48369 December 2008 SOAPBOX The Public-Private Partnership for Handwashing Newsletter FOCUS ON... continue promoting handwashing with soap, not First ever Global Handwashing Day only on this annual day, but every day of the year." celebrated worldwide In Peru, children, government and municipal Global Handwashing Day was celebrated on authorities, teachers and parents in four regions - October 15 in more than 70 countries across five Amazonas, Lambayeque, Ica and Cusco ­ continents. This inaugural event focused on organized various activities, such as children's children and schools. Under the theme "Clean parades and handwashing activities in open spaces, hands save lives", playgrounds and classrooms, in a joint effort to raise awareness about the local communities and big cities held high profile, importance of handwashing with soap for children's awareness-raising, and educational activities to health. accelerate handwashing behavior change on a scale never seen before. In Colombia, the Minister of Environment, Housing and Territorial Development - Mr. Juan Lozano - joined Global Handwashing Day celebrations with more than 7,000 children in the province of Soacha, Cundinamarca. The event was also attended by 1,000 adults, including parents and local leaders. In Indonesia, Global Handwashing Day's logo hit the scene on October 15, reminding governments, teachers, caregivers, mothers and children worldwide that "Clean hands save lives". The initiative, driven by the Public-Private Colombia's Minister of Environment, Housing and Partnership for Handwashing (PPPHW), succeeded Territorial Development, Mr. Juan Lozano, joined Global in mobilizing and motivating millions around the Handwashing Day celebrations with children in the province world to wash their hands with soap, a feat that of Soacha. marks a landmark in hygiene history. In Senegal, the official ceremony brought together "The Public-Private Partnership for Handwashing the Minister of Health, Dr. Safiatou Thiam, and is excited to be a part of this important event," says representatives of both the Ministry of Education Nat Paynter, global coordinator of the PPPHW and Dakar's city council. The national Secretariat. "The world has come together today to Handwashing Team took advantage of this global recognize the health potential of proper celebration to pretest a game that enables kids to handwashing behaviors. We look forward to memorize the critical junctures and get a practical sense of handwashing behavior. SOAPBOX NEWSLETTER DECEMBER 2008 In Ghana, the day was launched by the Minister of In Bangladesh, over 15 million children in 75,000 State for Water Resources, Works and Housing, Ms schools washed hands with soap on Global Cecilia Abena Dapaah, who had the chance to see Handwashing Day, including a successful event in children perform a series of plays underscoring the Dhaka that earned the national handwashing importance of proper handwashing with soap. Also, initiative a place in the Guinness Book of Records. two radio talk shows turned handwashing into their main topic of discussion, with children calling from their homes to raise questions on the issue. In Kenya, different handwashing activities were launched with the support of the Minister for Public Health and Sanitation, Ms. Beth Mugo, gathering over 6,000 children in Kisumu Town and over 230,000 nationwide. A record moment: greatest number of children washing hands at the same time in Dhaka (Bangladesh). The achievement was officially certified by the Guinness Book of Records. In India, the support of the famous cricket player, Sachin Tendulkar, helped give the event a huge impact nationwide. Also, in Australia the music band The Wiggles ­as Kenya's Minister for Public Health and Sanitation, Ms. UNICEF ambassadors- endorsed the cause by Beth Mugo, flags Global Handwashing Day celebrations in composing and performing in Sydney the catchy Kisumu Town. song: "Wash your hands with soap and water". In Tanzania, the day was celebrated with media Global Handwashing Day attracted the attention briefings and school activations. Over 2,000 pupils of media outlets worldwide, and was covered by from five primary schools participated in the BBC, The Times of India, Nairobi Star and handwashing exercise and demonstrations. Kathmandu Post, among many other outlets. In Indonesia, around one million people washed The PPPHW is extremely grateful to all countries, hands and sang handwashing songs in a series of public and private partners and organizations who events supported by the national handwashing core made the inaugural Global Handwashing Day a group and NGOs in different areas of the country. great success. Their hard work and commitment In addition to mothers and kids, journalists were a have helped set the foundations for an annual event key target in these activities. The day became the in this joint and global effort to reduce children's trigger for a media competition that targets death rates through the simple act of washing hands professionals in print, electronic, audio and with soap. audiovisual media covering Indonesia. The winners will receive a certificate and a fully-paid trip to a For more information on Global Handwashing