WATER AND SANITATION PROGRAM: FIELD NOTE MAY 2011 64295 Handwashing with Soap — Two Paths to National-Scale Programs Lessons from the Field: Vietnam and Indonesia The Water and Sanitation Program is a multi-donor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services Acknowledgments: This document was written by Penelope Dutton with contributions from Contact Us: people in obtaining affordable, safe, and sustainable access to water Denmark, Finland, France, the Bill and Melinda Gates Foundation, conclusions expressed herein are entirely those of the author and should denominations, and other information shown on any map in this work do the legal status of any territory or the endorsement or acceptance of Handwashing with Soap—Two Paths to National Scale Programs Lessons from the Field: Vietnam and Indonesia EXECUTIVE SUMMARY This Field Note describes two Southeast Asian programs private partnerships outside of traditional hardware that are making handwashing a feature of everyday lives programs. on a national scale: the Handwashing Initiative (HWI) in These two examples show that there is no single approach Vietnam, which has reached nearly two million caretakers of for national handwashing programs. Individual country young children and 80,000 students; and the Public-Private contexts — population size, government leadership, Partnership for Handwashing with Soap (PPP-HWWS) in budget, prior hygiene programs, and willing partners — Indonesia, which has contributed to reaching millions of determine the path of national programs. In Indonesia, the students, mothers, workers, and travelers. The program in PPP-HWWS has reached a much wider target audience Vietnam has concentrated on first gaining an understanding than the government or development organizations, on how people actually behave and then determining how working independently from one another, could have to change that behavior, while the program in Indonesia reached. Experience in Vietnam has shown that a public- leverages the reach of the private sector and other partners private partnership model is not essential for a large-scale to scale up handwashing initiatives that were previously handwashing program. The national government was researched and already underway. They both demonstrate involved in the development of evidence-based materials ideas that can be applied in other countries. which were then acceptable to other partners for scaling up, including through provincial government partnerships. For countries about to embark on designing either a stand alone handwashing program or a handwashing component Common lessons learned are that: within a larger water and sanitation program, the process of developing evidenced based materials in Vietnam could be Behavior change messages must be based on research applied in the development of materials. The Indonesia case and developed by professionals study provides insights on how to leverage partnerships to Consistent messages and information about the critical increase reach in countries where handwashing with soap times for washing hands will improve implementation programs already exist. efficiency Implementers need to be trained in behavior change This document is most useful for: promotion techniques Build on earlier handwashing work to jumpstart Practitioners who see the need or potential for a national partnerships scale handwashing with soap promotion program, A national logo is valuable to unite all stakeholders Governments, and practitioners such as NGOs, who around the common message and campaign want to add a hygiene component to a new or existing water and sanitation program, and Both Indonesia and Vietnam demonstrate that if national Organizations who are interested in examining public- programs welcome new and different partners or promotion www.wsp.org 3 FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs opportunities, then the reach of handwashing promotion Vietnam and Indonesia are two of 15 developing countries can be enormous. around the world that are part of the global Public-Private Partnership for Handwashing with Soap. The PPPHW Challenges remain for the handwashing with soap programs was established in 2001 through the Global Handwashing in Indonesia and Vietnam and include: Initiative5 to promote handwashing with soap at a national scale, using partnerships between the private and public Ensuring handwashing promotional materials sectors. PPPHW programs target children, mothers, are inclusive of all people in these ethnically and teachers, and caregivers. Indonesia has gone on to further geographically diverse countries, develop these partnerships, while Vietnam’s approach Obtaining more physical investment in water supply initially built on the PPPHW but now has more bilateral and handwashing stations in schools to enable arrangements through its Handwashing Initiative.6 handwashing with soap, and Setting up monitoring and evaluation processes to This Field Note describes the success of two different give feedback and guide the future direction of the approaches in meeting the huge challenge of scaling programs. BOX 1. 7 INTRODUCTION The global Public-Private Partnership for Although mortality rates for children under five are Handwashing (PPPHW) works to save children’s lives declining in both Vietnam and Indonesia, in 2007 diarrhea by promoting the awareness of this simple practice. The claimed the lives of more than 27,000 children under five partnership is guided by the following principles: years of age in these countries. In Indonesia in particular, diarrhea causes 18 percent of all deaths of children under These deaths are preventable the age of five, compared to 10 percent in Vietnam.1 Research shows that, if widely practiced, handwash- Many thousands more children every year are unwell and ing with soap could reduce diarrhea by almost 50 malnourished because of diarrhea and other illnesses that percent and respiratory infections by nearly 25 per- are transmitted through poor hygiene. In some areas of cent. Handwashing with soap is a right Vietnam, 92 percent of school children have intestinal Every child has a right to vaccination and should also worm infections, while three-quarters of women nationally, have the right to protection from hand-transmitted including pregnant women, are infected with one or more diseases. type of worm.2 The simple action of washing hands with Large-scale changes in handwashing practices soap has been demonstrated to reduce the incidence of can be achieved diarrhea by up to 47 percent and acute respiratory infections A large-scale increase in the practice of handwash- by up to 34 percent.3,4 Washing hands with soap can also reduce the spread of SARS, cholera, Avian Flu, and H1N1 meeting the Millennium Development Goal of reduc- along with other emerging infectious diseases that occur in 2015. Southeast Asia. UNICEF. 2008. Indonesia Country Profile, Maternal, Newborn & Child Survival; and Vietnam Country Profile, Maternal, Newborn & Child Survival 1. Le, H.T., et al. 2007. “Anemia and intestinal parasite infection in school children in rural Vietnam.� Asia Pacific Journal of Clinical Nutrition. 2007;16(4):716-23. and Nguyen, P. H., et al. 2. 2006. “Intestinal Helminth Infections Among Reproductive Age Women in Vietnam: Prevalence, Co-Infection and Risk Factors.� Southeast Asian Journal of Tropical Medicine and Public Health, 2006:37(5). 3. Curtis,V; S. Cairncross. 2003. “Effect of washing hands with soap on diarrhea risk in the community, a systematic review.� Lancet Infectious Diseases 3:275-281. 4. Luby, Steve, et.al. 2005. “Effect of handwashing on child health; a randomized control trial.� Lancet Infectious Diseases 366:225-33. 