72217 Report Synthesis of Four Country Enabling Environment Assessments for Scaling Up Handwashing Programs Fred Rosenweig 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. We invite comments and feedback. Please send your feedback to: wsp@worldbank.org. WSP is a multi-donor partnership administered by the World Bank to assist the poor in gaining sustained access to improved water supply and sanitation services (WSS). For more information, please visit: www.wsp.org. Credits Editorial Support: Hope Steele Production: Katri Kontio, Hannatu Ogunnaike This report was reviewed by Eduardo Perez, Hnin Hnin Pyne, Rocio Florez, and Lene Jensen. ABOUT THE AUTHOR Fred Rosensweig Fred Rosensweig has 34 years of experience in international development, including 25 years of experience working on human resources and institutional development issues in the water supply and sanitation sector. He has worked in projects affecting rural communities, small towns, and the urban poor in over 30 countries in Eastern Europe, Latin America, the Middle East, and Africa. He speaks French and Spanish. 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 judgement 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 ACKNOWLEDGMENTS……………………………………………………………………………..iv LIST OF ACRONYMS AND ABBREVIATIONS……………………………………….......................v SUMMARY………………………………………………………………………..……....................vi Findings………………………………………………………………………...................................vi Learning Agenda………………………………………………………………………....................vii 1. INTRODUCTION……………………………………………………………..................................1 Purpose………………………………………………………...…………………..….……………...1 Water and Sanitation Program…………………………………....………………..….......................1 Scaling up Handwashing Behavior Change Program……………………………..………………...1 Enabling Environment Assessments……………………………………………..…....……………..3 2. SUMMARY OF COUNTRY PROJECTS…………………………………………….......................4 Tanzania……………………………………………………………………………….......................4 Senegal……………………………………………………………………………………………….5 Vietnam………………………………………………………………………………........................5 Peru…………………………………………………………………………………………………...6 3. ANALYSIS BY DIMENSION…………………….………………………………….......................8 Policy, strategy and direction………………………………………………………………………...8 Partnerships…………………………………………………………………………........................10 Institutional arrangements…………………………………………………………..........................12 Program methodology………………………………………………………………........................15 Implementation capacity……………………………………………………………........................17 Availability of products and tools……………………………………………………......................18 Financing……………………………………………………………………………........................19 Cost-effective implementation……………………………………………………………………...21 Monitoring and evaluation………………………………………………………….........................21 4. THE WAY FORWARD…………..………………………………………………..……………..23 Overall conclusions…………………………………………………………………………………23 Summary of Preliminary Guidance…………………………………………………………………24 Learning agenda for enabling environment………………………………………………………...27 LIST OF BOXES Box 1: Seven core principles of a Handwashing program………………………………………….15 LIST OF TABLES Table 1: Handwashing Targets by Country …………………………………....................................2 Table 2: Summary of Preliminary Recommendations……………………………………………...25 _____________________________________________________________________ iii Global Scaling Up Handwashing Project ACKNOWLEDGMENTS The author would especially like to acknowledge the authors of the four enabling environment assessment reports on which this report is based. The report on Peru was written by Michael Favin and Doris Alfaro, Senegal was written by Lynne Cogswell and Ali Diouf, Tanzania was written by Carol Hooks and the Vietnam report was written by Lynne Cogswell and Le Thi Anh Thu. These reports provided a wealth of insights and recommendations for this synthesis report. These reports were also aided by the guidance of WSP country team task managers: in Peru - Rocio Florez, in Senegal – Seydou Koita and Ousseynou Diop, in Tanzania – Nathaniel Paynter and Ousseynou Diop and in Vietnam – Nga Nguyen. The author is also grateful to those who reviewed early drafts of this report, including Eddy Perez, Lene Jensen, Hnin Hnin Pyne, Mike Favin, and Lynne Cogswell. Finally, the author would like to thank Eddy Perez and Lene Jensen from WSP for their overall guidance and support. _____________________________________________________________________ iv Global Scaling Up Handwashing Project LIST OF ACRONYMS AND ABBREVIATIONS ARIs Acute respiratory infections HWWS Handwashing with soap M&E Monitoring and evaluation MDGs Millennium Development Goals MOH Ministry of Health MOUs Memoranda of Understanding NGOs Nongovernmental organizations ONAS National Office for Sanitation of Senegal PPPHW Public-private partnership for Handwashing WSP Water and Sanitation Program _____________________________________________________________________ v Global Scaling Up Handwashing Project SUMMARY The Water and Sanitation Program (WSP) recently completed the first year of a four-year Global Scaling Up Handwashing Project. This project tests whether innovative approaches can generate large-scale and sustained increases in Handwashing with soap at critical times among the poor and vulnerable in Peru, Senegal, Tanzania, and Vietnam. During the first year of the project, baseline enabling environment assessments were conducted in the four target countries to better understand the programmatic and institutional conditions needed to scale up, sustain, and replicate the interventions used in the projects. The assessments will be repeated after three years of project implementation to assess progress in strengthening the enabling environment and to determine more definitive lessons learned. The purpose of this report is to synthesize the findings from the four enabling environment assessment reports, including preliminary conclusions and lessons learned as well as recommended interventions and practices that can be used to strengthen the enabling environment. The report also identifies knowledge gaps and, hence, priority areas for learning. This report and the findings from the four assessments should be seen as a work in progress that will be enhanced with additional lessons learned and insights as the Global Scaling-Up Handwashing projects move forward in each country. FINDINGS The enabling environment assessments were conducted using a common conceptual framework consisting of the following nine dimensions. _____________________________________________________________________ vi Global Scaling Up Handwashing Project • Policy, Strategy, and Direction • Partnerships • Institutional Arrangements • Program Methodology • Implementation Capacity • Availability of Products and Tools • Financing • Cost-Effective Implementation • Monitoring and Evaluation The definition of each dimension, as well as specific findings and recommendations from the four enabling environment assessment reports, are provided in the third section of this report. The overall conclusions from the analysis of the four reports are the following: • The enabling environment in all countries to create and sustain large-scale Handwashing programs is not yet in place. The enabling environment in Peru appears to be the most developed of the four countries. • Although some countries have issued ministerial decrees that support Handwashing, none of the assessments stated that a comprehensive national policy framework is in place and, further, that it has translated into sustained action. • National-level partnerships have been formed but not all are yet functioning effectively. • With increased decentralization, all the reports highlighted the importance of working through regional and local governments to achieve scale-up and sustainability. • The assessment reports emphasized the importance of adapting the public-private partnership for Handwashing (PPPHW) methodology to the specific context of each country to ensure ownership. • The availability of soap does not appear generally to be problematic, with the exception of some remote areas. • To date, country programs have relied primarily on external funding and have not addressed the long-term challenge of securing funding for a Handwashing program at scale. • Systems for tracking costs to determine the most cost-effective implementation are not yet in place. • Similarly, although capacity for monitoring and evaluation (M&E) exists in most countries, systems have not yet been established. LEARNING AGENDA The Scaling Up Handwashing Behavior Change Program places great emphasis on learning from the four country programs. The analysis and preliminary recommendations suggest a number of knowledge gaps in HWWS programs that are elements of scaled up and sustainable Handwashing programs. The synthesis report provides the following specific suggestions for a learning agenda for the strengthening of the enabling environment: • Documenting the process used to develop national partnerships to identify lessons learned • Developing case studies on how to establish linkages between Handwashing and other programs such as nutrition, water and sanitation, and schools • Involving local government in training, planning and budgeting, and M&E • Developing guidance on the appropriate balance between mass media and interpersonal communication _____________________________________________________________________ vii Global Scaling Up Handwashing Project • Developing case studies on how countries have used existing governmental operational structures to scale up • Designing a financial plan for scale-up as part of an exit strategy • Developing standard templates for tracking costs in order to determine how to achieve cost- effective implementation • Developing standard M&E indicators that can serve as a starting point for country M&E plans • Tracking the interest and commitment of the private sector, including soap manufacturers and other companies that contribute resources, to engage in PPPHW _____________________________________________________________________ viii Global Scaling Up Handwashing Project 1. INTRODUCTION The Water and Sanitation Program four assessments should be seen as a (WSP) recently completed the first work in progress to be enhanced with year of a four-year Global Scaling Up additional lessons learned and insights Handwashing Project. This project as the scaling up Handwashing tests whether innovative approaches can projects move forward in each country. generate large-scale and sustained increases in Handwashing with soap Water and Sanitation (HWWS) at critical times among the Program poor and vulnerable in Peru, Senegal, Tanzania, and Vietnam. The Water and Sanitation Program (WSP) is an international partnership Purpose to help the poor gain sustained access to water supply and sanitation services. During the first year of the project, Administered by the World Bank with baseline enabling environment financial support from several bi- and assessments were conducted in the multilateral and private donors, WSP four target countries to better is a