64489 Report Enabling Environment Assessment and Baseline for Scaling Up Handwashing Programs: Tanzania Carol Hooks Global Scaling Up Handwashing Project April 2008 This report is one in a series of products of the Water and Sanitation Program’s Scaling Up Handwashing Project funded by the Bill and Melinda Gates Foundation. The aim of the project is to test whether innovative promotional approaches can generate widespread and sustained increases in handwashing with soap at critical times among the poor and vulnerable. This series of reports documents the findings of work in progress about handwashing with soap in order to encourage the exchange of ideas and information and to promote learning. Please send your feedback to: wsp@worldbank.org . The Water and Sanitation Program (WSP) is a multi-donor partnership of the World Bank. For more than 30 years, WSP has helped the poor gain sustained access to improved water supply and sanitation services (WSS). WSP works with governments at the local and national level in 25 countries. For more information, please visit: www.wsp.org . Credits Editorial Support: Hope Steele Production: Paula Carazo This report was reviewed by Nat Paynter, Ousseynou Diop, Eduardo Perez, Lene Jensen, Jason Cardosi and Jacqueline Devine ABOUT THE AUTHOR Carol Hooks Carol Hooks has nearly 20 years of experience in public health communication, building on her early work in materials development and behavior change communication to take on advocacy, brand development and management, project development and evaluation, public relations, and training. She has a proven track record of bringing public health issues and organizations to the forefront of public discourse and preparing senior leaders and managers to represent their issues effectively. Ms. Hooks has worked with many types of organizations, including nonprofits, foundations, global partnerships, academia, government agencies, the United Nations, and biotech and pharmaceutical companies. Her experience covers a wide variety of health topics, including adolescent health, cancer prevention, child health, HIV/AIDS, hygiene and sanitation, immunization, malaria, maternal health, reproductive health, and substance abuse prevention. Ms. Hooks spent seven years focusing on brand management, crisis communications, advocacy, and public relations for a global vaccine development program. She has worked in the United States and more than 20 other countries in Africa, Asia, Europe, Latin America and the Caribbean. The findings, interpretations, and conclusions expressed in this report are entirely those of the author. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations or those of the Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility whatsoever for any consequence of their use. The boundaries, colors, denominations and other information shown on any map in the document do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. ii Global Scaling Up Handwashing Project Table of Contents CREDITS……………………………………………………………………..................................ii LIST OF ACRONYMS AND ABBREVIATIONS………………………………………………………v SUMMARY………………………………………………………………………………………...vi 1. BACKGROUND……………………………………….……………………………………….....1 The Scaling Up Handwashing Project………………………………………………………...…...1 Enabling Environment Assessment…………………………………...........……………….……..2 Key Recommendations……………………………………………………..……………….……..2 2. THE TANZANIA PROJECT………………………………………………………………………5 Rationale for Enabling Environment Assessment………………………………….……………...8 3. ASSESSMENT METHODOLOGY…………………………………………………………………9 Dimension Descriptions……………………………………………………………..………….....9 4. ASSESSMENT DESIGN………………………………………………………………………….11 Purpose and Objectives…………………………………………………………………………..11 Data Collection……………………………………………………………………………….…..11 Policy, Strategy, and Direction……………………………………………………….…………..16 Partnerships……………………………………………………………………………………….21 Institutional Arrangements………………………………………………….……………………24 Program Methodology……………………………………………………...…………………….25 Implementation Capacity…………………………………………………....................................27 Availability of Products and Tools……………………………………………………………….32 Financing…………………………………………………………………………….…...............34 Cost-Effective Implementation…………………………………………….……………………..36 Monitoring and Evaluation…………………………………………………..…………………...37 5. SELF-REPORT FINDINGS……………………………………………………………………...39 6. RECOMMENDATIONS………………………………………………………………………….41 Policy, Strategy, and Direction…………………………………………………………………...41 Partnerships………………………………………………………………………………………44 Institutional Arrangements……………………………………………………………………….45 Program Methodology……………………………………………………………………………46 Implementation Capacity…………………………………………………....................................46 Availability of Products and Tools……………………………………………………………….47 Financing………………………………………………………………………………………….48 Cost-Effective Implementation……………………………………………...................................48 Monitoring and Evaluation……………………………………………………………………….50 Marketing Considerations………………………………………………………………………...52 Miscellaneous Recommendations………………………………………………………………...52 7. NEXT STEPS…………………………………………………………………………………...52 APPENDIX A: RESPONDENTS BY LEVEL AND TYPE……………………………………………..54 iii Global Scaling Up Handwashing Project APPENDIX B: TANZANIA HYGIENE AND SANITATION INVENTORY……………………………..63 LIST OF BOXES Box 1. MOHSW Environmental Health, Hygiene, and Sanitation Policy Implementation Guiding Frameworks…………………………………………………………………………………………………7 Box 2. National Health Policy Objectives Relating to Environmental Health, Hygiene, and Sanitation…..7 Box 3. A Case for Building Behavior Change Capacity…………………………………………..……....27 Box 4. Potential Elements of a Long-Term Vision for Tanzanian HWWS…………………………….....43 LIST OF TABLES Table 1. Handwashing Targets by Country……………………………………………………….…….....2 Table 2. Tanzania WSP HWWS/TSSM Baseline Assessment: Self-Report Respondent Characteristics.13 Table 3. Respondent Organizations and Agencies by Type……………………………………………....15 Table 4. Hygiene-Related Topics in the October 2003 Draft National Health Policy…………………….16 Table 5. Current and Potential Ministerial Partners……………………………………………………….23 Table 6. Sample of 30 Tanzanian NGOs/CBOs/FBOs with Water/Sanitation/Hygiene Programs……….29 Table 7. Self-Report Key Findings………………………………………………………………………..40 Table 8. Summary of Types of Partnerships Needed……………………………………………………...45 Table 9. Cost-Effectiveness (US$/DALY), Hygiene Promotion vs. Other WSS Interventions…………..50 Table 10. Output and Outcome Indicators for Water, Sanitation, and Handwashing……………………..51 Table 11. Short-Term Action Plan (next 6 Months)……………………………………………………....53 Table 12. Medium-Term Action Plan (7–12 Months)………………………………………………….....54 Table 13. Long-Term Action Plan (13–15 Months)……………………………………………………....54 iv Global Scaling Up Handwashing Project List of Acronyms and Abbreviations ARI Acute respiratory infection CBO Community-based organization CLTS Community-led total sanitation CSPD Child Survival, Protection, and Development DD Diarrheal disease DED District executive director DEO District education officer DHS Demographic and Health Survey DOTS Directly observed therapy short course DSS Demographic surveillance system EEA Enabling environment assessment EEPCO Environmental Engineering and Pollution Control Organization FBO Faith-based organization FGD Focus group discussion HWWS Handwashing with soap IMCI Integrated management of childhood illness M&E Monitoring and evaluation MDG Millennium Development Goal METL Mohammed Enterprises Tanzania Ltd MIS Management information system MOCDGC Ministry of Community Development, Gender, and Children MOEVT Ministry of Education and Vocational Training MOHSW Ministry of Health and Social Welfare MOW Ministry of Water MP Member of Parliament NEHHASS National Environmental Health, Hygiene and Sanitation Strategy NGO Nongovernmental organization NID National Immunization Day PER Public expenditure review PHAST Participatory hygiene and sanitation transformation PIP Project implementation plan PMO-RALG Prime Minister’s Office - Regional Administration and Local Government PPP Public-private partnership PPPHW Public-Private Partnership for Handwashing PRS Poverty reduction strategy PS Permanent secretary RWSSP Rural Water Supply and Sanitation Program SACCOSs Savings and credit cooperative societies SADC South African Development Community SHWG Sanitation and Hygiene Working Group SWAP Sector wide approach T-MARC Tanzania Marketing and Communications TS Total sanitation TSSM Total sanitation and sanitation marketing WHO/AFRO World Health Organization/Africa Regional Office WHO World Health Organization WSDP Water Sector Development Program WSP Water and Sanitation Program WSS Water Supply and Sanitation v Global Scaling Up Handwashing Project Summary To follow up country work supported by the Public-Private Partnership for Handwashing (PPPHW), the World Bank Water and Sanitation Program (WSP) received funding from the Bill & Melinda Gates Foundation to support projects to scale up the promotion of handwashing with soap (HWWS) in Peru, Senegal, Tanzania, and Vietnam. The major project objectives of the Handwashing Initiative are: • inculcate the HWWS habit among millions of mothers and children in these countries, • use a strong monitoring and evaluation (M&E) component to enhance the conceptualizing and management of such programs, • establish sustainable programs that will continue and expand after this four-year grant ends. Enabling environment assessments were carried out in all four countries to assess current conditions for scalability and sustainability and to make recommendations for improving conditions that are not supportive. This report summarizes the study in Tanzania. All of the country studies followed a similar methodology, developed by the WSP, to examine nine dimensions of scalability/sustainability through individual and group in-depth interviews and a survey in which respondents are asked to score various statements. As part of the Behavior Change Program, the Tanzania Handwashing Initiative seeks to meet the basic sanitation and hygiene needs of Tanzania’s rural poor. HWWS in Tanzania builds on existing government ministerial strategies to maximize the health impact of the Water Sector Development Program (WSDP) and a National Environmental Health, Hygiene, and Sanitation Strategy (NEHHASS) by plugging hygiene promotion gaps, specifically HWWS. Activities are being developed in collaboration with the Ministries of Water and of Health and Social Welfare (MOW and MOHSW), with a goal of integrating them into the WSDP as results are available. The project also engages other relevant ministries. Planning, site selection, implementation, and capacity building are being done in consultation with the appropriate government agencies, and the private sector and civil society are being engaged as partners. This four-year project (1.5 years of planning, 2 years of implementation, and 6 months of evaluation) launched with a group of core partners in December 2006, and is expected to take place in 10 districts. The assessment methodology, findings, and recommendations that result from this assessment are documented in this report. vi Global Scaling Up Handwashing Project 1. Background Funded by the Bill & Melinda Gates Foundation, the Global Scaling Up Handwashing Project will follow the basic approach of the Public-Private Partnership for Handwashing (PPPHW), a global initiative established in 2001 to promote handwashing with soap at scale to reduce diarrheal and respiratory infections. 1 This approach draws extensively on lessons learned from two large-scale handwashing promotion programs. Programma Saniya, implemented in Bobo- Dioulasso, Burkina Faso, showed the importance of undertaking careful consumer research at the outset of a handwashing promotion program. The Central American Handwashing for Diarrheal Disease Prevention Program showed that an effective approach to changing hygiene behaviors at large scale was to work with a broad partnership of public and private sector stakeholders that have a mutual interest in increasing handwashing with soap, to focus on the one behavior with largest potential health impact (handwashing with soap), and to promote it with cost-effective, consumer-centered marketing. The Scaling Up Handwashing Project In hopes of facilitating effective replication and scaling-up of future handwashing-with-soap behavior-change programs, the new project will carry out a structured learning and dissemination process to develop and share evidence, practical knowledge, and tools. Specific project objectives are to: • design and support the implementation of innovative, large-scale, sustainable handwashing programs in four diverse countries (Peru, Senegal, Tanzania, and Vietnam); • document and learn about the impact and sustainability of innovative, large-scale handwashing programs; • learn about the most effective and sustainable approaches to triggering, scaling-up, and sustaining handwashing behaviors; • promote and enable the adoption of effective handwashing programs in other countries and position handwashing as a global public health priority through the translation of results and lessons learned into effective advocacy, applied knowledge, and communication products. The project is designed to achieve specific handwashing targets for each country (Table 1) at the end of two years of implementation. The target audience is defined as poor women of childbearing age (15–49) and poor children ages 5–9. 1 Global PPPHW partners include the Water and Sanitation Program, USAID, World Bank, UNICEF, London School of Hygiene and Tropical Medicine, Centers for Disease Control, Academy for Educational Development, Water Supply and Sanitation Collaborative Council, Colgate-Palmolive, Procter & Gamble, and Unilever. 1 Global Scaling Up Handwashing Project Table 1. Handwashing Targets by Country Target population Estimated target population washing hands Country (population) (millions) with soap at critical times (millions) Peru (28 million) 5.1 1.3 Senegal (11 million) 2.0 0.5 Tanzania (37 million) 5.2 1.3 Vietnam (84 million) 9.2 2.3 Source: World Bank (Water and Sanitation Program). 2007. “Terms of Reference. Enabling Environment Assessment and Baseline to Scale up, Sustain and Replicate Handwashing with Soap Behavior Change Programs.� March 9 Enabling Environment Assessment An enabling environment assessment was undertaken to determine to what extent the programmatic conditions for scale-up and sustainability are in place at the beginning of this project and, based on these findings, recommend what should be done to address the gaps during project implementation. To do this, it looked at nine dimensions representing a conceptual framework for assessing scalability and sustainability: Policy, Strategy, and Direction; Partnerships; Institutional Arrangements; Program Methodology; Implementation Capacity; Availability of Products and Tools; Financing; Cost-Effective Implementation; and Monitoring and Evaluation. A final assessment will be carried out toward project end to determine whether there is an enabling environment in place that can continue after 2009 without further project assistance. The current assessment took place in May 2007 and relied primarily on document review, Internet research, and interviews with main stakeholders including government, civil society, and the private sector. Key Recommendations 1. Policy, Strategy and Direction Advocacy • To approach an ideal policy/strategy environment, the project should begin advocacy now. • Build on the current goodwill toward the project concept. District executive directors (DEDs) and school administrators are key targets. As the project scales up, advocacy toward high-ranking officials and lawmakers will be increasingly helpful. • Use real-life stories and project successes to make critical issues accessible and to attract success and support. • Ensure that staff, project leaders, and other spokespersons have a core set of concise messages to use regarding the importance of HWWS. Incentives • Ensure appropriate provision and use of incentives. 2 Global Scaling Up Handwashing Project • Create opportunities for peoples’ stories to be told—in newspapers, newsletters, and other media. • Work with donors to organize a broad-based public-private partnership (PPP) summit-type meeting where successes, challenges, and ideas are presented. • Provide data from other countries to assist private sector in assessing how project success will affect them. 2. Partnership • Partnership is the most critical element to get right if this project is to be successful, scalable nationwide, and sustainable over time. • Use the services of a proven partnership facilitation firm or consultant as close to project start as possible. • Work with partners to create a shared vision, define clear and strategic roles and responsibilities, identify capacities and needs, and create an effective management structure. 3. Institutional Arrangements • Focus institutional arrangements on what is most likely to lead to sustainability and scale-up of HWWS. This may mean arrangements that favor districts, nongovernmental organizations (NGOs), and the private sector. • Support efforts to create effective coordination at the national level (such as getting permanent secretaries involved) and create district-level project management teams that include government and nongovernmental partners. 4. Program methodology • WSP should emphasize that the methodology is being adapted to the Tanzanian context, as has been done in other HWWS countries. • Incorporate feedback into the methodology to the extent that it is possible, constructive, and not in conflict with the core methodology. 5. Implementation capacity • Clarify with partners what and where the most important capacity building opportunities are. • Limit capacity building to what is needed to meet project objectives (for example, targeting the district government level for strengthening so that HWWS activities can be sustained). • Build community and ward capacity for planning and working with the private sector to identify efficient and effective ways to market to rural populations. 6. Availability of Products and Tools • Water supply at schools is essential to the long-term success of HWWS in Tanzania. 3 Global Scaling Up Handwashing Project • Get the MOEVT, DEDs, district water engineers, and communities to add handwashing facilities near school toilets. • Work with the WSS sector wide approach (SWAP) to integrate HWWS into WSS investment programs in Tanzania—being sure to include relevant indicators to encourage implementers to follow through. 7. Financing • Help districts effectively program and use their hygiene promotion funds. • Work with the MOEVT and DEDs to ensure funding is allocated for handwashing facilities at schools. • Allocate project resources to balance the need for both efficiency and commitment from the partners. 8. Cost effectiveness • Elucidate clear incentives for tracking cost data, including averted costs caused by decreases in DD and ARI, and simplify the collection of cost data. • Raise awareness within government about the cost-effective impact HWWS can have on DD and ARI reduction targets. 9. Monitoring • Use the minimum number of indicators necessary to guide and evaluate the project. • Build on an existing monitoring and evaluation (M&E) system that can be accessed by all partners. • Provide evidence of how monitoring will benefit partners, and work with an experienced research group to measure health outcomes. 4 Global Scaling Up Handwashing Project 2. The Tanzania Project WSP initially supported Tanzania from its regional office in Nairobi, providing input into the nation’s urban and rural water and sanitation programs. In October 2005, the WSP opened an office in Dar es Salaam and has since been active in donor and sector coordination and communications. The program seeks to harness the power of government, the private sector, nongovernmental organizations (NGOs), community-based organizations (CBOs), faith-based organizations (FBOs), and others committed to alleviating poverty and improving health by improving water and sanitation. Of the four countries participating in the Global Scaling Up Handwashing Project, Tanzania is the only one also participating in Global Scaling Up Sanitation Project (Total Sanitation and Sanitation Marketing) The vision for this dual effort is to meet the basic sanitation and hygiene needs of the Tanzanian rural poor, contributing to the attainment of MDG 4: Reduce child mortality (by two-thirds by 2015) and Tanzania’s Development Vision 2025 target “Reduction in infant and maternal mortality rates by three-quarters of current levels.