33512 Health in Your Hands: Lessons from Building Public- Private Partnerships for Washing Hands with Soap July 2002, 2nd Edition The World Bank does not accept responsibility for the views expressed herein, which are those of the authors, and should not be attributed to the World Bank or its affiliated organizations. The findings, interpretations and opinions expressed in this document are the result of a research supported by the Bank. The designations employed and the presentation of the material are solely for the convenience of the reader and do not imply the expression of any legal opinion whatsoever on the part of the World Bank or its affiliates concerning the legal status of any country, territory, city, area, or its authorities, or concerning the delimitations of its boundaries or national affiliations. Lessons from Building Public-Private Patnerships for Washing Hands with Soap Contents Introduction 2 Executive Summary 3 Part 1 The Public Private Partnership for Handwash: A Brief History 5 Part 2 Why Handwashing? And Why a Public Private Partnership? 6 Part 3 The Approach Step-by-Step 9 Part 4 Understanding Handwashing with Soap 14 Part 5 Future Challenges, Conclusions 19 List of Tables Partnership Partners 2 Possible incentives and contributions for public/private players in the Handwash Public Private Partnership 8 Handwashing with soap by mothers in Ghana and Kerala 15 List of Boxes Key Lessons 4 Observed handwashing practices in Ghana and Kerala 15 The soap habit 17 Key Lessons 19 List of Figures Steps 3 Leading Infectious Killers 7 Role of the partners in the Handwashing Public Private Partnership 14 The pyramid of cleanliness 16 Range of influences on a Kerala village that can potentially be harnessed 18 Introduction Washing hands with soap could save a million lives. Eighteen months ago, a small team from the Water and Sanitation Program, the World Bank and the London School of Hygiene and Tropical Medicine set out to answer the following question: "Can the expertise and resources of Industry and Governments be coupled to design and deliver large-scale, high-impact handwash promotion programs?" A year and a half on, public-private partnerships for handwashing with soap are in place in Ghana and Kerala, and full-scale handwash promotion programs have been designed. Other countries are set to join the initiative. This document outlines the approach that was taken, and offers lessons for those interested in setting up such programs in future. Partnership Partners International In Ghana In Kerala s Community Water and s Kerala Rural Water Supply s Water and Sanitation Program Sanitation Agency and Sanitation Agency s World Bank (CWSA) (KRWSA) s Ministries of Health, s Government of Kerala, s London School of Hygiene & Tropical Medicine Education, Works and Government of India Housing, Women and s Hindustan Lever Ltd. s UNICEF Children's Affairs s Indian Soap and Toiletries s Ministry of Local s USAID Government and Rural Makers' Association Development (ISTMA) s AED s Khadi and Cottage Industry s Association of Ghanaian Industries Board s Ministry of Health, Ministry s Unilever Ltd, GETTRADE, PZ Cussons of Rural Development s UNICEF s UNICEF s WHO s World Bank s World Bank s Water and Sanitation Program s Water and Sanitation Program 2 Executive Summary Programs to promote handwashing with soap could be amongst the most effective and cost- effective interventions for reducing infectious diseases in the world today. A million lives could be saved each year, if hands were washed systematically with soap. Whilst public agencies are interested in saving lives, private industry is more interested in selling soap. This is the founding rationale for a public-private partnership to promote handwashing with soap. However, partnership can bring other benefits; industry enhances its image and knowledge whilst the public sector benefits from state-of-the-art communication skills of private industry. After 18 months of work, two programs are ready for launch in the state of Kerala, India and in Ghana. Building up the partnerships was a slow and resource-intensive process. Success will ultimately be judged by carefully measuring the impact of the programs. In the meantime, four factors argue for the pursuit of the Public Private Partnership, both in the two trial countries and in expanding the initiative to a limited number of other countries: · The handwash programs that have been designed are groundbreaking. · Many enquiries on joining the initiative have come from Governments, NGOs and external support agencies. · Three major global industrial players are in discussions on expanding the initiative. · International interest in handwashing as an intervention has grown in the past two years, increasing the need for well-documented trials of new approaches. Many private and public agencies are interested in setting up Public Private Partnerships for Handwashing in their own countries. This document is primarily for them. It is also for decision makers in Industry, Government and external support agencies, who need to know if investing in such activities is likely to be worthwhile or not. Part 1 of this document explores the rationale for handwashing programs and for Public Private Partnerships; Part 2 outlines the history of the initiative; Part 3 documents the approach; and Part 4 covers insights about handwashing gleaned from consumer research and the implications of the findings for the handwash programs. Part 5 provides conclusions and key lessons. This document covers the lessons learnt about setting up Public Private Partnerships for Handwashing. A second document will cover operationalizing and monitoring. All program reports, products and materials are posted on our dedicated website at http://www.wsp.org/ english/activities/handwashing/ Steps Launch Baseline, M&E 10 Detailed design and test of approaches 9 Resource the program 8 Design the Handwashing program 7 Execute consumer studies 6 Form steering committee 5 Collect Info 4 Assign focal person 3 Initiate 2 1 3 Key Lessons The Public Private Partnership for Handwashing: an idea whose time has come? s Handwashing with soap could save a million lives. s Diarrhoeal diseases are losing ground to other health issues on the international agenda: new programs to promote handwashing provide a rallying point. s Combining the forces of the public and the private sector to promote handwashing with soap offers rewards to both. However, it needs time and effort... s Few individuals and agencies appreciate the importance of handwashing; advocacy is needed at all levels. s Building partnerships is time-consuming and resource intensive. It needs complementary skills and champions with drive and energy. s People at the top of key institutions provide the necessary leadership. s Industry players may be reluctant to work together, but they increasingly see that it makes sense to increase the market for all. To come on board, small-scale players may need extra assistance. s Partnership arrangements should be flexible and open to all who wish to join. ...and insight, understanding and particular skills s Industry is well placed to design communications programs; they have made huge investments in developing their own expertise in consumer insight, message design and media planning. s Consumer studies into handwashing should be carried out by professional market/consumer research agencies with Industry assistance. s Communication strategies require detailed trial and testing for effectiveness, otherwise the investment may be wasted. s Changing behavior patterns is not easy. According to industry, adopting a new practice needs at least six effective contacts a month. Drip-drip approaches do not provide a critical mass of stimulus for habits to change. s A champion from each organization at each level is essential. A trusted catalyst that can bring together industry, government and support agencies is also needed. But much remains to be learnt s Work is needed to validate indicators of handwashing behavior for baseline monitoring and evaluation. Trying to monitor the impact of the program on diarrhoeal diseases is a more difficult task. s External support agencies, government and industry have different expectations and time horizons; figuring out how to satisfy the needs of all partners while retaining innovative programming is a challenge. s Further challenges include how to make partnerships deliver new handwash products, and making handwashing cheaper for the poorest, possibly via tax incentives. Finally s The initiative cannot be evaluated until it has produced results, but the prospects look good for the continuation and expansion of the Public Private Partnership for Handwashing. 