relevant international Handwashing forum in 2009. Day, visit: www.globalhandwashingday.org In Vietnam, over 350 schools participated in HW events including 175,000 children washing hands with soap. 2 UPDATES FROM THE COUNTRY PROGRAMS AFRICA UPDATE of the favorite TV programmes for kids and it Benin generated discussions both among children and adults." Communicating Handwashing The Handwashing program in Benin is currently Education and training undertaking the initial studies that will form the In 4 Ghanaian regions, quiz competitions on basis of the upcoming countrywide communication hygiene and sanitation were held in schools, with campaign. topics that included handwashing with soap. Partners and expected outputs Also, there are ongoing training sessions on The program is developed by a national handwashing with soap for district school health coordination established and empowered by WSP- coordinators, district training officers and other AF under the supervision of the Hygiene Division stakeholders like district water and sanitation teams, (DHAB) of Benin Ministry of Health. environmental health assistants and community health nurses. At the community level, community- The main outputs of this partnership ­ also based volunteers have been trained for sensitization supported by Unilever and The London School of on handwashing with soap. Hygiene and Tropical Medicine - will include: a business plan, technical assistance in the The main focus is now on turning the increased preparation of basic studies, a baseline and awareness into sustained behavioral change. Almost formative research studies, a market study on soap all activities make use of interpersonal and the establishment of a Handwashing Task communication approaches to promote Force. handwashing with soap. Contributed by Joël Ahofodji, Handwashing Coordinator, Reaching out to the media Benin. An orientation course on handwashing with soap for media representatives was held in August as part Ghana of the sensitization of the press ­ an activity aimed at reinforcing the fundamental right to inform on Handwashing on TV hygiene and sanitation activities. A TV program for children was broadcast from April to July on national TV primetime on Contributed by Theodora Adomako ­ Adjei, PPPHW Saturdays. Coordinator in Ghana. The 13-week program was produced in the form of Kenya an interactive TV Magazine for kids, and its episodes were based on the general syllabus for Program for Internally Displaced Persons School Health Education Program. During and after the post-election violence experienced in Kenya in January 2008, the country Handwashing issues were integrated into all the had over 350,000 internally displaced people (IDP) topics. The program, called Handwash TV, living in several camps around the country. They encompassed different sections, such as; quiz faced a range of problems including exposure to competitions, drama, discussions, and public infectious diseases and poor sanitation. interviews. Handwashing is one way of preventing infectious diseases and the purpose of this initiative was to According to Michael Forson, Water and Sanitation communicate the importance of handwashing with Specialist, UNICEF, "Handwash TV is a very soap to people in the IDP camps. educative and interesting program. It became one SOAPBOX NEWSLETTER DECEMBER 2008 WSP initiated a process involving various accepted by attendees. These tools and videos will stakeholders (Ministry of Public Health and be shared through the learning platform shortly. Sanitation, Kenya Red Cross, Ministry of Water, and UNICEF, among others) to develop hygiene Growing team, growing advocacy promotion materials for internally displaced The handwashing team has been expanded recently persons in Kenya. with the hire of short-term consultants for operations, studies and monitoring and evaluation National Campaign, Regional Synergies programs. The Kenyan Handwashing Team organized pre- tests of concepts developed - and found In terms of institutionalization, the partnership is appropriate - in previous workshops in Kenya, working with the Ministry of Health to ensure that Uganda and Tanzania. The results are being used to the handwashing program is given full support. The design a national communication campaign. Ministry is also expected to sign a bylaw which will help set up the national steering committee. National baseline study A national handwashing with soap baseline and a Contributed by Seydou Koita, Handwashing Task consumer study was commissioned by the Ministry Manager, WSP, Senegal of Health with support from WSP in April 2007. The study results have been reviewed and Tanzania disseminated to key stakeholders. The report has been edited and will be published early next year. Policy Environment for Hygiene The Ministry of Health and Social Welfare is Contributed by Rufus Eshuchi, PPPHW Coordinator in working with WSP to develop a national hygiene Kenya. and sanitation policy. This process involves key government and non-government stakeholders, Senegal such as UNICEF, WaterAid, GTZ, and the National Environmental Management Council Steps forward ­ and upward (NEMC). The first handwashing initiative run through the PPPHW was