decentralized partnership and understand the programmatic and operates through regional offices in institutional conditions needed to scale Africa, East Asia, Latin America, and up, sustain and replicate the South Asia. A major thrust of the interventions used in the projects. programs is to help its clients prepare Sustainability is defined as the ability for and implement actions toward to maintain programs after external meeting the water supply and funding has ended. Replication is the sanitation Millennium Development eventual application of the approach in Goals (MDGs). In pursuing its other countries at scale. Scalability is mission, WSP staff provides advisory increasing the present scale and rate of support to projects and policies to help behavior change—that is, moving from identify and disseminate best practices a few districts to a majority of districts and lessons from experience across that reach the majority of the target countries, assist clients in the audience. implementation of pilot projects to test out new ideas, and facilitate informal The purpose of this report is to networks of practitioners and sector synthesize the findings from the four stakeholders. Additional information enabling environment assessment about WSP can be found on the reports, including preliminary program website, www.wsp.org. conclusions and lessons learned as well as recommended interventions Scaling Up Handwashing and practices that can be used to strengthen the enabling environment. Behavior Change Program This report and the findings from the With funding from the Bill & Melinda Gates Foundation, WSP is _____________________________________________________________________ 1 Global Scaling Up Handwashing Project implementing the Scaling Up the translation of results and Handwashing Behavior Change lessons learned into effective Program in partnership with the advocacy and applied governments in the respective knowledge and communication countries. In its four target countries, products WSP follows the basic approach of the public-private partnership for The project is designed to achieve key Handwashing (PPPHW), a global targets in each country at the end of initiative established in 2001 to three years of project implementation. promote HWWS at scale to reduce The specific Handwashing targets for diarrheal and respiratory infections. i each country are listed in Table 1. The This basic approach to hygiene target audience is defined as poor behavior change at scale is to work women of reproductive age (15–49) and with a broad partnership of public and poor children ages 5–9. private sector stakeholders who have a mutual interest in increasing HWWS, Table 1: Handwashing Targets by focus on the one behavior with largest potential health impact (HWWS), and Country promote it with a cost-effective, consumer-centered marketing Country Target Estimate approach. (population) population target (millions) population The objectives of the Handwashing adopting Initiative are: HWWS at critical times • Design and support the (millions) implementation of innovative, Peru (28 5.10 1.30 large-scale, sustainable million) Handwashing programs in four diverse countries Senegal (11 1.97 0.49 • Document and learn about the million) impact and sustainability of Tanzania (37 5.20 1.30 innovative, large-scale million) Handwashing programs • Learn about the most effective Vietnam (84 9.20 2.30 and sustainable approaches to million) triggering, scaling-up, and Source: Water and Sanitation sustaining Handwashing Program. Enabling Environment behaviors Assessment and Baseline Terms of • Promote and enable the Reference, 2007. adoption of effective Handwashing programs in The project uses communications and other countries and position commercial marketing approaches that Handwashing as a global have been proven successful at public health priority through facilitating behavior changes at large _____________________________________________________________________ 2 Global Scaling Up Handwashing Project scale. Message development, been strengthened and to determine the communication strategy, and media actions that still need to be taken. The mix are guided by detailed insights on assessment process is documented in consumer Handwashing habits, the WSP document, Guidelines for theoretically and empirically Assessing the Enabling Environment developed models of behavior change Conditions for Large Scale, Effective, determinants, and communication and Sustainable Handwashing with insights, which have been obtained Soap Behavior Change Programming, through consumer research. The April 2008. Handwashing programs in the four countries draw extensively on the In order to ensure consistency in the expertise of professional assessment findings, WSP developed a communications and marketing conceptual framework for assessing agencies and private sector partners in the enabling environment conditions the design, implementation, and needed for scalability and monitoring of Handwashing sustainability. These dimensions were campaigns. initially identified based on a review of the literature and discussions with key Enabling Environment informants, and are in large measure Assessments consistent with experience in the development community in other The project is committed to learning sectors. The conceptual framework how to increase the scale, impact, and also benefited from a review by sustainability of programs promoting experienced institutional development HWWS. In order to determine to what professionals. extent the Scaling Up Handwashing Behavior Change Program has The framework comprises nine contributed to establishing the dimensions that are considered conditions for scaling up, WSP essential to scaling up a HWWS conducted enabling environment behavior change program and assessments in all four countries. contributing to its sustainability. These These assessments were designed to dimensions, which include both provide a baseline for the enabling institutional and programmatic environment that could be used to conditions, are: assess progress at the end of project implementation and to inform project • Policy, Strategy, and Direction implementation. Each assessment was • Partnerships carried out by a two-person team • Institutional Arrangements consisting of an international and local • Program Methodology consultant over a three-week period • Implementation Capacity from April to September 2007. The • Availability of Products and assessments will be repeated in 2010, Tools after three years of project • Financing implementation, to determine to what • Cost-Effective Implementation extent the enabling environment has • Monitoring and Evaluation _____________________________________________________________________ 3 Global Scaling Up Handwashing Project 2. SUMMARY OF COUNTRY PROJECTS In order to provide context for the advocacy and awareness raising, findings in the next section, this consensus building, and fund-raising. section summarizes the four country In addition, WSP funded research on programs. Each summary describes the Handwashing behavior among the Handwashing programs that existed caregivers and children in Dar es prior to the Global Scaling Up Salaam and the areas around Handwashing Project. Mpwapwa and Rufiji districts. Although the study was small in scope, Tanzania the results provide useful glimpses into Handwashing behavior—such as In Tanzania, efforts to promote and washing one hand only or only scale up Handwashing as an effective rinsing—within households and intervention for improving child health schools. The results from the early began in 2005 with assistance from research were later confirmed by more WSP. In addition to WSP, initial detailed research in Kenya and supporters included the Ministry of Uganda. Starting in 2006, the PPPHW Health (MOH), UNICEF, WaterAid, received technical support and training and Tarmal Industries (a soap in marketing via Unilever/Lifebuoy’s manufacturing company). The group In Safe Hands program. The Tanzania established a PPPHW later that year. PPPHW now receives funding through the Scaling Up Handwashing Behavior Diarrheal disease is among the leading Change project and from the European causes of mortality and morbidity Union’s Water Facility. among children under five years old in Tanzania. According to the latest Handwashing-promotion efforts in Tanzania Demographic and Health Tanzania build on existing Survey, the prevalence of diarrheal Government of Tanzania ministerial disease in children under five was 13 strategies to maximize the health percent, ranging from 25 percent in impact of the Water Sector infants under one year to 5 percent at Development Program and a National five years old. Acute respiratory Environmental Health, Hygiene, and infections (ARIs) follow a similar Sanitation Strategy by plugging pattern, with an average prevalence of hygiene promotion gaps, specifically 8 percent in children under the age of HWWS. Activities are being five, ranging from 13 percent under developed in collaboration with the one year to 5 percent at five years. ii Ministries of Water and of Health and Social Welfare, with a goal of During the initial phase, Tanzania integrating them into the Water Sector PPPHW’s activities centered on Development Program as results are available. _____________________________________________________________________ 4 Global Scaling Up Handwashing Project Senegal Diourbel, Velingara, and Thies. With its activities to date, the PPPHW has In 2003, a national public-private sought to generate behavior change partnership to promote HWWS was among mothers and caregivers of established in Senegal. The partnership children under five years of age and seeks to reduce illness and death from school-age children. The diarrheal disease and ARIs in children Handwashing-promotion activities of under the age of five through the the Senegal PPPHW emphasized promotion of HWWS. In Senegal, interpersonal communication diarrheal disease kills approximately activities. 