4 The Public Private Partnership for Part 1 Handwash: A Brief History "A growing number of business leaders share unease about any form of global economic development that fails to emphasize the human dimension or that creates a globalization of opportunity without a corresponding globalization of responsibility" 1 The Water and Sanitation decade of the 1980s into hygiene behavior and the BASICS saw substantial improvements in the experience. This inspired the idea of trying to infrastructure of environmental health in the develop a new Public Private Partnership developing world. However, diarrhoeal model. Over the following year, discussions diseases remained amongst the top three killers were held between WB/WSP and LSHTM, and of children. The realization began to grow that management consultants McKinsey and Co the way in which facilities were used might be were consulted. They considered the just as important as their provision. Growing proposition sound, but pointed out the need interest in hygiene behavior in the 1990s gave for strong leadership and careful planning. researchers insight into the context and meaning of hygiene behavior2 and led to the The concept was further developed, and in development of approaches such as the year 2000, two sites willing and able to Participatory Hygiene and Sanitation trial the idea were located in Ghana and the Transformation (PHAST) and the social state of Kerala, India. The objective was to try marketing of hygiene 3, 4. to get private industry and the public sector to work together to develop programs to promote However, approaches that could be scaled up handwashing. We wanted to learn how to set to meet the need for improvement in hygiene up such programs, and to explore their on a mass scale, similar to vaccination feasibility, acceptability and value. A contract programs, were still needed. Consumer studies for technical assistance from the LSHTM for the in the late 1990s highlighted the complexity initiative was signed with WSP and the World of the determinants of hygiene behavior and Bank in March 2001. showed that simply teaching people about After a year in the field the partners have: health was not going to lead to substantial behavior change5. Rather, positive images and · Established bases in the Kerala Rural Water population-scale marketing of behavior change, Supply Agency (KRWSA) and the based on insight into the factors that motivate Community Water and Sanitation Agency consumer behavior, were required. (CWSA) in Ghana. · Built local partnerships of industry One program at the end of the 1990s was of associations, industrial and small-scale particular interest: the BASICS/EHP Central manufacturers, Ministries, external support American Handwashing Initiative, which agencies and NGOs. encouraged four private sector companies to · Setup national or state-level steering launch handwashing campaigns in five committees and made concerted national countries (Guatemala, Costa Rica, El Salvador, and international advocacy efforts to explain Honduras and Nicaragua). The results were the concept. encouraging, and proved that soap companies could be capable and willing partners for health · Designed, commissioned, and assisted in the promotion6. execution and analysis of studies of soap consumption and the soap market in Ghana A workshop on Hygiene, organized by the and Kerala. World Bank/Water and Sanitation Program · Designed communications programs to (WB/WSP) and the World Bank, with help promote handwashing with non-branded from the London School of Hygiene and soap across the state of Kerala and the whole Tropical Medicine (LSHTM), in May 2000 country of Ghana. Commitment to fund the considered both the results of recent research programs has been forthcoming from 5 government and external support agencies, and a dedicated website. whilst the private sector has agreed to · Carried out a brief study of the world market provide technical and managerial skills. for soaps. At the same time, at a global level, the · Carried out a study of the experience of team has: Public Private Partnerships in the health · Supported the documentation and sector. dissemination of the BASICS Central · Worked with three big multinationals on America experience. perspectives for wider expansion. · Set up an international advisory group. · Raised funds from the Bank-Netherlands · Been advocates for the initiative in Water Partnership for continuation and international fora, the international press expansion of the initiative. Part 2 Why Handwashing? And Why a Public Private Partnership? Handwashing with soap could only 18 percent after cleaning up a child's save a million lives bottom10. In rural Nigeria, structured observations by Omotade showed only 10 Diarrhoeal diseases are the second biggest percent of mothers were using soap to wash their killer of children in the world today (figure 1). hands after cleaning up a child11. In slums in In the same way that the mosquito is the vector Lucknow, India, 13 percent of mothers were of malaria; transferring the infection from person observed using soap after cleaning up a child to person, so hands are the main vector of and 20 percent after going outside to defecate. diarrhoeal pathogens; transferring them from Handwashing practices can also be poor in surface to surface and from person to person. more developed countries; one UK study showed Human excreta is the source of most diarrhoeal less than half of mothers used soap after pathogens and handwashing after contact with changing a dirty nappy12. human excreta is probably the single most important moment at which hands should be Programs to prevent diarrhoeal diseases have washed with soap7. A recent review of all the lost momentum over the past years. Whilst available evidence suggests that handwashing many new initiatives on AIDS, malaria and TB with soap could reduce diarrhoea incidence by have been announced, the diarrhoeas remain 42-46 percent and save at least one million orphan diseases. There are three main reasons: lives8. · Responsibility for combating the diarrhoeal Though the evidence base is weaker, similar diseases has been split between Ministries arguments apply to Acute Respiratory Tract of Health, Water, Environment and others, Infections, the number 1 killer of children. Hands and as a result, has been championed by are also a vector of ARI transmission. A number none. of studies suggest that handwashing could be · Advocacy has been flagging, possibly very effective in reducing the incidence of because the diarrhoeal diseases are an clinical cases of ARI9. unattractive, dirty topic, competing poorly While soap is found in most households, it is for political attention with other hot health often reserved for washing clothes, dishes and problems, such as HIV. bathing. Handwashing with soap is not common · Interventions to prevent Intestinal diseases though practice varies from country to country. have proven more complex and problematic For example, a study in urban Burkina Faso than expected. observed only one percent of mothers using soap Control of Diarrhoeal Diseases (CDD) to wash their hands after using the toilet, and programs in Ministries of Health worldwide are 6 flagging. Participatory methods that are services to the private sector or handed over commonly found associated with water and responsibility entirely via privatization, but only sanitation programs may be effective at recently has the idea of joint programming with improving hygiene on a small scale, but are joint responsibility become a reality. Over the unlikely to provide a feasible approach to last ten years Public Private Partnerships in the covering large populations. Handwashing health sector have been used to: needs to be tackled on the scale of vaccination "The primary programs, where population coverage is 1 develop and facilitate access to vaccines motivation for almost total. For this breadth of reach, social and treatments; Colgate-Palmolive is marketing style approaches based on 2 promote behaviors and products that reduce that a Public Private adequate formative research into risk behavior, disease occurrence and Partnership on context and motivation are most appropriate. 