5. The Global Handwashing Initiative was developed by an alliance of the World Bank, the Water and Sanitation Program, the London School of Hygiene and Tropical Medicine, the Academy for Educational Development, and the private sector, in collaboration with USAID, UNICEF, and the Bank-Netherlands Water Partnership 6. The Government of Vietnam was not ready for a multilateral partnership for handwashing, and already had programs in place with UNICEF and Unilever that were consolidated under the HWI. 7. http://www.globalhandwashing.org/ 4 www.wsp.org FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs up handwashing to a national level. In Vietnam, the FIGURE 1: focus is on well-researched and targeted communication Area: 331,210 km2 programs delivered through a mass organization and Number of provinces: 64 schools. In Indonesia, efforts concentrate on national level Population: (2009) 85.8 million coordination and leveraging private sector participation to Children under 5: 8.4% encourage handwashing. In both countries, handwashing Life expectancy: Males 70 initiatives have been adapted to local circumstances with Females 76 some interesting and unexpected results. Under 5 mortality: 15 per 1000 This document details ideas and approaches for designing Primary school enrollment: 96% and implementing behavior change programs, and fostering Source: CIA World Factbook, 2009 National Census, UNICEF 2008 private sector participation. It describes lessons learned in Mengzi Wenshan CH I N A Jingxi Guixian relation to implementing national handwashing with soap Me Ha ko Nanning ng Simao Giang ng Jia Yu Yulin Cao Bang Lao Cai programs. The approaches and lessons learned will have most Lai Chau R ed Tuyen Quang Lang Son Thai Pingxiang CH I N A Qinzhou Yen Bai Nguyen use for those countries wanting to scale up handwashing to Phongsali Viet Bla Tri Beihai Son La ck Bac Giang Zhanjiang Dao Cai Bau Hoa Hanoi Hong Gai Louang Binh reduce diarrheal and other infectious diseases. Ha Hai Namtha Haiphong Dong Duong Xam Nua Nam Dinh Xuwen Thai Binh LAOS Ninh Binh Dao Bach Long Vi Haikou Mekong Thanh Louangphrabang Ban Hoa Ban Ky Son Gulf Jiaji VIETNAM HANDWASHING INITIATIVE Nan Xiangkhoang Vinh Dien Chau of To n k i n Basuo Hainan Dao Muang Pakxan Ha Tinh Sanya Ron Vientiane Nong Khai Background Loei Udon Thani (Udorn) Sakon Nakhon Muang Khammouan Dong Hoi Phitsanulok Quang Tri Khon Kaen Savannakhet Hue M Lam Nam South ek Within the last ten years, Vietnam has made rapid on Ch g Da Nang i Cu Lao Cham TH A I L A N D Saravan China Ubon Tam Ky economic and development progress, including being on Sea Cu Lao Re Nakhon Mae Nam Mun Ratchathani Ratchasima Sisaket Pakxe (Korat) Warin Quang Chamrap Attapu Ngai Surin ng Dac To Ko track to achieve the Millennium Development Goal for Sara Buri Xe Pleiku Kon Tum KA M PU CH EA water supply. However, progress on sanitation and hygiene Bangkok Aranyaprathet Sisophon Siemreab Stoeng Treng Tonl eS Lumphat repo VIETNAM Qui Nhon Batdambang k Tuy Hoa lags behind other development. Acute respiratory infections Rayong To n l e Sap Kampong Mekon Sattahip Thurn Buon Ma Kracheh Thuot Pouthisat Ninh Hoa g Trat are still the leading causes of mortality and morbidity in Nha Trang Gulf Kampong Da Cham Lat of Dak Cam Ranh Loc Nong Thailand Phnom Penh Ninh children under five in Vietnam. Malnutrition is still Krong Tay Phan Rang Kaoh Kong Kampong Ninh Thap Cham Spoe Svay ng Rieng Meko Thu Dau Mot Bien Hoa Phan Thiet high relative to other Asian countries. The country has Ho Chi Vietnam Kampot Minh City Sa Tan An Cu Lao Thu Ha Long Dec My Tho nternational Boundary Tien Xuyen Vung Tau Vinh Ben Tre National Capital Rach Can also suffered from reoccurring outbreaks of SARS, Avian Dao Phu Long Quoc Gia Tho (VIETNAM) Soc Tra Road Trang Vinh Bac River Lieu Flu, cholera, and H1N1. These emerging diseases have Kilometers Miles Ca Mau Con Dao heightened the recognition by authorities that improved Hon Khoai Hon Sao hygiene is critical to contain and prevent outbreaks. impact. Communication campaigns in the past made many assumptions about the target audience such as presuming In Vietnam, handwashing has long been part of programs that health was the main driver for improved hygiene. They that focus on prevention of specific diseases, although also focused mainly on increasing knowledge, and often there was never a concerted effort to do a full handwashing used fear of disease as the motivating message. In addition, with soap campaign focusing on one behavior to improve communications materials were usually cut from different hygiene practices. Most water and sanitation projects in contexts and pasted and used again, rather than developing Vietnam now include a hygiene component (including materials derived from research about the target audience handwashing), but due to lack of resources allocated and their handwashing behavior. to hygiene promotion and inexperience in developing behavior change communications materials, the promotion Evidence shows that handwashing is not common practice of handwashing with soap has previously had limited in Vietnam, and using soap is rare. A baseline survey www.wsp.org 5 FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs (commissioned by Water and Sanitation Program) in 2006 channels to promote and reinforce handwashing with soap found that only 5 percent of mothers were observed to wash practice. their hands with soap before feeding their child and only 23 percent were observed to wash their hands with soap after These channels are: disposing of their child’s feces. Less than a third of people thought that washing hands with soap was important. If Creating positive social norms for handwashing with people did wash their hands, they usually used water only, soap through national and regional mass media; and did so at times that were not critical to reducing diarrhea Enhancing skills and intentions of mothers and in children. WSP observations found that the most likely caretakers to adopt handwashing with soap through time that people washed their hands (using water only) was community-based interpersonal communications when their hands felt dirty such as after coming back from via health and education staff and mass organization the field or after touching livestock. These results show that members; despite all the previous promotion efforts, people did not Raising the profile of handwashing with soap at the wash hands with soap, particularly at important times. community level through high-impact marketing events; and Description of the Program Public relations and advocacy activities aimed at national policymakers to strengthen the sustainability The Vietnam Handwashing Initiative began in January of the interventions. 2006 with the aim to reduce morbidity and mortality from diarrheal diseases in children under five years of age. Two communications initiatives have been developed The program uses strategic communications to promote — one for adults, and one for children. The campaigns handwashing with soap among poor women aged 15-49 have been rolled out in 600 communes (the lowest level and children aged 6-10. At the core of the initiative is an of government administration in Vietnam), via health integrated behavior change program that uses multiple workers, Vietnam Women’s Union members, and other partners of the program. BOX 2. In December 2006 Vietnam became one of four 8 countries The Vietnam Women’s Union (VWU) is a mass in WSP’s large Global Scaling Up Handwashing Project. organization – a political and social institution established Funded by the Bill and Melinda Gates Foundation, the aim by the government as a way to communicate down of the project is to test whether innovative promotional to the grassroots level about national government approaches can generate widespread and sustained programs and initiatives. The VWU’s objective is to improved handwashing with soap practiced, and quantify promote gender equity, foster the development of the anticipated resulting health benefits. The global project’s women, and protect the rights of Vietnamese women. It shares the same vertical structure as a line ministry. target is to change handwashing with soap behavior in 5.4 The VWU receives resources from the Government of million women of reproductive age and primary school-aged Vietnam, and external agencies such as UNICEF and children. In Vietnam, the Scaling Up Handwashing Project the World Bank, and from its members. The presence funds are used under the HWI to develop approaches and and structure of mass organizations such as the VWU in change the handwashing habits of 2.3 million women and Vietnam presented the HWI with a unique opportunity to children. A structured learning and dissemination process reach millions of women and children with face-to-face to develop and share evidence, practical knowledge, and communications activities. tools is a strong feature of the project. 8. Also Senegal, Peru, and Tanzania 6 www.wsp.org FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs BOX 3. Target Groups and Behaviors 2.3 million of target population (women 15-49 and children 6-10) adopt handwashing with soap at In Vietnam, two complementary communications critical times. campaigns were developed, one for caretakers of children 9.25 million of target population are exposed to under five including mothers and grandparents, and handwashing with soap communication. the other for primary school children. The campaign for mothers and caretakers began well ahead of the campaign The major objectives of the Handwashing Initiative are to: for school children; however the approaches for both have been very similar, using these steps: Make handwashing with soap a habit among millions of mothers and children, 1. Researching the audience; Use a strong monitoring and evaluation component to learn from and adapt program planning and 2. Developing a behavior change framework to management, analyze research findings, guide the formation of Establish a sustainable program that will continue and the communication campaign and track changes in expand after the five-year grant ends, and behavioral determinants throughout the life of the Document and disseminate the learning from program; designing, implementing, and evaluating a large scale 3. Developing the creative approach including messages behavior change program. and tactics; 4. Pre-testing and adjusting the messages based on The HWI’s focus on a single message gave an opportunity for audience feedback; a fresh look at evidence-based communications approaches and materials. 