40,000 children under the age of five each year, iii and in some years deaths In 2006–07, direct consumer contact are much higher because of cholera activities were carried out by an events outbreaks. According to the 2005 management firm in market places and Demographic and Health Survey, 13 in public schools as well as religious percent of children under the age of schools (also known as darras). In five had exhibited symptoms of ARIs addition, Handwashing-promotion during the two weeks preceding the activities were carried out with survey, and 22 percent of children women’s groups and in health centers. under five had diarrhea during the The interpersonal communication was same time period. complemented by mass media communication, such as TV spots The PPPHW was launched at the promoting Handwashing, which were request of the National Office for produced and aired by PPPHW partner Sanitation of Senegal (ONAS) and set UNICEF. By the end of 2006, the in motion with support from WSP, the Senegal PPPHW had more than 20 World Bank, and other members of the public and private partners. global PPPHW. ONAS is the national partnership’s lead agency. The agency Vietnam is also the key implementer of a World Bank–financed urban sanitation In 2006, the MOH, WSP, and project, which has a significant international soap companies, in hygiene promotion component. collaboration with other partners, established the Vietnam Handwashing A coordinator for the PPPHW was Initiative with the MOH of Vietnam as brought on board by ONAS in 2003. the lead agency. The overall objective During 2004, the efforts of the of the Vietnam Handwashing Initiative PPPHW Initiative in Senegal were is to safeguard the health of focused primarily on formative populations at risk of diarrhea and research, partnership building, and ARIs through a strategic fund-raising. The Initiative received communications campaign aimed at approximately US$700,000 in funding increasing HWWS. from the Japanese Social Development Fund in April 2005 to implement Diarrheal diseases and ARIs are the Handwashing-promotion activities in two most common causes of child four regions of Senegal: Dakar, illness and death in Vietnam. In 1998, _____________________________________________________________________ 5 Global Scaling Up Handwashing Project diarrhea accounted for roughly 18 Change Program. The Danish Embassy percent of all hospital admissions and funds will sponsor the groundwork for over 250,000 hospital cases. iv Use of the Handwashing communication oral rehydration salt is high in program, including development of the Vietnam, and thus mortality from campaign strategy and materials, airing diarrhea is very low. The 2002 of mass media, and roll-out of Vietnam Demographic and Health interpersonal communications in eight Survey estimated that 20 percent of provinces. Scaling Up Handwashing children under three showed symptoms Behavior Change funds from WSP will compatible with ARIs over a typical enable rapid scale-up of the same two-week period. v Improved hygiene activities in other locations within the is critical to reducing these numbers. country, with the additional benefit of Of all the hygiene behaviors, HWWS a strong M&E system and promotion is the most important and has the of lessons learned to other countries. potential to reduce diarrheal incidence by 42–47 percent. vi Studies also Peru suggest that washing hands with soap can reduce the incidence of ARIs by Attention to hygiene and Handwashing over 30 percent. vii got a significant boost in Peru in the 1990s because of the cholera epidemic, Based on a model developed in Latin but practice levels remained low, as America to promote HWWS, the shown by the Handwashing Initiative’s Vietnam Handwashing Initiative aims 2004 baseline. Only 11 percent of to capitalize on the extensive network mothers and 6 percent of children of Vietnam’s public health and washed their hands with soap before education systems coupled with the eating, and 17.6 percent of mothers private sector’s expertise in behavior and 12 percent of children after going change to more effectively promote to the bathroom. improved hygiene. The Initiative began with a Handwashing formative The PPPHW developed in Peru over research study funded by WSP. In several years beginning in 2002. In addition to formative research, the first 2003, PPPHW began intensive phase of activities in Vietnam focused advocacy efforts, carrying out a on fund-raising and building support Handwashing practices study and for the partnership among public and developing a business plan. In 2004, private institutions. USAID, WSP, and the Swiss Agency for Development and Cooperation Funding for Handwashing-promotion (COSUDE) agreed to provide funding. activities has been secured from two These funds were used to design an sources: US$860,000 for project overall project strategy and work plan, implementation from September 2006– initiate a Handwashing campaign, December 2007 from the Danish carry out communication activities, Embassy, and roughly US$2.5 million and monitor and evaluate the impact of for Handwashing activities from the campaign. The PPPHW also December 2006–December 2010 from secured the commitment of private the Scaling Up Handwashing Behavior sector funds. In 2006, training _____________________________________________________________________ 6 Global Scaling Up Handwashing Project workshops and promotional activities in gaining high-level national continued and a second campaign was commitment and in fostering a shared launched. This campaign was marked vision that transcends any particular by an effort to establish local alliances. member. In 2004, the MOH signed a In 2007, the WSP Scaling Up ministerial decree in support of the Handwashing Behavior Change Handwashing Initiative; in 2005, it Program began. These funds have been provided resources and a resolution in used to strengthen local alliances and support of a national program of continue the mass media campaigns. information dissemination. The To date the program has implemented participation of the Ministry of activities in 14 of Peru’s 24 regions. Education has resulted in an extension of the Initiative to schools. Fostering partnerships at the national, regional, and local levels has been a Both interpersonal communication (in key project strategy since the PPPHW schools and communities) and mass began. Although this has been difficult media (mostly print and radio) have and demanding at times, it has also made important contributions to been a major reason for progress. The changing knowledge, attitudes, and partnership has included donors; practices. M&E studies indicate that ministries of health and education; all of the communication channels provincial governments; used (mass media broadcasts, print nongovernmental organizations materials, training teachers and (NGOs); and private sector students, and training health staff and organizations such as banks, volunteers) contributed to reaching the agricultural companies, and soap target families, and that no single manufacturers. A national committee channel has predominated. formed in 2003 has been a key vehicle _____________________________________________________________________ 7 Global Scaling Up Handwashing Project 3. ANALYSIS BY DIMENSION This section is organized by each of remain an elusive goal. Developing the nine assessment dimensions. Each this shared vision and strategy in a dimension is defined and then further collaborative manner is also the subdivided into the key issues foundation for coordination and for identified across the four countries and creating motivation all levels. Policy is preliminary recommendations. In some defined as the set of procedures, rules, countries, these issues have been and allocation mechanisms that addressed effectively, while in other provide the basis for programs and countries, more work needs to be done. services. Policies set the priorities and When taken together, the issues often allocate resources for constitute the outline of an agenda for implementation. establishing the enabling environment for scaling up Handwashing programs. Analysis Rather than address all the issues, the preliminary recommendations focus on Developing a shared vision and those issues where there appears to be strategy. All four assessments enough experience to propose a emphasized the importance of a shared potential solution. vision and strategy among all key stakeholders. The national partnership In all four countries, the Handwashing in Peru, which has the most mature programs that existed prior to the WSP Handwashing program of the four Scaling Up Handwashing Behavior countries, also has a shared vision that Change Program used communications “transcends any particular member.� In and commercial marketing approaches large measure, this was accomplished aimed at facilitating behavior change by creating a strong and effective at a large scale. They also sought to National Committee that has served as involve a range of partners, including a vehicle for the partnership. In government agencies, NGOs, and contrast, neither Tanzania nor private sector companies. The WSP Vietnam, both of which are relatively assessment teams encountered new programs, has yet to develop a promising practices that have potential shared vision. In Vietnam, most applicability not only in the four target organizations interviewed said that countries but also in other countries. Handwashing activities are carried out based on individual agency strategies Policy, Strategy, and rather than on an agreed-upon national Direction vision and strategy. All of the countries emphasized the importance Establishing a shared vision and of developing the shared vision with strategy and ensuring the political will provincial and district governments, to implement it is the starting point for which, because of decentralization, scale-up. Without political will and a play key roles in project shared vision and strategy among implementation. stakeholders at all levels, scale-up will _____________________________________________________________________ 8 Global Scaling Up Handwashing Project Developing a formal national policy derailed by the agendas of one or two and translating it into sustained member organizations of the action. A formal national policy is a partnership. The consequences of necessary but insufficient condition for pursuing individual organizational scale-up. Further steps are needed. In agendas are that they may be in direct Peru in 2004, the MOH signed a conflict with the goals of the ministerial decree in support of the Handwashing Initiative and they may Handwashing Initiative. However, the discourage other partnership members decree has not necessarily led to from participating in the committee. In sustained action as manifested in work Vietnam, where the activity is still plans and activities on the ground. So, new, national leadership has not yet although the decree provides formal emerged. The MOH does not yet have recognition of the importance of a sense of ownership in part because of Handwashing, only when and where the perception that it is the WSP’s there has been a commitment of program. In Peru, the MOH has resources has there been sustained assumed program leadership primarily action. In Tanzania, a draft health because of their involvement at the policy has been in development since earliest stages of the Handwashing 2003, but there is no specific mention program and to national political of hygiene. The development of a commitment. national policy is further complicated in Tanzania by the role of the Ministry Developing linkages to other national of Water, which has funding for government programs. A common hygiene promotion but does not theme in the assessments was the need consider hygiene a priority, since its to develop linkages with other performance is not measured on programs in order to establish a hygiene-specific indicators. Although foundation for scaling up. In Vietnam, Senegal also issued a ministerial respondents suggested linking with an decree supporting Handwashing in existing strong Rural Water Supply April 2007, this has not yet been and Sanitation Partnership. In translated into guidance for local Tanzania, the importance of governments on how or whether to establishing