3 improve health services. handwashing is in The skills and resources of both the public and natural harmony with the private sector are needed if handwashing Examples include Roll Back Malaria and GAVI our value system is to be promoted successfully on a wide scale. (the Global Alliance for Vaccines and which is three- Immunization). A review of practice in health pronged: care, However these issues are not widely Public Private Partnerships can be found at continuous understood. The first condition for a successful http://www.wsp.org/english/activities/ improvement and Public Private Partnership for Handwashing is investment in dissemination and advocacy handwashing/bestpractice.pdf global team work." amongst decision makers. A partnership should pool resources and risk Diana Grina, Global Director, Professional and Government Programs to prevent diarrhoea that are not only and provide added value over and above what Relations, Personal Care demonstrably effective, and cost-effective, but each party could achieve alone11. Clearly, Products Colgate-Palmolive, Washington also attractive and eye catching, are needed partners will only join a partnership if they May 2300 if more support for eradicating these stand to gain from it. In the case of http://wsp.org/english/ preventable killer diseases is to be forthcoming. handwashing, there are obvious benefits to activities/handwashing/ both sides; industry may sell more soap, whilst workshop.pdf Why a Public Private Partnership Government benefits from the private for Handwashing? sector's expertise in designing effective While the public and private sector have communications to improve public health. always worked together in one way or another, Table 1 (on page 8) summarizes the potential the idea of a direct partnership is relatively incentives and contributions of players in a new. Governments have contracted out Handwash Public Private Partnership. Fig 1 3.5 Leading Infectious Killers Millions of deaths, worldwide, all ages,1998 3.0 2.5 Over age five 2.3 2.2 Under age five 2.0 millions in 1.5 1.5 Deaths 1.1 1.0 0.9 0.5 0 Acute respiratory AIDS* Diarrhoeal TB Malaria Measles infections (including disease pneumonia * HIV positive people who died with TB have been included among AIDS deaths and influenza) Source: WHO 1998 7 Table 1 Possible incentives and contributions for public/private players in the Handwash Public Private Partnership Industry Public Sector s Enhanced image as a global s Better services with higher coverage corporate citizen, enhancing brand leading to improved health, which, equity in turn, assists economic development. s Staff motivation and retention Benefit s Liberation of resources for other s Influence in development and Government circles priorities s Learning about consumer research, s Insight into future markets marketing and communication s Access to national and international management research and knowledge s Understanding clients as consumers s Access to public infrastructure to stimulate markets s Professional expertise in: s Catalyst role - Marketing s Legitimacy/Institutional home - Communications planning s Resources Contribution - Consumer research s Knowledge of target markets - Communication management s Facilitate regulatory environment - Product tracking s Best practices and global vision - Product development s Resources "We are good There are of course some costs for each partner dominated by a small number of multinational corporate in joining a Public Private Partnership. For the companies with strong brand identity and citizens." public sector, these may include loss of enormous advertising budgets. There is credibility through association with big cutthroat competition between these Procter and Gamble business, and potential loss of investment if the mission statement multinationals. The top global players include private partner decides to drop out. Costs to Procter and Gamble, Unilever, Colgate- http://www.pg.ma/ the private sector are mostly in the diversion page12.html Palmolive and Johnson & Johnson. Important of human resources from more immediately regional players include Beiersdorf in Europe, profitable activities. As the BASICS review6 the Kao Corporation in Asia-Pacific, Paterson points out, program managers in industry are Zochonis in Africa and Nirma and Godrej in human, they make decisions mainly on solid South Asia. Procter and Gamble is the world's commercial grounds, but can often be swayed 21st largest company valued at $116billion, by the desire to `do the right thing'. Unilever the 62nd, (worth $56billion) Colgate- Public Private Partnerships in the health sector Palmolive is the 141st ($31billion), Kao, the probably work best where there is a close 405th ($11billion) and Beiersdorf the 454th alignment between the objectives and activities ($10billion) (Financial Times, 10 May 2002). of the two partners (BDP 2002). Selling soap Whilst Johnson & Johnson is the world's 9th and promoting handwashing are two such largest company, soap forms a minor part of closely aligned activities. the portfolio. These companies, along with huge numbers of medium and small-scale soap The soap market producers, provide soap to almost every household in the world. The world market for soaps and detergents was worth US$88billion in 2000, having grown In developed economies, market expansion is by 29 percent since 1996. The market is attributable mainly to new product 8 developments, such as liquid soaps for Soap, soap and more soap washing hands and showering, supported by There are many kinds of soap available on heavy media advertising and promotional world markets, in bars, flakes, powders, liquids activity. Because the market for soap products and pastes ­ which are used to remove dirt is largely mature in developed economies and and stains from bodies, clothes, utensils, displays stagnant growth, global companies surfaces and hands. As a rule, the more are turning their eyes towards developing "For Unilever, developed the economy, the more species of countries or `emerging markets'. According to corporate social soap will be found in the cupboards of the director of Unilever, catering to the needs responsibility is an consumers. In an evolved market there is a of the poor is going to be a major source of integral part of our specific soap product for every surface, whilst future market growth. operating tradition. in an emerging market, one bar of laundry It is at the heart of Factors likely to encourage growth in soap soap, which may be locally or domestically our Corporate consumption in developing countries produced, can serve all purposes. Purpose and is include: reflected in our · Liberalization of markets and growth in free Soap is present in most households in the world Code of Business trade. and is a priority purchase, even for the Principles. We poorest. In order of importance to the · Phenomenal growth in the reach of mass believe that these consumer, keeping clothes clean is the first use media, especially TV. commitments are of soap products, bathing the body the second not just an · Demand driven by the widening gap and cleaning utensils the third. Handwashing expression of our between how consumers live and the comes far down the list of priorities.(http:// values, but that in increasing visibility of consumption. wsp.org/english/activities/handwashing/ living them out they · More educated and aware consumers. globalmarketsoap.pdf) contribute to our · Increasing disposable incomes. Whilst technically adequate for cleansing success." hands, bar soap has been largely displaced · Increasingly skilled advertising and market www.unilever.com by liquid soaps for handwashing in Northern research agencies. economies. There may be an equivalent growth · Improvements in transportation and potential in the marketplace for a cheap soap communication networks. designed specifically for handwashing in · Growth of supermarkets and retail outlets. emerging markets. · New technology enhancing productivity, making The next chapter explores the lessons that were products more attractive and reducing cost. learnt from the country programs. The Approach Step-by-Step Part 3 Once the overall concept and vision had been Step 1 Initiation elaborated and the technical team mobilized The Public Private Partnership for Handwashing in London and Washington, activities moved concept was presented to potential stakeholders to the country level. Seven steps, as set out in Ministries, NGOs, community groups, industrial below, were followed in each country. A associations and external support agencies to further three steps remain to be taken to reach raise interest and gauge support. In India, this full-scale implementation. The process of process began with a one-day workshop, while partnership building is similar to that followed a series of meetings were held in Ghana. by the BASICS initiative in Central America, · Meetings need to be repeated since not all though in the examples given here the key stakeholders can be present. Not all catalysts were based in quasi government partners come on board at the same speed. institutions, whilst in Central America they However, agencies that come to the first were independent). Lessons learnt are shown meetings may find follow-up meetings cover in italics. similar ground for the sake of newcomers. 