5. Producing materials and rolling out of the activities; 6. Monitoring changes in behavioral determinants during The Environmental Health Management Agency of the the program, and using this knowledge to fine-tune the Ministry of Health, and the Vietnam Women’s Union activities. implement the HWI with technical support from WSP. The Ministry of Education and Training also endorses Step 1 involved formative research to identify the barriers the school-based activities with active support from the to handwashing with soap that could be overcome through Department of Education and Training in the provinces. communication campaigns. Techniques for researching adults included: focus group discussions; in-depth In addition to the HWI, there are other ongoing programs interviews; structured observations within households to in Vietnam that promote handwashing with soap as part of see actual handwashing with soap; activities and product larger sanitation programs including: trials where caretakers were given soap to use for a week, and then interviewed about when and how they used it. The Unilever-supported “Share Love Not Germs� FIGURE 2: campaign, which has been implemented since 2006 in 10 provinces. This campaign is also designed to change the handwashing with soap rates in project areas; Target Access/ Belief and attitudes availability Knowledge UNICEF’s Water Sanitation and Health Program; and behaviour Outcome NGO programs to improve water supply and Product expectations attributes sanitation for households and schools, including Plan Target Threat Social in Vietnam, SNV, Church World Services, East Meets population Social support norms Intention West and others. www.wsp.org 7 FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs FIGURE 3: Studying the hygiene behaviors of school children, particularly younger children, is difficult. Novel methods SOCIETY SCHOOLS FAMILY CHILD were devised using games and play, and drawings or other Values Knowledge visual aids to facilitate interaction and get feedback from children. Principals, teachers, and caretakers were also Social Norms interviewed to understand the schools’ organization. The Siblings Social Support formative research included direct observation of water, Classmates sanitation, and hygiene facilities at school and home. Six primary schools chosen from three provinces to represent WSP Vietnam program staff utilized a framework called northern, central, and southern regions of Vietnam took “FOAM� (Focus, Opportunity, Ability, Motivation), part in the formative research study. In each province, one developed by WSP as a common conceptual framework peri-urban and one rural area were chosen. Research tools for all four countries taking part in the Global Scaling used with children included: Up Handwashing Project.9 FOAM provides a way to analyze handwashing behavior research to design effective Discussions on role models, and desired careers; handwashing programs. It looks at all the factors that can Daily clocks to show how time is spent both during help or hinder handwashing with soap, such as convenient school term and during summer holidays; access to soap, beliefs about the cause of diarrhea, who Drawing a family structure diagram to show influences behavior in the household, desirable attributes relationships within the household; of soap, or knowledge of the links between handwashing Belief interviews on the benefits of washing hands with with soap and diarrhea. Most importantly, the starting soap, causes of diarrhea; and point for the framework is to clearly identify and describe Storytelling using pictures to uncover motivations for exactly who is being targeted, and what behaviors are being handwashing. targeted for change. Ideally, FOAM would have been used FIGURE 4: to guide the development of the research design, however, since the FOAM model was developed after the formative research study was completed, FOAM was used to reanalyze the research findings and then inform the development of the campaign communications objectives. The FOAM framework was further adapted in Vietnam for primary school children. This variation, called FOAM- EM (Focus on Ability, Opportunity, and Motivation— Ecological Model), builds on findings from an innovative research study conducted in Vietnam with technical support by the London School of Hygiene and Tropical Medicine. In Vietnamese, “em� means “little brother or sister,� so FOAM-EM is a memorable acronym. FOAM-EM identifies key factors influencing primary school children’s Family structure diagram: the thick lines show the child’s strongest relationships and influences at home - in this case with Mother (M ) who is feared the most but handwashing behavior as well as their relationships with who also buys them presents, followed by the Grandmother (Bà), who the child family, school, and community. likes the most. 9. For more information about FOAM refer: http://www.wsp.org/wsp/sites/wsp.org/files/publications/WSP_IntroducingFOAM_HWWS.pdf 8 www.wsp.org FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs BOX 4. for the campaign included two television commercials, two posters and a logo that included the tagline: “Wash your hands with soap for the health and development of Formative research is conducted during the development children.� of a program to help identify and understand the characteristics — interests, behaviors, needs — of Based on the research findings about the importance of interpersonal communication to caretakers, comprehensive the decisions and actions of the target audience, and reference manuals were developed, one for health workers includes both qualitative and quantitative data collection and one for Vietnam Women’s Union members. These methods. manuals are used to lead group meetings with mothers, grandparents, and teachers, conduct household visits, and organize market meetings, club meetings and community Designing the Campaigns contests. Campaign messages were developed based on the most High-impact community marketing events including relevant findings of the formative research. games, quizzes, contests, and demonstrations were also held to reinforce the positive messages about handwashing with Research on Caretakers showed that caretakers were soap and to illustrate that clean-looking hands, and hands concerned most about making sure that their children meet that do not smell, can still have germs. The demonstration developmental milestones so that they are able to keep up involved participants rubbing a powder, detectable only with their peers. Washing hands was usually done with under ultraviolet light, on their hands to represent germs. water only, and using soap was not felt to be important or Because the powder is invisible to the naked eye, the hands necessary, but the smell of soap is an attractive attribute. still appear to be clean. Television is the best way to reach caretakers as mothers often enjoy watching TV programs in the evening with Research on children showed that children like the smell their families. Members of the Women’s Union and health of soap and knew that they need to wash their hands with workers are the most trusted sources of information. soap but could not identify the important times — before eating and after defecating. They have a desire to prevent Key Communications Concept: Caretakers are others, especially younger siblings, from getting sick. concerned most about making sure that their children Children used TV as a window to the wider society, and meet developmental milestones so that they are able to their role models reflected greater societal values: education, keep up with their peers hard work, and altruism. A campaign was developed based on the idea of promoting Key Communications Concept: Children want to “good motherhood.� Handwashing with soap was protect their younger brothers and sisters from getting positioned as an easy way for mothers to help ensure the sick. Regret at making someone ill from not cleaning health and well-being of their children. Using this platform, dirty hands is the primary motivator for hand washing with soap. six campaign concepts were developed and pretested throughout the country. One final concept was chosen by the target audience, based on the popular song Five Clean The school setting presents unique challenges to effectively Fingers. When teaching young children how to count, promoting hand washing with soap. The most likely time mothers and teachers often sing this song. The campaign when children will wash their hands in school is after uses the song to point out that, “Hands are not clean if you using the latrine, not before eating, as almost all rural wash only with water, soap is needed.