64342 Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals The Central American Handwashing Initiative Points the Way United Nations Children’s Fund 2 public-private partnerships are dynamic Initial Founding Partnership, 1996 Evolved Partnership, 1999 Public sector Soap Soap producers producers International development organizations Catalyst Media NGOs Industry foundations In the Central American Handwashing Initiative, the PPP began with the catalyst and the private sector soap producers. In time, the initial founding partnership evolved into a fuller partnership among the private sector, the public sector, international development organizations, the media, and many others. By 1999, the catalyst’s role had been phased out and the partners had assumed responsibility for campaign activities, with the soap producers taking the lead. Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 3 The PPP Approach Gets Results P ublic-private partnerships (PPP) can achieve positive public health results and at the same time meet the individual organizational goals of the partners. Such partnerships allow considerable leveraging of each partner s resources and unique strengths, and results are often attained in less time, at lower cost, Key Results and with greater sustainability than efforts by any single partner. 1. Improvements in handwashing From 1996 to 1999, public, private, and donor organizations in behavior and decreases in Guatemala, El Salvador, Costa Rica, and Honduras formed the diarrheal disease. Central American Handwashing Initiative. Together, four soap 2. Significant resources leveraged. companies and two projects supported by the U. S. Agency for International Development (USAID) designed an advertising and 3. Sustained involvement of the promotional campaign for effective handwashing with soap aimed private sector in social at reducing diarrheal disease in children. They collaborated with programs. ministries of health and education and other development organizations in the region to carry out the campaign. Read on to find out how results like these may be achieved. Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 4 Examples of Solutions Provided by PPP ■ Diarrheal disease. A joint What is a PPP? collaboration between producers of oral rehydration A PPP public-private partnership for health is an approach to salts (ORS) and the Ministry of addressing public health (and social development) problems through Health in Pakistan expanded the combined efforts of public, private, and development organizations. the sustainable commercialization of ORS in Each partner makes a contribution in its area of special competence, that country. This expansion bringing in expertise that is often not available in development projects. The minimized the burden on the partners in a PPP rally around a common cause, while at the same time government, while ensuring pursuing some of their own organizational objectives. Public sector that ORS supply and use were organizations such as ministries of health or education achieve their sustained. objectives in less time, with smaller investments. Private sector ■ Malnutrition. Producers of corn organizations producers of health-related products, for example are able flour, the main ingredient in the tortillas that are a staple food to expand their markets, develop new marketing techniques, and contribute across Central America, agreed to the communities in which they do business. Development organizations to fortify their product with iron achieve their strategic objectives in collaboration with others, leverage new in order to prevent iron resources for public health, and gain experience with a highly feasible and deficiency in targeted sustainable approach to public health promotion. Most important, the populations. targeted communities and populations benefit from improved health. ■ Malaria. With collaboration from ministries of health and media and communication Both public and private sectors agencies in six African brought to the table their own countries, insecticide and experiences and strengths, making mosquito net producers allied the partnership a solid team with a to launch an intervention promoting low-cost insecticide- common vision. treated materials for the Baudilio Lopez, USAID, Guatemala prevention of malaria. Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 5 Critical Steps in the PPP Approach T he Central American Handwashing Initiative used a highly successful approach to PPP that was developed by USAID through the Basic Support for Assess 14 Incorporate Evaluation Results into Strategy Institutionalizing Child Survival (BASICS) 3 2 Competitive Market Assess 13 Evaluate project. The process evolves in fourteen steps, from selection of a health issue to 4 Build Public Sector Collaboration Company Capacities Impact 12 Select 5 1 Monitor implementation of a marketing program to Relevant Develop Progress Public Health Partnership address it. Need Proposal 11 Launch Build Public/ Marketing The PPP process is set in motion by a 6Private Consensus Campaign 10 Develop 7 8 9 catalyst that provides the spark and Develop Promotional Marketing Conduct Finalize Materials initiates and guides the process. Catalysts Plan Marketing Market Research Strategy may be supported by a development organization, the private sector, or the public sector. The PPP process has four phases: BASICS’s approach to PPP—the “nautilus�—can be modified to Phase One: suit particular circumstances. In the Central American Handwashing Conceptualization and Development of Initiative, for example, the public sector joined the effort after, not before, the regional advertising campaign had been designed. The the Partnership (Nautilus Steps 1–6) private sector partners requested this change in timing and The catalyst. . . sequence so that they could present a more fully developed ■ with the relevant public health authority, strategy to the public sector in each country. selects problem to be addressed. Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 6 ■ identifies potential areas of common interest to Phase Three: public- and private-sector partners. Implementation (Step 11) ■ contacts potential partners (public and private) to The Task Force . . . gauge their interest. ■ plans the campaign launch event, using partners ■ selects participants according to agreed upon combined resources and networks. criteria. ■ joins forces to implement the common strategy, ■ forms and participates in Task Force. with each partner playing its unique role. ■ facilitates goal setting and development of a ■ enlists new partners to expand and strengthen work plan. the effort. ■ facilitates definition of partner roles and ■ looks for opportunities to continue project responsibilities. activities beyond the formal campaign. ■ formalizes the partnership. Phase Four: Phase Two: Assessment and Dissemination (Steps 12–14) Planning and Development (Steps 7–10) The catalyst . . . The Task Force ■ monitors implementation. ■ develops a marketing plan. ■ evaluates results. ■ plans and coordinates market research. ■ draws lessons learned for further planning. ■ guides the advertising agency in elaborating ■ shares information with all actual and potential creative strategies. The Central American Handwashing Initiative ■ develops and tests communication materials. We genuinely believed in the campaign and its cause. This allowed us to keep in mind at every moment that we were perhaps saving a life. Jorge Mario Lopez, La Popular, Guatemala Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 7 The Central American Handwashing Initiative D iarrheal disease is a serious threat to child survival in Central America. In fact, it is the most frequent significant illness among children under the age of five worldwide. Diarrhea is also a major contributor to childhood malnutrition, which in turn increases the severity of other childhood diseases. In 1995, a year before the beginning of the Central American Handwashing Initiative, diarrheal disease caused 19 percent of under- five mortality in Honduras, 23 percent in Nicaragua, 20 percent in El Salvador, and 45 percent in Guatemala. Partners in the Central American To address this important public health Handwashing Initiative problem, BASICS and the Environmental Health Project (EHP) another USAID Ministry of project played the role of catalyst in the Health Handwashing Initiative. The Initiative La Popular Ministry of Colgate-Palmolive Education whose mission was to reduce diarrheal Unisola (Unilever) disease among children under five by Punto Rojo promoting effective handwashing with UNICEF soap was a partnership among the BASICS II Canal 3 catalyst team, four soap companies, the Televisiete EHP ministries of health from participating Radio Association Prensa Libre countries Guatemala, El Salvador, and TeleTica Costa Rica and numerous NGOs and FUNDAZUCAR development organizations. Representatives World Vision ANACAFE from the various partner organizations CARE formed a Task Force that met periodically to guide the effort. Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 8 Targeted Strategy The basic approach of the Initiative was to get soap companies Effectiveness of Interventions to Reduce Diarrheal Disease to agree to promote correct handwashing in advertisements Morbidity targeted to low-income families whose children are at high risk Intervention of diarrheal disease. Through participation in the Task Force, Latrines 36% partners developed a slogan for the campaign and a generic advertising concept that soap producers could adapt in their Water quantity 20% branded campaigns. The advertisements and other Water quality 15% promotional materials focused on motivating consumers particularly mothers to wash their hands at appropriate times, Handwashing 35% using the correct technique. 