Enabling Environment Assessment and Baseline for Scaling Up Handwashing Programs: Peru

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1 Report Enabling Environment Assessment and Baseline for Scaling Up Handwashing Programs: Peru Michael Favin and Doris Alfaro

2 April 2008 This report is one in a series of products of the Water and Sanitation Program s Scaling Up Handwashing Project funded by the Bill and Melinda Gates Foundation. The aim of the project is to test whether innovative promotional approaches can generate widespread and sustained increases in handwashing with soap at critical times among the poor and vulnerable. This series of reports documents the findings of work in progress about handwashing with soap in order to encourage the exchange of ideas and information and to promote learning. Please send your feedback to: The Water and Sanitation Program (WSP) is a multi-donor partnership of the World Bank. For more than 30 years, WSP has helped the poor gain sustained access to improved water supply and sanitation services (WSS). WSP works with governments at the local and national level in 25 countries. For more information, please visit: Credits Editorial Support: Hope Steele Production: Paula Carazo This report was reviewed by Rocio Florez, Lene Jensen, and Eduardo Perez. ABOUT THE AUTHORS Michael Favin Michael Favin has over 30 years of experience in international public health in more than 25 countries in Africa, Asia, and Latin America, and has worked periodically in environmental health since his time as a community organizer and health educator for the Peace Corps in Brazil in the early 1970s. Since joining the Manoff Group in 1987, he has served as a senior technical adviser or a consultant to numerous health and nutrition projects. For these projects and others, Mr. Favin facilitated behavior change and communication strategy design, planning, implementation, and evaluation. He has worked in many critical public health areas, including child health and nutrition, school health and nutrition, maternal and neonatal health, and environmental health and has supported innovative tool development in areas such as routine immunization, growth promotion, care-seeking, and community surveillance. Mr. Favin has written or contributed to more than 60 books, manuals and articles. Doris Alfaro Doris Alfaro is a communications specialist with 15 years of experience participating in and managing projects in the fields of hygiene promotion, behavioral change, social mobilization, and advocacy for local development as well as partnership building at the community level. She has coordinated, designed, and implemented communication plans for health and nutrition programs nationwide. She has been a communications consultant for the health sector in Peru, Latin America, and the Caribbean for projects in environmental and public health. She has worked with CEPIS-PAHO/WHO, PAHO, municipalities, and Ministries of Health as well as for NGOs such as CARE and PRISMA. The findings, interpretations, and conclusions expressed in this report are entirely those of the author. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations or those of the Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility whatsoever for any consequence of their use. The boundaries, colors, denominations and other information shown on any map in the document do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. ii

3 TABLE OF CONTENTS LIST OF ACRONYMS AND ABBREVIATIONS V SUMMARY BACKGROUND...3 The..3 The Peru Handwashing Promotion Project...4 Rationale for Enabling Environment Assessment 5 2. ASSESSMENT METHODOLOGY...6 Dimension Descriptions...6 The Assessment Process...7 Feedback on the Assessment Methodology MAJOR FINDINGS BY DIMENSION...13 Policy, Strategy, and Direction...13 Partnerships.14 Institutional Arrangements..18 Program Methodology 19 Implementation Capacity 20 Availability of Products and Tools.21 Financing.21 Cost-Effective Implementation...23 Monitoring and Evaluation RECOMMENDATIONS BY DIMENSION...24 Policy, Strategy, and Direction...24 Partnerships.25 Institutional Arrangements..27 Program Methodology 29 Implementation Capacity 29 Availability of Products and Tools.30 Financing.31 Cost-Effective Implementation...31 Monitoring and Evaluation NEXT STEPS...33 APPENDIX A: SELECTED DOCUMENTS...34 APPENDIX B: LISTA DE ENTREVISTADOS...36 APPENDIX C: RESUMEN DE PUNTOS IMPORTANTES DE LAS ENTREVISTAS...42 APPENDIX D: ENCUESTA SOBRE LAS CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN: 10 RESPUESTAS...61 APPENDIX E: LAS CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN. GUÍA DE ENTREVISTA...69 APPENDIX F: ESTUDIO DE CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN (GUÍA DE ENTREVISTA PARA SOCIOS POTENCIALES)...75 iii