� The final products school children return home to eat their mid-day meal. www.wsp.org 9 FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs a superhero — selected. The Bi character was refined and pretested again several times before the final production. A series of ten comic strips was developed around Bi and his adventures with handwashing. The comics were printed in a popular children’s magazine, Nhi Dong, and then turned into animated cartoons that were then aired on a nightly children’s show, Good Night Baby. Bi was also included in the print materials in schools, along with singing of the Five Clean Fingers song used in the caretaker’s program, which was incorporated into games and activities. The school materials offered simple guidelines and an instructional DVD to help teachers apply the games as a supplement to existing lessons on handwashing with soap. Each school within the supported program area carried out School days are long and highly regimented with limited five extracurricular activities including participation in a opportunities for play. Teachers have a full teaching load national handwashing with soap drawing contest through with no time to introduce new activities. Handwashing the Nhi Dong magazine. with soap is already part of the curriculum, but hygiene lessons are often limited to theory as the lack of water, soap, Scale basins, and clean, working latrines prevents children from practicing handwashing with soap at schools. Between May 2008 and November 2010, health workers and Women’s Union staff have reached nearly two million The campaign for children was developed based on caretakers through interpersonal communications activities. the platform of children as the “pride of the family.� Importantly, over 15,000 health workers, teachers and Handwashing with soap was positioned as an easy, fun, and Vietnam Women’s Union staff were trained in the theory smart behavior with a tagline of, “Wash your hands with and practice of handwashing with soap. This enabled them soap for your own health and the health of others around you.� FIGURE 3: 1,400,000 The handwashing with soap campaign for school children used a fresh, interactive approach to education, combining 1,200,000 mass media and interpersonal communications activities, 1,000,000 especially through teachers. As Vietnamese children have little free time in their daily lives, WSP supported an 800,000 advertising agency to develop an entertainment/education program to generate interest, enthusiasm, and promote the 600,000 practice of handwashing with soap. A campaign, focused on colorful, attractive, and positive characters, was developed 400,000 around a superhero who acquires special powers by 200,000 handwashing with soap in order to help his family and others. Two different concepts for the superhero were pre-tested 0 with a final character — a rural schoolboy, Bi, who becomes Phase I (2008) Phase II (2008 - 2009) Phase III (2009 - 2010) 10 www.wsp.org FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs Costs Initially, in 2006, the Danish Embassy in Vietnam provided US$1 million for the HWI. The HWI was then scaled up with a further US$2.5 million from the Bill and Melinda Gates Foundation between 2007 and 2011 as part of the Global Scaling Up Handwashing Project implemented by WSP. Water supply and sanitation projects and programs have shared the implementation costs of handwashing promotion in selected locations, while private companies such as Unilever have also contributed to handwashing promotion. Monitoring of Results to then communicate with many people in the community, The HWI has invested a significant amount of resources through thousands of mothers’ meetings, grandparents’ in monitoring and evaluation. A global Results Framework meetings, market meetings, Women’s Union members’ sets clear, specific targets to guide program monitoring, meetings, kindergarten teachers’ meetings, and visits to including tracking the number of activities completed and more than 425,000 households. Other events to support estimating audience reach for all communications channels. interpersonal communication included 10 community In Vietnam, data are collected monthly at the commune level marketing events and 48 cooking contests that integrated and aggregated to the national level for a country specific handwashing with soap into the event. picture. Semi-annually, the Vietnam data are compiled with data from the other three countries to form a global picture Through school events and mass media activities, of project progress. Another significant component of the handwashing with soap promotion has reached an estimated program is an impact evaluation to quantify the health and 800,000 students nationwide. Direct promotional activities poverty impacts of a large-scale handwashing with soap in 512 rural and semi-urban schools throughout Vietnam program. have resulted in: Unique Features of the Handwashing Initiative in Training for over 670 teachers, Vietnam 772 Global Handwashing Day school events, 260 “My Superhero� contests, The HWI is a programmatic approach to handwashing, 512 school handwashing with soap launch events, and concentrating on implementation and achieving tangible 1,260 meetings/events for handwashing promotion at and ambitious results set by the Global Scaling Up school. Handwashing Project. At the heart of the Project is the goal to improve communication techniques for handwashing To address the challenge of insufficient handwashing promotion. facilities at schools, guidance on how to make low cost handwashing with soap stations is given to teachers and Vietnam is fortunate in having extra funding through the principals during the training courses in schools. Simple Gates Foundation to test and implement handwashing and affordable solutions such as plastic buckets, plastic campaigns. Other countries attempting to scale up have water dippers, and techniques to manage soap are shared. difficulty getting enough funds to achieve this on a scale. www.wsp.org 11 FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs The HWI has made deliberate use of professional expertise financial resources. They may be tempted to skip or shortcut to help build credibility and objectivity in the research. the consumer research stage. The experience from Vietnam However, Vietnamese expertise in social marketing and is that this first step is the most crucial in designing an health promotion is not yet well developed. A market evidence-based campaign. The research findings are critical research firm was hired to carry out the adult formative to identifying behavioral determinants that subsequently research study and an international advertising agency was guide the development of the communications campaign contracted to design both the caretaker and school children objectives. The campaign objectives are then used as the communications campaigns. Close supervision by WSP basis for a monitoring and evaluation system. is critical to keeping the marketing campaigns true to the research findings as advertising agencies do not always INDONESIA PUBLIC-PRIVATE base their creative ideas on evidence and research data. PARTNERSHIP FOR HANDWASHING The Agency Brief (which contains the research reports and WITH SOAP guidelines for the agency) serves as an important tool to guide and measure the creative ideas of the agency, and for Background accountability. Handwashing with soap has been promoted in Indonesia Strong partnerships are forged directly at the provincial since the 1980s by many government, development level where there is enthusiastic demand for handwashing assistance, and NGO programs. Handwashing was support. WSP and the Women’s Union work directly with included in diverse health and hygiene programs such as interested provincial Health and Education Departments, breast-feeding, prevention of the spread of avian flu, and rather than working through the central level of government. water and sanitation projects. Usually the focus was on creating awareness and increasing knowledge to change Vietnam’s National Target Program for Rural Water Supply behavior. Promotional efforts were sporadic, uncoordinated and Sanitation has helped to leverage the HWI.10 By 2010, and unevenly spread across the vast Indonesian archipelago. almost all nine pilot provinces participating in the National Target Program had requested and received support for According to a baseline survey of six provinces in 2006 handwashing promotion, in most