9 · Representatives from Industry may not attend government and business structures, open meetings but have to be visited knowledge of hygiene promotion, well- individually. regarded professionally, ability to open · People at the top of key institutions should doors at a high level, ability to conduct/ be approached early on as they legitimise oversee research and a lot of energy and the participation of their staff. drive. · Surprisingly few partners had (or voiced) Step 3 Information collection ideological objections to the Public Private Partnership. There were, nevertheless, some Development of the initiative requires that it fit concerns that the initiative might appear to within the institutional and programmatic provide `easy' benefits to the private sector environment in country. One of the first tasks by promoting their products for them. of the focal person was to identify key stakeholders including industrial players, trade · The backing by the WB/WSP gave players associations, ministries, external support confidence that intentions were serious. agencies, NGOs, and organizations capable · Other international agencies such as of carrying out consumer and market research. UNICEF and DFID, that had been working Agencies involved in hygiene promotion were in hygiene promotion, showed interest in contacted and briefed about the work. tying this into their ongoing work. · Information collection helped identify all · Key skills required at this stage were potential partners who could participate political championing from WB/WSP staff and/or benefit from the program. and persuasive communications concerning the potential benefits of the · The proposal for the Public Private initiative. The involvement of academics Partnership was well received by almost all helped validate the case for handwashing. stakeholders. Champions had also to be able to · A specific directory of contacts for programs understand both sides sufficiently to be should be created and maintained. able to `translate' between the different public and private cultures. Step 4 Formation of Steering Committees Step 2 Assignment of focal person Stakeholders from ministries, industry and NGOs The local agencies housing the initiative were were invited to form a steering committee. These the Kerala Rural Water Supply and Sanitation met about every four months or at critical Agency and the Community Water and junctures. They reviewed progress, advised on Sanitation Agency in Ghana. Both are donor plans and had a legislative role in monitoring supported and semi-autonomous. Both have a contracts. In addition, in Ghana a technical mandate to work on water, sanitation and committee was formed to help advise on hygiene and both are struggling to develop consultant selection and other technical issues. effective hygiene promotion programs. The local agencies arranged for the assignment of a key · Steering committees confer legitimacy and person to lead the initiative from within their allow continued advocacy as personnel agency (Kerala) or as a consultant (Ghana). change. They help get all stakeholders on board and keep them involved. · Existing agencies have full workloads: additional help to set up a new and · They offer a forum for public and private substantial work program is needed early employees to meet and exchange views. on. · They are flexible and informal in this · Management needs to be persuaded of the preparatory stage, but their role may need need to hire and resource consultants or to be formalized as programs begin. assign competent staff. This can require · In Kerala, a MoU was signed between the repeated efforts. soap industry association (ISTMA) and the · Key attributes of the focal person are: Government of Kerala to provide a communications skills, familiarity with framework under which to operate. 10 Step 5 Design and implementation · It is hard to gauge how much artisanal soap of studies is produced, and how much is sold through Two studies were commissioned in each unofficial channels without a detailed field location. The first, a consumer study, was study. designed to provide an understanding of · The results of such studies are only as good handwashing behavior that would help to as the brief and the demands from the client. inform the design of the communications Commissioning such studies requires skills that program. Key questions to be answered were: may not be readily available. Again, What is the current rate of handwashing with assistance from professionals in industry may soap at critical times? What are the be one solution to getting good design and characteristics of the target audiences? What hence good results. motivates handwashing with soap and what are the barriers to its adoption? What channels · Study designs have to take into account the of communication are most appropriate? research capacity of the professional Secondly, market studies were commissioned agencies, which may not be equally to understand the state of the market for soap developed in all countries. in each location. The results of these studies · It remains to be seen whether the public and the technical issues they raise are sector will use the studies as expected. discussed in more detail in the next section. Detailed Market Studies might not be essential for future Handwash Public Private · Consumer studies must be carried out by Partnerships. professional market/consumer research agencies, if their results are to be credible Step 6 Design of the Handwash to industry. Program · Some research agencies divide their staff An outline design for the handwashing into commercial and social project teams. communication program based on past In such instances, the commercial teams insight, available data and the consumer should be preferred, for reasons similar to research, was prepared by industry in Kerala the above. and by the Public Private Partnership team in · Industry should be involved in the design of Ghana. While the plans had to be detailed the consumer studies from the outset. enough to meet the administrative needs of · Key skills required were an understanding potential funders, a great deal of work was of hygiene behavior and knowledge of still required in designing and testing the formative research design. detailed communications package. For · Studies required a lot of work in briefing example an effective TV advertisement might and training the agencies as well as in require the equivalent of five years of work debriefing and collaborating with them in by senior marketers. Detailed messages and the production of the final results. media for direct contact have also to be The market studies were commissioned to allow designed and tested. Project preparation the public sector to better understand the nature proceeds iteratively. of the soap market. They were designed to find Possible steps would be to: out about total volumes of soap, suppliers and brands, soap used specifically for 1 prepare an outline design; handwashing and existing promotional 2 secure funds and determine institutional strategies. They aimed to offer the public sector roles; partner sufficient insight into the operation of 3 prepare a detailed design using professional soap industry to enable them to negotiate a creative teams and agencies; good deal with industry. 