� This will be accomplished by building on what has been learned by previous efforts in Tanzania and elsewhere to design hygiene programs that improve health and are sustainable on a large scale. The project will test promising approaches for creating demand for HWWS, improve the supply of handwashing-related products, and promote HWWS. It will assess the effectiveness of the HWWS approach alone and in combination with total sanitation and sanitation marketing (TSSM). The HWWS project will increase the incidence of people washing their hands with soap at critical times—after defecating, after cleaning a child who has defecated, and before eating or feeding. It targets children under 5 (via their caregivers—women ages 15–49) and school children ages 6–13. It will use a marketing approach to change people’s behaviors. Studies show that HWWS can reduce diarrheal disease (DD) incidence by 42–47 percent and the transmission of acute respiratory infections (ARI) by over 30 percent. 2 Observations carried out in Dar es Salaam and the rural districts of Mpwapwa and Rufiji indicated that after using the toilet, only 4 percent of mothers and 5 percent of children washed their hands with soap. In addition, Tanzania reports a high level of sanitation coverage—over 90 percent—yet still reports a relatively high diarrhea incidence at 12.6 percent for under-five-year- old (<5) children, with children under two years suffering the most (malarial incidence is 16.5 percent, 3 and HIV is 0.6 percent 4 ). This could indicate a lack of appropriate hygiene behavior, such as HWWS, in addition to other factors such as poor latrine design. The low rates of handwashing are rarely due to a lack of soap in the household. Soap is believed to exist in almost all households, but is commonly used for bathing and laundry—not washing hands at the critical times. 2 Tanzania Project Implementation Plan, Scaling Up Handwashing with Soap. 3 UNICEF, State of the World’s Children. 2003. Excerpted from Nathaniel Paynter’s “Tanzania Project Implementation Plan, Scaling Up Handwashing with Soap,� Draft April 12, 2007, Dar es Salaam, Tanzania. 4 UNAIDS. 2005. Excerpted from Nathaniel Paynter’s “Tanzania Project Implementation Plan, Scaling Up Handwashing with Soap,� Draft April 12, 2007, Dar es Salaam, Tanzania. 5 Global Scaling Up Handwashing Project People are more likely to practice HWWS after eating something oily (traditional meals are eaten with hands instead of utensils) than they are before eating. Many Tanzanians consider children’s feces to be safe.5 People also seem to believe that lack of visible dirt means that hands are clean enough. Further consumer research should uncover reasons for not practicing HWWS and suggest strategies to change this behavior. Based on Tanzanian experience and research, it also will be necessary to examine (1) the willingness and ability of the private sector to engage in an HWWS program, either unilaterally or with the government, and (2) the relative proximity of water as a component of the enabling environment as initial research indicated that easy access to water is critical to adopting handwashing practices. In 2000, 42 percent of rural Tanzanian households had ready access to a public water point or household connection. 6 The rural population with access to clean and safe water was 53.00 percent in 2003 and 53.56 percent in 2005. Tanzania has an estimated population of 37 million. 7 The target population for this project is 5,200,000, with an expectation that, by project end, 1,300,000 people will adopt HWWS at critical times. The government has taken a number of institutional steps to address the low rates of HWWS. The Ministry of Water (MOW) has recently launched the national Water Sector Development (WSDP) comprised of rural and urban water supply, sanitation, and hygiene, along with water resource management. Funding for the initial five-year period of the WSDP has been fully committed by the government and development partners in Tanzania. Under the WSDP, the MOW has committed US$50 million to sanitation and hygiene promotion (including school and clinic sanitation) over the program’s 20-year lifespan. Also under the WSDP, the MOW has instituted several technical working groups, including a Sanitation and Hygiene Working Group (SHWG). The SHWG is currently chaired by the acting director of Urban Water Supply and is comprised of representatives from the MOW, the Ministry of Health and Social Welfare (MOHSW), donors, NGOs, and other agencies. At the same time, the MOHSW has developed a draft National Environmental Health, Hygiene and Sanitation Strategy (NEHHASS), 8 which outlines the strategies and activities it will undertake to improve sanitation and hygiene practices. It lists several “policy implementation guiding frameworks� developed to address environmental health, hygiene, and sanitation issues (Box 1) as well as the National Health Policy objectives relating to the same (Box 2). It also refers to Second Health Sector Strategic Plan (July 2003–June 2008) and states that “the Essential Health Intervention Package includes the provision of Environmental Health, Sanitation and Occupational Health Services.� 5 The United Republic of Tanzania, Ministry of Health, The National Environmental Health, Hygiene and Sanitation Strategy, 00 Draft, February 2005, published by the Department of Public Services-Ministry of Health. 6 World Health Organization, Water Supply & Sanitation Sector Assessment 2000. 7 Government of Tanzania, http://www.tanzania.go.tz/population/tzclock.html. 8 The United Republic of Tanzania, Ministry of Health, The National Environmental Health, Hygiene and Sanitation Strategy, 00 Draft, February 2005, published by the Department of Public Services-Ministry of Health. 6 Global Scaling Up Handwashing Project Box 1. MOHSW Environmental Health, Hygiene, and Sanitation Policy Implementation Guiding Frameworks Environmental Health and Sanitation Policy Guidelines 2004 Waste Management Policy Guidelines 2004, Participatory Hygiene and Sanitation Transformation (PHAST) Training Guidelines 2004 Occupational Health Guidelines 2004 Port Health Guidelines Box 2. National Health Policy Objectives Relating to Environmental Health, Hygiene, and Sanitation Reduce the burden of disease and maternal and infant mortality, and increase life expectancy by providing adequate and equitable maternal and child health services; facilitate the promotion of environmental health and sanitation, promotion of adequate nutrition, control of communicable diseases, and treatment of common conditions. Ensure that health services are available and accessible to all the people in the country (urban and rural areas). Sensitize the community on common preventable health problems, and improve the capabilities at all levels of society to assess and analyze problems and design appropriate action through genuine community involvement. Promote awareness among government employees and the community at large that health problems can be adequately solved only through multisectoral cooperation involving other sectors such as education, agriculture, water, the private sector including NGOs, civil society, and central ministries as well as president’s office, regional administration and local government, and the Ministry of Community Development Gender and Children. Promote and sustain public-private partnership in the delivery of health services. The WSDP and the NEHHASS both incorporate current thinking on sanitation and hygiene, including sanitation marketing, hygiene promotion, and developing the domestic private sector. The Tanzania Handwashing Initiative is building on already-existing government ministerial strategies for maximizing the health impact of the WSDP and NEHHASS by plugging hygiene promotion gaps, specifically those related to HWWS. All activities are being developed in collaboration with the sanitation and hygiene teams of the MOW and the MOHSW, with a goal of integrating them into the WSDP once results are available. Because hygiene is a multisectoral issue, the project also seeks to engage other relevant ministries, including the Ministry of Education and Vocational Training (MOEVT); Ministry of Community Development, Gender, and Children (MOCDGC); and the Prime Minister’s Office - Regional Administration and Local Government (PMO-RALG). Planning, site selection, implementation, and capacity-building are being done in consultation with the appropriate government agencies. The donors involved in the WSS SWAP, private sector, NGOs, CBOs, and FBOs are also being engaged as partners. 7 Global Scaling Up Handwashing Project This four-year project (1.5 years of planning, 2 years of implementation, and 6 months of evaluation) launched with a group of core partners in December 2006, and was expected to take place in four districts: Iringa Rural, Mpwapwa, Rufiji, and Igunga, in the Iringa, Dodoma, Coast, and Tabora regions respectively. Following the enabling environment assessment (EEA), six districts were added: Kondoa, Sumbawanga, Kiteto, Masasi, Musoma, and Karagwe. Rationale for Enabling Environment Assessment The EEA sought to (1) assess to what extent the programmatic conditions for scale up and sustainability are in place at the beginning of the project and (2) on the basis of the baseline assessment findings, recommend what should be done to address the gaps during project implementation. 8 Global Scaling Up Handwashing Project 3. ASSESSMENT METHODOLOGY In order to ensure consistency in the assessment findings, the WSP has developed a conceptual framework for assessing scalability and sustainability. This framework was developed based on a review of relevant literature and discussions with key individuals. Dimension Descriptions The framework comprises nine dimensions that are considered essential to scaling up a handwashing-with-soap behavior change program. The following nine dimensions represent a conceptual framework for assessing scalability and sustainability. Scale-up has been defined as an increase the present scale, rate of behavior change, and sustainability of programs promoting HWWS. For the purposes of this report, sustainable is defined as able to continue when international funding and technical support are no longer available. Policy, Strategy, and Direction: Establishing a shared vision and strategy and ensuring the political will to implement them is the starting point for scale up. Without political will and a shared vision and strategy among stakeholders at all levels, scale up will remain an elusive goal. Developing this shared vision and strategy in a collaborative manner is also the foundation for coordination and for creating motivation all levels. Partnerships: This handwashing-with-soap program model is based on a establishing a public- private partnership. A partnership is a relationship where two or more parties, having compatible goals, form an agreement to share the work, share the risk, share the power, and share the results or proceeds. Partnerships need to be built at all levels among public, private, and NGO sectors and between communities and local governments. Institutional Arrangements: Institutions at all levels must clearly understand their roles, responsibilities, and authority. They must also have the resources to carry out their roles. In addition to clear roles and responsibilities, institutional arrangements must include the mechanisms for actors at all levels to coordinate their activities. Program Methodology: Handwashing-with-soap programs have a seven-step program methodology. This methodology, adapted to each country context, should be clear and agreed upon by all key stakeholders. Implementation Capacity: In addition to clearly defined institutional roles and responsibilities, institutions at all levels must have the capacity to carry out their roles and responsibilities. Institutional capacity includes adequate human resources with the full range of skills required to carry out their functions; an “organizational home� within the institution that has the assigned responsibility; mastery of the agreed-upon program methodology, systems, and procedures required for implementation; and the ability to monitor program effectiveness and make adjustments. Availability of Products and Tools: A handwashing-with-soap behavior-change program is predicated on the existence of the soap that responds to consumer preferences and their willingness and ability to pay for them. In addition, handwashing station supplies—that is, basins, towels, and so on—need to be easily available. 9 Global Scaling Up Handwashing Project Financing: This dimension is aimed at assessing the adequacy of arrangements for financing the programmatic costs. These costs include training, staff salaries, transportation, office equipment and supplies, and the development of communication and educational materials as well as programmatic line items in budgets for handwashing-promotion activities. Cost-Effective Implementation: The potentially high costs of promoting handwashing-with- soap behavior at scale make cost-effective implementation a key element. It is essential to understand how the unit costs change as activities are scaled up. Although it will not be possible to assess the cost-effectiveness of the approach and how best to achieve economies of scale until the end of the project, data must still be collected during implementation to make this determination at the end of the project. Therefore, this assessment will try to ensure that information will be collected from the outset and that the capacity to collect the information is in place. Monitoring and Evaluation: A large-scale handwashing-with-soap behavior-change program requires regular monitoring and, perhaps more importantly, the willingness and ability to use the monitoring process to make adjustments in the program. Effective monitoring will identify strengths and weaknesses in the program methodology, implementation arrangements, and cost efficiencies. Overall monitoring responsibility must be at the highest level of the program, but must be based on information collected at the local government or district level. A final assessment will be carried out toward the end of the project to determine whether there is an enabling environment in place that can continue after 2009 without further project assistance. 10 Global Scaling Up Handwashing Project 4. ASSESSMENT DESIGN The Tanzania HWWS enabling environment assessment took place in May 2007. The purpose of the assessment was to determine to what extent the programmatic conditions for scale up and sustainability are in place (the nine dimensions discussed above) at the beginning of this project and, based on these baseline findings, recommend what should be done to address the gaps during project implementation. Purpose and Objectives Specific assessment objectives include: 1. Determine what is presently in place and happening under each dimension. 2. Detail the level of the program to be carried out—that is, start-up, expansion, or national. 3. Identify strengths and weaknesses of each dimension, with a focus on deficiencies. 4. Establish the baseline against which the enabling environment will be assessed at end of project. 5. Make recommendations for improvements to the enabling environment over the life of the project to the country task manager, WSP headquarters staff, and main in-country partners. 6. Obtain consensus among current partnering organizations for recommendations and next steps. 9 Data Collection A team of three consultants assessed the enabling environment for the Scaling Up Handwashing and Scaling Up Sanitations activities, conducting a number of interviews together, others apart, and making separate field trips to districts (HWWS to Iringa, along with a representative of the MOHSW; TSSM to Mpwapwa, with an MOW representative). The WSP task manager and handwashing coordinator accompanied the consultants on some interviews, with the handwashing coordinator also participated in the Iringa field visit. Findings and conclusions from the separate interviews and visits were shared upon return. Methodology Description Four qualitative data collection methodologies were used: (1) interviews, (2) focus group discussions, (3) self-reporting, and (4) field observations in communities. Interviews or focus group discussions were conducted with all primary data sources. Thirty-five people were interviewed (1–3 respondents per session), and focus group discussions were conducted with the MOW (4 participants), Iringa health officers (11 participants), and Iringa’s district council (6 participants). Interview guides were developed for each dimension and for each level as appropriate, with a subset of questions appropriate to focus group discussions highlighted. 9 WSP partnerships for HWWS had not yet been formalized, so obtaining consensus from collaborative partners was beyond the scope and time allotted for this assessment. 11 Global Scaling Up Handwashing Project Information from courtesy calls with Iringa’s regional administrative secretary,10 regional medical officer, regional health officer, and regional water technician and with the MOW’s director of policy and planning have been included in the findings and recommendations. Also in Iringa district, consultants met with the village council of Kitisi and participated in a town meeting with approximately 70 villagers, including council members. Kitisi is one of five villages across Tanzania selected by the MOHSW to pilot a Healthy Villages project about one year ago. 11 Courtesy calls were paid to the MOW director of policy and planning, to the ward manager for the ward that includes Kitisi, and to the Iringa regional health officer, regional medical officer, regional administrative secretary, and regional water technician. Valuable information gained from these meetings is included in the findings and recommendations. Self-reporting involved the use of a grading scale questionnaire completed by primary and secondary data sources (see the section on self-reporting findings). The questionnaire was e- mailed or hand-delivered to 28 organizational representatives, with a request to also forward to others in their organizations involved in sanitation and hygiene activities. Ten self-reports were completed and returned by respondents, described in Table 2. Given the responses, it is unclear whether all respondents completed the self-reports based on the Scaling Up Handwashing and Sanitation projects or on their own work, even though it was clarified orally that the program in question were the projects currently being developed. 10 The assistant to and spokesperson for the regional commissioner. 11 Based on a WHO model developed in 1986, it takes a “whole village� approach that seeks to help communities raise their quality of life by improving in areas including health, environmental sanitation, water supply, agriculture, community development, infrastructure, and housing. 12 Global Scaling Up Handwashing Project Table 2. Tanzania WSP Scaling Up Handwashing and Sanitation Baseline Assessment: Self-Report Respondent Characteristics Organization How Respondent Views Others Who Will Length of Association Role Type on Program* 6 1 yr > 1 yr Decide Implement Super/Manage Other Stakeholders Partners Agenc mos. NGO NGO NGO District Government District Government District Government District Facilitator Government Regional Government District Government National Desk Officer Government Total 4 1 4 3 4 6 6 4 1 * No respondent selected Players, Organizations, Staff Members, or Other, so they have been omitted here. Note: Observations were carried out during the visits to Kitisi and Mpwapwa. 13 Global Scaling Up Handwashing Project Selection (Sampling, Sample Size, Site Selection) Sampling was purposive for all primary data sources. Criteria for selection for both interviews and self-reports included: (1) have participated in handwashing program for at least 6 months; (2) are a potential partner; (3) represent a main workforce type—a decision maker, an implementer, or a mid-line supervisor/manager of the process/program; and (4) represent the different levels of the organization that are involved in the program—that is, national, regional, district, and local. Sources Primary data sources comprised main stakeholders (including present and potential partners) for the in-country program work, including but not limited to government agencies, international agencies, international NGOs, local NGOs, FBOs, CBOs, private sector businesses, and a village council. These primary data sources were contacted at all appropriate levels, when possible—that is, national, regional, district, and local. As noted above, a town meeting was held with residents of Kitisi, the MOHSW’s Healthy Village in the Iringa Rural District. Because the project is at an early stage (month 5), over half of respondent agencies were potential rather than current partners. Although interviews were conducted with specific dimensions in mind according to level and type of respondent, they often covered more or different dimensions according to the flow of conversation. Table 3 describes respondent organizations. A list of respondents by level and type is attached as Appendix A, and a full contact list was sent to the Tanzania task manager, handwashing coordinator, and EEA consultants. 