cases sharing the costs (conducted by Environmental Services Program-USAID11), to implement promotional activities in schools and the mothers rarely washed hands with soap at critical times. community. WSP funded a limited number of training Only 6 percent of mothers washed hands with soap before courses for provincial and district health workers and preparing food. When taking care of children only 7 percent printing of all communications materials for most of the FIGURE 6: pilot provinces. The pilot provinces then, in turn, funded Area: 1,904,569 km2 commune level training and supported interpersonal Number of provinces: 33 communications from their National Target Program Population: (2010 est.) 237.5 million budget allocation for hygiene promotion. This partnership approach can serve as a model to advocate for provincial Children under 5: 9.2% government allocations for handwashing nationally. Life expectancy: Males 68 Females 73 In Vietnam, policy makers and program managers are Under 5 mortality: 31 per 1000 often under pressure to quickly roll out a communications Primary school enrollment: 96% campaign, especially if they are stretched in terms of time or Source: UNICEF 2008 10. AusAID, Danida and the Netherlands jointly fund the National Target Program. Pilot provinces are supported with technical and capacity-building assistance to improve the effectiveness of RWSS expenditure and make progress towards achieving the national water supply and sanitation targets in rural areas. 11. Environmental Services Program – United States Agency for International Development. 12 www.wsp.org FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs Songkhla Davao PALAU THAILAND amboanga ISLANDS Bandar Seri PHILIPPINES Banda Lhokseuma e Begawan Aceh MALAYSIA BRUNEI Langsa eh Medan P a c i f i c O c e a n Manggeng Bin ai Kuala Lumpur Tan ungselor Balige Labuhanbilik MALAYSIA Sumate a Tan ungredeb Padangsidempuan ta a Manado Duri iau Singapore Sambas Kalimantan Timu Pakanbaru Singka ang Sulawesi ta a Kotanopan Sanggau Bangkinang Mempa ah Pontianak Nangpinch Samarinda Molucca Sea Bukittinggi Kalimantan Ba at Sumate a Sandae Padang ambi Manok ari Ba at Sulawesi Tengah Kalimantan Tengah Airhad i Jam i Ketapang Sampit Sulawesi M a l u k u Jaya u a Palembang Selatan Sumate a Kalimantan Sulawesi Selatan Ban armasin Selatan Tengga a We ak Bengkulu I N D O N E S I A ian Jaya Banja masin S U ungpandang Lam ung J a v a S e a I N D O N E S I A Jaka ta aya Jakarta Banda Sea PAPUA Jawa Ba at Semarang Pati l u k u NEW GUINEA Bandung Garut Jawa M a Tengah Jawa Surabaya Kebumen Nusa Tengga a Ba at Yogyaka ta Timu Malang Bali Dili Lun uk besar East Timor A r a f u r a S e a Nusa Tengga a Timu S Kupang I n d i a n O c e a n Timor Sea of mothers washed hands with soap before feeding a child, Private national and multinational companies: Reckitt and 9 percent after cleaning their baby’s bottom. Few Benckiser (Dettol), Unilever, Triple Ace, Exxon Mobil, women washed their hands with soap after they defecated Indofood, Bank BTPN; or before eating. Non-governmental organizations: Save the Children Fund, CARE, Johns Hopkins University, Mercy Corps Description of the Program and Plan International; and Community-based organizations: PKK (national In 2007, as part of a national “community-based total women’s organization), Muhammadiyah (Indonesia’s sanitation strategy,� the Indonesian Government and second largest faith-based mass organization). partners called for a national handwashing with soap program to improve the coordination and focus of The partnership operates through regular meetings of the handwashing activities, and move away from the piece- core group, special issues sub-committees, and a National meal, project-by-project or district-by-district approach of Steering Committee. Since 2007, WSP has supported a the past. The Public-Private Partnership for Handwashing full-time person located within the Ministry of Health to With Soap (PPP-HWWS) was created as a response. The act as PPP-HWWS Coordinator. partnership supports the Ministry of Health in the creation of healthy communities by promoting sustainable large- Members of the Core Group develop activities in areas scale handwashing with soap campaigns targeting audiences related to their interests and strengths. Some work directly countrywide. with local government, while others develop their own projects with NGOs active at community level. Each The PPP-HWWS begun in 2007 as a small core group partnership member contributes in some way to national of national-level member organizations from public, handwashing promotion, within the overall objectives private and non-profit sectors, but now includes large and of the PPP-HWWS. The Ministry of Health has few influential organizations such as: resources to do promotional activities in Indonesia’s many communities, but together with BAPPENAS, it provides a Government: Ministry of Health, and the National national framework and leadership, and strategic links to Development Planning Agency (BAPPENAS); provincial and district government administration. Donors Donor organizations: WSP-World Bank, Asian who typically conduct projects outside of the government Development Bank, USAID, UNICEF, and WHO; system are now bringing handwashing with soap promotion www.wsp.org 13 FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs into their water and sanitation projects using the guidelines Target Groups and Behaviors and approaches agreed between partners. Businesses contribute to financing and implementation of marketing Mothers and caretakers of children under five years of age techniques. Community-based organizations use their and school children are the ultimate target audience for networks to reach out to communities around the nation. handwashing activities. However promotional activities are not limited to these target groups. For example, handwashing The first phase of the PPP-HWWS involved consolidating is promoted to wider audiences such as religious travelers, and raising awareness of the national handwashing factory workers, bank customers, or the public in general. partnership itself. The second phase is more directly working The PPP-HWWS aims to make handwashing with soap an at changing handwashing behavior. everyday behavior in all situations for everyone. One of the major outcomes of the PPP-HWWS has been agreement on promoting both the need to use soap and the critical times for handwashing. Before the PPP-HWWS was established, various health programs that promoted handwashing focused on many different times for handwashing such as: before eating, before serving food, before feeding a child, after going to the toilet, after touching animals (poultry), before breastfeeding, after cleaning a baby’s bottom, after sneezing, after cleaning out rubbish, and for children after playing and touching dirt. The critical times were not identified or standardized. Prompted by a sharper focus on high priority health issues, such as diarrheal diseases among under-fives and the Avian Flu epidemic, the Ministry of Health endorsed five times as critical for handwashing with soap: Before eating, Before preparing and serving food, Before feeding a child, After going to the toilet, and After touching animals (poultry). All stakeholders now universally promote these five critical times. A second important outcome is the development of strong links, coordinated by the Ministry of Health, between the PPP-HWWS and large scale water and sanitation projects supported by the World Bank, Asian Development Bank, and NGOs such as Mercy Corps, Plan International, and CARE. The partners agreed that all project plans must Mother with a hanging “home made� handwashing station include a component for handwashing with soap. This 14 www.wsp.org FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs has helped bring handwashing with soap messages to large FIGURE 7: numbers of local officials and their project teams. Through them, the PPP-HWWS has been able to connect with local administrations at various levels around the nation, helping to scale up the program and reach wider target audiences. Campaign Materials The PPP-HWWS did not set about to develop new communication materials, as there are many examples already in use across Indonesia. The available materials were largely based on formative research undertaken by previous and current USAID and NGO projects. Also, in 2006 new formative research from the USAID’s Environmental Services Project confirmed and clarified the findings of Nationally coordinated activities by the partnership are previous studies. aimed at drawing nationwide attention to handwashing messages and showing national Government leadership in Instead, attention has been given to national level program the activities. The national program uses a common logo guidelines to provide a common basic framework for the with the slogan “Make a habit of washing hands with soap.