4 proceed to testing of concepts, reframing, · Again, if they are to be credible, such studies testing again, testing effectiveness; must be done by professional agencies with 5 finalization of communication package; and experience in accessing and interpreting then such data. 6 full-scale roll out. 11 Neither program envisages using any potential funders, who may be expecting to established brands. However, some form of see the full program design. new generic handwash brand may be needed · However, having access to the results of the to make the campaign effective and consumer research helps show how recognizable. The partners would also welcome companies piggy-backing their own programs are designed to cater to local independent branded handwash campaigns circumstances. onto the partnership initiative if they so wish. · Industry does not have major funds available for use in non-branded campaigns. However, · All communication strategies require their input in communications expertise, detailed trial and testing for effectiveness, otherwise the investment may be lost. access to creative and media planning agencies, methodologies for developing and · Generating a new behavior requires at least testing approaches and in management skills six effective contacts a month. Drip-drip program is critical. approaches are not effective because the critical mass that can effect a change in · External support agencies funding may not habits is never achieved. be available through existing channels or in · Key skills needed are marketing, media a useful period. The project should be offered planning and consumer science, these are to as many donors as possible, and the initial generally not available in the public sector approach should be to senior decision- and were provided by industry. makers. Networking with agencies at head · Industry is well placed to design office level can assist. communications programs; they have · Key skills needed at this stage are insight invested hugely in developing their own into, and access to, the bureaucracy of expertise in consumer insight, message Government and external support agencies. design and media planning. · Fund-raising is an on-going process and it · There is scope for the private sector to may be necessary to plan a multi-year collaborate and explore the great potential intervention and raise funds sequentially as for effective communication using public results are achieved. sector information channels. · A cost-benefit analysis is useful in marketing Step 7 Resources for the Handwash the proposed program to potential funders. Program Additional preliminary research on the economic benefits would also be useful. Project design and financing have to move in step. The outline design for the handwash Step 8 Baselines and M&E program has to be appropriate to the indicators requirements of potential funders. Whilst industry can often make major funding There is no perfect way of measuring decisions on thin documents, external support handwashing practices. Many options have agencies and Governments require detailed been tried but all have drawbacks: responses background and justification, complete activity to direct questions bear little relation to reality, plans, logframes, etc. It may be hard to provide measuring soap use does not distinguish the all the detail at this stage because commitments other uses of soap and structured observation of funds are required before the detailed is time-consuming, intrusive and expensive. design can be produced. Nevertheless, structured observation is probably the best tool available13 for For the Kerala program, both the State and monitoring changes of behavior patterns in a Indian Government were ready to contribute population. Monitoring soap consumption can very substantially to the costs of the program. provide additional evidence for program Getting funds committed from external support effectiveness, though any changes detected agencies has been more difficult, largely may not be due to the program interventions. because they are tied up in existing projects, Program performance indicators, in terms of and the funding cycle can take several years. coverage and audience recall give further · It can be hard to sell an outline design to indicators of progress. 12 As trial programs, these two initiatives will be The Global Partnership especially closely monitored and data collected At the same time as work was progressing at for cost-effectiveness analysis. Preliminary country level, tentative steps were made calculations from Kerala suggest that the towards building a global partnership program will pay for itself in two years by platform. Interested parties from WSP, World savings in health care costs. In Ghana, savings Bank, UNICEF, USAID, EHP, BASICS and the from reduced disease will be in the order of LSHTM met together four times over the year twice program costs. and a number of preliminary meetings with · Work is still needed to find and validate global soap companies were also held with a indicators of handwashing behavior for view to establishing a global group. In baseline monitoring and evaluation. addition, annual technical meetings at the · Ideally, the consumer study should provide World Bank have provided opportunities for an opportunity to collect baseline experience sharing and dissemination. handwashing data. The methodology has to be watertight enough to provide credible · Contrary to expectation of the need for a results, whatever the circumstances. This is governance structure with rules and hard to do and requires further work. processes, no such role for a global organization was identified. · The Monitoring and Evaluation program would focus on measuring behavior · Meetings of global groups should only be improvements related to handwashing, the organized in response to a clear need, as effectiveness of different intervention they are expensive and have opportunity strategies, and where adequate data exist, costs for busy sector professionals. the impact of the program on diarrhoeal · One advantage of such meetings is that head disease reduction. offices of international agencies can lead · Given the likely high cost of such programs, country offices to support the initiative. data will need to be collected for the International media exposure can be helpful, evaluation of cost-effectiveness. though it is not possible to control exactly what will be said. An article on the initiative Step 9 Detailed design and test of that appeared in `The Economist' galvanized communications approaches a lot of support but failed to describe the This step is yet to be completed in Kerala and roles of all partners. Ghana. Once funding and management is in · Some partners at the global level who would place in the project cell, detailed program very much like to be involved in the initiative design will begin. Creative agencies will be are constrained by a lack of resources that briefed, and a variety of ads will be sketched their agency can bring to the table. out for radio and TV, as will concepts for posters · The role of a global partnership platform will and kits for schools and health centers, and continue to be reviewed as the initiative support materials for partners. These will be spreads to other countries. tested on a small scale with samples of the target · Annual or biannual technical meetings serve audiences. Those that are deemed most effective to share experience, advocate and will be refined and retested. Finally, all print disseminate the approach. and audiovisual materials will be commissioned and produced for full-scale roll out. The approach: Key lessons · Setting up a Public Private Partnerships takes Step 10 Launch and execute a great deal of time, and requires major campaigns investments in communication at all levels. When funds are in place and when testing has Partners take time to learn the capabilities been carried out, the programs as a whole of each other. For example: industry did not can be launched. realize how much Government was capable 13 of in terms of direct contact with the played major roles in getting the Public population, Government did not realize the Private Partnerships off the ground at every complexity and difficulty of behavior change level. The individuals have to like and respect or that professional marketers had so much each other if motivation and energy levels to contribute. are to remain high. · Building trust is a slow and cumulative · Time scales differ: Industry can expect to process. As money began to be spent