strong linkages to the promote Handwashing. Ministry of Water was highlighted since that ministry has funding that Ensuring program leadership by could be used for Handwashing designating a lead national agency. programs. In Peru, one of the While all the assessments emphasized program’s successes has been the the importance of a broad-based integration with other initiatives, such partnership, they also emphasized the as the Ministry of Education’s Clean, importance of national government Safe, and Healthy Schools Program. leadership in any scaling-up effort. In The active engagement of the Ministry Senegal, for example, although there is of Education has been a very positive a shared vision in the Handwashing development. All the assessments also partnership, the lack of strong program indicated the importance of leadership by a national agency has establishing strong linkages with resulted in a program that risks being regional and district governments. _____________________________________________________________________ 9 Global Scaling Up Handwashing Project programs and access to water and Seeking high-level political support. sanitation facilities. The assessment Several of the assessments discussed teams for all four countries strongly the importance of high-level political endorse the current efforts to support at both the national and sub integrate Handwashing into existing national levels that can speak to the programs. importance of HWWS. In Tanzania, • Gaining high-level political support several respondents suggested the will benefit from an advocacy involvement of the permanent campaign aimed at decision makers. secretaries and possibly members of The Peru and Tanzania assessment parliament. Although political support teams both suggested the does not always translate into action, it development of an advocacy can lead to increased awareness and strategy along with materials for funding for Handwashing programs. In different levels of decision makers Peru, one of the recommendations that would be aimed at creating from the assessment was to develop legitimacy for Handwashing as a and implement an advocacy strategy health intervention. with arguments and materials for different levels and types of decision Partnerships makers. The HWWS program model is based Preliminary Recommendations on a establishing a public-private partnership. A partnership is a • Each country program should work relationship where two or more toward the development of a parties, having compatible goals, make national policy on Handwashing, an agreement to share the work, the such as the ministerial decree issued risk, the power, and the results or in Peru by the MOH. Such a policy proceeds. Partnerships need to be built is a precondition toward making at all levels among public, private, and available national government NGO sectors, among different levels of budgetary resources. The Senegal government, and between communities report recommends, for example, and local governments. the development of a national hygiene policy endorsed by the Analysis government. As yet, there is no evidence if a standalone hygiene Ensuring broad membership in the policy is better than having a partnership. The Peru report suggests hygiene policy that is integrated into a useful typology for the types of health or water and sanitation organizational partners common to policies. Handwashing initiatives. • Link with other national programs to the extent possible. In general, • Donors and governmental linkages with the ministries organizations that are involved responsible for education and water at the national level and share seem especially important given the responsibility for managing the importance of school-based program _____________________________________________________________________ 10 Global Scaling Up Handwashing Project • National-level implementation public, NGO, and private sectors. partners from the public sector, Although these members perceive the NGOs, and private companies benefits of the partnership, they also • Regional and local say the partnership has not functioned implementing partners, both well. The partnership has lacked strong public and private leadership, shared vision, and a coherent set of activities and messages The Peru assessment indicates that the and has not used a participatory partnership has been a particularly decision-making process. The successful aspect of the program, consequence is that organizations especially in involving the national pursue their own agendas. In Tanzania, private sector. Organizations have the partnership appears to be worked well together, although the functioning well at the national level in different working styles of the private terms of communication and and public sectors do occasionally collaboration, but the communication cause some friction. The partnership does not yet extend to the regions and also allows for differing levels of districts. Mechanisms are being engagement from being fully involved established for coordination between in the National Committee to simply the national and district levels and for providing financing. In contrast, at the collaboration at the district level. time of the assessment the Vietnam partnership had not yet really been Effective leadership of the partnership. formed, in part because of a delay in Like any organization, partnerships government approval and in part require effective leadership. The because the Handwashing Initiative assessments indicated in all cases that was being perceived as WSP’s project. this leadership logically belongs with However, the organizations involved the lead national government agency, acknowledge the value of such usually the MOH, in order to create collaboration. The Vietnam example government ownership of the program also points out the importance of and increase the potential for scale-up. involving local government partners in Partnership leadership must sometimes the partnership, since that is where be shared by more than one agency, as implementation decisions are made. in Tanzania where the Ministry of Health and Social Welfare and the Making the partnership function Ministry of Water are both key to the effectively. All the participating success of the Handwashing program. countries have formed partnership committees, but not all are functioning Recognizing the special nature of effectively. In Peru, where the partnerships. Organizations that partnership does function effectively, participate in partnerships generally do the primary factors seem to be so by choice and not by requirement. common agreement on goals and While strong leadership is important, strategy and regular information effective partnerships must also use a sharing on progress. In contrast, in participatory decision-making process Senegal a partnership has been formed based on consensus. Participatory with more than 30 members from the decision making is a key aspect in _____________________________________________________________________ 11 Global Scaling Up Handwashing Project generating partner buy-in and implementation of the agreements. ownership. In Senegal, the assessment Both the Senegal and Vietnam pointed out the potential for the assessment teams recommended the partnership to fall apart because of the development of Memoranda of perception that a “few organizations Understanding (MOUs) and clear might make unilateral decisions for the protocols that would clearly define program by proxy� in order to achieve the roles of partners as well as the their internal organizational goals. role of the steering committee and Because partnerships are not any technical committees. In Peru, hierarchical in nature, they require a the assessment team also special effort to clarify roles and recommended the more systematic responsibilities to avoid overlaps in use of MOUs than in the past. activities and maximize the use of • Actively seek to strengthen resources. One of the reasons for institutional leadership for HWWS. Peru’s successful national partnership Partnerships require institutionally appears to be its broad-based nature based leadership. Experience to date and the fact that it allows partners to seems to indicate that this leadership play different roles aligned with their should come from the lead national interests. Some provide only funding agency with responsibility for while others are involved with HWWS, as in the case of Peru. In particular aspects, such as the Vietnam, the promotion of the implementation of communication MOH’s leadership role is a key activities or M&E. The national-level recommendation in the assessment partnership in Tanzania has benefited report. from frequent communication and effective collaboration. Institutional Arrangements Preliminary Recommendations Institutions at all levels must clearly understand their roles, responsibilities, • Seek outside help in building the and authorities. They must also have partnership through a skilled the resources to carry out their roles. organizational development or In addition to clear roles and partnership facilitation expert. There responsibilities, institutional is a body of knowledge on how to arrangements must include the build effective partnerships that can mechanisms for actors at all levels to be tapped to address many of the coordinate their activities. deficiencies identified in the assessment reports. The Tanzania Analysis report explicitly recommended the use of partnership facilitation Identifying a ministerial home. A expertise to build a strong successful Handwashing program partnership structure. operating at scale needs a ministerial • Develop a formal partnership home that has the mandate, capacity, agreement that clarifies the roles staffing, and resources to play a and responsibilities of each partner leadership role. All the assessments and a way to monitor the pointed to the importance of having a _____________________________________________________________________ 12 Global Scaling Up Handwashing Project clearly identified ministerial home for advocacy role and support the Handwashing program. Typically implementation in specific areas such the ministerial home is in the MOH, as consumer marketing and capacity- although the decision might be less building. This appears to be a logical straightforward in a situation such as division of roles, although there could that of Tanzania, where both the be variation in other countries. In Ministry of Water and the Ministry of Senegal, most partners “seem unsure Health and Social Welfare logically where to start in defining and share the responsibility. In Senegal, the structuring roles.