0 10 20 30 40 50 Campaign Activities Median reduction (%) Source: S. A. Esrey et al. 1991. "Effects of Improved Water Supply The campaign was launched in March 1998 in Guatemala, and Sanitation on Ascariasis, Diarrhoea, Dracunculiasis, Hookworm Infection, Schistosomiasis, and Tracoma," Bulletin of the World Health Organization 69(5):609-621 and S. R. A. Hutley et al. 1997. Costa Rica, and El Salvador, and included: "Prevention of Diarrhoea in Young Children in Developing Countries," Bulletin of the World Health Organization 75:163-174. ■ Extensive use of television, radio, and newspaper advertisements. Television stations in Guatemala, Costa Handwashing is among the four top Rica, and El Salvador donated free air time for campaign measures to prevent diarrheal disease in commercials that were broadcast nationwide, and two children under five. Guatemalan radio stations aired over 6,300 radio spots in Guatemala City and the Altiplano. A Guatemalan newspaper donated space for vignettes about handwashing for over eight months. ■ Distribution of posters, banners, brochures, and video- and audiotapes. In Costa Rica, Punto Rojo worked with the U.S.-based private voluntary organization World Vision and the Office of the First Lady of Costa Times and Technique for Correct Handwashing Behavior Three components of correct technique: Three critical times: ■ Wash both hands with water and soap. ■ Before cooking or preparing food. ■ Rub hands together at least three times. ■ Before eating or before feeding children. ■ Dry hands hygienically. ■ After defecating and after changing or cleaning babies. Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 9 The slogan adopted by the At a local level, the campaign Handwashing Initiative was “I had a great impact. People were wash my hands for health.� even saying, I wash my hands for my health. Almeda Aguilar, Ministry of Health, Guatemala Rica to print and distribute 6,600 campaign ■ Participation in markets and fairs. In El Salvador, posters. In El Salvador, Unisola/Unilever Unisola/Unilever distributed banners that were distributed videotapes of the television displayed at 150 health fairs. In Guatemala, La advertisement to 3,500 schools and audiotapes of Popular printed 5,000 posters and distributed the radio spots to 31 health posts. posters and banners to local markets. ■ Community activities. Two U.S.-based private voluntary organizations, CARE and World Vision, The generic advertising and a Guatemalan foundation, Fundazucar, concept: “one, two, and strengthened their hygiene programs in three.� The three critical communities through use of generic campaign times and the three materials. aspects of handwashing ■ Participation in school hygiene programs. In El technique are illustrated, Salvador, Unisola/Unilever bolstered that country s the image of the mother is upbeat and cheerful, and Healthy Schools Program through donation of both the image and the 25,000 soap samples and other materials. In setting are appropriate for Guatemala, Colgate-Palmolive developed the target audience. handwashing kits and other school program Television and radio materials (coloring books, flyers, games) in advertisements used the addition to donating soap samples to schools. same concepts. Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 10 Improvements in Handwashing Practices Percent 30 25 1996 25 1999 PPP Achieves 20 19 Sustainable Results 15 10 7 5 3 A major benefit of the Central American Handwashing Initiative was the awareness it 0 Good Optimal built among the private sector that public health Changes in mothers’ handwashing practices after the objectives are compatible with business 12-month campaign in Guatemala (n=1500). The opportunities. The new approaches and number of mothers with “good� handwashing practices techniques introduced during the project continue increased by over 30 percent from 1996 to 1999. The to influence the activities of soap companies and number of mothers using “optimal� handwashing other partners, pointing to the sustainability of the practices more than doubled in that period. PPP approach. Key Result #1 Improvements in handwashing behavior and decreases in diarrheal disease. Ten percent of mothers in the study sample in Guatemala improved their handwashing practices, and the percentage of mothers using optimal practices (correct technique at all three critical times) more than doubled. In addition, the number of mothers using good handwashing practices (correct technique at one or more of the critical times) increased by more than 30 percent. In Guatemala, which has an estimated 1.8 million children under the age of