense implementation adjustments. current media coverage. Meet with (including keeping alert for 101 Global Scaling Up Handwashing Project government’s the leading political opportunities to add HWWS to broader focus on health candidates during electoral advocacy events) (Phases II and III). and education is a campaigns to ask them to positive factor. make a public commitment ►Meet to review implementation to improving child health progress and results (every 6 months, and nutrition and to HWWS Phases II and III). specifically. The implementing agencies (contracted by WSP) would have major implementation responsibility at the regional, provincial, and district levels. Understanding Provide Circulate draft documents ►Prepare and disseminate a brief ►The main challenge is WSP has the and expectations opportunities for and hold meetings to obtain description on the new project that simply for WSP staff to find project partners to have partner suggestions and summarizes the proposed strategy and the time during this busy management Although many input into the clarify roles and plans, making clear which features are period to have adequate experience and people praise the project strategy expectations. required under the Gates grant (Phase two-way communication negotiation and open and and plans; and I) with key partners. other expertise collaborative for them to ►Hold individual and group meetings ►Another challenge is to be required. management in understand the with the key partners to clarify their able to repeat similar the project, it methodology, expectations and the project’s processes at the regional appears that even plans, and their intentions and constraints. Initial level and below. This some key partners roles. discussions of each partner’s roles and responsibility may be shared lack a good responsibilities should also occur between WSP and the understanding of during these meetings, leading implementing agencies that the expanded eventually to MOUs or similar it contracts. project. agreements (Phase I). (This process has Decentralization in the begun with the MOE.) public sector creates the ►In abbreviated form, repeat this need for intense work at the process at the regional, provincial, and regional level and below. district levels, once the intervention ►A final challenge will be districts have been selected (Phase I to negotiate clear roles and and early Phase II). responsibilities at the sub- national level with organizations that already have active programs and 102 Global Scaling Up Handwashing Project many priorities. Strong Stronger Strengthen alliances at all ►Invite the MOE (environmental Challenges include: ►Excellent partnerships alliances are levels with partners that health division), and the MOH ►inviting the right partners analytical and needed, have both the resources and (PRONASAR), and possibly a and individuals to play key communication In general, public- particularly with desire to contribute. Give representative of CONFIEP to join the roles skills, as well as a private alliances partners that can particular attention to coordinating committee (Phase I). ►adding HWWS thorough have been a make strategic district-level partnerships ►Add HWWS to the agenda of an coordination to already full understanding of successful and contributions. that include organizations existing coordinating group in each agendas of coordinating the Initiative and innovative aspect that enjoy popular participating region, province, and groups its methodology. of the program. confidence and that are district (early Phase II). ►identifying the strongest ►Ability to Adding a few new committed to ongoing ►Seek inclusion of the strongest partners in each district identify and national partners follow-up and supervision programs/institutions in each district. A ►developing guidelines and accurately assess might strengthen of HWWS promotion strong partner organization is one that tools that are easy to use and potential partners, the program. activities. has good reach into communities, that adapt in a variety of settings their resources, and There has been has built confidence among the and conditions their true interest in minor, temporary population, and that is committed to ►getting sufficient collaborating. tension between ongoing follow-up and supervision of attention and participation public and private promotion activities. Particular targets of key government officials, organizations, of opportunity are those organizations many of whom are because the public that support water and sanitation overwhelmed with sector tends to be infrastructure improvements in the competing priorities. more formal. project districts (early Phase II). ►Develop, pretest, and finalize guidelines and tools for local partnerships (early Phase II) Partnerships ►Keep partners Develop and maintain a ►Draft a project communication ►Keep these activities ►Capability to motivated and strong project strategy. At a minimum there should be strategically focused, that is, design and Some partners engaged communication program an electronic newsletter (featuring a directed toward clearly implement strategic note the lack of throughout the directed at both partner or district of the month or defined audiences and communication regular project period. collaborating organizations quarter), a section on WSP &/or MOH objectives. activities, not communication ►Recognize and the outside world Web sites (with links to partners’ sites), ►Provide information in merely activities from the Initiative their (political leaders, donors, and radio and press coverage of appropriate detail and that make a lot of about its organizational the public) in order to accomplishments and activities. These formats. noise but with no activities, contributions. maintain a positive program communication spaces should include ►Collect good information clear purpose. progress and ►Collect and image, motivate partners basic information on the program, from people in the field who ►Ability to