piloted in four provinces during 2008. The new policy will build on the past success Furthermore, the Scaling Up behavior change registered in the country especially the `Man is project will be implemented in 80 localities across health campaign', implemented in the 1970s, which eight provinces. An Impact Evaluation study will be elevated hygiene and sanitation in the country and undertaken in these localities. built foundations on which the current efforts are riding on. An additional formative research has been launched and its results are expected in end of December The new policy empowers the local authorities to 2008. lead all implementation while the central government and stakeholders focus on the strategic Aiming at mothers and caregivers direction, including resources mobilizations for Around 1.5 million women, caregivers and kids will scaling up hygiene activities. In addition, financial be exposed to the handwashing messages supported resources from the national government's WSS by the partnership. The communication strategy SWAP have been earmarked for hygiene and includes interpersonal communication, direct sanitation at the local government level. The consumer contact (through road shows) and media. Ministry of Water and Irrigation has agreed to a dedicated budget line on hygiene and sanitation and Another activity targeting women and caregivers will be allocating funds to each district for hygiene was organized in the suburb of Dakar in presence promotion. of local authorities. Handwashing messages were conveyed through cultural activities through the "charm and art" of traditional dancers, wrestlers and theater plays. The messages conveyed were well 4 SOAPBOX NEWSLETTER DECEMBER 2008 Empowering districts to roll out The regional commissioner for Mwanza, Dr. James handwashing activities Msekela, read the main message on behalf of the A two-day workshop was held in Mwanza in Minister for Health and Social Welfare. The November to help district team update their plans director of preventive services and several senior on hygiene, sanitation and handwashing. officers from the Ministries of Water, Education, and Local Government attended and reiterated Guided by representatives from WSP and the their commitment to raising sanitation profile in the Ministries for Health, Water, and Education, the country. Over 5,000 people attended the event, sanitation and hygiene leaders of the involved which was widely covered by local, regional, and districts had an opportunity to share successes and national media. experiences and deliberate on the strategies to address the challenges they are facing. Contributed by Abdul Razak Badru, Handwashing Task Manager, WSP, Tanzania. Organizations like UNICEF, WaterAid, WASH, and Plan were invited and participated in this Uganda workshop. The latter shared their experiences in the implementation of a community intervention to Fruitful advocacy improve sanitation and personal hygiene. A national advocacy effort has reached 78 out of 80 districts in the country. The outcome includes the 1st Hygiene and Sanitation Week and 4th World integration of handwashing promotion in district Toilet Day Celebrations and NGO work plans and an enhancement of the The Ministry of Health and Social Welfare launched profile of handwashing, which was featured the first Tanzanian Hygiene and Sanitation Week. strongly in both the WSS and health annual Joint During November 13-14, a number of activities sector reviews this year. These efforts are helping across the country aimed at creating awareness and change the perception of handwashing. interest about improved sanitation and hygiene, especially handwashing with soap. Also, some districts and NGOs have allocated funds for the promotion of handwashing. A small Also, a special message delivered in Dar step in the right direction. emphasized the government's commitment to achieve national sanitation and hygiene goals as `Hands to be proud of' has emerged as the stipulated in the national strategy for growth and promotional campaign catchphrase and it is poverty reduction. resonating strongly among Women in East Africa. The concept is being used in Kenya, Tanzania, and In Mwanza - where the national events were held ­ Uganda to develop a communication campaign for activities included road shows, school events and the national roll outs. Across the East Africa region, clinic shows, which paved the way for World Toilet all handwashing-related communications, Day climax on November 19. An essay educational and direct consumer activations will be competition among schools took place, and the run under the hands-to-be-proud-of platform. winning students were awarded with prizes. Grassroot mobilization With the help of Dr. Yolande Coomes, the Uganda Handwashing Team is completing a training manual for grassroot mobilization for handwashing. This has a possibility to help other countries in the region and, hopefully, the global fraternity. Contributed by Chris Nsubuga-Mugga, Handwashing Coordinator, WSP, Uganda. School children deliver handwashing messages through a choir performance during the climax of the national hygiene and sanitation week in Mwanza, Tanzania. 