14 Global Scaling Up Handwashing Project Table 3. Respondent Organizations and Agencies by Type Government International International Local NGOs Private CBOs FBOs Universities Agencies Agencies NGOs Sector Iringa UNICEF AED EEPO METL Isimani World Aga Khan District Rural Vision University Africare T-MARC Soap & Council Water Allied UCLAS AMREF WATSANET Association Iringa District Concern Health Team Worldwide Iringa International Region Trachoma Initiative Kitisi Village Council Mennonite Economic MOCDGC Development MOEVT Associates MOHSW WaterAid MOW Mpwapwa District: DED, DWST, WAMMA Team, 5 village governments Parliament PMO-RALG Secondary data sources comprised document review, Internet research, and discussions or interviews with potential influencers or secondary implementers such as interested individuals or ministries not currently involved. Project and partner documents reviewed prior to and during the course of the assessment included, for example, the WSP proposal to the Gates Foundation, The Handwashing Handbook: A Guide for Developing a Hygiene Promotion Program to Increase Handwashing with Soap (World Bank BNWP, and WSP, 2005); the Tanzania 2004–05 Demographic and Health Survey (DHS); the Tanzania Project Implementation Plan: Scaling Up Handwashing with Soap; Total Sanitation and Sanitation Marketing in Tanzania; Spio & Spio Preliminary Report on Mission to Tanzania; NEHHASS 00 Draft 2005; Water Sector Development Program 2006–2025; Lynne Cogswell 2005, Tanzania Hygiene Improvement Project trip report; Tanzania Development Vision 2025; and the Tanzanian Ministry of Health National Health Policy, October 2003 (draft). Major Findings, Conclusions, and Implications by Dimension The findings, conclusions, and implications in this report follow the WSP assessment protocol to allow for comparison with the follow-up assessment of the enabling environment at the project end. An effort has been made to focus on what is most relevant for scale-up and sustainability of 15 Global Scaling Up Handwashing Project HWWS promotion in Tanzania. Scale-up requires shared vision, partnerships with clear roles and responsibilities, effective coordination mechanisms, a critical mass of interest and capacity, prioritization of HWWS as an essential tool for improving health, evidence of success, streamlined methodology and messaging, willingness and ability to adapt to important local differences, a well-functioning skill transfer system, and of course, funding and product availability. Sustainability requires broad partnership, shared goals and success, integration into ongoing programs (true ownership), a functioning system for training new staff, influential champions to keep it a priority, and funding. Policy, Strategy, and Direction The policy environment for this project is less than ideal. The agency with primary responsibility for hygiene, the MOHSW, did not at the time of the assessment have an updated health policy in place with sufficient guidance on hygiene promotion. A draft policy meant to replace the 1990 policy has been circulating since at least 2003. Hygiene-related sections from an October 2003 draft available on the Internet are listed in Table 4. 12 The draft policy also covers the structure of health services, human resource development, financing, development partners, and M&E. It does not specifically mention hygiene. The consultants requested but were not afforded a current version of the draft policy, so cannot confirm that it contains satisfactory hygiene or sanitation content. Table 4. Hygiene-Related Topics in the October 2003 Draft National Health Policy Topic Section Advocacy and IEC to address communicable disease, child health, and school health 3.3.2 The multisectoral nature of health promotion 3.3.6 Collaboration with development partners 3.4.1 The essential health care package 3.5.2 Reproductive and child health 3.5.2.1 Prevention of ARI and DD 3.5.2.2 Environmental health and sanitation 3.5.2.4 In anticipation of approval of an updated health policy, the MOHSW developed the very detailed NEHHASS described earlier. 13 In the February 2005 version of the NEHHASS made available to the consultants, the discussion of hygiene promotion begins on page 38 (of 57), after solid waste management, liquid waste management, hazardous waste, air pollution control, human settlement development, HIV/AIDS in the workplace, port health, and water and sanitation. The 12 http://www.districthealthservice.com/cms/upload/policies_12_1060.pdf. 13 Generally a policy is developed before the strategy to implement it, but in the case of Tanzania, the strategy has been developed prior to a substantive policy being finalized. 16 Global Scaling Up Handwashing Project remaining “main strategic areas� were food safety and disasters/emergency preparedness. This placement probably reflects the priority of hygiene. The NEHHASS describes hygiene as “an important component of water and sanitation in promoting health at community level� that is needed to reach the water and sanitation MDGs. It notes handwashing statistics (for example, 67 percent don’t wash their hands after visiting the toilet), posits reasons for the minimal impact of hygiene promotion efforts (inadequate capacity, low prioritization, and lack of patience for achieving behavior change), links hygiene to MOHSW and MOW national policies to demonstrate how hygiene contributes to national goals, and sets out a goal (everyone practicing proper hygiene daily), strategies (capacity building, participatory education, integration into multisectoral programs, and guideline dissemination), and activities (needs assessment, participatory education, information, education, and communication materials, a Healthy Village program, advocacy, school health, water supply, monitoring, and so on). While lack of a policy constitutes an obstacle, even once the new policy (or NEHHASS) is approved, commitment, funding, coordinated planning, effective monitoring, and adequate technical support will be required in order for the MOHSW to be effective in this area. The MOW has funding for hygiene promotion, but since the MOW is not measured on hygiene- specific indicators, hygiene has not been a priority. On a positive note, respondents from all sectors were very receptive to the project concept, expressed the sentiment that this is the right time for the HWWS project, and wanted to participate. Most respondents indicated that they are already acting alone or in collaboration to promote handwashing specifically or hygiene in general. Advocacy and good public relations will be essential in further stimulating this sentiment and moving HWWS up in priority. Work to develop a shared vision and strategy for improving health by improving handwashing practices at the regional, district, and local levels is just beginning. Even at the national level, where most effort has been placed thus far, care must be taken to ensure that partners have the opportunity to own and shape the program. Several respondents emphasized the need to avoid a cookie-cutter approach in Tanzania, the apparent implication being that donors often propose or insist on programs that are not tailored to the local reality, with the typical result being lack of ownership. Ownership by partners is critical if sustainability is to be achieved. Critical to both scale-up and sustainability is the need to engage the private sector in a way that speaks to its needs and ensures mutual benefit. Soap companies, for example, would like recognition for their corporate social responsibility programs, help with marketing, to see their market size increase, and to improve distribution networks. Political Goodwill • Respondents were very receptive to the idea of promoting HWWS, strongly agreeing that it is important to health and should be widely adopted. • On the other hand, lack of an MOHSW policy was raised by almost all respondents as a key reason for inaction and lack of cooperation and coordination. This is evidenced at the national level, where MOHSW-MOW participation in hygiene-related working groups is uneven, with decision makers from either ministry rarely attending meetings chaired by the other. This lack of collaboration is, in turn, reflected at the district level, where decision making tends to happen independently in each sector. The result is extremely 17 Global Scaling Up Handwashing Project low prioritization, low funding of hygiene-promotion activities, and suboptimal use of expertise from all of the sectors that are or could be involved in hygiene and HWWS promotion. • Competing priorities: Many respondents expressed concern that diarrhea is not among the top 10 health problems outlined in Tanzania’s essential health package. Childhood disease and integrated management of childhood illness (IMCI) are part of the package, and, according to Tanzania DSS data, diarrhea is the number 3 complaint for inpatient and outpatient care for children under five, behind malaria and anemia. This connection needs to be emphasized to service providers. Advocacy is needed to ensure that health, water, education, and community development personnel and DEDs are aware of diarrhea’s importance in childhood morbidity and mortality and are motivated to take action to help reduce it. • Curative versus preventive: Despite national and international efforts to emphasize preventive health, physicians and communities still tend, in practice, to favor cure over prevention. This typically is evident in the funding priorities of the district medical officers. The essential health package serves as a policy guide and is thought by some respondents to emphasize curative interventions. Even at the community level, a village councilman said they needed a clinic to treat children because they get severe malaria and die before making it to dispensary 8 kilometers away. When asked about bed nets, he acknowledged the importance of prevention but felt having a clinic nearby was even more important because no matter what, children will get sick. • The school health and hygiene policy does not appear to be functional. Examples include recent news stories about new schools built without latrines and inconsistent teaching of the health curriculum. Few if any primary schools have running water near latrines, and water brought to latrines is used for anal cleaning after defecation. According to a World Health Organization/Africa Regional Office (WHO/AFRO) report, all primary school curricula in Tanzania have a hygiene component, but this does not guarantee that hygiene is always taught or that HWWS at critical times is mentioned. 14 The consultants did not meet with the School Health Program, which, although it is a joint MOEVT-MOHSW program, sits in the MOHSW. The project will need to work with School Health to review curricula, update content, develop a plan for getting the new information (and how to use it) to teachers, promote it, and incorporate this aspect in the project monitoring system. Revitalization of hygiene education in schools, with an emphasis on HWWS, should contribute significantly to the success and sustainability of the HWWS project. Channels of influence • DEDs have “final� decision making authority on resource allocation at the district level. (Many of the macro-level decisions such as budget still need approval at the regional and national levels.) It will be important to sensitize DEDs and understand what participation and success will mean for them. Relationships are key, meeting with district councils will give insight into which members are likely to be most influential. 14 WHO/AFRO Water Supply & Sanitation Sector Assessment 2000 Part II, available at http://www.afro.who.int/wsh/countryprofiles/tanzania.pdf. 18 Global Scaling Up Handwashing Project • News media can provide both pressure and positive reinforcement regarding the need for policy change or implementation. During the assessment visit, we witnessed the unfolding of a national public relations effort to get the government to provide nutritious food to people taking antiretroviral treatment for AIDS. The number of politicians and NGO leaders responding to the issue increased over several days. The challenge with this and any issue is to keep it newsworthy over time so that talk and promises translate into action. • Community development officers appear to garner significant respect at the community level, so they should be influential with ward managers and village councils. • One respondent suggested that the NGO Policy Forum be invited to join the partnership in order to further the project’s likely advocacy aims. 15 Policy Barriers • As noted, the biggest policy barrier seems to be lack of policy. Funding will be required to facilitate implementation of the new policy once approved. Although WSP cannot provide these funds, perhaps it can encourage other donors to do so. • Private sector respondents noted the following policy constraints: East African free trade benefits Kenya and Uganda over Tanzania, which hurts the domestic soap industry; Tanzania’s non-membership in the South African Development Community (SADC) reduces competitiveness of Tanzania’s exports to SADC, limiting the growth of Tanzania’s industry; insufficient interaction between ministry departments leads to mixed signals (for example WaterGuard—a water disinfection system—was approved by MOW but not by MOHSW); inadequate attention to roads and railways, which impedes market penetration; and a weak educational system that produces workers who are not as prepared as they need to be, which impacts manufacturing and marketing capacity. If this project can use even informal channels to influence any of these areas, industry would perceive benefit from the project (even if the efforts are not successful, credit could be derived from making a good faith attempt). Institutional Incentives • When something belongs to everyone, it becomes the priority of no one. Carving out distinct and complementary domains for the MOHSW and MOW within the context of this project could help incentivize both and have a positive carryover effect. The MOHSW Preventive Health Services Division, Environmental Health and Sanitation Section (responsible for hygiene) might need help identifying funding (internal or external) to support its ownership. 16 15 The NGO Policy Forum (NPF; see http://www.hakikazi.org/ngopf/) brings together about 70 national and international NGOs that are engaged with critical policy processes in Tanzania. NPF focuses in the Poverty Reduction Strategy (PRS), the Public Expenditure Review (PER), and Local Government. A major focus is to make policies be more transparent and democratic, and accountable to the people. For more information, contact npf@cats-net.com. 16 In this case the MOHSW should create a concise document (2–4 pages) summarizing and contextualizing the most pertinent elements of the documents in Box 1, the national health policy, and NEHHASS. 19 Global Scaling Up Handwashing Project • Training has been a primary motivator for institutions at all levels. In supporting training, this project must find a workable balance between that short-term incentive and the long- term commitment needed to sustain the project and ensure scale-up. Respondents quoted MKUKUTA, 17 MDGs, and specific MOW and MOHSW targets as reasons for their activities and for their participation in this project. They also mentioned synergy between this project and what they are already doing. Underlying the conversations seemed to be what typically motivates leaders and workers: the desire for recognition (looking good in front of donors, peers, subordinates, and others), some degree of power or control, the opportunity to advance, and the opportunity to make a difference. Streamlining monitoring and evaluation so that the myriad donor-funded projects come closer to using one system or framework could provide additional incentive to workers overburdened with disparate reporting requirements. • Large soap manufacturers have provided free soap for hygiene-promotion activities and are looking for ways to also derive benefit. They and other private sector partners will want to know how project success will likely affect their bottom line during and after scale-up. WSP should calculate estimates and provide data from other countries as available and relevant. At least one soap manufacturer would be interested in a distribution partnership to enhance access to areas that are hard to reach because of bad roads and a dysfunctional railroad. All seek a broader customer base (for example, schools) and could benefit from marketing assistance. They also want to derive goodwill for being socially responsible and to be viewed without suspicion by government. They were agreeable to generic marketing but would welcome opportunities for their brands to be promoted. 18 Champions and Catalysts • In Iringa, the team met with MP Lediana Mafuru. She immediately made four telephone calls to fellow MPs to inform them of the project and seek their support. She has committed to be a champion of this effort and recommended working closely with NGOs to ensure its success and replicability. • No one in the ministries visited emerged as a natural champion for HWWS. Unless this changes, the sustainability of HWWS could be jeopardized. Several respondents recommended involving the permanent secretaries of the MOHSW and MOW in the effort to improve coordination. MP Mafuru might be able to assist in this area and in getting high-ranking officials to speak out on the importance of HWWS. • WaterAid, a well-established international NGO, is formulating an advocacy strategy to promote shared vision and direction in sanitation and hygiene. This advocacy strategy will be informed by baseline data now being gathered and analyzed and will support an approach (not yet articulated) for addressing the issues identified in the baseline study. WaterAid plans to begin implementing an advocacy strategy by the end of 2007. 17 This is the acronym of the Kiswahili translation of the National Strategy for Growth and Poverty Reduction. 18 This is not a recommendation to do generic marketing. 