by make a decision and have a program up partners and their backers, confidence in the and running in a matter of months; for seriousness of each other's intentions grew. government the time horizon may be a year; while for external support agencies the · Champions: Committed individuals have funding cycle may be three years. Industry, in particular, may not be prepared to wait if funding negotiations drag on. Fig 2 Roles of the partners in the Handwashing Public Private Partnership P P Government · Health, social welfare and educational infrastructure · Local-level institutions · Resources and expertise Private Sector Scientific community P · Crafting communication · Defining scope and thrust for behaviour change of the program · Program design and · Credibility control · Knowledge capture and · Optimising resources dissemination across channels and media External Support Agencies · Financial resources · Past experience Part 4 Understanding Handwashing with Soap Handwashing behavior is complex. This fact · What channels of communication reach came as a surprise to some partners who target audiences effectively? assumed that getting people to wash their The consumer studies were designed to answer hands was a simple matter of telling people these questions. They used methods drawn they would get sick if they didn't do it. Four key questions about handwashing behavior from social and consumer research, including have to be answered: structured observation, in-depth interviews, focus groups and behavior trials. They each · What are current handwashing practices? took around six weeks, cost an average of · Who should the target audience of the $35,000 and covered between five hundred programs be and what are their characteristics? and a thousand households, selected to · What factors motivate, facilitate and hinder represent the whole state/country. Mothers, handwashing? fathers, children and schools were targeted. 14 In Kerala, the Indian Market Research Bureau approach available, structured observations, (IMRB), and in Ghana, Research International which required trained observers spending (RI) did the detailed design, the fieldwork and three hours in the early mornings watching the preliminary analysis, in conjunction with what happened in courtyards and households. the client organizations (KRWSA and CWSA). Both teams found higher than expected rates Some assistance was provided by the LSHTM of soap use by mothers after using the toilet. and from industry. Both agencies did well in a field unfamiliar to them, though both required Handwashing with soap by mothers Ghana Kerala considerable help and guidance. The studies were commissioned before industry was fully After using on board. More industry input at the design the toilet 37 % 42 % and execution stage could have added value to the studies. After cleaning The following give some of the preliminary up a child 31 % 25 % findings from the two studies. Before eating 16 % 11 % Current handwashing practices Before preparing Measuring handwashing behavior is complex food N/A 10 % and difficult. Both teams used the best Observed handwashing practices in Ghana and Kerala The results of the studies proved controversial and highlighted the need for an agreed methodology, acceptable to all, for measuring handwashing. Closer examination of the methodology adopted in both locations suggests that many non-handwashing events were missed, for example, when defecation took place away from the house. Structured observation requires careful introduction so as not to bias results and much patience and supervision. Some of these safeguards may have failed in either or both studies. Alternatively, handwashing with soap after contact with excreta may actually be higher than was predicted. More careful measures of handwashing to provide a reliable baseline are needed, otherwise changes over the time of the intervention cannot be measured accurately. Handwashing at key times other than after defecation and cleaning up a child is poor and these occasions could also be the focus of attempts to improve handwashing. A weighted average of handwashing with soap in Kerala at different critical times suggested that soap was only used on about 14 percent of these occasions. In Kerala, hands were washed with soap more often when water was available in the toilet or when soap was available in the toilet. In better-off households separate soaps were kept for separate purposes (bathing, cleaning clothes, for menstrual stains) and all households used special soap, (e.g. Johnsons' baby soap), for a new baby. Soaps claimed to be used for handwashing were all beauty soaps, not laundry soaps. Commonest brands mentioned were: Lexus Gold, Nima Rose, Lux and Santoor. The monthly amount claimed to be spent on soap did not vary much between social classes. In over half of households, the father purchased soap, but mothers chose the brand. One hundred percent of households had soap on the day of the interview. The Kerala results showed that those who did not use soap to wash their hands after using the toilet reported diarrhoea five times more often than those who did. Both studies concluded that poor disposal of children's stools (often thrown in the yard, on an open rubbish heap, in a field or drain) could be a source of the faecal pathogens that cause child diarrhoea. One option may be to add this issue to the program at a later date, once the handwashing message is well established. 15 Target audiences been in contact with a poison or an impurity Both studies concluded that women of like non-vegetarian food, or before prayer; or childbearing age and children were the a sense of stickiness. One's own and one's primary target audience; mothers because they children's faeces do not bad smell and therefore were the principle caretakers of children and may not cue soap use. preparers of food, and children, because they The research divided people into habitual users were at an age where handwashing habits and non-users of soap after faecal contact. can be inculcated for life. In Kerala, men have Users seemed to practice what they had always also to be targeted, because they are the done since childhood in a mechanical fashion. principle buyers of soap, though women Habitual users felt dirty if they did not use soap normally specified the brand. In Ghana, after faecal contact, whereas non-users did not. women usually buy the soap but may have to Non-users explained that they never had the negotiate a budget with their husband. habit, they often did not have time, or soap Previous studies have indicated that life- nearby. Another group of users took up the change events, and particularly the time of habit after having a baby. They explained that the arrival of a new baby, are particularly keeping a baby clean nurtures its mental and good opportunities to introduce new habits. physical growth as well as its health. Handwashing with soap is a closeted subject, Motivation for handwashing not seen or talked about, therefore the The qualitative research in Kerala found that motivation of social contempt for those with cleanliness was very important to mothers. dirty hands is absent. Figure 3 schematizes how the dirtiest jobs are saved up until just before the midday bath. In Ghana, hands were washed with soap to Following this, a woman will typically try to remove dirt, oil or an unpleasant smell, to stay clean for the rest of the day. prevent diseases and to appear neat. The disgust of having been to a dirty public toilet Hands tended to be washed with soap when often cued the use of soap. However, if soap there was a cue. The cue might be a smell; or water was not to hand, hands were less from cutting fish, touching animal dung or likely to be washed. Soap was often stored diarrhoeal faeces; something visible such as away to keep it from being used by others, the sight of dirt; or a feeling, such as having which made it inaccessible for handwashing. Fig 3 The pyramid of cleanliness Sweeping courtyard Low dirt Numerous/varied tasks Cleaning house, vessels, cooking Cutting cleaning fish High dirt Handling specific tasks cow dung Cleaning laterine Becoming clean and staying clean Bath KRWSA PQR 16 The soap habit Care for children was one of the strongest motivators for handwashing in both locations. "There are no particular reasons for not Whilst pump-dispensed products are beyond washing hands with soap, it is just that the reach