5 SOAPBOX NEWSLETTER DECEMBER 2008 ASIA UPDATE Indonesia Handwashing with soap messages in Hajj Embarkations Handwashing with soap: a key pillar The Hajj pilgrim season takes place in November In September 2008 the Minister of Health signed a and December. The Ministry of Health and District decree on Community-Led Total Sanitation, where Health offices staff helped distribute posters and handwashing with soap is considered a major health stickers on the 5 critical times of handwashing, pillar. This secures the program in Government's which are being displayed in dining halls, toilets and agenda and enables scaling up the campaign in the kitchens. entire country. Upcoming event: Mother Day Three main documents supporting this regulation On December 22, PPPHW and its partners will have been developed with the support of PPP- conduct a one-day workshop about mothers in HWWS: General Guidelines for handwashing with family and business. Participants will include soap management, Technical Guidelines for Co- women organizations, associations of small scale Branding Campaign, and Handwashing Stations restaurants and snacks producers. The workshop Options Catalogue. will be inaugurated by an inspiring leading woman in Indonesia. Also, the "Train the Trainer" document includes sections on Partnership and Behavioral change Contributed by Ida Rafiqah, Handwashing Coordinator, promotion. WSP, Indonesia A time of achievements Vietnam Some major handwashing events took place in the second half of 2008, starting with a record-breaking Communication efforts moment involving 12,000 people washing hands Communications materials were completed in May simultaneously. after some rounds of creative development, pretesting and revisions. The Bird Flu campaign was launched on August 24, led by Muhammadiyah ­ the largest NGO in The launch of the handwashing National Program Indonesia. A morning walk from the National took place in June, and was followed by a first burst Monument to the headquarters of this NGO of mass media aired from July to September on marked the campaign, which was conducted in nine both national and provincial TV stations. cities and supported by USAID, WSP, Unilever, and Reckitt Benckiser. `Below the Line' events took place soon after in 10 districts in 8 provinces, with an average of 500 In Safe Hands Expo and Workshop attendees per event. A forum on the role of marketing techniques in handwashing campaigns was created by the Training sessions Indonesian partnership for handwashing with the A master training course in interpersonal support of the Unilever Academy. communications to members of the Women's Union - a leading partner in the PPP for On November 3, the Safe Hands Expo was handwashing in Vietnam - was completed in attended by high level Government dignitaries and August. Immediately following the master training, it was followed by a 3 ½ day workshop to develop the provincial Women's Union members carried non-branded Communication Pack for a out 260 trainings for community 6,760 HW handwashing campaign in Indonesia. Champions and IEC Committee Members. In December, the mid-year review will be held, together with a baseline impact evaluation. 6 SOAPBOX NEWSLETTER DECEMBER 2008 Upcoming activities Peru March 2009 will see the launch of the handwashing program in schools that will run through the A year of progress summer and into the fall of next year. Other This year the handwashing initiative made clear activities planned for the next months include: progress in Peru, as it was institutionalized by the meetings with mothers and grandparents, Ministries of Health, Education, and Water & workshops with preschool teachers, household Sanitation. visits, market meetings and provincial launches. Parallel to this, the work made with local authorities Contributed by Nga Kim Nguyen, Handwashing Task at regional, provincial and district level was crucial Manager, WSP, Vietnam to promote local ownership. In fact, some local governments have sealed their commitment to the LATIN AMERICA UPDATE initiative by publishing handwashing decrees in four regions, two provinces and one district. Colombia Throughout 2008, Colgate's handwashing education efforts in Colombia were aimed at increasing hand washing frequency among children and their families. The strategy of this educational initiative was to generate awareness of the importance in developing consistent handwashing habits by partnering with UNICEF and the Colombian Social Protection Ministry to communicate this message throughout the local community. Local authorities are proving a key partner in Peru. "Schools should promote hygiene and This successful outreach included grassroots health culture among children", says Ricardo Arone, activities and a poster campaign to promote the the Ayacucho Regional Educational Director (left side) health benefits of handwashing among the general accompanied by Edgar Jayo, tutoring specialist. public. Additionally, an extensive in-store program used informative displays to remind shoppers of the An advocacy strategy was conducted in 21 regions importance of handwashing. In several cities and over 490 professionals were trained during this including Bogotá, Medellin and Cali, handwashing year. Also, local