20 Global Scaling Up Handwashing Project Shared Vision and Strategy • It was encouraging to hear respondents from all sectors and levels emphasize the health benefits of HWWS. Self-reports strongly indicated that the project has a clear vision and can communicate it effectively to partners. However, it is not clear that this nascent partnership has yet developed or disseminated a shared vision—what is different about Tanzania once large-scale behavior change is achieved? Establishing and integrating this shared vision should be an early priority. • Different partners are implementing different strategies to improve hygiene, including different handwashing approaches. For example, some engage the private sector as equal partners, while others are suspicious of industry or feel that industry owes the public more; some focus on education while others focus on behavior change. This project must find common ground from which to operate in partnership, especially in a complementary rather than contradictory manner. Such a core approach could allow partners to maintain certain differences in approach that ideally would be evaluated to determine the most effective set of tactics and messages to implement during scale-up. Partnerships WSP has engaged a range of partners and stakeholders around this project: WaterAid, Environmental Engineering and Pollution Control Organization (EEPCO), Mohammed Enterprises Tanzania Limited (METL), Plan International, Soap & Allied Industries, UNICEF, the Ministries of Education, Health, and Water, and others. The key challenges now are to develop a transparent partnership structure that is effective in moving forward on project objectives, find common ground as noted above, and broaden and deepen the list of partners, particularly at the district level. This includes working with (key) partners to expressly identify the value this partnership can bring to their organizations and to the nation; agreeing on a limited number of common goals; defining a set of core activities that will take place under the aegis of partnership; and clarifying the roles, responsibilities, and authorities of the various partners. How the money will be spent is an important issue because it appears to depart from the traditional way of funding development projects. For example, if the WSP cannot give funds to ministries (a traditional way of setting priorities), it must demonstrate that full participation will still benefit the ministries and ministry staff. Current Partnerships • A core group of partners at the national level are already meeting under the leadership of the WSP and beginning to coordinate efforts. These include those mentioned above, and a main challenge seems to be to identify and work from common ground. Communication, Collaboration, Coordination, Compromise • The project is communicating, collaborating, and compromising effectively at the national level. Memoranda of understanding are planned, and a communication committee will be established. More communication is needed to ensure that the widening base of partners—and the various levels within those partner organizations— have the same understanding of the project, its goals, and their roles. • The good communication happening at the national level needs to be extended to the regions, districts, and communities. The EEA site visits were one step in making this happen and demonstrated effective compromise to ensure MOW and MOHSW 21 Global Scaling Up Handwashing Project participation. It may be helpful to clarify to all partners how the project districts were selected. • More than one respondent mentioned that donor funding does not adequately encourage collaboration and, in some cases, can even discourage it. This represents an opportunity for donors working together in the donor coordination group. Effective Community-Local Government-NGO Partnerships • This project has not as yet established local partnerships. • Models for establishing effective local partnerships exist (International Trachoma Initiative [ITI], UNICEF Child Survival, Protection and Development); building on and gleaning from these models can facilitate introduction of this project. Potential Strategic Partnerships • WaterAid brought together local and international organizations with interest in sanitation/hygiene, convening its first multiday activity in May 2007. This group might serve as a partner in and of itself and be tapped for information, inputs into mapping, monitoring, and advocacy at district level. • Women listen to and like to keep up with other women. This project should seek partnerships with women’s CBOs and NGOs, microcredit groups, and water users’ associations. • Aga Khan University School of Nursing expressed interest in partnering; it trains nurses in the areas of infection control, hygiene, and interpersonal communication and conducts community-level projects. Nurses can impact change at pivotal moments, as has been seen in projects that focus on the birth of (especially) a first child, and they have effectively promoted breastfeeding and other healthful practices. Integrating the HWWS approach in nursing and other pre-service and in-service training could contribute to sustainability of HWWS. • Tanzania Gender Network Program (who work on HIV and sanitation and have experience in policy analysis) might be willing, able, and appropriate to take a lead role in advocacy. • A strong effort should be made to include religious organizations in the partnership, especially at the district and local level, even if they are not immediately warm to the proposed methodology. Table 5 lists ministries that could logically be engaged in the project (especially leading to scale- up) because they have some area of overlap with the goals, audience, or partners in the project. 22 Global Scaling Up Handwashing Project Table 5. Current and Potential Ministerial Partners Ministry Connection Priority of stakeholders (WSP) to get this ministry as a partner Public Service Management Ministry performance 3 Political Affairs and Civil Societies Work with civil society 3 Relations Regional Administration and Local District government participation & leadership 1 Government Industry, Trade and Marketing Private sector relations 2 Agriculture, Food Security and Co- Contamination of food supply; potential for women’s 2 operatives cooperatives to make & market soap Water Water provision & HWWS promotion 1 Infrastructure Development Road and other infrastructure improvements increasing 3 availability of supplies Health and Social Welfare HWWS promotion & behavior change 1 Education and Vocational Training Primary school curricula 1 Higher Education, Science and Future parents; ensuring ability of current primary 3 Technology school students to continue HWWS practice as they further their education Labor, Employment and Youth Engaging youth in the project as motivators; influencing 2 Development workforce development (as industry incentive) Lands, Housing and Human Settlements Changing norms re: home construction 2 Development Community Development, Gender and Behavior change at community level 1 Children Home Affairs NGO engagement & identification 2 Source: Consultant, based on interviews and Tanzanian government’s ministry listing and ministry information pages, http://www.tanzania.go.tz/government/. Integration of HWWS into Partners’ Ongoing Activities • Hygiene, including handwashing, is promoted in several MOHSW initiatives including but not limited to antenatal care (according to the 2004–05 DHS, over 90 percent of rural women receive at least some antenatal care from a medical professional), breastfeeding, school health, home-based care, food handler safety, reproductive health, IMCI, tuberculosis directly observed treatment, short course (DOTS), and traditional birth attendant training. The handwashing advice these initiatives deliver should be consistent and include using soap. The HWWS project can play a role in updating training curricula and getting updated messages to already-trained trainers and workers. • Other partners and potential partners also have integrated handwashing components— WaterAid, Africare, UNICEF, Concern, Plan International, and ITI are examples—while 23 Global Scaling Up Handwashing Project others had not thought of it even though they have a sanitation focus. HWWS should be promoted with TSSM. Institutional Arrangements The WSP has held several meetings to begin to sort out roles and responsibilities of the MOW, MOHSW, MOEVT, PMO-RALG, local government authorities, and the MOW-led SHWG. NGO and new partners presumably will be incorporated as the project moves forward. A full partner meeting and project launch, preferably facilitated by a development partnership expert, should go a long way toward making this a comprehensive, highly functional, and successful partnership. Implementation Arrangements, Including Roles, Responsibilities, and Mutual Expectations • Everyone wants the Bank to provide resources. It is not clear how well government and some NGOs will leverage what they already have and do to contribute to the success of this project, but current goodwill, shared concern, and obvious opportunities (such as district funds for hygiene promotion) are a good starting place, as are the ongoing efforts of WSP and partners. The project needs to identify and emphasize how existing programs can benefit by contributing in cash or in kind. The recommended partnership development meeting would be a good forum for this. • The following are examples of roles current and potential partners might play within the partnership: o The MOEVT’s Department of Policy and Planning determines school design and should be engaged to ensure school construction routinely includes water near latrines for HWWS. o T-MARC (Tanzania Marketing and Communications Company Ltd.) could do a retail audit and has a radio soap opera that the project could buy into. o METL’s founder is an MP for Singida District and could become an advocate for government-private partnership. • It should be noted that in the Government of Tanzania: o Central ministries have normative responsibilities and provide guidance in planning and implementation to Districts. o Districts have implementation responsibility and receive disbursements from central government. o Regional government is meant to collect, manage, and share information from the districts to different audiences, including national ministries. National-Level Coordination • The unbalanced MOHSW and MOW relationship regarding sanitation (and, by association but not emphasis, hygiene) is counterproductive.. Perhaps a broader interministerial committee could be created under the PMO-RALG if other efforts (such as getting the permanent secretaries to intervene) do not succeed quickly enough. Although interministerial committees have tended to be short-lived and somewhat ineffective on implementation issues, constituting one could at least bring attention to HWWS. 24 Global Scaling Up Handwashing Project • WSP is playing an important role in national-level coordination, as noted by respondents and observed by the EEA consultants. Mechanisms for Interagency, Inter-Level, Inter-Audience Coordination • Establishing mechanisms for interagency, inter-level, inter-audience coordination is just beginning and should be addressed in detail at a partner meeting (after some advance thinking, with a partnership facilitator, by WSP and key partners based on their experience). • Intersectoral collaboration at district level will require incentive and encouragement. It is not clear that DEDs or regional administrative secretaries actively facilitate intersectoral collaboration, so efforts are needed to ensure that they do so for this project. In Iringa, the district community development officer, Patrick Golwike, was assigned as the contact for the HWWS project and should be able to help facilitate dialogue between the various sectors, levels (including ward development committees), and local nongovernmental partners. • DEDs chair a district management team represented by all sectors. This team collaborates on a medium-term expenditure framework (which replaces sector plans). The framework in Iringa contains seven objectives, and each sector determines targets based on those shared objectives. HWWS fits under Objective A, “Improved health services.� Sector heads meet weekly. • At the time of the assessment, Iringa did not have a district water and sanitation team but said it planned to constitute one. A permanent health, water, and education committee brings relevant sectors together for regular coordination. They agreed on the need to also plan together so that coordination would be easier. Program Methodology The HWWS program methodology, including the process for adapting it to Tanzania, had not yet been widely disseminated at the time the assessment was carried out. Defined, Detailed, and Documented Program Methodology • Respondents were aware of or expecting a defined program methodology. Almost to a person, they expressed the need to let communities define or at least tailor the program rather than getting a predesigned program to implement. Some partners (for example, WaterAid and EEPCO) had participated in project meetings and presentations and were more conversant with the proposed methodology than others. Those at district level knew the least about the program and methodology. • At the time of the assessment, a draft project implementation plan (PIP) had not yet been shared with partners. The task manager planned to first tailor it to Tanzanian audiences. Understanding and Acceptance • Respondents had many questions about the proposed methodology. In some cases, this reflected that new individuals within organizations were being added to the discussion. People at the district and local levels largely had not yet been introduced to the program. • Participatory Hygiene and Sanitation Transformation (PHAST), a program designed to build the capacity of communities to assess their hygiene and sanitation needs and then plan, implement, monitor, and evaluate activities to address them, is ubiquitous. Districts 25 Global Scaling Up Handwashing Project like it because it is a complete package and provides training. WSP is supporting a PHAST evaluation, but it appears to raise awareness without really changing behavior. It is also resource intensive. Because PHAST is appreciated at district level, the HWWS methodology could be presented as incorporating and building upon the best aspects of PHAST. • Respondents interpreted marketing in different ways. Some understood it as just using advertising, while others gave examples from social marketing (in that they included community outreach, discussion sessions following radio programs, use of community mobilizers, and the like) without calling it social marketing. Respondents who felt poor villagers would not be able to afford soap were skeptical of the value of any kind of marketing in rural areas. Consumer research will be carried out to provide information about willingness and ability to pay for soap and other products such as handwashing basins. Working with partners at all levels to understand, refine, and monitor the social marketing methodology will also be critical. Respondents’ Suggestions for Improvement • Although the program methodology has not yet been applied or evaluated in Tanzania, respondents had many suggestions for improving chances of success. They are included here in italics (with comments) to give a sense of stakeholders’ concerns and expectations. • Communities must determine and own the project and methodology. This could be true for the community-based aspects, but an effective commercial marketing approach will use audience research to develop messages and strategies that speak to what is important to community members. • Link HWWS to high-profile issues such as HIV/AIDS care and prevention, since their target audiences—women of childbearing age and caregivers of young children— overlap. • Scaling Up HWWS could be effective with NGOs that show strong commitment to project objectives and truly value the behavior change the HWWS approach should bring. Otherwise, the HWWS messages could easily be lost. • Use traditional drama and enlist village health workers (VHWs). In addition, form discussion groups where women listen to health-focused radio soap operas together and then have a facilitated discussion. • Consult local stakeholders—MOHSW, MOW, media, and others—and then create a team to develop information, education, and communication materials. The marketing/communications firm must engage stakeholders. • Use soap producers, artisans, and politicians at national, regional, and district levels to carry the message. This is important for sustainability. Also engage producers of wash basins, water storage devices, and other tools used in improved HWWS techniques. • Health education is what is needed. Since handwashing studies show people know but fail to do, consider holding a workshop where the marketing concept is fully laid out and 26 Global Scaling Up Handwashing Project contrasted to the typical health promotion approach so that partners buy into spending sizeable project funds on marketing. 19 • Promote local soap production; link with an entrepreneur development group to provide business planning (including marketing), training, and support. This should be explored. Implementation Capacity Many of the necessary people and systems are in place to make the project successful— marketers, community workers, managers, leaders. Orienting, training, and motivating these resources will be a top priority for the project. Systems and mechanisms for planning, coordination, and monitoring project activities need to be clarified, streamlined, revamped, or built upon. Getting the human resources to the communities where they are needed will be an ongoing challenge unless mechanisms can be agreed and put in place to facilitate this by better using existing resources (such as funding, vehicles, and technology) and existing systems (such as regular support and monitoring visits that do, or are supposed to, take place from central, regional, district, and ward government levels to regional, district, ward, and community levels, respectively). Given their limited marketing budgets and focus on urban customers, the private sector may need assistance (with market research data, for example) to efficiently market to rural populations. Capacity to Facilitate Behavior Change • A key issue here is ensuring that partners at all levels distinguish between education and behavior change. Capacity to educate is high. As demonstrated in Box 3, capacity to facilitate behavior change may be less developed. Box 3. A Case for Building Behavior Change Capacity According to the 2004–2005 DHS: • 96 percent of mothers with children born in the last five years know about ORS packets. • Yet, in the two weeks before the survey: o Only 54 percent of children with diarrhea were treated with ORS. o One-third were offered increased fluids. o 46 percent were taken to a health care provider. o One in six received no treatment. • Tanzania uses community-owned resource persons—VHWs, eye care promoters, home- based care providers—to promote health in villages. These resources and their 19 WSP has developed a behavior change model called FOAM (Focus, Opportunity, Ability, Motivation), with an introductory workshop planned for Tanzania in July 2007. See www.wsp.org/docs/Gates/Introducing%20FOAM.ppt#613,3,Background. 27 Global Scaling Up Handwashing Project supervision structures should be consulted to see where and how they best fit into the project. Training and follow-up will require substantial resources. • CBOs focused on sanitation, health, community development, women’s issues, and children are well placed to help if supported in integrating HWWS into their programs. Current partners should be asked to recommend strong CBOs with strong affinity to the target audiences. • Primary school teachers, administrators, and parents will be interested and able to help improve and sustain the handwashing behavior of children in the target group. They should be helped to lead by example. HWWS Promotion Capacity • The NEHHASS states that hygiene promotion capacity is inadequate at all levels. VHWs used to promote handwashing but stopped due to shifting priorities and lack of reinforcement. These workers are selected by communities and are largely a volunteer force, though they can receive some compensation, including help in their fields and per diem for participating in government- or donor-funded training. Their training could be updated to re-emphasize HWWS at critical times. • Primary Health Care Institute of Iringa (http://www.phci.ac.tz/) promotes health, including personal hygiene, using dialogue and demonstrations. Advanced-course students do practicums in three villages. • Many more government agencies, NGOs, FBOs, and CBOs focus on other aspects of health promotion, including HIV/AIDS prevention and treatment, malaria, IMCI, reproductive health, vision, and others. Even animal husbandry projects promote handwashing. • Tanzania has many local and international NGOs that focus on water, sanitation, hygiene, and maternal/child health. The WSP should work to identify more as district planning begins and as the project proceeds toward national scale-up. See Table 6 for a sample of local NGOs that the project could engage. (Engagement could range from simply providing information about the project to funding project activities.) These organizations have been successful in raising awareness about hygiene issues but, given the statistics, appear to be much less effective at changing handwashing behavior. The same is true of government programs. 