impact. share tools and and supporters, and share descriptions of particularly effective or are too busy with monitor activities lessons learned useful technical and innovative strategies or activities; implementation to sit back and impact and to that can strategic information. exchanges (meetings, visits) on lessons and reflect and document make needed improve the learned, M&E, and cost-effectiveness activities. adjustments. effectiveness of ►Find channels to reach ►Responsibility 103 Global Scaling Up Handwashing Project activities. information (Phase I). people and organizations at should be shared the local level, in more by WSP, the ►Send draft strategy to partners for isolated districts that lack national comments; solicit their comments and access to the Internet. communication suggestions (Phase I). subcommittee, and ►Share the project communication possibly contracted strategy with the implementing individuals or agencies and include in their terms of groups. reference their tasks in implementing the strategy at the local level in support of national activities (early Phase II). ►Implement the strategy (Phases II and III). ►Review implementation progress and results (every 6 months during Phases II and III). Institutional ►Achieve Although MOUs and other ►Meet with partners and reach ►Negotiating and getting Negotiation and arrangements clearer formal agreements are no agreements on their expected roles and MOUs signed is likely to be interpersonal skills definition and guarantee of follow-up, they responsibilities at the national level. more difficult the more are needed, as well Most commitment to are very important, For government agencies and other bureaucratic the organiza- as the ability to arrangements roles and particularly for working partners that so desire, prepare and sign tion is. There could easily craft agreements have been responsibilities with government agencies. MOUs describing the agreements. For be setbacks if key personnel that are at the right informal, yet they of partners at all They should also facilitate other partners, the WSP can simply change. level of specificity. have worked well levels. longer-term commitments prepare a letter to the organization ►The periodic reviews of WSP possesses based on personal ►Facilitate from NGOs and other describing expected roles and MOUs could cause ill such skills. relations, sustainability of private partners. Therefore, responsibilities (Phase I, early Phase feelings unless done in a particularly for organizational the Initiative should II). spirit of working together to NGOs and private commitments to actively pursue at least ►Engage with partners with informal achieve the most possible in organizations. HWWS. semi-formal agreements at agreements to try to move them to the existing circumstances. Nonetheless, all levels. make formal commitments (Phase II). many partners feel ►At the regional, provincial, and that more formal district levels, the coordinating groups relations would should prepare a brief document on help with clearer HWWS activities that describes the understandings of expected role of major partners. The the program and members should approve this document roles and (early Phase II). (This document should responsibilities in be considered the conceptual the expanded framework for development of the HWWS work plans at the local levels.) 104 Global Scaling Up Handwashing Project program. ►Coordinating groups should review MOUs and committee documents every 6 months to assess to degree to which they are being implemented, barriers to implementation and how these may be resolved, and any needed revisions in roles and responsibilities (Phases II and III). Program The general The basic strategy is a ►Develop methodology and ►To manage and support Designing and methodology objective is to decentralized one in which instruments for assessment visits at the program activities in so implementing the achieve good the national level prepares provincial and district levels that will many diverse districts, with program Although impact on the useful tools and guidelines support identification of existing different challenges and methodology will respondents feel practice of and aims to stimulate strong activities in which handwashing resources, scattered all over require a range of that most aspects HWWS at local partnerships, and then promotion could be added or the country. This requires communication, of the pilot critical times in provides strategic support strengthened and the strongest and excellent communication managerial, and methodology the short run, by as needed to local levels. most collaborative partner and a national program political skills. worked well, using an Build strong alliances first, organizations and HWWS champions capable of supporting but Although these some felt there approach that at all levels, beginning with (Phase I). not trying to control district certainly exist was too much can be sustained the implementation of the ►At the national level, develop, activities. within the WSP reliance on mass and advocacy strategy and of a pretest, and finalize communication ►In some districts, poverty, and its partners, media and a institutionalized. thorough assessment and training materials for the coast, isolation, climatic and this is a complex campaign process at regional, mountains, and jungle areas of Peru geographical conditions, project to manage approach with provincial, and district (early Phase II). lack of access to water and since—given the uncertain follow- levels. A major project ►Develop an operational guide for the to mass media, and so on multiplicity of up. objective should be to build district level (early Phase II). will make implementation partners and promotion of HWWS into ►Make a few small additions to the more difficult. variety of local ongoing, permanent workshop methodology and ►Local effectiveness will settings—it must activities of agencies and supplementary materials: (1) put be very dependent on the be done in