�13 PPP-HWWS initiative. With many different, sometimes The core group and partners coordinate communication competing stakeholders (e.g. soap manufacturers) the process activities through mass media such as radio and television itself of preparing guidelines can help to unify approaches and in national events or commemorative days for specific and understanding, as well as clarify responsibilities, audiences. promote transparency and equity of participation, and standardize technical approaches. These “rules of the game� Standard handwashing program materials were developed include: that can be reproduced by the private sector if credit is given to the original developer — either the PPP-HWWS General Guideline for Handwashing with Soap Program secretariat or a partner organization. These materials Management,12 explaining the design of the program, include traditional health promotion materials as well as policy and the strategy; more innovative ones including: Technical Guidelines, providing instruction on how to carry out handwashing with soap programs; A pocket book for community organizations and local The Catalogue of Handwashing Facilities Options, health promoters; showing design options for areas with and without A story book for mothers of younger children and piped water supply; comics for school children; Technical Guidelines for Co-Branding, outlining rules of Public service announcements for use on TV, in-house work between local authorities and the private sector; video, and audio systems; Private-Public Participation General Guidelines, Jingles for use on radio; describing who can be partners in the handwashing Re-usable shopping bags with handwashing with soap program; and logo and slogan; and The Advocacy and Communication Strategy, describing Stickers for toilets and handwashing stations to remind strategies for communicating handwashing with soap people of the five critical times and how to wash hands messages to audiences. properly. 12. General and Technical Guidelines for Handwashing with Soap Program Management was developed by the PPP to support the Government’s total sanitation strategy. 13. The logo and slogan were developed from formative research carried out by USAID in 2006. www.wsp.org 15 FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs Some of the standard materials were designed and produced Indonesian Mothers Day (December 18) and the National (based on formative research) for specific events but not Health Day events during December 20-21. fully pre-tested, due to time constraints. However, limited numbers were produced and pre-testing was carried out In 2008 the public’s attention was captured by an officially later. Revisions were incorporated before mass production recognized record-breaking feat for the most number of to ensure that the messages are well understood and the people washing hands together at the same time and in the materials effective. same place. This exploit involved 5,000 school children and 7,000 mothers, led by Tangerang Regency with support Other materials have included Training-of-Trainer modules from USAID, CARE, and Unilever. For Indonesia’s first prepared to aid implementation of WASH projects by Global Handwashing Day, sponsored by Lifebuoy on regional and local handwashing with soap teams within the October 15, 2008, a record-breaking event was organized Ministry of Health. These are guidelines about the program for the largest number of school children and parents and content such as: the importance of soap in preventing washing their hands simultaneously in four major cities in the spread of germs from hands, types of diseases that can be Indonesia. The following year, for Global Handwashing controlled, social marketing, steps in building partnerships Day 2009, the Ministry of Health led more than 1 million at local level, and choices of settings to carry out activities. students in five cities across the country to simultaneously There is also information about how to conduct group wash their hands. discussions, make action plans, and invigorate training. Indonesia has the largest Muslim population of any country Scale in the world. Each year more than 220,000 people take part in the Hajj Pilgrimage. Before departing for Saudi Arabia, Through high level organization and coordination, pilgrims are hosted for a couple of nights by six regional handwashing with soap has gained much prominence in offices for Hajj Travel. The posters and stickers about the national events, programs, and celebrations. The approach five critical times for handwashing are placed in dining taken in Indonesia has been to forge increased synergy and halls, toilets, and kitchens of these regional travel offices to develop joint implementation guidelines across various remind people of the importance of handwashing. initiatives, in order to enable rapid scaling up to reach across such a vast nation. The nature of this did not lend An H5N1 Bird Flu campaign was launched in August itself to target setting of quantitative behavior change, as 2008 in conjunction with Muhammadiyah, the second- the evolution of the program was organic and often outside largest faith-based mass organization in Indonesia, and was of the direct control of the PPP-HWWS. conducted in nine cities in five provinces. The campaign recommended adopting handwashing with soap as a habit Handwashing with soap is now being integrated into a to prevent bird flu, and was supported by USAID, WSP, wide variety of programs and situations on a broad scale. Unilever and Reckitt Benckiser. More recently, a talk show, Promotion is through normal avenues such as the Ministry supported by Reckitt Benckiser (Dettol) and the Royal of Health activities and water and sanitation programs, but Taruma Hospital to increase public awareness on the H1N1 also many unexpected channels including private hospitals, Swine Flu pandemic and the importance of handwashing food producers, oil and gas companies, religious groups, with soap, reached around 11 million viewers. and banks. Private companies use the framework and materials of the Handwashing with soap promotion features are part PPP-HWWS for their own large-scale initiatives. One of of Indonesia’s national World Water Day celebrations, Indonesia’s mid-size national banks, Bank BTPN, displayed 16 www.wsp.org FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs Getting the numbers: national promotion of handwashing with soap has enabled this record breaking attempt at the most people washing hands with soap at one place and time. the handwashing with soap video and posters in all of its representatives and NGOs. The company then supported a 366 branches and outlets in 14 provinces. It also held workshop for the Ministry of Health and NGOs to develop monthly interactive discussions on handwashing with soap handwashing promotion communications. with customers at 46 branches. The oil and gas company Exxon Mobil supported a series of radio talk shows on Indonesia’s national PPP-HWWS has also been the object handwashing with soap promotion and has integrated of study from its Asian neighbors, with government and handwashing with soap messages into mothers and girls NGO groups coming from Timor-Leste, Vietnam, and empowerment and education programs in Aceh, Central Lao Peoples’ Democratic Republic to learn about the and East Java. Some 62,000 staff of Indofood, Indonesia’s mechanisms. largest noodle and snack food manufacturer, watched the handwashing with soap video public service announcement Monitoring over a 3-month period in 2009 on TV terminals in all of the company’s 32 production sites. The first three years of work focused on advocacy, raising awareness of handwashing with soap and of the national Private business has demonstrated its role in scaling logo, and establishing a framework for Government’s future up handwashing promotion by leading the sharing of role in handwashing with soap promotion, rather than information and experience on handwashing promotion. on behavior change at community level. Consequently In late 2008, Unilever hosted a half-day “Marketing Expo� monitoring has focused on the delivery of activities not on of successful behavior change promotions for government behavior change. www.wsp.org 17 FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs WSP’s budget contributes to a larger picture where handwashing with soap promotion costs are shared among the national government, international development agencies, private sector players, NGOs, and other hygiene promotion projects. Local government administrations are encouraged to take a greater part in the handwashing with soap program by allocating budgets and cooperating with the private sector. Although contributions from partners and participants are not monetized, the total