28 Global Scaling Up Handwashing Project Table 6. Sample of 30 Tanzanian NGOs/CBOs/FBOs with Water/Sanitation/Hygiene Programs Tanzanian NGOs/CBOs/FBOs (in alphabetical order) Activities CAPS Christian Social Services Commission www.cssc.or.tz Advocacy, capacity building Community-Based Resource Center (CBRC) Water and sanitation community http://tawasa.objectis.net/cso-profiles/CBRC%20flyer%20eng.pdf engagement, capacity building; Lake Victoria zone The Centre for Counseling, Nutrition & Health Care (COUNSENUTH) Health & nutrition promotion Dodoma Environmental Network (DoNet) Community conservation donet@maf.or.tz initiatives (beekeeping, forestation, land-use planning Environmental Engineering and Pollution Control Organization (EEPCO) Planning, design, training in water supply and sanitation, environmental impact assessment Family Planning Association of Tanzania (UMATI) HIV, reproductive health, IEC, advocacy Famine Health Improvement Project, East African Development Youth education: sexuality, Communication Foundation (EADCF) femina-hip@raha.com reproductive health, life skills, http://www.chezasalama.com/G- job opportunities; WaterAid Behind/view_partner.php?id=384&intVariationID=1 edutainment partner Health Actions Promotion Association (HAPA) Water and sanitation community engagement; school, water & http://tawasa.objectis.net/cso-profiles/HAPA.pdf health infrastructure Ingeniera sin Fronteras (ISF) Water infrastructure, http://tawasa.objectis.net/cso-profiles/ISF.pdf/view hygiene/sanitation promotion, communication technology IngoNet Iringa NGOs Iringa Development of Youth, Disabled, and Children Care (IDYDC) Youth, microfinance http://tawasa.objectis.net/cso-profiles/IDYDC%20profile.pdf/view KAPS Iringa Maji Na Maendeleo Dodoma (MAMADO) Water & sanitation; established mamado@do.ucc.co.tz by WaterAid Network for Water and Sanitation Tanzania Limited (NETWAS Tanzania) Water and sanitation capacity http://www.netwas.org building, water resources and sustainable development Policy Forum WaterAid partner Primary Healthcare Institute Iringa Semi-independent training http://www.phci.ac.tz institute: health education and health promotion, plus short courses related to health services Sustainable Environment Management Action (SEMA) Water and sanitation installation; http://tawasa.objectis.net/cso-profiles/SEMA.pdf participatory rural appraisal; Singida Region Southern Highlands Participatory Organization (SHIPO) Rural community facilitation: http://tawasa.objectis.net/cso-profiles/SHIPO.pdf; shipo@cats-net.com education, health, water supply Tanzania Council for Social Development (TACOSODE) voluntary coordinating body for www.tacosode.or.tz NGOs; poverty eradication Tanzania Gender Network Program (TGNP) Water campaign; advocacy, www.tgnp.org capacity building Tanzania Home Economics Association (TAHEA) AIDS orphans, prevention Tanzania NGO Forum (TANGO), www.tango.or.tz Networking, advocacy Tanzanian Water and Sanitation Network (TaWaSa.Net) Water and sanitation information www.tawasa.net (Joerg Henkel) network Tanzania Water and Environmental Sanitation (TWESA) Water supply & sanitation; http://tawasa.objectis.net/cso-profiles/TWESA.pdf hygiene education; community 29 Global Scaling Up Handwashing Project development T-MARC Marketing communication: HIV, www.aed.org/Projects/TMARC.cfm reproductive health, child survival, infectious disease Water and Sanitation Water & Sanitation Network in Tanzania Water and sanitation information (WATSANET) exchange, capacity building, watsanet@wri.ac.tz networking, research, policy advocacy; newsletter Water Users’ Associations Water management; fee collection Water and Environmental Sanitation Projects Maintenance Organization Water and sanitation & hygiene (WEPMO) www.cepis.ops-oms.org/bvsacd/encuen/wepmo.pdf promotion, capacity building Wepmo@hotmail.com Youth Advisory and Development Council (YADEC) Income generation Source: Consultant, based on interviews and web research. • Private sector collaboration: The MOEVT has allowed the private sector (for example Coca Cola, WhiteDent) into schools to promote health and hygiene. The MOHSW and the MOW got soap companies to donate soap for promotional activities, including World Toilet Day. AED, African Youth Alliance, T-MARC, and PSI have used advertising and radio programs for health promotion. Steadman Group collects radio listenership data. Manufacturing companies have marketing expertise that could translate to rural HWWS, but that does not appear to be happening. Capacity of Existing Promotional Networks • Since 1997, health and community development staff (government, CBO, NGO, and perhaps others) at all levels have been trained to implement PHAST. It makes sense to try to use these staff to promote HWWS. • UNICEF and ITI have networks at the district level on which the project could build. Capacity to Implement and Monitor • Respondents largely thought that the human capacity exists but that training would have to be a high priority. In fact, though, only 40 percent of wards have a ward community development worker, for example. To be comfortable with the program and to enable effective supervision/monitoring, stakeholders at the national level want to know and understand what implementers at the local and district level know, understand, and do. • Decentralization by devolution seems to be causing some paralysis. Ministries and districts both say that have insufficient funds, ministries stress lack of capacity at district level, and both national and regional levels stress lack of funding to increase capacity at the district level. • Nonetheless, district health officers say they have the capacity to implement but would need training in the methodology. There are typically four to five community health staff per district and one at regional level. • At the time of the assessment, WSP’s M&E team had not yet begun in-country work to identify or develop capacity for monitoring behavior change at the community and household levels. However, the NEHHASS cites MOH and UNICEF studies on handwashing behavior, indicating relevant capacity. 30 Global Scaling Up Handwashing Project • The Primary Health Care Institute of Iringa may have collected baseline data on observed HW. More information has been requested, but WSP should follow up. Examples of Successful Health Promotion Projects and Programs • In Iringa, health officers described National Immunization Days (NIDs) HIV/AIDS control, UNICEF’s Child Survival, Protection, and Development (CSPD) program, and VHWs as successful. o Factors in the success of NIDs included intersectoral collaboration; availability of vaccine, funds, supplies, and transportation; use of existing structures (the MOHSW Expanded Programme on Immunization, regional administrative secretary, regional and district multisectoral teams, and ward teams); and clear roles. o They felt the success of HIV/AIDS control programs was the result of the use of existing structures and committees at the village and ward level. According to an Iringa NGO source, however, HIV infection rates are increasing in that region. This points to the likelihood that health promotion is increasing awareness but not having enough impact on behavior change. o CSPD’s success was attributed to clear goals and objectives, visible progress toward objectives, quarterly reports and review meetings, and external evaluation. • ITI has documented successful behavior change in its handwashing and face washing program aimed at reducing transmission of dangerous eye infections. Availability of Products and Tools Soap for laundry and bathing can be found in most households. Promoting the use of small amounts of that soap for HWWS at critical times should be explored. Although the WSS is implementing a long-term nationwide water supply program, access to water continues to be a limiting factor. Fortunately, low-cost options for collecting and storing water for HWWS are available. Extent to which Product, Price, and Place Have Been Addressed • Spio & Spio Consulting has done a basic assessment of marketing opportunities. They concluded that homes and schools do not have handwashing facilities, that school children walk up to 1.5 kilometers to obtain water to flush and clean toilets, and that HWWS at critical times rarely happens. • In addition, the EEA team made the following observations: Product o Laundry soap bars appear to be the least expensive and most widely used soap in Tanzania, at T Sh 500 for a full bar. We saw no marketing of laundry soap for other uses, nor did we see evidence of marketing containers for use in handwashing. o In Kitisi, the community had been taught to use cooking oil containers to store water for handwashing (Figure 1). A neighboring village has copied this new practice. o Ready access to water is critical to the success of this project. Opportunities to harvest rainwater are missed. The local company Simba Tanks and others sell water storage 31 Global Scaling Up Handwashing Project solutions useful to schools, communities, and households—these suppliers should be invited into the partnership. o Soap companies indicated they were operating below capacity and suffering from regional competition (especially Kenyan and Ugandan producers) eating into their market share, especially in the Lake Victoria area. Both companies interviewed sell inexpensive laundry soap that could be marketed for HWWS. Price o We were told consistently that rural people could not afford soap for handwashing. When presented with the possibility of using leftover small bits of laundry soap, respondents seemed open to the possibility of that being acceptable. o In stores and markets, long bars of laundry soap are cut into T Sh 100 pieces for customers who cannot afford to buy the entire bar. o Time is a serious consideration when it comes to mothers caring for families that include young children. Given the number of times per day such mothers clean soiled children and prepare food, it is likely that the time spent rubbing hands together and rinsing will be less than optimal. o The cost of water (including the time and effort required to fetch water from long distances) is a limiting issue. One liter of piped water can cost 0.1 cent US. With 20 washes per liter (50 milliliters per wash) using a Tippy Tap, 400 students washing twice a day would use 40 liters of water per day, for a total water cost of 4 cents US. To put this in perspective, in 2001, rural Tanzanian households survived on US$0.32 per day; 20 the MOEVT aims to spend less than US$10 total per student per year (and is not yet able to meet this modest target). Place o One soap company is operating at 50 percent capacity due to limited distribution blamed on poor roads in large areas of the country and easier penetration of those markets by Kenyan companies. o As would be expected, proximity to supplies varies considerably. Many villages have a small, individually run store with basic necessities. Prices may be higher than in the weekly markets that come within 10 or so kilometers of villages. Local soap making could be a good option in remote communities, given proximity and entrepreneurial opportunity. Part of the planning at the district level should include gathering information on the current use and acceptability of locally produced soap and on the results of any previous efforts to stimulate local soap production. o Many schools don’t have water, many were built without latrines, and rarely do latrines have water available for handwashing. Latrine standards now exist, but handwashing largely has not been considered. HWWS at schools ideally would include infrastructure improvement—running water near the latrines or at least installing Tippy Taps or another appropriate technology. The MOEVT Division of Policy and Planning determines 20 World Resources Institute, http://pubs.wri.org/pubs_content_print.cfm?ContentID=3622 32 Global Scaling Up Handwashing Project building design. A directive from PMO-RALG or MOEVT could lead to budget for handwashing facilities in schools. Availability of Products and Capacity of Local Soap Makers • The Rural Water Supply and Sanitation Programme (RWSSP) of the WSDP is set to bring water to 10 villages per district annually, raising coverage in rural areas from 53 percent in 2003 to 79 percent by 2015 and 90 percent by 2025. 21 Their pace could impact the success of HWWS in that it is believed that women and children will be more likely to wash their hands with soap if water is closer to home, clean, and easier to get. (ITI data from Tanzania show a correlation between access to clean water and lower trachoma incidence.) The HWWS project should capitalize on progress by working with the district water engineers and district water and sanitation teams to plan some community-based HWWS activities around the launch of new water supply facilities. These also could be good opportunities for the water, health, education, and community development sectors to support each other and derive mutual benefit. • Home soap making did not seem to be common. VHWs and community development officers could teach and promote this if deemed cost-effective. The project should learn about a Rufiji women’s group that makes soap—low price, some income. Financing The project seems adequately funded if the emphasis remains overwhelmingly commercial and if WSP can avoid funds being drained in a traditional development paradigm. People associate the project with the World Bank and so expect money to be available to support their participation. The idea that the Bank might want others to use their own funds to participate in a project designed and dropped in is even resented in some quarters. It would be nice to change the perception that this is a Bank-funded project, but experience shows that changing such perceptions is quite difficult. Therefore, emphasis should be placed on transparency and sticking to the rules while being just flexible enough to get and maintain the necessary level of engagement. Training, for example, in addition to improving the skills and knowledge of staff and leadership, appears to be a form of income generation for underpaid staff at all levels, particularly in the public sector. Since the project has limited funding and no funds going directly to ministries, the WSP must decide on a balanced approach to give an incentive for participation. Public Financing Opportunities and Willingness • Government action tends to follow financing and, to a lesser extent, policy. Hygiene resides in a relatively weak part of the MOHSW, and little money appears to be attached to it. This does not bode well for active participation and support, but work can be done to raise awareness within government about the cost-effective impact HWWS can have on DD and ARI reduction targets and thereby raise its profile and importance. • Money flows from the MOEVT to districts to schools. It might be possible to program funds for HWWS facilities at primary schools (for bringing water close to latrines, for example, or for discount soap purchase agreements with manufacturers). More likely, parents and communities will be asked to share any costs associated with bringing HWWS to schools. WSP in Tanzania should examine HWWS programs in other 21 Ministry of Water of Tanzania. 2005. Water Sector Development Program 2006–2025. 33 Global Scaling Up Handwashing Project countries to see whether industry partnership or community contribution has proven more sustainable in rural areas. The latter seems more promising and more in line with what is already happening around schools in rural Tanzania, though communities complain about what they consider double taxation—that is, paying taxes and contributing for local projects such as borehole and school construction. Financing Ongoing Programmatic Costs • The availability of sustainable financing for program implementation costs depends largely on the approach adopted by the project. One soap company told us it could not afford much advertising and would appreciate assistance in that area. If the market size increased substantially in the two years of project implementation, it should be able to carry on without assistance. • For fiscal year 2007–08, the MOW has allocated US$1.95 million for sanitation and hygiene initiatives. 22 Other ministries and district governments were not happy to learn WSP could not provide direct funding. • Current NGO partners were aware that funds would be available to them for program implementation. By the end of the four-year project, many could conceivably incorporate HWWS promotion into their normal activities, thereby absorbing some of the cost of ongoing implementation. • Everyone wants more resources—primarily money. WSP needs to try to reduce dependence while at the same time helping the most vulnerable escape poverty in a sustainable way. Inclusion of Handwashing Promotion Activities in National, Regional, and District-Level Budgets • The project must begin work to ensure that HWWS promotion is included in the programming of the T Sh 10 million allotted to districts annually. Allocating some of that funding for HWWS promotion could help ensure sustainability and national scale-up. One problem is that the funds are controlled by people not likely to have HWWS or even hygiene as a high priority. Also, although the funding exists, there are no related indicators to measure or encourage its appropriate use (MOW targets are about water supply). • It appears that guidance for use does not necessarily accompany the district allocation, leading to the funds not being spent or being spent on other activities. This project (local and national partners) should work with districts to develop guidelines and templates for programming those funds in a way that directly supports HWWS goals. Examples of how funds could be used include district planning workshops, baseline assessments, M&E, generic marketing, and school HWWS demonstration projects. Budgets are due in February of each year. In the interest of sustainability, some of the money could be used to share learning across districts (via World Toilet Day or site visits). The project needs local advocates to ensure joint planning and implementation. 22 Ebow Spio Preliminary Report, Mission to Tanzania, Spio & Spio Consulting, Ghana, April 2007. 34 Global Scaling Up Handwashing Project • As noted, several health programs include handwashing promotion, so at least some time is budgeted for it. Private Sector Contributions and Incentives • The campaigns in the private sector have not yet begun. Soap companies said they could benefit by expanding rural distribution, and thereby selling more soap. Companies are wary of contributing financially to the program and would prefer not to continue donating soap without seeing a clear return. In the long term, they could also benefit from creation of a rural market for toilet soap (soap styled and sold for washing hands and faces, and, for some, bathing). Although marketing toilet soap is not the project’s focus, it is possible that some demand will be created if HWWS is promoted as a status symbol. • Companies that produce water storage tanks could be encouraged to sell them to schools and communities at or below cost. • Micro credit organizations called Savings and Credit Cooperative Societies (SACCOSs) exist throughout Tanzania. Fundis (local skilled laborers) and women’s groups may be able to tap these organizations for enhancing their product line by adding soap or handwashing equipment or starting new businesses. This could be a small part of the marketing and communication strategy where determined appropriate. Cost-Effective Implementation Cost-effectiveness did not seem to be a key concern at any level, though one can almost assume it is a consideration of the director of planning in any ministry. Partners need to be brought together very soon to agree on a limited set of cost-effectiveness indicators to be tracked. It might help if there were clear incentive for tracking cost data, including averted costs that result from decreases in DD and ARI. Will additional resources be made available for cost effective approaches? Will measuring cost-effectiveness reduce the number of things workers have to cover in their daily schedule? Will cost savings be applied to the priorities of stakeholders? Information that Should Be Collected on Program Costs • assessment costs (market, enabling environment, willingness to pay, project baseline) • meeting costs (for coordination, information, dissemination, and advocacy at all levels) • project design costs • community contributions to HWWS facilities and bringing water and soap to school toilet areas • capital and long-term costs, including human resources • training costs (including materials, per diem, transportation, and other costs) • marketing support/costs (agency, media, materials, and other costs) • other promotional activities • any form of subsidy Nonpermanent, Supporting Programs • NGO handwashing or hygiene programs can be considered nonpermanent but needed by the project. 