� The partnership is specific responsibility for developing memoranda of Handwashing rests with the understanding, but these do not yet Department of Preventive Hygiene and appear to be a linked with an overall Sanitation within the MOH. A related framework for defining the roles and question is the needed number of staff responsibilities of all partners. In Peru, and their specific roles. Although there as stated previously, the partnership is not yet enough experience to answer structure allows the members to play a this question with any degree of role that is consistent with their confidence, in Vietnam the plan is for specific area of interest. Organizational the Center for Environment and members play three broad roles: Community Health in the MOH to hire program management (donors and three persons focused on government), national level Handwashing: a technical officer, a implementation, and regional and local financial/procurement officer, and a implementing and financing partners. monitoring and evaluation (M&E) specialist. Country programs should all Clarifying the operational structure. assess whether the number of This issue is related to the structure of ministerial staff allocated to the partnership itself. The Peru Handwashing is sufficient to play a PPPHW mentions that one of the leadership role effectively. difficulties inherent in developing an operational structure with clear Clarifying roles and responsibilities. procedures is the preferred style of Since the institutional model for the informality of the private sector, Scaling Up Handwashing Behavior especially in contrast with the typical Change Program is based on rules-based culture of government partnership, it is especially critical to organizations. The development of a have clear roles and responsibilities clear operational structure will allow among the public, private, and NGO the partnership to function effectively, sectors and among different levels of but it is also important to implement a government. Broadly speaking, the Handwashing Initiative at scale. The Tanzania assessment suggested that Senegal assessment report mentions the central ministries play a normative the very nitty-gritty issues of role and provide guidance in planning communications, procurement, and implementation; districts have warehousing, and transportation that responsibility for planning, need clearly defined procedures. implementation, and M&E; and NGOs and private sector companies play an _____________________________________________________________________ 13 Global Scaling Up Handwashing Project Establishing coordination mechanisms Preliminary Recommendations at all levels. In Tanzania, which does not have a history of Handwashing • Establish the identification of a programs, the mechanisms for ministerial home with adequate interagency and interlevel coordination staffing as early in the program as are being established. Although the possible in order to use the Scaling- partnership committee seemed to focus Up Handwashing Behavior Change initially on coordination at the national Program as an opportunity for level, the Tanzania report says the building capacity. This issue has same kind of interagency and been flagged in Vietnam, for intersectoral coordination must occur example, and recommendations at the district level to facilitate have been made to develop the planning and implementation. In capacity of the Center for Tanzania, this could be the role of the Environment and Community district executive director or regional Health in the MOH. administrative secretary. This kind of • Clarify in broad terms a framework intersectoral coordination is especially for the roles and responsibilities of important when there are multiple all categories of partners for ministries involved in the program. implementation. There appears to be general agreement in all countries Involving all levels of government. that central ministries have a One of the common themes in all the normative role and provide program countries is the need to involve the guidance; districts have lead regions and districts in the planning implementation responsibility; and implementation of the PPPHW. In NGOs carry out special enabling Vietnam, provincial Department of functions such as advocacy, Health staff stated that the People’s capacity-building, and Committee in each province must implementing interpersonal agree with any activities that the MOH communication at the local level; proposes. Aside from the issue of buy- and the private sector provides in at the district level, there is the issue financing and marketing, and makes of financial resources for available Handwashing products. implementing the Handwashing • Establish coordination mechanisms Initiative at scale. With the at both the national and local to decentralization of functions to local ensure interagency and intersectoral government, budget requests for coordination. This could occur district-level implementation must through existing interagency or originate at the district level since they intersectoral mechanisms, as in are now responsible for planning and Tanzania, or possibly through budgeting. In Peru, where tapping into fully functioning decentralization is relatively advanced, partnerships, such as the Rural the assessment makes specific mention Water Supply and Sanitation of this point, as does the Tanzania Partnership in Vietnam. assessment. _____________________________________________________________________ 14 Global Scaling Up Handwashing Project Program Methodology principles of the methodology. In addition, there seems to be general HWWS programs have a seven-step acceptance of other key aspects of the program methodology. A program program, such as the use of formative methodology consists of the program research to develop a plan for rules and specific activities, with their promoting behavior change, the use of timing and sequence. Each country participatory training methodologies, adapts and applies the program and interpersonal communication that methodology to make it specific and is supported by print materials. In appropriate to the country context. A Peru, there seems to be widespread workable program methodology that is understanding and acceptance of the clear and agreed upon by all key PPPHW methodology, which is the stakeholders is a key programmatic result, in large measure, of the condition. effectiveness of the national level partnership and the effective Analysis engagement of provinces and districts. In Senegal, rigid application of the Box 1: Seven core principles of a PPPHW methodology appears to have Handwashing program alienated partners who use other approaches, especially those who 1) Target a small number of risk would rather rely more on practices interpersonal communication. There is also a perception in Senegal (a 2) Target specific audiences perception shared by a few informants 3) Identify the motives for changed in Peru) that the program relies on behavior “one-shot campaigns.� In both Tanzania and Vietnam, the 4) Ensure that hygiene messages are methodology is not yet widely positive understood. In Tanzania this was in part because new individuals had been 5) Identify appropriate channels of introduced to the program. In Vietnam, communication most organizations do not understand 6) Decide on a cost-effective mix of the social marketing approach and were unaware that the approach was channels intended to use both social marketing 7) Carefully plan, execute, monitor, and partnering. The reason for this and evaluate hygiene promotion appears to be that a formal review of the approaches currently being used in Vietnam had not yet taken place and that no focused effort at building the Commonly understood and accepted capacity of partners in the PPPHW program methodology. The Scaling- methodology has been done. Clearly, Up Handwashing Behavior Change capacity needs to be built in social Program has a defined methodology marketing and behavior change in based on the use of mass media, order to gain widespread acceptance. interpersonal communication, and partnership. Box 1 lists the seven core _____________________________________________________________________ 15 Global Scaling Up Handwashing Project Balance of interpersonal and even communities to adapt the communication and mass media. One methodology. The question this raises recurring theme is the appropriate is whether an approach that is tailored balance of mass media and to each country and makes greater use interpersonal communication. Critics of interpersonal communication can be of interpersonal communication cite its done at scale. A possible approach is labor intensiveness, especially for a to create an umbrella project at the program designed to reach scale. This national level that includes print and issue was raised in every assessment broadcast media, training, and other report. In Peru respondents at the tools and then allowing local partners district and regional level emphasized to adapt them. the need for interpersonal communication and viewed mass Integration of Handwashing into other media as a supporting element. The programs. Several of the assessments authors of the Peru report believe cited the integration of PPPHW with interpersonal communication can be existing programs as an essential effective on a large scale if there are strategy for scaling up. Existing strong local partnerships, training of programs leverage resources since they change agents, and contracts with already have an established implementing agencies for training programmatic infrastructure. In teachers and health personnel. In addition, there are natural Senegal, there was a strong feeling programmatic synergies such as the among some partners that linkage between hygiene behavior interpersonal communication must be change and nutrition. The Tanzania an essential element of the report suggested linking PPPHW to methodology. HIV/AIDS care and prevention since the target audiences—mothers of Degree of flexibility in adapting childbearing age and caregivers of methodology to the country context young children—are similar. In Peru, and even down to districts. In the assessment team mentioned three Tanzania, Vietnam, and Senegal, national initiatives—Reduction of respondents cited the importance of Infant Malnutrition, Healthy Schools, adapting PPPHW methodology to the and Water for Everyone—as local context. In the case of Senegal, possibilities for integrating this is important to gain buy-in and Handwashing into other programs. As ownership over the approach. Partners of yet, there is relatively little said that a “Senegal-developed and documented experience in how to adopted HWWS behavior change bring about this kind of integration. approach� is needed. In Vietnam, one of the primary recommendations is the Preliminary Recommendations need to understand the approaches currently being used and assess how • Widespread acceptance of the much they have changed behavior in PPPHW methodology will not order to develop a tailored approach happen without a full discussion for Vietnam. In Tanzania, partners among partners about existing pointed out the need to allow districts Handwashing programs and their _____________________________________________________________________ 16 Global Scaling Up Handwashing Project experience with those programs. Analysis Program managers need to be open to country-level adaptation if Linkages to the existing government ownership of the methodology is the operational structures. All the goal. In both Senegal and Vietnam, assessments made the important point the assessment teams recommended that scaling up requires tapping into that the