mass media and handwashing stations were featured at shopping malls and promotional events started in October 2008. sampling was distributed to encourage families to practice good hand washing habits at home. The behavioral change program will be implemented in close to 500 districts randomly To build good hand washing habits among children, selected from the 24 regions of the country. the Clean Hands Good Health campaign was launched throughout Colombia. This program promoted Impact Evaluation proper handwashing practices among school A survey in 3,600 households - including biometric children with developmentally-appropriate and anthropometric tests ­ was completed in education materials and a classroom curriculum that August. A report with detailed data and outcomes relayed the fundamentals of hand washing with will be concluded shortly. soap. Learning process Contributed by Oscar Caicedo, Marketing Director, Two publications are underway: one on partnership Colgate-Palmolive, Colombia building and another one on the application of the children formative research findings on the design of the communication strategy. 7 SOAPBOX NEWSLETTER DECEMBER 2008 Moreover, the blog of the Peru handwashing Future efforts to address logistical barriers, such as initiative is proving a useful platform to share the location of the soap, protection of the soap, and experiences on handwashing activities, updates and location of the handwashing water source, may findings. The blog (written both in Spanish and provide a means to change handwashing behavior. English) can be visited at: http://handwashing-peru.blogspot.com/ This research was made in collaboration with Brookline Sister City Project, Quezalguaque, Contributed by Rocío Flórez, Handwashing Task Manager, Nicaragua Ministry of Health and Boston WSP, Peru University School of Public Health. NEW PUBLICATIONS & RESEARCH Authors may be contacted by email at: courtney.cawthon@vanderbilt.edu Quezalguaque Hygiene Survey and Pilot Project: A Handwashing Education Handwashing for preventing diarrhea Intervention in rural Nicaragua. Authors: Ejemot RI, Ehiri JE, Meremikwu MM, Authors: Denise Burke, Courtney Cawthon, Casey Critchley JA. Rebholz, Karen Sherk. This review looked at trials of interventions to The purpose of this research, funded by Colgate increase the use of handwashing in institutions in Palmolive through an American Public Health high-income countries and in communities in low- Association-administered grant, was to determine if or middle-income countries, and found many of the a handwashing promotion program would improve interventions like educational programs, leaflets, community health in Quezalguaque, Nicaragua. and discussions to be effective. The program, which lasted from June 2007 to Objectives January 2008, focused on increasing handwashing To evaluate the effects of interventions to promote with soap at three key times: (1) before food handwashing on diarrheal episodes in children and preparation or feeding, (2) after defecation or using adults. the latrine, and (3) after cleaning a child who has defecated among children under six years old and Search strategy their caretakers. In May 2007, the team searched the Cochrane Infectious Diseases Group Specialized Register, The project occurred in four communities in CENTRAL (The Cochrane Library 2007, Issue 2), Quezalguaque; two communities served as the MEDLINE, EMBASE, LILACS, PsycINFO, intervention and two communities served as the Science Citation Index and Social Science Citation control. Caregivers in the intervention communities Index, ERIC, SPECTR, Bibliomap, RoRe, The received monthly educational workshops focused Grey Literature, and reference lists of articles. We on hygiene. Enrolled families in the intervention also contacted researchers and organizations in the communities received free soap during biweekly field. visits from outreach workers. Selection criteria The handwashing education intervention was Randomized controlled trials, where the unit of successful in increasing the knowledge of randomization is an institution (e.g., day-care handwashing among the intervention community. center), household, or community, which compared However, no demonstrable health outcomes, such interventions to promote handwashing or a hygiene as a decrease in diarrheal and ARI incidence, were promotion that included handwashing with no shown as a result of the intervention. The increased intervention to promote handwashing. awareness of disease symptoms and subsequent increase of reporting of these symptoms by the Data collection and analysis intervention community may have masked any Two authors independently assessed trial eligibility health outcome. and risk of bias. The team stratified the analyses for cluster adjusted and non-adjusted trials. Where 8 SOAPBOX NEWSLETTER DECEMBER 2008 appropriate, incidence rate ratios (IRR) were pooled inexpensive way to prevent diarrheal diseases and using the generic inverse variance method and pneumonia. random-effects model with 95% confidence intervals. At the opening ceremony, APHA's Executive Director, Georges Benjamin, emphasized the Main results importance of collaboration among countries in a