35 Global Scaling Up Handwashing Project • The UNICEF-funded CSPD clusters that promote health, water, education, and community development might not be considered permanent. • The MOHSW’s Healthy Villages program is in its pilot stage, with plans to scale up, but might not be considered permanent. • Cost information needed includes items mentioned above and, specifically, human resource and transportation costs. Identification of the Size of the Targeted and Affected Populations • It is not evident that appropriate systems are in place, so the project would need to work with districts to identify or develop and use such capacity. Other • Morogoro’s district engineer is studying the health impact of water interventions and should be asked for a briefing on that activity, including lessons learned thus far. Monitoring and Evaluation Some monitoring takes place at all levels and within all the agencies interviewed. Consistency (both in time and across districts and regions) and effective use and sharing of monitoring data are less apparent. Quickly getting accurate and useful information to those who will act on it or approve changes in policies and practices should be a priority for this project. Streamlining and otherwise improving systems already in place should make monitoring for this project more palatable to those who will have to do it. WSP might be able to learn from and build on lessons being learned from the efforts to improve coordination and monitoring in the national immunization program and the national coordinating committee intended to oversee Global Fund projects. As noted below, UNICEF also appears to have an effective project monitoring system in place. Monitoring Process at the National Level • The MOW has an Internet-based management information system (MIS) that was supported through the RWSSP and tested in 12 districts. It is designed to be available to all stakeholders. (HWWS indicators would have to be added). This and other systems should be reviewed, with one selected and tailored to accommodate the HWWS project. Emphasis should be placed on user-friendliness (including streamlined data collection), helping teams analyze and use data, and sustainability. • EEPCO monitored trainees using pre-stamped monthly update forms and following up by telephone with district health officers and district water engineers but dropped the pre- stamped forms, possibly due to low compliance. Another option would be to consider a text-message format for getting information from the field. • International NGO projects usually have a monitoring component, but reports tend to be sent to donors rather than to the Government of Tanzania (even the ministries to which the NGOs answer in theory seldom receive reports), and formats and requirements differ by NGO, donor, and project. Capacity to Implement a Monitoring Process at the National and Local Levels • Externally funded projects have their own MIS and focal point to ensure monitoring and evaluation. District staff expressed that the capacity to monitor the handwashing project 36 Global Scaling Up Handwashing Project exists but that staff would need training. They are accustomed to using M&E data to determine what works, what does not work, and what needs to be changed. As an example, district health facility staff monitor the ITI project (each has an area to supervise and transportation to get there) and form a multisectoral task force that holds coordination meetings. There is also a malaria focal person at district level. • The UNICEF-funded CSPD program seems to have a monitoring system in place that district staff understands and use. It includes quarterly reports for a single joint report to the regional administrative secretary, joint monitoring visits, and twice-yearly planning. • The regional education officer is responsible for monitoring adherence to policy. • National level (government and nongovernment) respondents feel that monitoring capacity at district level is weak. Ability of Current or Planned Process to Monitor It is important to determine the ability of the current or planned process to monitor quality of services, identify gaps and weaknesses, and determine lessons learned and best practices. At the time of the EEA, M&E design was not yet complete. Technical, Administrative, or Financial Improvements or Support Needed • Information flow between levels is erratic and especially does not flow well from national through regional to district to division to ward to village. Two-way and cross dissemination flows will help ensure that information flows efficiently between levels in each sector and between the sectors • Tanzania has demographic surveillance sites that could be tapped by the project for monitoring DD and ARI incidence during both the initial and scale-up phases. 23 Incentives for Monitoring Implementation and Using Monitoring Results • Performance assessment based on meeting targets seems to motivate the government officials with whom we spoke. Respondents also seem to value recognition of their work. Prospects for publication, public acknowledgment, and opportunity to train others could generate enthusiasm for M&E. • Districts seem interested in measuring impact, as do untouched wards, so they can get the help they need and recognition of their successes. • Partners (ministry as well as NGO) want reports and data. The M&E system should take that into consideration. 23 Sites in Ifakara, Magu, and Rufigi are members of the INDEPTH Network, www.indepth-network.org, and are three possibilities. 37 Global Scaling Up Handwashing Project 5. SELF-REPORT FINDINGS Ten self-reports were completed and returned (see Table 7). Respondents indicated that those who will participate in the project should be called stakeholders or partners. (The term partner can imply more active participation, while stakeholder can be someone who benefits from the activity but who may or may not have an active role in implementation.) Taken at face value, the weakest areas—determined by having 5 or more responses indicating unknown, neutral, or improvement needed—seem to reflect a heavy emphasis on the desire for training, capacity building, and financing, which is not unexpected. 24 The responses also reflect that an M&E system for the project had not yet been introduced at the time of the assessment. The weakest areas are (1) institutional arrangements; (2) implementation capacity, especially providing training, skills, and resources; and (3) monitoring, which, as noted, likely reflects lack of knowledge about the M&E plan. 24 The use of “unknown,� “neutral,� or “improvement needed� in defining areas of weakness is based on the importance of agreement and awareness in order to have the most effective partnership. Partners should not be neutral or ignorant on important areas, and areas they identify as weak are important to address. Strongest areas received 10 responses of “agree� or “strongly agree.� 38 Global Scaling Up Handwashing Project Table 7. Self-Report Key Findings Dimension Strongest Areas Weakest Areas Policy, Strategy, and Can bring its vision to its members and Direction their communities Partnerships Collaboration and team building play an Ensures that sufficient resources are available important role in program development to members to meet objectives Learning is an everyday part of the job and is built into routine tasks Cross-sectoral teams are encouraged Members are involved in identifying solutions to program challenges Partners benefit from collaboration Institutional Has current budget information available to Arrangements assess project expenditures Has a history of providing tools/resources needed to support initiatives Implementation Has a good array of information technology Capacity applications to meet its needs Understands the value of information technology as a strategic and operational tool for improving the program Supports training for members Provides opportunities to attend training Does a skills assessment as part of its planning process Has sufficient resources devoted to providing regular opportunities for skill development Provides members with skill and resources to be successful Monitoring and Makes a continuous effort to assess the Reviews outcome targets each year and Evaluation needs of clients through brief surveys and expects to see improvement each year interviews Has an outcome system that uses quality as well as quantity measures Measures client satisfaction regularly (at least quarterly). Links its internal processes to programmatic impact. Has a comprehensive monitoring and evaluation plan. Has tested and adapted tools to measure process. Has tested and adapted tools to measure program impact. 39 Global Scaling Up Handwashing Project 6. RECOMMENDATIONS The findings, conclusions, and implications section above includes many recommendations for creating an enabling environment that allows for scale-up to national level and makes it possible to sustain effective HWWS promotion over the long term. Key recommendations are highlighted below. A vision of what the ideal enabling environment looks like prefaces the recommendation for each dimension. Policy, Strategy, and Direction In this dimension, an ideal enabling environment would have: • a comprehensive, widely supported, and fully funded health policy that prioritizes hygiene and mentions HWWS for DD and ARI reduction • a shared vision (among all partners) of where the project should take Tanzania • one hundred percent support for the project concept and strategy • full buy-in from all key partners, with a feeling of collective ownership and responsibility • everyone speaking the same language about the project, progress, and challenges • all MOHSW departments incorporating a common HWWS approach (the departments of Epidemiology and Disease, Reproductive and Child Health, and Health Education in addition to the current partner department, Environmental Health Services) • strong leadership and commitment demonstrated by both actions and statements • industry recognition and appreciation of efforts to support policies that help them • community leaders and politicians speaking of HWWS as the obvious norm all Tanzanians should and will adopt • high compliance with national and local regulations requiring soap and water for handwashing in restaurants • updated HWWS information, guidance, educational, and counseling tools included in key pre-service (paramedical and educational) institutions curricula. Recommendations for improving the environment from a Policy, Strategy, and Direction perspective: Political Goodwill • Building on the current goodwill, begin advocacy now. Advocacy is badly needed to raise the profile of HWWS and ensure that decision makers and implementers are aware and motivated about the impact it can have childhood morbidity and mortality. DEDs and school administrators are key targets. As the project accumulates successes and prepares for scale-up, advocacy toward lawmakers and other high-ranking officials will be increasingly helpful. • Get the prime minister to mandate a joint annual report on the state of hygiene in Tanzania, with specific emphasis on HWWS. 40 Global Scaling Up Handwashing Project • Engage and fund at least one group with a proven track record of effective advocacy in Tanzania. Partners can identify groups that have been successful in bringing low-profile issues to the forefront. • Use real-life stories and project successes in advocacy efforts. Human interest stories make critical issues accessible (that is, real), and success attracts success (and additional support). Channels of Influence • As good public relations will be important for success and scale-up, ensure that project leaders and other likely spokespersons, as well as managers and implementation staff, have a core set of concise messages to use and are prepared to use them. Also consider (1) periodic briefings that make public officials and other leaders accessible to journalists; (2) inviting journalists to project launches; and (3) at least one workshop for journalists where ways to report effectively on HWWS for disease control are covered, as well as why it is worth focusing on. Such workshops must be hands-on and provide feedback on draft news reports, tips on getting editors sufficiently interested in the topic, and access to partners and communities. Policy Barriers • Use informal channels and contacts to support industry on its policy issues. Institutional Incentives • Ensure appropriate use and provision of incentives, selecting according to the audience. For example, vet those selected for training and institute a system to follow up on how they are using new skills and information. Another example would be a partner newsletter and submission of success stories to other health, development, and business publications, since people and organizations like to see their names in print. The project can also emphasize how joining individual efforts into a broad-based strategy can improve everyone’s reach, visibility, and effectiveness. • For the private sector, consider working with other donors to organize a broad-based PPP summit-type meeting where ideas for ensuring mutual benefit, as well as project successes and challenges, are presented. The private sector will also want to know how project success will likely affect their bottom line during and after scale-up. Calculate estimates and provide data from other countries as available and relevant. Champions and Catalysts • Identify champions, engage them in speaking and demonstrating HWWS at public events, doing television and radio interviews, and one-on-one advocacy with parliamentarians and other officials. • Maintain and utilize support from MP Mafuru immediately. Provide messages and opportunities to speak and demonstrate. She can make inroads to other MPs, ministers, and even the prime minister. • Meet with the permanent secretaries of all the relevant ministries, perhaps in conjunction with or preparation for the planned high-level visit. 41 Global Scaling Up Handwashing Project • Brief the director of school health and MOEVT’s director of policy and planning on the project and identify ways to strengthen hygiene in school curricula and ensure specific teaching of HWWS. Involve primary education and MOHSW in the meeting. • For consistent messaging, provide actual and potential spokespersons with key messages, holding group meetings akin to media training to review and practice them. • Target medical associations and sponsor colloquia or events to raise awareness of HWWS and their role in increasing HWWS rates. Shared Vision and Strategy • Use the services of a partnership facilitation firm to convene all partners to develop a shared vision and strategy. Because longstanding actors seem deeply committed to their own strategies, finding common ground early—without trying to radically alter partner approaches—will be essential to project success. Use the data that emerge from project implementation to influence partners to further adjust their unique strategies as needed for effective scale-up and sustainability. Box 4 provides examples of what a very long- term vision might include. Box 4. Potential Elements of a Long-Term Vision for Tanzanian HWWS Childhood diarrhea and ARI have decreased dramatically, and deaths from pathogens that can be eliminated through proper handwashing are rare. Installing handwashing facilities near toilets is the norm rather than an afterthought—in homes, schools, health facilities, businesses, and public gathering places. Companies successfully market HWWS products in rural areas via radio, point-of-purchase advertising, and participation in large community events such as World Toilet Day and Children’s Day, partnerships with schools and health facilities, and other means. A wide variety of affordable soap products is available for HWWS. All Tanzanians have ready access to clean water and feel able to afford enough for HWWS at critical times. HWWS at critical times is institutionalized and vital in the school health curriculum. A critical mass of teachers and students routinely wash their hands after using the toilet and exert constructive pressure on those who do not. Teaching and reinforcing HWWS at critical times is standard practice in antenatal care. Health facilities, schools, restaurants, and other public places with handwashing facilities install and update signs reminding users to wash hands with soap. Encouraging and facilitating HWWS is routine for health care providers and health educators, especially when illness related to poor hygiene is present. Families and individuals, not just children and caregivers, adopt the social norm of HWWS at critical times. Health information systems are highly effective at capturing, analyzing, and disseminating data related to HWWS (for example, disease burden, behaviors, costs, and savings). Partnering with other ministries, the private sector, and civil society, the MOHSW organizes occasional campaigns to reinforce HWWS. These campaigns highlight the difference widespread HWWS has made and indicate what must be done to maintain and further improve upon gains. 42 Global Scaling Up Handwashing Project Partnerships Partnership is the most critical element to get right if this project is to be successful, scalable nationwide, and sustainable over time. At its best, the partnering strategy is driven by project objectives—especially those related to replication and institutionalization of the HWWS approach. The sustainability, replication, and institutionalization objectives are core to the partnering strategy, and new partnerships are developed through this lens. HWWS partners make regular use of partner and external forums to share experiences, seek advice, report on progress, and support one another. The WSP and lead agencies demonstrate humility and finesse in developing partnerships with donor organizations—bilaterals, foundations, private sector social responsibility funds, Government of Tanzania ministries (who can earmark internal funds)— taking into account donor agencies’ own distinct priorities, approaches, and perceptions of other donors and finding common ground with them. To grow this ideal environment: • Identify a partnership facilitation firm to work with partners to ensure efficient, open collaboration. This firm should help plan and implement annual partnership meetings, including the first full partner meeting where roles, responsibilities, and capacities are determined and a shared vision is created. This meeting could also be a venue for naming and branding the project (based on formative research and consultation that would have been completed by then to reach consensus with the partners). • Develop a partnership strategy that encompasses the range of civil society and private sector partners with clear strategic roles for each. Table 8 summarizes suggested partnership opportunities. • Expand the partnership to include as many interested organizations as possible, including programs that increase women’s purchasing power and youth groups. • Simultaneously narrow the truly active and decision making part of the partnership by creating a steering committee and focusing resources primarily on the partners and partnerships critical to success and sustainability while keeping other partners informed, knowing what they are doing, and accepting input from them. • Make effective partnerships a key outcome of advocacy activities. Partnerships must operate within a strategic framework, and not just for the sake of having “number of partners� as a project output. • The NGO, donor, and civil society mapping activity is critical and should be done in coordination with the Ministry of Community Development and the cooperation of TANGO and WATSANET, two NGO umbrella organizations. TANGO maintains an NGO directory, WATSANET has begun collecting information from water and sanitation NGOs through its newsletter and Web site, and the consultant compiled and sent an extensive but partial inventory to the country office and local EEA consultant. • Leverage others to make project goals attainable. For example, if people need better housing, connect with the housing authority. Meeting communities where they are will demonstrate that you are listening, that you see the whole community as opposed to just 43 Global Scaling Up Handwashing Project its hygiene needs, and are responsive. Do not, however, leave the impression that the WSP can help them meet all of their needs. • Regularly update partners on the status of the project, including summaries of the different studies and assessment completed to date. A quarterly or semiannual partnership newsletter can encourage partners to produce and be a vehicle for sharing lessons, challenges, successes, and other project information. Create forums for sharing information across and between levels and partners and for partners to successfully interact and build relationships. Table 8. Summary of Types of Partnerships Needed Type Examples Advocacy MPs, Tanzania NGO Forum, journalists, WaterAid, Tanzania Gender Network Program Finance MOW, donors, MOEVT, NGOs, private sector, microcredit organizations Implementation Private sector, national and international NGOs, CBOs, FBOs, ministries, School Health Program, district governments, pre- and post-natal care givers, universities, agricultural projects that promote handwashing when handling animals Marketing Private sector, marketing communications firm, local businesses, T-MARC M&E MOW, MOHSW, IHRDC Policy Government and those directly affected by policy—for example, businesses, parent-teacher associations Institutional Arrangements Optimally, partners are clear about their roles and limitations related to HWWS interventions. Each is willing and able to step in and fill gaps where they have expertise. Key partners send to partnership meetings representatives who are authorized to make decisions on behalf of the organization and have significant influence on the head of their agency. To begin to achieve this: • Focus institutional arrangements on what is most likely to lead to sustainability and scale- up of HWWS. This may mean limited roles for ministries that do not have funding adequate to the task and arrangements that favor of districts, NGOs, and the private sector. • Given devolution, perhaps PMO-RALG could call a coordination meeting to help allocate responsibilities, with permanent secretaries designating specific, appropriate staff (that is, those who are able to make decisions in groups that have decision making authority) to participate in working groups. Supporting efforts to create effective coordination will drive improved institutional arrangements at national level and outward. • Study the WaterAid work in governance and water/sanitation as a potential model for building district and local institutional arrangements that can sustain HWWS efforts. Likewise, study the UNICEF Child Survival and Development Project as a monitoring and reporting model. • Form a project management team in each district, based on the district water and sanitation team but including key nongovernment partners. 