partnerships thoroughly the government operational structures discuss and agree upon a at the central, regional, district, and methodology adapted to the country community levels. All the reports context. either stated or implied that scaling up • Each country program should cannot occur without the intentional actively seek to identify use of these structures, since these staff opportunities for integrating are already on the payroll with secure Handwashing into other initiatives jobs and are not project-based and to define what integration employees. In Senegal there are over means operationally. The Peru 600 trained field-based staff that could assessment recommends that the be utilized for Handwashing. The Handwashing Initiative encourage assessment teams acknowledged the the strengthening of Handwashing role of NGOs and the contribution they promotion within existing programs, can make, but also implied that NGOs especially those aimed at schools, are not the complete answer for a nutrition, and water and sanitation. national-level program. Implementation Capacity Capacity building at all levels. Capacity building is necessary in all Clearly defined institutional roles and aspects of PPPHW, including such responsibilities are not sufficient for areas as behavior change programs to operate at scale. In communication, M&E, and the addition, institutions at all levels must training of trainers. None of the have the institutional capacity to carry countries appears to have developed a out their roles and responsibilities. comprehensive and systematic training Institutional capacity includes strategy or training plan that identifies adequate human resources with the the target population, areas in which full range of skills required to carry training is needed, training providers, out their functions, an “organizational and a schedule. To date, capacity- home� within the institution that has building efforts in most countries seem the assigned responsibility, mastery of to have focused primarily on national- the agreed-upon program level capacity but have not extended methodology, systems and procedures their focus to the districts. However, in required for implementation, and the Peru there has been training of local ability to monitor program personnel, especially teachers, in the effectiveness and make continual regions. The assessments indicate that adjustments. capacity building at the local level is especially important. District officers in Tanzania stated that they need training in the PPPHW methodology. _____________________________________________________________________ 17 Global Scaling Up Handwashing Project Also in Tanzania, the report cites the • Systems and procedures should be need to train existing community-level developed as part of the approach to cadres such as the village health strengthening implementation workers and home-based providers. It capacity. In Vietnam, the is also important to note that capacity assessment team recommends that a building is more than training and also system for distribution and includes technical support, mentoring, dissemination of materials be and knowledge-sharing. established. In Senegal, the recommendation is to develop Development of systems and systems for sharing information on procedures. Capacity building is not a regular basis. sufficient to develop full implementation capacity. In addition, Availability of Products and systems and procedures and the use of Tools the information that they generate must be built in all aspects of the A HWWS behavior change program Handwashing program. Interestingly, requires—in addition to promotion of the only systems that were explicitly the behavior—that the product, price, discussed in the assessment reports in and place dimensions of the any depth were M&E, and in the case Handwashing marketing mix are of Senegal the absence of information- addressed. The ability of the target sharing systems. In addition to M&E, consumers to adopt the promoted systems that are equally important behavior is highly dependent on the include supervision, production of existence and availability of soap(s) communication materials and their that respond to consumer preferences distribution, means of transport of field and their willingness and ability to pay staff to communities, training systems, for them. In addition to soap, the and information-sharing systems. It Handwashing marketing mix may may not be advisable to create systems include water and other items, specific just for HWWS, as there may be to each country situation, such as systems for the broader health services to maintain Handwashing programs that can be built upon. The facilities. lack of discussion about the systems and procedures that need to be Analysis developed indicates the need to focus on this. Linkage of Handwashing to access to water and sanitation. All the Preliminary Recommendations assessments cited the importance of linking Handwashing activities to • Each country should develop a access to water and sanitation comprehensive plan for building facilities. In Tanzania, access to water capacity at all levels. As the Peru continues to be a limiting factor in report recommends, the approach promoting Handwashing. In addition should be one based on the training to household access in rural of trainers and systematic follow-up communities, many schools do not after the training has taken place. have water, and rarely do latrines have _____________________________________________________________________ 18 Global Scaling Up Handwashing Project water available for Handwashing. The Provision of Handwashing facilities. Tanzania assessment team suggested There does not appear to be any linking Handwashing efforts to the consistency in how Handwashing Rural Water Supply and Sanitation facilities are provided. In Peru, Program, which aims to raise water respondents stated that the provision of supply coverage in rural areas from 53 plastic washing bowls and pitchers percent in 2003 to 79 percent in 2015. have been useful. The Peru assessment Clearly, women and children are more team believes that the districts should likely to wash their hands with soap if continue to do this rather than the water is available close to home. national partnership. In Senegal, Similarly, in Vietnam, respondents felt although several NGOs suggested strongly that Handwashing should be including Handwashing facilities as included in water supply programs and part of the construction package, they should not be promoted in areas where also said they are rarely included. In access is limited. general, the best way to provide Handwashing facilities is an area Availability of soap. Soap generally worthy of further study. appears to be available in households in all the target countries, although in Preliminary Recommendations some countries, such as Tanzania, proximity to supplies may be a • Each country should develop a problem. Peru reports 98 percent plan for ensuring the availability of availability in homes with the key products and tools—soap, exception of some isolated mountain Handwashing facilities, and communities. Senegal and Vietnam materials. The Vietnam report also appear to have wide availability. makes the explicit recommendation However, questions have been raised to develop such a plan for the eight in Senegal concerning whether pilot provinces. In Peru, the households have the actual buying recommendation was made to power to purchase soap, since soap and encourage municipal governments Handwashing station materials have to support infrastructure such as been subsidized 100 percent to date by water faucets near kitchens and the PPPHW. So while there may be latrines to facilitate Handwashing access to soap, there is no evidence at key times. that households would purchase it if subsidies were removed. Similarly, in Financing Tanzania, the assessment team was told that rural people could not afford This dimension is aimed at assessing soap for Handwashing, although the the adequacy of arrangements for report did not indicate whether the financing the programmatic costs. marketing study addressed this issue. These costs include training, staff In Vietnam, there has been insufficient salaries, transportation, office attention given to the overall question equipment and supplies, and the of availability of soap, including development of communication and access, affordability, and willingness education materials, as well as to pay. _____________________________________________________________________ 19 Global Scaling Up Handwashing Project programmatic line items in budgets for Senegal, the budget does not appear Handwashing-promotion activities. sufficient for all activities, including mass media airing, regional training, Analysis and institutional capacity building. The Vietnam assessment concludes that the Minimizing dependency on donor budgets do not clearly distinguish funding. To date, PPPHW efforts have between investment and recurrent been dependent on donor funding. costs and that all costs have not been Only in Peru have funds been raised budgeted, including those for capacity from national sources, including building and reproducing materials. government, although the report does not provide a breakdown. In Senegal, Working through the local government no national monies have been allocated budget process. The Tanzania and for the Handwashing Initiative. In Peru assessments both point out that Tanzania, the degree of donor the long-range solution to financial dependency is such that the sustainability and scale-up is to Handwashing project is seen as a allocate funds for Handwashing World Bank–funded project rather promotion in local government than a partnership with substantial budgets. The Peru report suggests that funding from national sources. The implementing agencies from the Ministry of Water has allocated Handwashing Initiative should US$1.95 million for sanitation and participate in these deliberations. hygiene, but it is not clear how the Similarly, the Tanzania report says that hygiene portion of these funds is to be Handwashing promotion must be used. In Vietnam, funding for included in the programming of the Handwashing to date has come from monies allocated to districts each year. the Danish Embassy and now the In Tanzania, however, it is problematic Gates Foundation through WSP. that the performance of those who Scaling up cannot occur without the control these funding decisions is not national government’s financial being measured by any indicators participation. related to Handwashing. Finding a way to allocate funds for Handwashing in Budgeting for a full range of costs to local government budgets will require ensure sustainability and expansion. guidance to districts on how to The full range of costs needed to program those funds in a way that ensure sustainability and expansion supports the goals of the Handwashing has not yet been fully considered. program and therefore contributes to These costs include the upfront the country’s diarrhea incidence investment costs needed to start up a reductions targets. program and the recurrent costs needed to sustain it over