of poorer consumers in developing we don't do it" (India Palghat-B-NU) countries, cheaper products, designed "Our parents never taught us this" specifically for handwashing could have real (India Trichur-S-NU) potential for growth. (Soap on a rope or in a net to hang in a toilet, small tablets or threads "Nobody has made us understand the of soap, tubes or tubs of liquid soap, recyclable benefit of washing our hands with soap containers for liquid soap). In Ghana, some after using the toilet" (India Trichur-S-NU) mothers even pounded up the soap that was "How will the outside people know provided in behavior trials to make a liquid whether we wash our hands or not?" (India soap for hand washing. Idd-B-TU) Handwashing was not generally hindered by "My children normally use the soap lack of water or soap. However, the problem indiscriminately so I hide it from them and of where to keep the soap free from that saves me money." (Ghana Ga-rural) interference was a major problem in the behavior trials in Ghana. "When we put the Key soap under the bed it makes the soap very hard and it makes Channels of communication it last longer. We also put it there because we want to prevent the children from Both studies were charged with mapping having access to it." (Ghana Western Region- channels of communication from the household urban) perspective. Combined with national commercially available figures, this data "Some of the children tend to eat soap provides the basis for calculating the reach of when they see it, but if I have hidden it the handwash program when designing the they could not see it and that will save me media mix. Figure 4 (on page 18) shows typical from trouble." (Ghana Ga-rural) communications routes into a Kerala village. "Caring for our children is the most In Kerala while more than half of the households important thing and is of great concern to had TV, many Muslim women did not watch us as mothers... ...Bathing, cooking and for religious reasons. Two thirds of households washing of their clothes is what we mean had working radios and over a third read by caring for our children. You as a mother newspapers and magazines regularly. Whilst should make sure your child dresses neatly data on mass media use is readily available and should be well fed." (Ghana Ga -rural) from national surveys, data on contact with the existing health system and any other local "Looking at things, you see that both channels of communication is often not mother and child always look cheerful and available. In Kerala, the 98 percent success of healthy when they are neat." the pulse polio program showed that a program (Ghana Accra -urban) using the existing health, immunization, "Whenever my child goes on a visit to my anganwadi and education system could have sister's place, his friends do not want him a major impact on target populations. to leave because he is always neat." In Ghana 55 percent of urban households and (Ghana Accra -urban) 24 percent of rural households had TV. The Keysoap ad was the most popular TV ad, cited This was especially true in schools. None of by 38 percent of women. Over a half of women the rural schools had handwashing facilities. and three quarters of men listened to the radio Only one school of 20 sampled had running every day. water. The ideal soap for handwashing was Complex studies such as these operate at the said to be small enough to handle and limits of the capability of research agencies. preferably in liquid form to make it easy to There is a temptation to take the opportunity use and to restrict its usage to handwashing. that such studies offer to add on further issues. 17 Fig 4 Range of influence on a Kerala village that can potentially be harnessed Development of women Aanganwadis 96% and child program 51% Local panchayats Intergrated rural develop- Secondary school 74% ment program 57% Primary school 90% Middle school 87% Community TV 62% Adult education centre 58% Community centre 40% Target village Primary health centre 74% Fair price shop 91% Health sub-centres 79% Retail shop 67% Bank 89% Post-office 89% Private doctor 88% Milk cooperative 67% NGOs Traditional birth attendant Village health guide 38% 49% * All India-Rural % - NFHS-2, 98/99 However, this can dilute the quality of the through existing public services. In Kerala, the whole exercise. Ways need to be found to program will target those life change events simplify, and certainly not complicate, such when new behaviors are most likely to be formative research. adopted such as the arrival of a new baby or vaccination. Change will also be enforced Implications through the addition of a handwashing The preliminary results from the studies suggest program to the midday meals program in that handwashing is a complex practice that primary schools. Mass media and direct is carried out for a number of reasons. These contact together have additive and synergistic reasons can by physical (`I see/feel/smell dirt effects. Media will be generic with no company on my hands') and metaphysical (`I feel logos. Interestingly, industry is keen not to be unclean/ polluted/ disgusted/ dirty'). seen to be associated with the handwash Cleaning hands with soap serves to refresh, initiative because they expect Government rejuvenate, and contributes to a sense of well- sponsored health messages to be more credible being. Fear of disease and germs may also in the eyes of the consumer. However, a new play a part in the decision to wash hands, but non-commercial `brand' may have to be only a part. Full results will be posted on the created to add coherence and recognition to website http://www.wsp.org/english/ the program. activities/handwashing/ Calculations for Kerala suggest that 70 percent The outline designs of both programs were built of households will be reached 43 times a year on the preliminary results of the consumer via mass media and 35 percent of households studies. The detailed design is an on-going nine times a year through the Direct Contact process that will revisit the study data for more program. To achieve this density of contact is insight into specific issues. Ideas generated by expensive. The initial cost estimate for Kerala both studies will be tested with consumers. is $10million spread over three years to cover the whole state. The outline design for the The programs will use state-of-the-art communications program can be viewed at communication design approaches and deliver http://www.wsp.org/english/activities/ messages via mass media and direct contact handwashing 18 Key Lessons s Handwashing behavior is complex s Measuring handwashing behavior is difficult s Formative research study designs should be further simplified to provide a clearer focus, and training and supervision require substantial international inputs. s Keys to behavior change are likely to be i) making people feel that they have something on their hands after defecation; ii) making it easier to wash hands by having soap to hand; iii) targeting life change events. s The study results need further detailed analysis, both for the insights they offer into the design of each program and to increase the knowledge base about handwashing. s To generate a behavior change, industry specialists believe that effective contact with the message in the mass media has to be made at least six times a month. Drip-drip strategies do not provide the critical mass of stimulus needed to change habits. s Communications programs will be non-branded and use both mass media and direct contact. s Industry involvement at the design and execution stage of the studies would have added to their value. Future Challenges, Conclusions Part 5 Future challenges will, at least, benefit from this exercise. As Tom One year on, the idea of the Public Private Clasen points out14, multiple partnerships can be Partnership for handwashing is well and truly difficult and complex and there are many launched. However, as we move towards precedents for engaging with single companies replication in other countries, challenges remain: in public-private partnerships. Single partnerships might prove the most effective use of public Single or multiple industrial partners resources. For the moment, the basic principles of transparency and openness to all partners As a matter of principle, this Public Private remain non-negotiable as this initiative moves to Partnership is kept open to all industrial players other