44 Global Scaling Up Handwashing Project Program Methodology Ideally, the partners at all levels will have the same understanding of what the project is trying to achieve and the steps that are being followed to do so. They will have contributed to defining those goals and steps and therefore embrace them. If a partner starts to move depart from the agreed methodology, other partners will use constructive measures to help get the partner back on track. Project progress will determine which methodology is the best one for Tanzania. • Say often and loudly that the methodology is being and will continue to be adapted by Tanzania to the Tanzanian context. This cannot be overemphasized. o Tailor presentations of the methodology for district, regional, and local audiences based on reactions to all the activities undertaken thus far (meetings, assessments, surveys, and so on). The presentation should clearly and repeatedly cite examples of where and how stakeholders will be involved in adapting the methodology to Tanzania while keeping the core aspects of the methodology intact. In presenting examples from other countries, it might be helpful to offer and request input on how Tanzania is different and during those sessions begin incorporating this input. • Ensure that women at the community level have a say in adapting the methodology. This may be best achieved by meeting with them separately from the men of the community or male ward leaders. Be sure to include older women in community outreach efforts, as they have strong influence on the child rearing habits of younger women in the community (this is not limited to their own daughters). It is important to speak to their beliefs and concerns to avoid having them contradict HWWS messages. • Combining HWWS with TSSM should work well in Tanzania, given that both are about improving practices that Tanzanians have—with up to 97 percent latrine coverage and hands washed but generally without soap and not necessarily at critical times. 25 This could offer a good messaging opportunity in areas where both will be promoted as well as during scale-up. Handwashing stations must be part of latrine design, especially at schools, and increasingly in households. Sanitation hardware and services must include HWWS solutions. • Reducing diarrhea incidence should drive programming methodology rather than output indicators such as number of handwashing facilities created, water supply, or number of latrines improved. • Monitors should help create checklists that help implementers and managers efficiently identify strengths and weaknesses in the methodology and its implementation— understanding that the two are closely related but distinct. Implementation Capacity In an ideal enabling environment, the partnership has agreed on what training is needed by whom, developed a plan for ensuring such training in a timely fashion (including who will fund and provide the training), and is implementing the plan. Training is seen as a way to improve job 25 This does not take into account the quality of the latrines, nor is it believed that coverage still approaches this upper limit. 45 Global Scaling Up Handwashing Project performance, advance in one’s career, and better serve the needs of clients. The MOEVT has worked with public health professionals, community development workers, NGOs, CBOs, and FBOs to update primary and other curricula to include practical material on HWWS and hygiene in general. The private sector is increasing budget for marketing in rural areas. Partner efforts are monitored and partners are acknowledged for their successes and assisted (preferably with capacity building) in areas where they fall short but can improve enough to have meaningful positive impact. To move toward this ideal: • Since money drives action, quickly clarify and decide with partners what and where the capacity-building opportunities are. This should generate increased commitment from the various actors. That said, limit capacity building to what is needed to meet project objectives, and ensure that behavior change training really does help partners facilitate behavior change—promotion and education are not sufficient. • Have partners come to the first or second full partner meeting prepared to chart in detail what capacity they have and what they need. This includes private sector marketing capacity. Partners will need to have a background understanding of what the project will entail, even if the methodology is not finalized by then. Encourage realism given the limited funds and restrictions on their use. A potential incentive for giving a realistic assessment is the possibility of increased support for scale-up. • Invest in government strengthening very cautiously, and target the lowest government levels for strengthening so that HWWS activities can be sustained. This will most likely be at the district level. Include nurses and midwives since they are likely to interact with most pregnant women and can be a strong influence on newborn care. Include regional officers in initial district training. • Invest in increasing district government’s ability to form and sustain effective HWWS partnerships and in capturing best practices in this area for use during scale-up. • Identify and act on opportunities to build community and ward capacity for planning— existing capacity is not being used to produce quality, coordinated planning. This project can and should help address that gap—in coordination with WaterAid and others working on this deficit. Availability of Products and Tools Program implementers should strive for an environment where all partners understand and are able to deliver the HWWS products and support that the target audiences want and need. Distribution networks function well, and demand increases steadily. In order to reach this target the following is necessary: • Schools are crucial to the long-term success of HWWS in Tanzania. Sufficient emphasis must be placed on getting the MOEVT, DEDs, district water engineers, and communities to add handwashing facilities near school toilets. • Use the Scaling Up Sanitation market study to check respondent assumptions about whether rural people can afford soap for handwashing. Use those data and information on how little water is needed for HWWS to change naysayer attitudes of managers and implementers in partner agencies. • Work with the WSS SWAP to integrate HWWS into WSS investment programs in Tanzania—being sure to include relevant indicators to encourage implementers to follow through. 46 Global Scaling Up Handwashing Project • Handwashing products and services to promote: o Tippy Tap and myriad variations—Ethiopia gourd and pen, Tanzanian Tippy Tap, Malawi dipper. o Rainwater harvesting technologies: explore simple ferro cement tanks (there is a Peace Corps model in Mpwapwa) as well as brick and reinforcement tanks. Highlight the need to protect storage containers to avoid mosquito breeding. o Gutters from cut tin, eliminate down pipe. o Consider identifying and encouraging donors, NGOs, and charitable arms of companies (Aveda, for example) who have a water supply focus to work in the initial districts. o Tap communities for innovative solutions they have or can think of but are not using—this will encourage ownership and sustainability. The project could hold contests (including school contests) to develop best technologies and encourage entrepreneurship. Awards could be presented in communities and at national or regional Water Week or World Toilet Day events. o Explore with T-MARC and PSI the feasibility of pre-testing and socially marketing a branded Tippy Tap that could be sourced locally or regionally. At the very least, discussions could be held with soap companies to fund an attractive pre-tested Tippy Tap (branded with campaign logo) that could serve as a promotional item redeemed with soap purchase. • Use women’s groups as focal points and consider women as fundis, learning to make and sell a variety of products (for example, handwashing and rain collection solutions, soap). • Since the MOHSW promotes the use of ash or soap, evaluate the effectiveness of ash for handwashing. If it adequately reduces contamination, include it in the messaging and demonstrate it during exhibits and demonstrations. To diminish any stigma attached to it, promote the use of ash as sustainable and good for the environment. Also have available data on how effective ash is in reducing fecal contamination and lessening related disease. • Assist the private sector to develop the rural market. This is a long-term undertaking and might entail activities such as exploring the pros and cons to manufacturers of promoting laundry soap for handwashing and of offering differential pricing to rural distributors in the initial years. Financing The goal here should be that government agencies and the private sector so value the benefits of increasing HWWS that they seek and deliver funds to implement and expand the program—to the extent of fully funding their own participation. Districts are happy to have a way to effectively program and leverage their hygiene promotion budgets. Donor agencies are attracted to the cost-effectiveness of the intervention and the transparency with which financial dealings are conducted. Partners gladly share financial information with other partners, and there is a general culture of financial efficiency. To reach this level: • This project is well positioned to help target districts program hygiene promotion funds in a way that directly supports HWWS goals. In the interest of sustainability, some of the money could be used to share lessons learned across districts (via World Toilet Day or 47 Global Scaling Up Handwashing Project site visits). The project needs local advocates to ensure joint planning and implementation, including convincing DEDs to add relevant targets to their medium-term plans so that district water engineers are motivated to use the funds for HWWS promotion. • Work with the MOEVT and DEDs to clarify current plans to improve school hygiene and determine how to include improvements using existing school infrastructure funds. Once suggested some things seem readily doable. • If local soap making is found to be cost-effective and able to contribute to scale-up, do not take short cuts on studying local economics and markets related to making this a sustainable (profitable) business. Look closely at willingness to pay, supply and value chains, pricing of products and services, market size, and saturation potential. Partner with an NGO that can assist with business planning, including planning for getting and repaying microloans. • Emphasize transparency and sticking to the rules while being just flexible enough to get and maintain the necessary level of engagement. For example, training, in addition to improving the skills and knowledge of staff and leadership, appears to be a form of income generation for underpaid staff at all levels, particularly in the public sector. Since the project has limited funding and none going directly to ministries, WSP must decide on a balanced approach to creating incentives for participation. • Engage other donors and large international NGOs to support HWWS scale-up in Tanzania based on project potential and success. Cost-Effective Implementation In the perfect environment, all stakeholders are very concerned about getting good value for national, local, and personal investments in health. The health system is willing and able to monitor costs, track health outcomes, and shift funding from low-impact interventions to highly cost effective interventions. Systems to collect, analyze, and use cost-effectiveness data function well and are used consistently. Attention to cost-effectiveness is allowing Tanzania to become a healthier nation much faster than it would have otherwise, and politicians, journalists, and advocates ensure that this is widely recognized. Politicians, administrators, medical and public health professionals, engineers, and social science professionals view HWWS as a cost-effective and critical route to achieving health and poverty MDGs. WSP can take the following steps to progress toward this ideal situation: • Elucidate clear incentives for tracking cost data, including averted costs due to decreases in DD and ARI. For example, additional resources could be made available for cost- effective approaches, documenting cost-effectiveness could allow workers to drop ineffective strategies and thereby reduce the number of things they have to cover in their weekly or monthly schedule, or cost savings could be applied to the priorities of stakeholders. These would have to be determined in conjunction with managers and decision makers in their institutions. Simplify the collection of cost data. • Raise awareness within government about the cost-effective impact HWWS can have on DD and ARI reduction targets. • Provide data on the cost-effectiveness of other health interventions so partners— including the national government and donors—have something to which they can compare HWWS, see the example in Table 9. 48 Global Scaling Up Handwashing Project Table 9. Cost-Effectiveness (US$/DALY), Hygiene Promotion vs. Other WSS Interventions Intervention Cost-Effectiveness Water supply Hand pump or standpost 94.00 House connection 223.00 Water sector regulation and advocacy 47.00 Basic sanitation Construction and promotion 270.00 Promotion only 11.15 Hygiene promotion 3.35 Source: Sandy Cairncross and Vivian Valdmanis, "Water Supply, Sanitation, and Hygiene Promotion." 2006. Disease Control Priorities in Developing Countries (2nd Edition), ed., 771–92. New York: Oxford University Press. Chapter 41, table 41.12. Available at http://www.dcp2.org/pubs/DCP. Monitoring and Evaluation For monitoring, the ideal enabling environment would be one where stakeholders have similar enough objectives that a small number of common indicators are agreed to, and systems would be in place to monitor, report on, and make program adjustments based on those indicators. This would require increased access to computers and the Internet and/or novel use of text-messaging at least from the community and district levels up to higher levels where the data could be processed and disseminated. Appropriate monitoring indicators and systems are in place and being used to assess attitude and behavior change and availability of HWWS facilities. A culture of using data for decision making—and widely sharing negative as well as positive project data—would also be part of an ideal environment. • The M&E system used by this project must require the minimum amount of data/indicators needed to identify need for adjustments and measure change. • To the extent possible, incorporate M&E into an existing system. This can encourage sustainability by integration, build capacity within government and NGOS, and increase ownership of the program by Tanzania. Train staff to use it for data collection, analysis, advocacy, and course correction. o The MOW has identified monitoring as its key activity, so the project should work with that ministry to incorporate HWWS into its targets and monitoring system. Table 10 presents one possibility. For further information contact the ITI and UNICEF district coordinators about the monitoring system they use. 49 Global Scaling Up Handwashing Project Table 10. Output and Outcome Indicators for Water, Sanitation, and Handwashing Output and Outcome Indicators for Water and Sanitation Output Measured Baseline Outcome indicator Measured by Baseline indicator by data Rural Water Supply Number of MOW Currently Percent household NBS – new water not using improved Periodically 2002 points built reported sources for drinking by survey Census: water Census, HBS, Percent of PMO- Water 42% DHS functional RALG point water points monitoring mapping system surveys Sanitation Number of LGAs & Currently Percent household NBS - To be new MOH not using improved Periodically determined household annual reported sanitation/handwashing by survey 2002 latrines with health facilities Census, HBS, Census: handwashing reports DHS 89% facilities constructed HWWS Number of LGAs & Currently Percent household NBS - To be households MOHSW not using handwashing Periodically determined with annual reported facilities with and by survey handwashing health without soap Census, HBS, facilities reports DHS constructed Schools School Number of LGA & Current Percent of schools with MOEVT/IMIS To be Sanitation/Handwashing new MOEVT annual adequate sanitation determined On annual sanitation annual reports facilities basis with reports handwashing facilities built in schools School HWWS Number of LGA & Current Percent of schools with MOEVT/IMIS To be handwashing MOEVT annual adequate HWWS determined On annual facilities annual reports facilities basis built in reports schools Source: Engineer Modhakkiru Katakweba. Ifakara Health Research and Development Centre (IHRDC) provides reliable data for informing health policy. It does demographic and health surveillance in Rufiji (and other areas) and might be able and willing to provide good data on diarrhea and ARI prevalence. Consider a text-message format for collecting data from the field since mobile phones are even more ubiquitous than PHAST, even in rural areas. WSP could provide a subsidy sufficient to cover monthly data submissions. 50 Global Scaling Up Handwashing Project Marketing Considerations • In at least some areas of the country, women take the initiative on home improvements and are able to save enough to make them or to convince their husbands to pay for them. Women also follow the lead of other women in making purchase and improvement decisions—keeping up with the Joneses. • Handwashing is an afterthought, if thought of at all, in the realms of sanitation and hygiene. The marketing strategy must make people begin to make an automatic link between using the toilet and washing hands with soap. Immunization was once promoted as the most important public health intervention since soap and water. Maybe it is time to turn that around for Tanzania, which has fairly high immunization coverage for Sub- Saharan Africa (perhaps more relevant for advocacy and public relations than for marketing—as would be “national pride� messaging). • The consultant was told that nurses blame and scold mothers when they bring in a child suffering from diarrhea, telling them that “diarrhea is dirtiness, not a disease.� This could have a chilling effect on willingness to bring the child back to the clinic in the event of other episodes of severe diarrhea and could have implications for messaging. • T-MARC produces a radio soap opera, Mama Ushari that might be worth buying into, especially for the fairly low cost of US$30,000–35,000. Key considerations would be determining how it fits into the overall marketing strategy and ensuring adequate control over HWWS messaging. T-MARC should be able to provide audience data. T-MARC intends to expand content, adding child health (vitamin A, zinc, intermittent presumptive treatment, insecticide-treated nets—with buy-in from other NGOs) to reproductive health. The program now airs on radio stations RTD, Radio 1, and RFA six times per week (twice per station), with 10 episodes, 15 to 20 minutes each. WaterAid, Feminina, and Tanzania NGO Forum co-sponsor a radio soap opera (Pitici Pitica, 5 broadcasts per week) that could also be used to promote HWWS. • As a point of reference, African Youth Alliance spent US$100,000–200,000 for radio spots. • TRADECO, one of the companies interviewed, says its soap business is growing, due to its improved distribution network and to “people becoming also more quality and appearance conscious and therefore more conscious about using soap.