time. The focus so far Preliminary Recommendations has been primarily on the investment costs—market surveys, training, • Each country should develop a communication materials—that are financial plan for sustainability and needed to implement Handwashing scale-up that includes donors, the activities in the pilot regions. In private sector, and national _____________________________________________________________________ 20 Global Scaling Up Handwashing Project government sources. The Senegal focus in this assessment is to ensure and Vietnam reports both that information will be collected from recommended that national budgets the outset and that the capacity to include a line item for HWWS. All collect the information is in place. the reports acknowledge, however, that other sources of financing are Analysis needed, including donors and the private sector. Raising awareness about the concept • Scale-up is unlikely to occur of cost-effective implementation. At the without a process to involve time of the assessment, only Peru had regional and district governments, collected cost information. However, since planning and budgeting is this is largely a reflection of the fact increasingly the responsibility of that when the assessments were carried local government. In Peru and out, WSP impact evaluation and M&E Tanzania, the authors strongly system designs were still in draft and suggested that more attention be were therefore not reflected in the paid to utilizing the local enabling environment analysis. WSP is government planning and budgeting now setting up systems to measure process as a way to finance scale- cost effectiveness in each of the up. countries. • Affordability for a scaled-up program cannot really be Capacity to collect and analyze cost determined unless subsidies are data. All the countries appear to have removed. The Senegal team the capacity at the national level to recommended that a policy position collect and analyze information cost be formulated on Handwashing data to determine cost-effective subsidies and that a test of implementation. When the systems for willingness to pay and affordability measuring cost effectiveness are be conducted on a pilot basis. established, some additional capacity building may be necessary, especially Cost-Effective at the local government level. Implementation Preliminary Recommendations The potentially high costs of promoting • Systems need to be set up to track HWWS behavior at scale make cost- implementation costs or the effective implementation a key element. follow-up assessment in three It is essential to understand how the years will not be able to inform unit costs change as activities are project learning in this dimension. scaled up. Although it will not be This effort is apparently underway possible to assess the cost effectiveness in all countries. of the approach and how best to achieve economies of scale until the end of the project, data must still be Monitoring and Evaluation collected during implementation to make this determination when the A large-scale HWWS behavior change project is completed. Therefore, the program requires regular monitoring _____________________________________________________________________ 21 Global Scaling Up Handwashing Project and, perhaps more importantly, the points out the importance of utilizing willingness and ability to use the the existing M&E systems rather than monitoring process to make creating a parallel system. adjustments in the program. Effective monitoring will identify strengths and Developing capacity for M&E. All the weaknesses in the program countries except Vietnam reported that methodology, implementation the capacity for M&E does exist at the arrangements, and cost efficiencies. national level. Increased Overall monitoring responsibility must decentralization has led to the be at the highest level of the program, development of capacity at the local but must be based on information government level. In Vietnam, collected at the local government or provincial and district staff report that district level. they have developed M&E systems to collect traditional epidemiological Analysis data. So while capacity may exist at the national and local level, it is not Putting in place M&E systems. The being used for Handwashing. In some assessment teams reported that, at the cases, this is the result of the lack of time of the assessment, M&E systems adequate staff; in others, Handwashing were not yet in place for the is simply not on the list of health Handwashing Initiative. However, interventions that are monitored. As a WSP has concrete plans to establish result, in Peru, a national NGO partner such systems. There does appear to be assumed M&E responsibilities for the broad awareness of the importance of Handwashing Initiative. A critical M&E. In Peru, for example, aspect of strengthening M&E capacity respondents said that “M&E needs to is to improve the use of M&E data to be a key component of the expanded advance program implementation. program and the opportunity to show how well different interventions work Preliminary Recommendations should not be lost.� One especially important issue raised in the Peru • Define and agree upon indicators for assessment is how to “allow local Handwashing in each country. implementers flexibility in the • Establish M&E systems. A critical program, yet keep sufficient issue to resolve is where to place the uniformity in the project districts to be responsibility for M&E—in an able to generalize about them in NGO partner, as in Peru, or with the relation to the control districts.� Since national government lead agency. flexibility at the local level is a WSP is assisting in setting up these common theme in the assessment, this systems in all countries. issue will need to be addressed as countries develop their M&E systems for the initiative. The Tanzania report _____________________________________________________________________ 22 Global Scaling Up Handwashing Project 4. THE WAY FORWARD This section provides preliminary available. The policy must also guidance on the way forward to be complemented by an strengthen the enabling environment implementation plan that for Handwashing. As discussed earlier provides the resources and in this document, this guidance should activities needed to translate be seen as preliminary, since the the policy into action. Scaling Up Handwashing Behavior • Developing a broad-based Change Program is still in the early partnership is essential, but it is stages of implementation and has not not a replacement for the developed a fully informed set of leadership that only a national recommendations. Nevertheless, the government agency can analysis of the four enabling provide. In most countries, the environment assessments does provide leadership of the partnership an early indication of some key lessons committee seems to be in the learned. ministry of health. • Partnerships will not function Overall Conclusions effectively merely because they are formed. Partnerships are The following are overall conclusions, organizations and as such will derived from the assessments, about require a shared vision, strengthening the enabling effective leadership, environment for scaling up a organizational structure, clear Handwashing initiative. They have partner roles and broad significance for the wider responsibilities, agreed upon Handwashing community. set of activities, agreed upon operating agreements, regular • Developing a shared national communication, and vision and strategy at all levels participatory decision making. requires a focused effort A partnership needs to involving key partners. The intentionally and systematically assessments indicate that the work through these issues to be vision and strategy cannot be effective. lifted wholesale from the basis • Scale-up requires working PPPHW methodology and that through the government some country-level adaptation operational structure at the is necessary to ensure local central, regional, and local ownership and buy-in. levels. Only the national • A formal government policy is government has the personnel a necessary but insufficient to implement an initiative such condition for scaling up. as Handwashing at scale. Without it, national budget Increased decentralization resources are unlikely to be means that implementation responsibility for Handwashing _____________________________________________________________________ 23 Global Scaling Up Handwashing Project is located principally at the addressed the financial district level. requirements and funding • The general PPPHW program sources for a scaled-up methodology is likely to face program. some resistance unless there • Cost-effective implementation are thorough discussions in is a concern, but is not yet well each country, so country understood, with the exception programs feel the methodology of Peru. is tailored to their context. • Although capacity for M&E Some flexibility in the exists in most countries, methodology is necessary. In indicators have not been particular, the right balance defined and, with the exception between mass media and of Peru, M&E systems have interpersonal communication not yet been established. needs to be discussed. • The integration of HWWS into Preliminary Guidance other programs, such as programs concerned with Table 2 summarizes the water, health, and education, recommendations from each increases the likelihood of dimension found in the third section of scale-up. In particular, the report for strengthening the countries believe that enabling environment for Handwashing should not be Handwashing. The guidance in this promoted in areas where access table is based both on actual practices to water and sanitation and on the recommendations provided facilities is limited. in the assessment reports and were, for • Capacity building requires the most part, reflected in more than more than training. In addition, one assessment. These it requires the development of recommendations are intended to systems and procedures to provide guidance for actions at the enable the application of the country level. As discussed previously, skills and knowledge learned in this guidance is not intended to be a training programs. comprehensive set of • The availability of soap does recommendations that addresses all the not appear to be a problem, elements in each dimension. They are, although its affordability to instead, what can be reasonably put rural populations is not entirely forth at this stage of the Scaling Up clear where it has been Handwashing Behavior Change subsidized by the Handwashing Program. Initiative. • A financial plan to achieve scale-up is essential. To date, programs have relied on external funding and have not _____________________________________________________________________ 24 Global Scaling Up Handwashing Project Table 2: Summary of Preliminary Recommendations Dimension Guidance Policy, Strategy, • Gaining high-level support will benefit from an advocacy and Direction campaign aimed at decision makers. Advocacy is also important in creating legitimacy for Handwashing as a health intervention. • Each country program