five, improvements in handwashing behavior during the first year of the campaign were associated with an estimated 4.5 percent overall reduction in diarrhea risk for children under five years of age in the two lowest socioeconomic groups, resulting in an estimated: ■ 14,500 fewer children with diarrhea during any two-week period during the rainy (high diarrhea) season ■ 7,000 fewer children with diarrhea during any two-week period during the dry (low diarrhea) season ■ 322,000 fewer cases of diarrhea a year ■ 1,287,000 fewer days of diarrhea a year Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 11 ■ Colgate-Palmolive is adopting the messages of the Handwashing Initiative to advertise its antibacterial soap ( Protex ) to the general public in Central America. ■ Colgate-Palmolive developed a new region-wide school program targeting elementary school children in Guatemala, El Salvador, Panama, and Costa Rica. This program reached 450,000 school children in 2001. ■ Using the one, two, and three message of the Initiative, health workers in Guatemala strengthened their skills in communicating handwashing messages, a sustainable change in health workers behavior. Similarly, UNICEF/Guatemala incorporated elements of the Initiative in its ongoing community-level hygiene programs. Key Result #2 Significant resources leveraged. A total catalyst investment of $389,000 leveraged private-sector contributions of nearly $615,000 in promotional expenditures alone in the first year of the campaign. These contributions helped stretch public sector and donor resources farther. Key Result #3 Sustained involvement of the private sector in social programs. Catalyst involvement in the formal campaign ended in 1999, but promotional activities inspired by the Handwashing Initiative were still ongoing in 2001: ■ Unilever, the Ministry of Health in El Salvador, and BASICS mounted a diarrhea prevention campaign in the aftermath of the massive earthquake in January Colgate-Palmolive’s school program includes a classroom poster 2001. The market research, creative concepts, and with teaching aids (shown here), a board game, and a take-home dissemination techniques of the Initiative were adapted calendar for monitoring daily handwashing. A handwashing story to this special situation in record time. is told by Manolo, the program’s octopus mascot. Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 12 PPP: A proven approach That Benefits Public and Private Partners A PPP begins when an organization decides to take on the catalyst role and bring public and private organizations together to tackle a specific social problem. The catalyst s investment makes it possible for public and private organizations to join forces and apply their strengths to achieve specific health goals. This investment may be relatively modest, but it unleashes considerable energy and commitment. PPP is a practical option that uses existing resources to address health and social problems. And, as shown in the table below, all partners contribute and all benefit. Catalyst Investment and Leveraged Year 2000 onwards Resources $614,900 In the Central American Handwashing Initiative, the catalyst team invested $389,000 over four years. This investment covered technical assistance (approximately 330 person days over four $389,000 years), travel expenses, Task Force meetings, contracts for a baseline and a follow-up market survey, and a contract with an Leveraged advertising agency. This modest catalyst investment leveraged resources $614,900 in just one year from the various partners. But this is 1998–1999 Catalyst only part of the story: the catalyst contribution continues to expenditures leverage resources as promotional activities inspired by the 1996–1999 Handwashing Initiative continue. Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 13 What Partners Contribute to a PPP and How They Benefit Partner Contributions Benefits Private sector ■ Assigns personnel for planning ■ Increases sales; improves market share. and championing the effort. ■ Leverages resources to achieve ■ Implements strategy using own resources. organizational goals. ■ Continues to use new techniques ■ Receives kudos/media recognition and approaches. for public service. ■ Creates new alliances with public sector and other organizations. ■ Learns new methods of market research and marketing for behavior change. ■ Shares risks of market development. Public sector ■ Assigns personnel for planning and ■ Improves public health in less time coordination with the private sector. and with less investment. ■ Provides health expertise to the ■ Improves and strengthens its programs. private sector. ■ Leverages resources to achieve ■ Assists in implementing the strategy. organizational goals. ■ Motivates involvement at the local level. ■ Learns new techniques for social marketing. ■ Reinforces healthy behavior at the household and community level. ■ Enlists new, nontraditional partners in public health. Catalyst ■ Facilitates partnership. ■ Leverages resources to achieve ■ Provides technical assistance. organizational goals. ■ Guides development of the strategy. ■ Brings about sustainable, public-health ■ Monitors implementation. oriented changes in private sector ■ Disseminates information about results. approaches. ■ Demonstrates the benefits of PPP. ■ Provides a proven approach other organizations can use. Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 14 We are working with businesses to enhance opportunities for the poor, to devise more effective solutions for the delivery of services, and to ensure more equitable access to development gains. Mobilizing resources and expertise from both (private and public) sectors to focus attention and promote action on the need for sanitation and handwashing in poor communities only makes sense. Nigel Twose, Manager, World Bank Business Partnership & Outreach Group The unique benefit of partnerships between corporations and non-profit organizations is the ability to focus on a fundamental human need that has societal benefits of importance to both organizations and society as a whole. Diana Grina, Director, Personal Care Products, Colgate-Palmolive Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals 15 I n a PPP, participants redirect their resources and expertise, using existing networks and processes. A variety of partners contribute according to their strengths to increase the overall level of effort and effectiveness. Critical Success Factors The following factors proved to be essential to the Central American Handwashing Initiative’s success and will generally be key to any PPP endeavor: ■ Presence of a catalyst. A catalyst can bring partners ■ Conducive environment for behavior change. In the together, contribute resources, and offer expertise in a case of the Handwashing Initiative, this meant wide wide range of technical areas. availability of soap and easy access to water. ■ Public sector backing. Enthusiastic support from the ■ Behavioral research. Market surveys provide public sector lends reassurance to private sector firms information vital to designing effective advertising that participation in a PPP campaign is worthwhile. strategies and establishing a baseline for measuring ■ Existence of a vibrant private sector. The private progress. sector must have the capacity to effectively market to ■ Road map. Having a well-defined approach to a PPP the targeted population. gives all partners a clear idea of the sequence of ■ Commitment of private sector decision-makers. events and helps keep activities on track. Invested private sector decision-makers can also ■ Ownership. Fostering ownership in participants encourage integration of PPP elements in their ensures long-term sustainability. company s corporate strategy, ensuring sustainability ■ Understanding roles, responsibilities, expectations. into the future. Clearly defined and agreed upon goals, expected outcomes, and roles and responsibilities of partners provide structure and guidance to a PPP campaign. Opportunities abound for forging PPP s. In fact, PPP s are already being implemented all over the world in areas as diverse as health, nutrition, education, and the environment. Increasingly, decision-makers in the public and private sectors are embracing the PPP approach and adapting it to their strategic objectives. Public-private partnerships: Mobilizing Resources to Achieve Public Health Goals Getting Started Other publications are available to help you learn more about how PPP could help your organization or business contribute to the achievement of key public health goals: The Story of a Successful Public-Private Partnership in Central America: Handwashing for Diarrheal Disease Prevention by Camille Saad , Massee Bateman, and Diane B. Bendahmane. Available from the organizational contacts below or downloadable from www.EHProject.org Mobilizing the Commercial Sector for Public Health Objectives: A Practical Guide by Sharon Slater and Camille Saad , downloadable from http://www.basics.org/publications/abs/abs_mobilizing.html Organizational Contacts BASICS II Project UNICEF www.basics.org www.unicef.org/programme/wes/ Camille Saad Lizette Burgers csaade@aed.org lburgers@unicef.org The Environmental Health Project The World Bank www.ehproject.org www.worldbank.org/watsan Massee Bateman Jennifer Sara batemanom@ehproject.org jsara@worldbank.org Credits Photos: Cover photo, Servicios Estrategicos; page 11, Colgate-Palmolive Guatemala; page 6, UNICEF/90-0008/Ellen Tolmie; page 14, Colgate-Palmolive Senegal Authors: Frances Tain and Diane Bendahmane Editing: Kathleen Shears Layout and design: Kathy Strauss December 2001