� Miscellaneous Recommendations • If group interviews cannot be completed, plan to follow up with key individuals by phone or in person. • Relationships are still everything. Developing and maintaining good relationships with key players and the broad partnership will serve the project well. • Project documents have different age groups attached to the target audiences. The project may want to ensure consistency and also to ensure that children older than 5 years but not yet 6 are not omitted (this could be done by using 0-60 months and 61 months to 13 years, for example, instead of just years). • The timeframes on the self-report should be adjusted to “less than 6 months,� “6–12 months,� and “more than 12 months,� for example. 51 Global Scaling Up Handwashing Project 7. NEXT STEPS The following work plans propose short-, medium-, and long-term actions to improve the enabling environment for the HWWS project. Table 11. Short-Term Action Plan (next 6 Months) Contact if Task Who identified Hire partnership development firm and develop partnership WSP strategy Organize and hold partner meeting and public launch Partnership firm, WSP Meet with ministries’ permanent secretaries and PMO-RALG on Partnership firm, WSP Varies coordination Meet with DEDs WSP, Ministries Varies by district Work with key partners to identify value-added and shared vision WSP Share Steadman market study with private sector partners WSP Meet with METL’s marketing division WSP Mr. Husein Respond to T-MARC about radio soap opera WSP Hally Mahler Talk to Morogoro district engineer about health impact study WSP Can ask Katakewba or Kaposo Ask T-MARC for study on handwashing in health facilities WSP Hally Mahler Conduct district-level planning meetings WSP Varies Complete sanitation and hygiene inventory Katakweba Update current partners on the status of the project WSP Conduct consumer research and baseline studies Partnership Kaposo Mwambuli Create and implement early advocacy strategy WSP, partners MP Mafuru Brief the director of school health and the MOEVT’s director of WSP Lipangitekun policy and planning; clarify plans for adding handwashing u Megio facilities Review school health curriculum; add HWWS at critical times WSP, MOEVT, Mr. MOHSW Lipangitekun u Megio Finalize and distribute 2-page project description WSP Develop and disseminate key messages for spokespeople WSP, communications. firm Create forums (including newsletter) for sharing project Communications information among partners committee Ensure consistency across project documents WSP Tailor PIP and methodology presentation to district-level audience WSP Form a project management team in each district Partnership Quickly clarify capacity-building opportunities Partnership Discuss cost-effectiveness at district level WSP M&E Review existing M&E systems WSP M&E Create checklists for managers and implementers to adapt and use M&E team Contact IHRDC about Rufiji surveillance data and other possible WSP Hassan collaboration Mshinda Explore text-messaging for field data submission WSP M&E Study WaterAid governance model WSP Vivienne Abbott Study UNICEF monitoring model WSP Rebecca Budianu 52 Global Scaling Up Handwashing Project Table 12. Medium-Term Action Plan (7–12 Months) Contact if Task Who identified Find support for the review and dissemination of the school health WSP and hygiene policy Use informal channels to support industry policy issues WSP, World Bank Convene a group to draft an HWWS declaration for advocacy Communications purposes committee Establish quarterly or half-yearly multisectoral, multilevel review Partnership meetings Begin exploring outreach to new ministries WSP MP Mafuru Table 13. Long-Term Action Plan (13–15 Months) Contact if Task Who identified Work with strengthened district water and sanitation teams to be early WSP Varies by replicators district Prepare to share district learnings at World Toilet Day and Water Partnership Week events near end of project Leverage others as needed to make goals attainable WSP, World Bank Step up advocacy using preliminary results if they are positive Partnership 53 Global Scaling Up Handwashing Project Appendix A: Respondents by Level and Type Agency & Level Work Type Organization Type Status Respondent Regional District Local National Decider Manager Implementer Government International NGO Local NGO University Local Faith- Based Organization Community- Based Organization Private Sector International Partner Lediana Mafuru, Nat’l D G Member of Parliament Co-Chair Iringa Water & Sewerage Committee Exec. Dir., Tanzania Home Economics Association (TAHEA) AED/T-MARC, Nat’l D I/L I/L Hally Mahler, NGO NGO Country Director AED/T-MARC, Nat’l M I/L I/L Prisca Rwezahura, NGO NGO Marketing Director Africare, Alfred Nat’l D I Kalaghe, Senior NGO Project. Manager Africare, Alan C. Nat’l D I Alemian, MPH, NGO Acting Director Aga Khan Nat’l I U University, (formerly BCC Officer, African Youth Alliance), 54 Global Scaling Up Handwashing Project Agency & Level Work Type Organization Type Status Respondent Regional District Local National Decider Manager Implementer Government International NGO Local NGO University Local Faith- Based Organization Community- Based Organization Private Sector International Partner Amina Ali, MS, Senior Lecturer, Advanced Nursing Programme AMREF, Christian Nat’l I I Chonya, WSS NGO Officer Christian Social Nat’l D L FBO Services Commission, Dr. Adeline I. Kimambo, Director Concern Worldwide Nat’l M I Audax Rukonge, NGO Governance Officer Concern Worldwide Nat’l I I Suzie A. Isangya, NGO Governance Officer EEPCO Nat’l D L X Edmund John, NGO Engineer EEPCO Nat’l M L X Godwin Maleko NGO International Nat’l D I Trachoma Initiative NGO (ITI) Dr. Edith Ngirwamungu, Country Representative 55 Global Scaling Up Handwashing Project Agency & Level Work Type Organization Type Status Respondent Regional District Local National Decider Manager Implementer Government International NGO Local NGO University Local Faith- Based Organization Community- Based Organization Private Sector International Partner Iringa District Health G X Team Aidan N. D Chinangwa, DHO, D Acting DMO Tecla F. Orio, I TB/HIVA A.H. Kirerege, I DCCO Frederick N. I Mwanga, H.O. DFDC/DHEPW A.A. Mwalubunda, I DHS F.A. Kisika, I DRCHCO E. Mosha, PNO I R.M. Jengela, DSC I R.C. Ulawdass, DSC I Alexander Khihatura, I PHO Blandina Mamburke, M DCBHCCO/MIFP Iringa District D M G X Council Tina Sakrombo, D DED Dominic Rusasi, M HRO Hugolin Haule, DWE M 56 Global Scaling Up Handwashing Project Agency & Level Work Type Organization Type Status Respondent Regional District Local National Decider Manager Implementer Government International NGO Local NGO University Local Faith- Based Organization Community- Based Organization Private Sector International Partner Poncian Kazee, M Planning Officer Patrick Golwike, DCDO, HWWS M contact Iringa Region R M G X Mr. Theophile Likangaga, RHO Iringa Region R D G X Dr. Ezekiel Mpuga, RMO Iringa Region R D X El Hadj Juma, Acting RAS Iringa Region R M G X Rajia Ng’ondrya, Regional Water Technician Isimani Water Users’ D I CBO Assn (Iringa Rural) Salima Said, Treasurer Kitisi (Iringa’s MOH L G X Healthy Village) M Ward Manager D Village Council I Town Mtg -70 adults Mennonite Economic Nat’l D I Development NGO Associates (MEDA) Melanie Newman, 57 Global Scaling Up Handwashing Project Agency & Level Work Type Organization Type Status Respondent Regional District Local National Decider Manager Implementer Government International NGO Local NGO University Local Faith- Based Organization Community- Based Organization Private Sector International Partner Microfinance Project Manager METL – East Coast Nat’l D PS Oils and Fats, Ltd, R. Vaijayraghavan, M.Tech., MBA, Chief Executive Officer Ministry of Nat’l D G Community Development, Gender, and Children (MOCDGC) Eng. Leoni G.Msimbe (Msc.), Director of Community Development MOCDGC Nat’l M G Eng. Jeremiah Chimbuh MOCDGC Nat’l M G Eng. Leoni G. Msimbe Ministry of Nat’l M G X Education (MOE) Mr. Lipangitekunu Megio, Senior Education Officer, 58 Global Scaling Up Handwashing Project Agency & Level Work Type Organization Type Status Respondent Regional District Local National Decider Manager Implementer Government International NGO Local NGO University Local Faith- Based Organization Community- Based Organization Private Sector International Partner Primary Education Dept. Ministry of Health Nat’l M G X (MOH) Honesty ______________, Acting Dir., Preventive Health MoH Nat’l M G X Mary Swai, Health Officer MoH Nat’l M G X Anyitike Mwakitalima, Health Officer Ministry of Water Nat’l D G X (MoW) Aloysius G.T. Nyenza, BA, MA, Director of Policy and Planning MOW Nat’l M G X Eng. Reuben Kwigizile, Asst. Dir., Rural Water Supply Div. MoW Nat’l M G X Eng. A. K. Kigingi, PE, MIET, Principal Engineer 59 Global Scaling Up Handwashing Project Agency & Level Work Type Organization Type Status Respondent Regional District Local National Decider Manager Implementer Government International NGO Local NGO University Local Faith- Based Organization Community- Based Organization Private Sector International Partner MoW Nat’l M G X Dorisia Mulashani, Engineer MoW Nat’l M G X Freda Rueyamamu, Senior Engineer Mpwapwa District D M G X Water & Sanitation Team (DWST) Eng. Amani Mafuru, DWE, Mpwapwa PMO-RALG Nat’l M G Rep. seconded to DSM City Council LGSP Component 2 DSM Upgrading & Inst. Strengthening Margareth Mazwile, Community Infrastructure Upgrading Program Coordinator Soap & Allied Nat’l D PS X Industries Ltd. Zain Bharmal, Director UCLAS Nat’l D U Damas Mashauri, PhD, Assoc. Prof., Water Resource & Engineering Dept, College of 60 Global Scaling Up Handwashing Project Agency & Level Work Type Organization Type Status Respondent Regional District Local National Decider Manager Implementer Government International NGO Local NGO University Local Faith- Based Organization Community- Based Organization Private Sector International Partner Engineering & Technology UNICEF Nat’l M INT X Rebecca Budianu, Project Officer-WES UNICEF Nat’l D INT X Sam Agbo, EPI Officer WaterAid, Nat’l D I X www.wateraid.org.uk NGO Vivienne Abbott, Country Rep. Alexander Mawi, R M I X Hygiene and NGO Sanitation Advisor, Dodoma Mr. Saad Makwali. R I I X Programme Officer, NGO Dodoma Eng. Herbert J. R M I X Kashililah, Senior NGO Programme Manager, Dodoma WATSANET Nat’l D L (Water and NGO Sanitation Network in Tanzania) Deo Binamungu 61 Global Scaling Up Handwashing Project Agency & Level Work Type Organization Type Status Respondent Regional District Local National Decider Manager Implementer Government International NGO Local NGO University Local Faith- Based Organization Community- Based Organization Private Sector International Partner World Vision Nat’l M I FBO Richard C.V, Rugemalira, Mktg Manager, Marketing Division 22 2 4 1 21 27 15 11 8* 3* 2 2 1 2 1 11 Note: *Plus one that is both a local and international NGO (AED is international; as of April 2007, T-MARC is a local NGO). 62 Global Scaling Up Handwashing Project Appendix B: Tanzania Hygiene and Sanitation Inventory Tanzanian NGOs/CBOs/FBOs Location/Contact Address Activities ACCORD – Agency for Corporation in Research & Donald Kasongi – Programme Manger. Facilitates collaborative action on grassroots Development P.O. Box 164 Mwanza development programs as well as policy, advocacy and e-mail: donaldkasongi@yahoo.co.uk; public education programmes. HIV and AIDS is one of acordmza@africaonline.co.tz four key themes that define ACORD's work. tel: +255 28 2 500 965; mob: 0754830828: http://www.acord.org.uk Christian Social Services Commission www.cssc.or.tz Advocacy, capacity bldg Community-Based Resource Center (CBRC) Godfrey Kawa – Resource Engineer Watsan comm. engagement, capacity bldg; Lake Victoria P.O. Box 1200 Shinyanga. zone. initial support from DWSP Shinyanga Organize e-mail: cbrc@africaonline.co.tz training programmes for water user groups, mechanics, Mob: 0713-313196 The Centre for Counseling, Nutrition & Health Care Health & nutrition promotion (COUNSENUTH) Dodoma Environmental Network (DoNet) Dodoma Environmental Network community conservation initiatives (beekeeping, P.O. Box 1414, Dodoma Tanzania afforestation, land-use planning Tel/fax : 0262324750 e-mail : donet@maf.or.tz Environmental Engineering and Pollution Control Edmund John – Environmental Engineer Planning, Design, Training in Water Supply and Organization (EEPCO) P.O. Box 7018, Dar es Salaam Sanitation, EIA e-mail: edmundjoh@gmail.com ENVITECH Graciana Lwakibalira – P/Manager Community facilitation in implementation water supply P.O. Box Dar es Salaam and sanitation; Innovative solutions to environmental e-mail: mob: 0754264185 problems Environmental Conservation, Water Supply and Aids Stanley Shekigenda – Programme Coordinator Capacity building, training and community facilitation in Control (EWACO) P.O. Box 71091, Dar es Salaam water supply and sanitation e-mail: ewacoprojects@yahoo.co.uk mob: 0713-858389 Family Planning Association of Tanzania (UMATI) HIV, Reproductive health, IEC, advocacy Femina Health Improvement Project, East African femina-hip@raha.com Youth ed: sexuality, repro health, life skills, job Development Communication Foundation (EADCF) http://www.chezasalama.com/ opportunities; WaterAid edutainment partner 63 Global Scaling Up Handwashing Project Health Actions Promotion Association (HAPA) http://tawasa.objectis.net/cso-profiles/HAPA.pdf Watsan community engagement; school, water & health infra. Ingeniera sin Fronteras (ISF) http://tawasa.objectis.net/cso-profiles/ISF.pdf/view Water infrastructure, hygiene/san promotion, communication tech Iringa Development of Youth, Disabled, and Children Jorg Henkel – Programme Officer Youth, microfinance Care (IDYDC) http://tawasa.objectis.net/cso- P.O. Box 795 Iringa profiles/IDYDC e-mail: joerghenkel@web.com Maji Na Maendeleo Dodoma (MAMADO) Msangu, Mathew Halla, Managing Director. Tel: 026 Water & sanitation; established by WaterAid, community – 2322469; Mobile: 0744 – 891556; facilitation and empowerment e-mail: mamado@do.ucc.co.tz Network for Water and Sanitation Tanzania Limited Ryuba Magesa – Head and Senior Programme Watsan capacity building, water resources and (NETWAS Tanzania) Officer sustainable dev. http://www.netwas.org Box 54068, Dar es Salaam – 2775576 (O) 0754- 282859 e-mail: netwastz@africaonline.co.tz People’s Voice for Development (PEVODE) Gogfrey Ignas Facilitation, training and capacity building of Community e-mail: goef_os@yahoo.com water supply and sanitation Policy Forum WaterAid partner Sustainable Environment Management Action (SEMA) Valerian. Makusaro – WATSAN Officer Watsan installation; Participatory Rural Appraisal; http://tawasa.objectis.net/cso-profiles/SEMA.pdf P.O. box 365 Singida Singida Region e-mail : semasingida@yahoo.com tel : o262562833 Southern Highlands Participatory Organization Kyomo, A. B. Rural community facilitation: education, health, water (SHIPO) P.O. Box 227 Njombe supply http://tawasa.objectis.net/cso-profiles/SHIPO.pdf; e-mail: shopo@cats-net.co shipo@cats-net.com mob: 0717-655552 Tanzania Council for Social Development P.o.Box 56565 voluntary coordinating body for NGOs; poverty (TACOSODE) Tel:+255 741 683886 eradication www.tacosode.or.tz Dar es salaam, TANZANIA Email:issaya@hotmail.com Tanzania Gender Network Programme (TGNP) Water campaign; advocacy, capacity building www.tgnp.org Tanzania Home Economics Assn. (TAHEA) AIDS orphans, prevention Tanzania NGO Forum (TANGO), www.tango.or.tz Networking, advocacy Tanzanian Water and Sanitation Network www.tawasa.net (Joerg Henkel) Watsan info network (TaWaSa.Net) 64 Global Scaling Up Handwashing Project Tanzania Water and Environmental Sanitation Ms Nyanzobe Malimi - National Coordinator Water supply & sanitation; hygiene ed.; community dev. (TWESA) P.O. Box 80099, Dar es Salaam. training NGO currently involved in WATSAN activities http://tawasa.objectis.net/cso-profiles/TWESA.pdf Tel: 0222460301; with refugee and refugee-affected areas in western e-mail: twesa@africaonline.co.tz Tanzania. T-MARC www.aed.org/Projects/TMARC.cfm Mktg comm.: HIV, repro health, child survival, infectious disease Water and Sanitation Water & Sanitation Network in Pitio Ndyeshumba – Programme Manager. Watsan info exchange, capacity building, networking, Tanzania (WATSANET) University Road; P.O. Box 35586 Dar es Salaam. research, policy advocacy; newsletter Phone: 0222410076; Fax: 0222410564. Email: watsanet@wri.ac.tz Water and Environmental Sanitation Projects Amani Kasisi - Programme Manager. Watsan & hygiene promotion, capacity bldg Maintenance Organization (WEPMO) P.O BOX 38340, Dar es salaam Tel 255222410299/255741448580 e-mail: wepmoprojects@hotmail.com WEDECO (Water & Environmental Development Mwanasha Ally – General Manager. Private sector Company based in Shinyanga – initially Company) P.O. Box 125.Shinyanga. established by DWSP. Watsan, hygiene training, capacity e-mail: wedeco@africaonline.co.tz building & construction. Mob: 0713-341937; 0784-364962 WODECHE (Women Development and Child Health) Abdillahy Tawah – Public Health Expert. P.O. Box 2110, Dodoma Tel: 0754-466097 World Care -- E-mail: worldcare@newafrica.com World Care P.O.Box 35059 Dar es Salaam Tel. 255 744 833682 Fax: 255 22 240404 E-mail:worldcare@newafrica.com Youth Advisory and Development Council (YADEC) Income generation International NGOs African Medical Research Foundation (AMREF) www.amref.org Africare www.africare.org Child survival, AIDS home-based care, reproductive health; capacity building Capacity Building for Integrated Water Resources Info-sharing & training to build effective water resource Management (Cap-Net); www.cap-net.org mgmt capacity Centro Mondialita’ Sviluppo Reciproco (CMSR) www.cmsr.org health, ed, rural H20 supply, basic sanitation standards, http://tawasa.objectis.net/cso-profiles/CMSR- social dev. TANZANIAPROFILE.pdf/view 65 Global Scaling Up Handwashing Project Concern Worldwide; www.concern.net Doctors with Africa CUAAM (Dar es Salaam, Iringa, Hospital services & training, VCT, home-based care, Dodoma) malaria http://www.doctorswithafrica.org/ing/home.asp Family Care International; Safe motherhood http://www.familycareintl.org Global Environment and Technology Foundation facilitating USAID-Coca Cola water partnership (GETF) www.getf.org Helen Keller International (HKI) International Trachoma Initiative (ITI); www.trachoma.or.tz Institute for Water and Sanitation Development Resources for sustainable development of water resources (IWSD) and waste management http://www.iwsd.co.zw/index.cfm Jane Goodall Institute; www.janegoodall.org Community-centered conservation Marie Stopes Mennonite Economic Development Associates (MEDA) www.meda.org PACT (journalist training) Plan International Population Services International (PSI) Rotary Club Save the Children WaterAid: www.wateraid.org.uk Watsan capacity bldg WaterCan; www.watercan.org clean water, basic sanitation and hygiene education WorldVision www.wvt.or.tz Health, water, nutrition, ag., etc. 66 Global Scaling Up Handwashing Project Fred Kwame – Programme Manager. Regent Estate, Livelihood sustainability including education – child- Oxfam GB; www.oxfam.org.uk/tanzania Mlingotini close, Plot 52, Box 10962 Dar es salaam. centred learning, water and sanitation. Tel: +255 222 772 789. e-mail: fkwame@oxfam.org.uk Media Associations http://www.mct.or.tz/membersmct.asp Development issues Media Council of Tanzania Journalists Environment Association of Tanzania Environment, women’s affairs and sustainable, development http://www.jet.or.tz/ Tanzania Media Women’s Association (TAMWA) Social transformation, media advocacy http://www.tamwa.org/aboutsus.asp Universities Aga Khan Univ. Nursing education; community health UCLAS: www.ucc.co.tz/wetlands Sanitation demonstration project Bilateral Canadian International Development Agency DFID GTZ Ireland Aid Swiss Agency for Development and Co-operation US Peace Corps: Secondary education, health education, and environment http://www.peacecorps.gov/index.cfmshell=learn.wher projects; 170 volunteers epc.africa.tanzania USAID Tanzania, Asukile Kajuni, WSS Officer Local Address: Education USAID/Tanzania 686 Old Bagamoyo Road Msasani P.O. Box 9130 Dar es Salaam Tel: 255-22-266-8482 / 8489 / 8490 Fax: 255-22-266-8421 67 Global Scaling Up Handwashing Project ttp://tanzania.usaid.gov Multilaterals UNDP Joint UN programming; strengthening development mgmt; fostering partnerships ILO UNICEF WHO WB Private Sector Aquasan TZ Ltd. www.kentainers.com Sanitation systems Deloitte TZ Sabuni Products Limited : Sabuni Products Limited http://www.sumariagroup.com/html/group_companies/ P.O. Box 483, Tanga, Tanzania sdl.html Phones : +255 (022) 2863972 (Dar es Salaam Depot), 2862025, 2865096 Fax : +255 (022) 2863016 Email Address : sdl@sumariagroup.com Simba Tanks Soap & Allied Industries Ltd. www.soapandallied.com TRADECO SOAP INDUSTRIES Ltd (A division of TRADECO SOAP INDUSTRIES Ltd Soap; social responsibility—health, education, METL) Mohammed Enterprises Tanzania Ltd environment http://www.metl.net/tradeco_soap.htm 7th Floor PPF Towers Junction of Ohio Street/Garden Avenue Tel: +255 22 2122837 / 854 / 830 / 819 Fax: +255 22 2122843 Email: info@metl.net 68 Global Scaling Up Handwashing Project