Fourteen randomized controlled trials met the globalized world. "From infectious diseases to inclusion criteria. Eight trials were institution-based climate change, today's public health threats know in high-income countries, five were community- no boundaries. A decision made in one country based in low or middle-income countries, and one today could affect a population halfway across the was in a high-risk group (people with AIDS). world." Also, keynote speaker Sir Michael Marmot, Considering only trial results that adjusted for chair of the World Health Organization's cluster randomization, interventions promoting commission on social determinants of health, called handwashing resulted in a 39% reduction in for imperative action "to create the conditions for diarrhea episodes in children in institutions in high- people to lead flourishing lives" and concluded that income countries (IRR 0.61, 95% CI 0.40 to 0.92; 2 health equity is an achievable goal. trials) and a 32% reduction in such episodes in children living in communities in low- or middle- At the conference, some educational sessions income countries (IRR 0.68%, 95% CI 0.52 to 0.90: revolved around the beneficial effects of 4 trials). handwashing. Dr. Regina Idu Ejemot, from Calabas University in Nigeria, presented a study on "Effects Authors' conclusions of intervention promoting handwashing for Interventions that promote handwashing can preventing diarrhea" and researcher Courtney reduce diarrhea episodes by about one-third. This Cawthon, from Vanderbilt University Medical significant reduction is comparable to the effect of Center, shared with attendees her experiences and providing clean water in low-income areas. findings in a handwashing program implemented However, trials with longer follow up and that test recently in Nicaragua. (See Soapbox section different methods of promoting handwashing are "Research and publications".) needed. Both studies can be downloaded from: http://www.globalhandwashing.org/Global%20act ivities/Advocacy.htm CAPACITY-BUILDING, OUTREACH, AND ADVOCACY PPPHW Exhibits at APHA Conference The PPPHW exhibited at the 136th American Public Health Association (APHA) Annual Dr. Regina Idu Ejemot (right side) presents on the Conference and Exhibition, held in San Diego "Effects of intervention promoting handwashing for (United States) from October 25-29, 2008. preventing diarrhea" - APHA Conference in San Diego, United States. Under the theme Public Health without Borders this year's conference attracted more than 12,000 attendees, including epidemiologists, international development professionals and health researchers. A fair number of them visited the PPPHW stand, where they were informed about the work of the partnership and its mission to promote handwashing with soap as an effective and 9 SOAPBOX NEWSLETTER DECEMBER 2008 Water and Public Health: the 21st Century The joint press release sent out by the participating Challenge countries emphasized that, "behavior change communication and information sharing will be `Water and Public Health' will be the theme of the effectively utilized for creating demand for a clean 2009 American Public Health Association Annual and healthy environment, and for promoting good Meeting, to be held in Philadelphia (United States) hygiene behavior." The text also mentions that a, from November 7-11, 2009. "greater thrust will be placed on promoting adequate sanitation in schools and hygiene Submission of abstracts will be open from education will be incorporated into the school December 19, 2008 to February 9-13, 2009. curricula to promote good hygiene behavior and upkeep of facilities." For more information on how to become a speaker at APHA 2009, visit: SACoSan 2010 and 2012 will take place in Sri Lanka http://www.apha.org/meetings/sessions/. and Nepal, respectively. IN THE NEWS UPCOMING ACTIVITIES The PPPHW's Steering Committee will meet next India's Prime Minister supports in early 2009, in Washington DC. handwashing at SACoSan Conference Manmohan Singh, the Indian Prime Minister, opened the Third South Asia Conference on Sanitation (SACOSAN III) in New Delhi on November 18, 2008. Two thirds of South Asia's 1.5 billion people lack access to appropriate sanitation, an alarming reality that calls for immediate action. As Mr. Singh said, "[S]anitation is concerned with not just personal health but also human dignity." In his speech, the Prime Minister called for sanitation to be recognized as the, "birthright of every citizen of South Asia" and pointed out the simple act of washing hands properly as a means to significantly reduce diarrheal diseases. SACoSan III concluded on November 21 with the Delhi Declaration, whereby the heads of delegations of eight South Asian countries ­ Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka ­ confirmed their commitment to achieving the Millennium Development Goal (MDG) on sanitation in a time- bound manner in their respective countries. We encourage and welcome your comments and contributions to SoapBox. Please send them to Eloy Parra at eparra@worldbank.org Want to learn more about the global Public-Private Partnership for Handwashing with Soap? Visit our website at www.globalhandwashing.org 10