amount is estimated to be in the order of five times WSP’s annual contribution. Each partner in the PPP-HWWS has its own tools for Unique Features of Public-Private Partnership for baseline surveys and monitoring. The Ministry of Health Handwashing with Soap in Indonesia has developed means to measure advocacy and awareness activities, which are used by local government health officers The PPP-HWWS program works through an agreed for reporting to the national level. framework and operating guidelines for partners developed at the national level, but then allows handwashing In 2010, an integrated activity with WSP’s Total Sanitation promotion activities to happen organically according to the and Sanitation Marketing Program was carried out to interests, energies and resources of partners. measure handwashing with soap behavior among people in areas that have been declared free from open defecation. The Ministry of Health is in the central position of the Data reported by the different partners from their project handwashing with soap partnership. Its leadership is active areas, and data collected by Ministry of Health, were and engaged. The WSP-funded PPP-HWWS Coordinator combined to present an overall picture of both handwashing and Secretariat is physically located within the Ministry of with soap programs and practices in Indonesia. Health to enhance coordination. Costs The budget for handwashing promotion is small and therefore has to be targeted effectively. Support from the WSP has supported the PPP-HWWS secretariat in private sector is feasible as Indonesia’s Corporate Social Indonesia. The annual budget for secretariat staffing costs, Responsibility Law has made active participation by the materials, research, training and workshops has been around private sector easier. Passed in 2007, the law requires that US$180,000 per year. As the leader of the PPP-HWWS, limited liability companies operating a business related the Ministry of Health co-funds the work through its to natural resources support social and environmental Community-Based Total Sanitation Strategy budget. responsibility programs. The Law provides opportunities The Government’s 2008 national strategy for Community-Based Total Sanitation (STBM) has been a key to mainstreaming Open-defecation free communities, Handwashing with soap, Safe and sustainable household water supply, Safe treatment of household waste water, and Safe disposal of solid waste. 18 www.wsp.org FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs for partnership between the Government and private of the national handwashing with soap logo. The design sector, and has helped scale up the PPP-HWWS program. featured a yellow colored soap that was perceived to favor one of the two soap manufacturers in the partnership, The Ministry of Health’s Community-Based Total leading the other soap manufacturer to refuse to use the Sanitation decree serves as an umbrella law for managing national campaign logo while the yellow soap was depicted. the handwashing program in Indonesia. Through the A neutral colored orange soap (as used in the Global strategy and initial target of 10,000 villages to achieve Handwashing Campaign logo) was eventually selected to all five pillars, water and sanitation projects around the feature in promotional materials. Both soap manufacturers country are required to integrate handwashing with soap then gave their full support to the campaign. Coordinating components into their plan, greatly increasing the reach of the PPP-HWWS in a transparent way with fair competition the PPP-HWWS. among companies who are direct competitors has helped the Government stay neutral in the partnership. Indonesia’s handwashing partnership involves private companies that are natural business competitors. The Summary of Country Approaches PPP-HWWS has developed transparent protocols and practices to avoid any conflicts of interest or perceived Vietnam and Indonesia’s approaches to national unfair promotional advantage for private businesses. An handwashing program have varied. Each country program example of the type of conflict that can occur is the design is summarized in the following table: TABLE 1: Criteria Vietnam Indonesia Women aged 15-49 and children aged 6-10 adopt handwashing with soap at critical times: and sustainability of handwashing promotion Program Objectives before feeding a child, before preparing food, by strengthening the roles of stakeholders, in after using the toilet, and after cleaning a baby’s particular the private sector bottom Improving the content and delivery of Coordinating and leading handwashing with WSP Program Focus handwashing with soap communication soap promotional activities at the national level materials and scaling-up across the country Ministry of Health Ministry of Health (Directorate of Environmental Main WSP Partners Vietnam Women’s Union Health, and the Center for Health Promotion) Critical. Various soap and non-soap private Role of Private Sector Limited. Some support from soap manufacturers. companies involved in developing, funding, and implementing national and local campaigns. Main Target Audience aged 6-10. general public. Personal communication through the Women’s Method Used to Reach Target Audience community marketing events. commemorative day celebrations. “Wash your hands with soap for the health and development of children� (Caretakers) Main Messages “Make a habit of washing hands with soap.� “Wash your hands with soap for your own health and the health of others around you�. (Children) www.wsp.org 19 FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs LESSONS LEARNED Both national handwashing with soap case studies provide enabling environment has been created at national level, important lessons learned for future work in Indonesia and a nationwide community-based behavior change program Vietnam. The following section provides insights that may will be more easily introduced, and all hygiene community be useful for other countries in Asia and beyond that plan players including the private sector can support each other to nationally scale up handwashing with soap activities. in different areas to cover all audiences in the country. There is no one way. There is no one solution or approach In a decentralized environment, where program priorities to starting a national handwashing program. Each program and use of local resources are at the discretion of the will be different depending on the country context in which respective local governments, the key to adoption of it is implemented. Experience in Vietnam demonstrated national policies and programs at the local levels lies in that a PPP model is not essential to starting up a large- “lobbying� or “socialization� of these policies and programs, scale handwashing program where other resources and with appropriate guidelines and capacity building. partnership are available. Factors which affect the country context include: size and ethnic diversity of the target Leading the way. Whoever is the lead agency for a national audience; previous handwashing initiatives; dynamism and handwashing program will influence the dynamics of the leadership ability of government; the type and number of partnership, and the effectiveness and sustainability of partners; resources and budget available; and the framework handwashing promotion. The best lead agency may not of laws and policies. be the most obvious choice. For example in Vietnam, the Women’s Union plays a crucial role in national program Build on earlier work. In both Vietnam and Indonesia, implementation. the national programs built upon existing handwashing experience, integrated with other programs, or were In terms of the role of Government, it is important to complementary to existing programs. In Vietnam, the understand the organizational structure, roles, mandates, Handwashing Initiative was complementary to the work of and budgets of various departments and department the Global PPPHW, UNICEF, and others. In Indonesia, sections, along with knowledge of how the departments the PPP-HWWS developed and assimilated other and divisions relate to each other. handwashing forums such as the Johns Hopkins University- managed health promotion forum Koalisi untuk Indonesia Partnerships are not easy. Partnerships involving Sehat, which was building coordination for handwashing government, donors, private businesses and community amongst donors and the private sector. Failure to recognize groups bring different perspectives, interests, cultures, earlier work, or starting an entirely new initiative, would and styles of working. Inevitably, this will result in some have alienated partners in the sector. disagreements or misunderstandings. Having a mutually agreed-upon set of guidelines and procedures for how Create a supportive environment. Creating a strong partners work together can