a programs, as indicated by greater emphasis on how persons strength of local partners, decentralized official directives, work promoting HWWS can work with their reputations and manner. A final plans, and budget individual mothers on solving abilities to reach and challenge is to allocations. Focus on problems … such as (perceptions of) influence families in the avoid devoting interpersonal limited water, soap, or time; and (2) communities where they time and effort to communication local radio incorporate ideas for what students and work. communication (interactive formats) and health promoters can do in homes and activities that group activities. communities to motivate, teach, and remind people facilitate HWWS (early Phase II). about HWWS temporarily but that have no 105 Global Scaling Up Handwashing Project follow-up. Implementation Improved local Improve the implementation ►As parts of regional, provincial, and ►To establish and The skills needed capacity implementation capacity in regions, district assessments, assess local implement mechanisms that are those required capacity. provinces, and districts that implementation capacity (early Phase will detect and feedback to establish a While the skills have weak capacity. II). local needs for capacity monitoring and and systems ►Where the local assessments show support. feedback system, needed to particular weaknesses, provide training ►To provide appropriate as well as a variety implement the and mentoring and exchange visits with and effective support in a of capacity program well pilot districts with effective programs timely manner. The WSP building skills, certainly exist at (Phase II). and its main partners, ranging from the national level, ►Develop implementation guidelines including the implementing conducting good there is some and tools to support implementation at agencies, should share this needs assessments concern about the provincial and district levels (early responsibility. to making good capacity at the Phase II). choices on modes local level. of capacity building and implementing those actions. Financing Secure ►Explore possibilities for ►Continue to explore a co-financing ►It is difficult to predict The skills needed additional national and local financing, agreement by the Fund of the Americas what challenges may arise, are basically There are many financial and in- and publicly acknowledge (FONDAM), which has expressed but in general funding diplomatic and potential sources kind resources contributions. interest in supporting HWWS in Peru agencies and programs have interpersonal, as of funding and in- at the national ►Lobby for budgetary (Phase I). their own unique well as the ability kind and local levels commitments beyond this ►Obtain information on USAID’s requirements, which may or to write appropriate contributions, for this phase phase. small grants program and then decide may not fit well with the proposals. WSP although and beyond. whether to share this with local planned activities and time and its partners accessing them partners (Phase I, early Phase II). line of the Handwashing possess these skills. will require effort. ►As part of advocacy activities, lobby Initiative. What may be Some government at all levels of government for ►In-kind contributions lacking is sufficient programs have budgetary funds directed toward from the private sector are time. limited handwashing or hygiene. relatively easy to obtain; implementation ►Monitor the extent to which the focus on those that are most funding. partner organizations have included likely to effectively support funds for the promotion of HWWS or HWWS. provision of water in their annual ►Government agencies budgets. may be reluctant to commit ►Give public recognition for free air funds to such a narrow time and other contributions from objective. private companies, on Web page, in 106 Global Scaling Up Handwashing Project newsletter, and so on (Phases II and III). Cost-effective Without over- Defining data collection and Steps should be defined by the WSP The main challenge is to Skills needed are implementation burdening analysis procedures should with the executive committee. collect, analyze, and use the ability to partners, collect be the task of the M&E essential information, conceptualize ►The pilot and use cost and group. without overburdening essential needs and project collected effective-ness persons in the field who decide how to extensive cost information to need to focus on collect needed information and improve this implementation. information in a some impact and future manner that least information, but projects. burdens field there was no people; also needed attempt to are analytical skills calculate the cost- and the ability to effectiveness of share, discuss, and various activities use the results both or strategies. to improve the Peru ►The capability program and for collection and similar programs. analysis does exist in Peru. M&E Measure impact Defining data collection and Steps should be defined by WSP with The main challenge is to Skills needed are on behavior and, analysis procedures should the executive committee. collect, analyze, and use the ability to Persons to the extent be the task of the M&E essential information, conceptualize interviewed possible, the group. without overburdening essential needs and generally consider strategies and persons in the field who decide how to monitoring and inputs most need to focus on collect needed evaluation to be closely implementation. information in a very important associated with manner that least and to have impact; use this burdens field received information to people; as also insufficient improve this needed are attention in the and future analytical skills, pilot phase. The projects. and the ability to real problem may share, discuss, and have been use the results both insufficient to improve the Peru dissemination. program and similar programs. 107 Global Scaling Up Handwashing Project 108 Global Scaling Up Handwashing Project