should work toward the development of a national policy on Handwashing, such as the ministerial decree issued in Peru by the MOH. Such a policy is a precondition for making available national government budgetary resources. • Link with other national programs to the extent possible. In general, linkages with the ministries responsible for education and water seem especially important, given the importance of school-based programs and access to water and sanitation facilities. Partnerships • Seek outside help in building the partnership through a skilled organizational development or partnership facilitation expert. There is a body of knowledge on how to build effective partnerships that can be tapped into that would address many of the deficiencies identified in the assessment reports. • Develop a formal partnership agreement that clarifies the roles and responsibilities of each partner and a way to monitor the implementation of the agreements. • Partnerships require institutionally based leadership. Experience to date seems to indicate that this leadership should come from the lead national agency. Institutional • Identification of a ministerial home and staffing it should Arrangements occur as early in the program as possible in order to use the Scaling Up Handwashing Behavior Change Program as an opportunity for building capacity. • Clarify, in broad terms, a framework for the roles and responsibilities of all categories of partners for implementation. There appears to be general agreement that central ministries have a normative role and provide program guidance; districts have lead implementation responsibility; NGOs carry out special enabling functions such as advocacy and capacity building; and the private sector provides financing and marketing, and makes available Handwashing products. • Coordination mechanisms at both the national and local levels need to be established to ensure interagency and intersectoral coordination. This could occur through existing interagency mechanisms, as in Tanzania, or possibly tapping into fully functioning partnerships such as the Rural Water Supply and _____________________________________________________________________ 25 Global Scaling Up Handwashing Project Dimension Guidance Sanitation Partnership in Vietnam. Program • Widespread acceptance of the PPPHW methodology will not Methodology happen without a full discussion among partners about existing Handwashing programs and experience with them. Program managers need to be open to country-level adaptation if ownership of the methodology is the goal. • Each country program should actively seek to identify opportunities for integration of Handwashing into other initiatives and define what integration means operationally. Implementation • Each country should develop a comprehensive plan for Capacity building capacity at all levels. As the Peru report recommends, the approach should be one based on the training of trainers and systematic follow-up after the training has taken place. • Systems and procedures should be developed as part of the approach to strengthening implementation capacity. Availability of • Each country should develop a plan for ensuring the Products and availability of key products and tools—soap, Tools Handwashing facilities, and materials. Financing • Each country should develop a financial plan for sustainability and scale-up that includes donors, the private sector, and national government sources. • Scale-up is unlikely to occur without a process to involve regional and district governments, since the responsibility for planning and budgeting is increasingly the responsibility of local government. • Affordability for a scaled-up program cannot really be determined unless subsidies are removed. Cost-Effective • Systems need to be set up to track implementation costs Implementation or the follow-up assessment in three years will not be able to inform project learning in this dimension. Monitoring and • Indicators for Handwashing need to be defined and Evaluation agreed upon in each country. • M&E systems need to be put in place. A critical issue to resolve is where to place the responsibility for M&E—in an NGO partner, as is the case in Peru, or with the national government lead agency. _____________________________________________________________________ 26 Global Scaling Up Handwashing Project Learning Agenda for linkages with other programs is Enabling Environment a key strategy in scaling up to avoid creating duplicative The Scaling Up Handwashing program structures and to take Behavior Change Program places great advantage of programmatic emphasis on learning from the four synergies. Understanding how country programs. The analysis and these linkages were established preliminary recommendations in the would serve to identify analysis by dimension have suggested practices that could be a number of knowledge gaps in replicated in other countries, HWWS programs that are elements of especially from an operational scaled-up and sustainable standpoint. Handwashing programs. This section provides specific suggestions for a 3. Involving local government in learning agenda for WSP for training, planning and strengthening the enabling budgeting, and M&E. Another environment. The items in the learning recurring theme in all the agenda are intended to better inform countries is the importance of the creation of an enabling involving local government in environment for Handwashing implementation. None of the programs at scale. WSP should ensure assessment reports provided that the knowledge products suggested much information on how this below are used to further learning experience has worked to date about strengthening the enabling and what has been learned. For environment for Handwashing. the most part, the recommendations were 1. Documenting the process used prospective, which means there to develop national is much to learn as partnerships. One of the Handwashing initiatives common themes in this report increasingly work with local is the need to pay focused governments. attention to how to develop an effective national partnership. 4. Guidance on the use of mass Peru appears to have the media versus interpersonal strongest national partnership communication. The of the four countries, but there assessment reports indicate that is relatively little information this remains a somewhat in the report on the steps that unresolved methodological were taken to build the issue. The question is whether partnership and the lessons that a program that uses extensive were learned. interpersonal communication can be scaled up efficiently. 2. Case studies on how to Because partners in countries establish linkages with other such as Senegal and Tanzania programs. Establishing believe this to be an important issue, this methodological issue _____________________________________________________________________ 27 Global Scaling Up Handwashing Project should be studied further and 7. Standard templates for tracking guidance provided. costs. Although all four countries appear to have the 5. Case studies on how countries capacity for tracking cost have used existing operational information, none except for structures to scale up. One of Peru has the systems to do so. the conclusions of this report is WSP could provide standard that the use of existing templates with line items and operational structures, often cost factors. government staff, is one of the key strategies for scaling up. 8. Developing standard M&E Which operational structures indicators. Several of the have been used? What was assessment reports stated that required to tap into them? How indicators that will serve as the was the new responsibility for basis for M&E have not yet Handwashing added on to job been developed. Indicators descriptions? What training should not be limited to was done to develop the tracking behavior change but capacity of these staff? also include enabling environment indicators related 6. Designing a financial plan for to key dimensions such as scale-up. The reliance on partnership, policy, external funding from donors implementation capacity, and and the private sector has not financing. led to a comprehensive understanding of how to 9. Tracking the interest and estimate and fund scale-up. commitment of the private What exactly does it cost to sector. None of the reports, implement a Handwashing with the exception of Peru, say campaign in a province or much about the role of the district once the investment private sector. WSP should costs of forming a partnership, continue to monitor the interest creating institutional structures, of the private sector and its and developing communication companies’ sustained materials have been made? commitment to HWWS. The Understanding these marginal private sector includes not only costs will allow policy makers soap manufacturers, but other to determine whether the companies that contribute program can be funded from resources as part of their government sources. Without commitment to being socially such a plan, there will be no responsible. exit strategy for the donors and organizations that initiate the In addition to these items, in the campaign. course of the implementation of the country programs, other items for a learning agenda for the enabling _____________________________________________________________________ 28 Global Scaling Up Handwashing Project environment may be identified. programs offer lessons about The post-implementation enabling partnership, and water and environment assessment will also sanitation programs can provide be an opportunity to identify what lessons about how to involve local worked and what did not to create governments. Together, these kinds an effective enabling environment of activities can continue to inform for Handwashing. Other sectors the central challenge of creating an may also offer lessons learned that enabling environment for scaled up can be applied to HWWS and sustainable HWWS programs. programs. For example, HIV/AIDS i Global PPPHW partners include the Water and Sanitation Program, USAID, the World Bank, UNICEF, the London School of Hygiene and Tropical Medicine, U.S. Centers for Disease Control and Prevention, the Academy for Educational Development, the Water Supply and Sanitation Collaborative Council, Colgate-Palmolive, Procter & Gamble, and Unilever. ii Tanzania Demographic and Health Survey 2004. iii Senegal Demographic and Health Survey 2005. iv World Bank (East Asia and Pacific Region. Vietnam Country Unit. Human Development Sector Unit). 2001. Vietnam, Growing Healthy: A Review of Vietnam’s Health Sector. Washington, DC: World Bank. June 29. v Vietnam Demographic and Health Survey 2002. vi Curtis, Valerie and Cairncross Sandy. 2003. “Effect on Handwashing with Soap on Diarrhea Risk in the Community: A Systematic Review.� The Lancet Infectious Disease 3: 280–81. 7 Rabie, Tamer and Valerie Curtis. 2006. “Handwashing and Risk of Respiratory Infections: A Quantitative Systematic Review.� Tropical Medicine & International Health 11 (3): 258–67. _____________________________________________________________________ 29 Global Scaling Up Handwashing Project