prevent (or mend) breakdowns supportive environment with Government is an important in partnerships. An independently appointed coordinator first step for countries with a large diverse population can help keep activities focused and communication lines and many existing or potential players in handwashing open, as can the government if it facilitates in a neutral promotion. The creation of umbrella laws, strategies, way. Patient discussion, trust, and goodwill, combined with guidelines and structures for the long-term participation effective coordination can resolve most issues. by government and stakeholders, will move the program from piecemeal activities to a coordinated nationwide Independent coordination. In both countries, WSP has program. As seen in Indonesia, once a supportive played a unique role, ranging from initiator to facilitator, 20 www.wsp.org FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs coordinator to mediator. An independent handwashing partnership members being mired in minor issues and coordinator is a useful focal point for national partnerships. decisions. However, it is still important to involve partners However thought needs to be given to where the in the development of promotional materials and to have a coordinator is placed, in order to optimize the effectiveness professional quality production. A message that is developed of communication between the lead ministry and members without the involvement of partnership members, or of the partnership. Placement may also change over time, as poorly produced materials will not have the support of needs change. In Indonesia, the PPP-HWWS coordinator implementers. was originally based in the Ministry of Health for four days per week. As the program has evolved, she now divides her The right channels. No matter how good the handwashing time between the Directorate of Environmental Health, the promotion message is, if the wrong channels are selected Center for Health Promotion (Ministry of Health), and for spreading that message then the message is wasted. WSP. Selecting the right channel is about making sure the message is heard or seen by the people for whom it is intended. In Taking the time. Instigating a national handwashing Vietnam, formative research identified the best channels campaign cannot be done quickly. All partners need to to reach caretakers and children such as popular TV shows understand the implementation time involved, especially and newspapers. Members of the Women’s Union were the time needed to obtain agreement and consensus between also identified as being trusted sources of information. The partners. Regardless of whether the political structure is Women’s Union was the perfect choice for a communication socialist or democratic, when it comes to implementing a channel as it is a national organization with a wide reach national program governments will require time for their down to village women; it has a mandate to promote own internal consensus and approval processes. Recruiting health and hygiene, and has experience in communication. specialist services and preparation and agreement on Terms In Indonesia, formative research contributed to the of Reference or Agency Briefs is also time consuming. There communications strategy, and the many channels used is no fast track solution and the desire to shortcut national reflect the diversity of the national partnership members. campaigns should be vigorously resisted. The flexibility in channels has resulted in handwashing promotion to large numbers of people in situations where Using the same messages. Well researched, but standardized the government and donors could never penetrate. handwashing with soap messages can have a high impact on target audiences, and make campaign implementation easier Training for partners and implementers. Training for and more efficient. In Vietnam, there were consistent and partners and implementers is an essential part of any overlapping messages for caretakers and school children. In national handwashing campaign to give people the skills Indonesia, agreement by all key partners on the umbrella and understanding to carry out the program. In Vietnam, key messages based on formative research, on a well-tested participatory workshops were organized on behavior and accepted national logo, and on the five critical times for change communication, program planning, and selection handwashing resulted in delivery of consistent information of communes targeted for the program. The Vietnam and reduced delays in the production and consequent Women’s Union was also trained in the use of interpersonal broadcast of public service announcements. communication for promoting handwashing with soap. Capacity building of the Ministry of Health and Women’s Using professional skills. Engaging people with professional Union staff is a continuous need. In Indonesia a number of experience and training in their field, whether it is media workshops and national conferences have been organized production, research, or hygiene promotion, improves for partners to learn about the handwashing with soap the chances that communication strategies will succeed. program and to share information, experiences, ideas and Professional inputs from outside of the handwashing techniques. These events occur on an ongoing basis. Health partnerships can bring independence, and minimize staff have also been guided in implementation. www.wsp.org 21 FIELD NOTE: Handwashing with Soap — Two Paths to Starting Up National-Scale Programs Being open to opportunities. National handwashing ongoing challenge is that communication materials need to campaigns need to be open and willing to take on new be tailor-made or adjusted at the provincial or even district partners or new opportunities as they arise to leverage level to reach all citizens. This requires more research on the the promotion of handwashing with soap. New partners specific behaviors of different ethnic groups. and opportunities bring more energy and wider exposure to handwashing campaigns. Having a clear framework, School environments in both Indonesia and Vietnam operating guidelines, and agreed goals help keep the lack water supply and adequate handwashing stations. In partners focused on the initiatives’ objectives. In Indonesia, Vietnam of the 35,000 main schools, only 65 percent have the number of core partners in the PPP-HWWS has grown water and 41 percent have sanitation facilities. In both to include a very diverse membership, increasing the reach countries water and sanitation projects are helping address of handwashing messages far beyond what was initially these needs but more needs to be done if promotion of thought possible. In Vietnam, the HWI has worked with handwashing with soap is to be effective. The challenge the National Target Program for rural water supply and is how to ensure water and sanitation projects devote sanitation as well as provincial partners. enough resources to ensuring the physical infrastructure for handwashing and to carrying out effective promotional What else we need to know activities. Both case studies are examples of successful national handwashing programs implemented in different ways Only through evaluation will it be known how the national that are appropriate to each country context. Nevertheless, campaigns have changed handwashing behavior. More there are still challenges remaining. Vietnam and Indonesia work is needed to monitor and evaluate these programs have many ethnic groups, many traditions and languages so so that in the future it might be possible to measure and that one national campaign material may not “fit� all. An compare achievements between these and other countries. FURTHER READING The Global Public Private Partnership for Handwashing Nguyen, N. 2010. “The development of an entertainment (no date). The Handwashing Handbook: A guide for education program to promote handwashing with developing a hygiene promotion program to increase soap among primary school children in Vietnam.� handwashing with soap. World Bank. Sharing Experiences: Effective hygiene promotion in South-East Asia and the Pacific. WaterAid Australia, Coombes, Y and J. Devine. 2010. Introducing FOAM: A International Water Centre. IRC International Framework to Analyze Handwashing Behaviors Water and Sanitation Centre. to Design Effective Handwashing Programs. WSP. http://www.wsp.org/wsp/sites/wsp.org/files/ Rafiqah, I, and I. Blackett. 2010. �Public-Private Partnership publications/WSP_IntroducingFOAM_HWWS. for Handwashing with Soap in Indonesia.� Sharing pdf Experiences: Effective hygiene promotion in South- East Asia and the Pacific. WaterAid Australia, Nguyen, N, M. Nguyen, N. Paynter. 2011. A Handwashing International Water Centre. IRC International Behaviour-Change Journey: Vietnam Mothers. WSP. Water and Sanitation Centre. 22 www.wsp.org