countries with other major industrial who want to join. All key players in both large partners. and small-scale soap production were contacted either directly or via industry associations. In Overall costs Kerala, the partnership remains formally with the Programs designed to effect behavior change on industry association, though we have found a mass scale are likely to be expensive, requiring ourselves working mainly with just one partner, both mass media and direct consumer contact. the dominant player: Unilever. Though small and Current estimates are in the order of $0.10 per cottage industry representatives are on the head of the population per year. However, steering committee, their participation has been savings in reduced health costs, and lost working limited. Full participation is relatively more costly days can more than compensate for this for small players. In Ghana, there are three expenditure. In Kerala, the program will pay for industrial partners, two large and one small-scale, itself after two years; in Ghana likely savings and individual companies and industry amount to twice the estimated program costs. associations form part of the steering committee, Donor agencies may find the idea of spending though Unilever still plays the biggest role. It many millions on handwashing surprising, and should be noted that the results of all the research may be more amenable to phased approaches will be in the public domain and smaller players with a year-on-year incremental approach. The 19 private sector needs to see a business plan that promoting both but, for the sake of clarity, the can reliably change behavior in whole targeted sanitation aim was dropped. However, this populations in a reasonable period if they are to approach has many lessons to teach about how remain interested. Bridging these two perspectives sanitation might be marketed in future. is difficult, and compromise on the large-scale objectives may not be advisable, if the program Research needs is to produce measurable results. A further cost Hygiene and handwashing are poorly issue is the contribution that can be expected from researched. More and better quality data is industry. Industry can contribute only to the extent needed on the impact of handwashing on that they profit from increased sales of soap, diarrhoeal diseases, respiratory tract and skin improved Public Relations and new learning. infections. Better indicators of handwashing Current contributions in kind of about 25 percent practice are required, and the learning from the of total program costs may or may not represent two handwashing studies need to be distilled and a `fair' contribution and negotiations continue in disseminated. both Kerala and Ghana. Conclusions Human resource capacity From a good idea and a vague plan, this Public Recruiting the necessary personnel, both Private Partnership has found its feet and become nationally and internationally, proved very a concrete reality in two countries in one year. difficult. People who can span industrial marketing This is good progress for a new health program and international public health are a rare breed. that is to be delivered via a new paradigm. Bringing junior members of staff on board early External champions who were prepared to push and training them up may be one solution. hard were required to get this off the ground, but it still took a long time to do the talking and to Measuring results build up the trust that was needed to forge an Measuring actual handwashing practice is a effective partnership. complex task, as we have discussed. We hope that the partnership with Industry will lead to To be successful, international health programs innovative new means of measuring the impact must not only be well founded, but also come at of the handwash programs. The Kerala and the right time. This program exhibits a Ghana programs will need to test a number of combination of: approaches if they are to be able to recommend · A novel, attractive and mould-breaking idea the most feasible and reliable. Involving outside · An intervention that should be highly effective, organizations such as CDC and WHO will add that could save many lives and that we knew credibility to any results. is doable. Other tasks for the Public Private · A potential for a win-win partnership of the Partnership skills and capacities of industry, Governments and external support agencies, at a time when Though most work has been carried out on the idea of Public Private Partnerships are handwashing promotion, in the long term greater sweeping into all spheres of public policy. health benefits might be had through public support for R&D into soaps designed specifically After a year of exploring the practical implications for handwashing, or through engagement with of trying to do such programs, the team is even governments to reduce the unit cost of soap via more convinced that Public Private Partnerships the tax burden on raw materials and sales tax. It for Handwashing have huge potential. Agencies, remains to be seen if this would translate into a Industry and Governments in many countries are serious price reduction. clamoring to join the initiative. The idea has taken on a life of its own and is beginning to influence A model for sanitation? policy beyond our immediate programs. Teams There are parallels between soap and toilets, both from Industry, Governments, external support are consumer goods that are largely provided agencies and academia are finding that they have for privately and both impact on environmental complementary roles and skills and can work health. This initiative began with the objective of surprisingly well together. 20 References 1 "Business Partners for Development. Putting Partnering to work." London: Business Partners for Development, 2001. 2 Almedom A. "Recent developments in hygiene behavior research: an emphasis on methods and meaning." Trop Med Int Health 1996;1(2):171-82. 3 Pinfold JV, Horan NJ. "Measuring the effect of a hygiene behavior intervention by indicators of behavior and diarrhoeal disease." Transactions of the royal society of tropical medicine and hygiene 1996;90:366-371. 4 Curtis V, Kanki B, Cousens S, Sanou A, Diallo I, Mertens T. "Dirt and diarrhoea: Formative research for hygiene promotion programs." Health Policy and Planning 1997;12(2):122-131. 5 Curtis VA. "Hygiene: how myths, monsters and mothers-in-law can promote behavior change." Journal of Infection 2001;43:75-79. 6 Saadé C, Bateman M, Bendahmane. D. "The Story of a Successful Public-Private Partnership in Central America: Handwashing for Diarrheal Disease Prevention." Washington DC: BASICS, 2001. 7 Curtis VA, Cairncross S, Yonli R. "Domestic hygiene and diarrhoea, pinpointing the problem." Tropical Medicine and International Health 2000;5(1):22-32. 8 Curtis V, Cairncross S. "Could washing hands with saop save a million lives?" submitted. 9 Ryan MAK, Christian R, Wohlrabe J. 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Acronyms AED Academy for Educational Development IID Infectious Intestinal Diseases ARI Acute Respiratory Tract Infections ISTMA Indian Soap and Toiletry Manufacturers BASICS Basic Support for Institutionalising Child Association Survival KRWSA Kerala Rural Water Supply Agency BPD Business Partners for Development LSHTM London School of Hygiene and Tropical CDD Control of Diarrhoeal Diseases Medicine CWSA Community Water and Sanitation Agency ORS Oral Rehydration Salts (Ghana) ORT Oral Rehydration Therapy DFID UK Department for International PPP Public-Private-Partnerships Development USAID United States Agency for International EHP The Environmental Health Program Development ESAs External Support Agencies WB The World Bank IFH International Forum for the Scientific Study WSP Water and Sanitation Program of Home Hygiene Water and Sanitation Program The World Bank Water Supply and Sanitation Division 1818 H Street, NW Washington, D.C. 20433 Telephone: (+1202) 4739785 Fax: (+1202) 5223313 Email: info@wsp.org Website: http://www.wsp.org Task Managers: Param Iyer Jennifer Sara Author: Dr. Valerie Curtis Contributors: Nana Gabrah-Aidoo B Ashok Sandy Cairncross Perry Gollo Esther Monier Illouz Yuri Jain Baby Kurian Yaw Sarkodie Ebow Spio Ann Thomas James Varghese July 2002, 2nd Edition Picture credit: KRWSA, Kerala, India. CWSA, Ghana. Created by Green Design Associates Email: gdapress@bol.net.in Printed by PS Press Services Pvt. Ltd.