4 APPENDIX G: INFORME DE VIAJE A PIURA...83 APPENDIX H: CONDICIONES PARA LA PROMOCIÓN DE LAVADO DE MANOS...88 APPENDIX I: SUMMARY OF MAJOR FINDINGS AND RECOMMENDATIONS BY DIMENSION...93 APPENDIX J: MENÚ DE ACTIVIDADES PARA ALUMNOS (IDEAS PRELIMINARES)...97 APPENDIX K: MENÚ DE ACTIVIDADES PARA PROMOTORES DE SALUD (IDEAS PRELIMINARES).99 APPENDIX L: ACTION PLAN TO IMPROVE THE ENVIRONMENT FOR AN EXPANDED HANDWASHING PROJECT IN PERU LIST OF FIGURES Figure 1. Partner Contributions to Interpersonal Communications...16 Figure 2. Partner Contributions to Mass Media.17 LIST OF TABLES Table 1. Handwashing Targets by Country.4 Table 2. The Public-Private Partnership for Handwashing in Peru.4 Table 3. Dimension Addressed by Stakeholder Type.8 Table 4. Persons Interviewed by Organization Type.10 Table 5. Self-Reporting Questionnaire Responses by Organization Type 10 Table 6. Calendar of Assessment Team Activities, May June, Table 7. Committee Participants 27 iv

5 List of Acronyms and Abbreviations CBO Community-based organization COSUDE Swiss aid organization DIRESA Regional health directorate DREA Regional education directorate FBO Faith-based organization HWWS Handwashing with soap M&E Monitoring and evaluation MIMDES Ministry of Women and Social Development MOE Ministry of Education MOH Ministry of Health MOU Memorandum of understanding NGO Nongovernmental organization PAC/SEDAPAL Program in Lima to install/improve small water systems PPPHW Public-Private Partnership for Handwashing PRONASAR National program to install/improve small water systems (Ministry of Housing) UGEL Local educational management unit USAID U.S. Agency for International Development WSP Water and Sanitation Program v

6 SUMMARY To follow up country work supported by the Public-Private Partnership for Handwashing, the World Bank Water and Sanitation Program (WSP) received funding from the Bill & Melinda Gates Foundation to support projects to scale up the promotion of handwashing with soap (HWWS) in Peru, Senegal, Tanzania, and Vietnam. The major project objectives of the Handwashing Initiative are: inculcate the HWWS habit among millions of mothers and children in these countries, use a strong monitoring and evaluation (M&E) component to enhance the conceptualizing and management of such programs, establish sustainable programs that will continue and expand after this four-year grant ends. Enabling environment assessments were carried out in all four countries to assess current conditions for scalability and sustainability and to make recommendations for improving conditions that are not supportive. This report summarizes the study in Peru, which was carried out by an international and a national consultant during three and a half weeks in May All four county studies are following a similar methodology, developed by WSP, to examine nine dimensions of scalability/sustainability through individual and group in-depth interviews, an electronic survey in which respondents are asked to score various statements, and a review of documents (Appendix A). A partnership of many public and private organizations has supported handwashing promotion in Peru since 2002, achieving impressive results in advocacy, partnership development, tool development, and many other areas. The Initiative supported partnership formation, mass media, and capacity building for on-the-ground promotion in 14 of Peru s 24 regions. Evaluation of actual impact on knowledge, attitudes, and practice regarding HWWS shows some positive and some inconclusive findings. However, the study team feels that much excellent groundwork for the expanded program in Peru has been solidly laid by efforts to date and that, in combination with strong 1

7 political will from the national government and a certain level of guaranteed funding, the outlook for effective expansion is very good. Nonetheless, the team has a number of suggestions, many of which expand ideas suggested by persons interviewed. Some of the key recommendations are the following: Plan and implement a dynamic advocacy strategy that begins immediately and that continues throughout implementation. Plan and implement a strong project communication strategy directed primarily to partners but also to decision makers at various levels and to the public. Materials, formats, and activities should be directly related to reaching one of the strategy s objectives (for example, partner motivation, sharing good ideas) and audiences, which should be clearly defined. Develop and implement an exit strategy that includes steps for dissemination and sustainability of program activities and achievements. Continue to negotiate and sign more formal agreements on partners roles and responsibilities and develop systematic mechanisms to monitor the implementation of the agreements. Have the key national-level partners, including the implementing organizations (which will be contracted to manage local implementation), dedicate themselves to establishing the conditions and providing the tools and support for successful local implementation. In this decentralized vision, the team expects that key factors for program success will be strong and dedicated partnerships at local levels, with effective tools, methodologies, and support from the national level. Greater attention should be given to carrying out thorough regional, provincial, and district assessments of organizations, potential champions, resources, programs, and conditions and to establishing and encouraging strong local partnerships. The assessment methodology, findings, and recommendations are documented in this report and its many appendixes (a number of which are in Spanish). 2

8 1. BACKGROUND Funded by the Bill & Melinda Gates Foundation, the WSP Global Scaling Up Handwashing Project will follow the basic approach of the Public-Private Partnership for Handwashing (PPPHW), a global initiative established in 2001 to promote handwashing with soap at scale to reduce diarrheal and respiratory infections. 1 This approach draws extensively on lessons learned from two large-scale handwashing promotion programs. Programma Saniya, implemented in Bobo-Dioulasso, Burkina Faso, showed the importance of undertaking careful consumer research at the outset of a handwashing promotion program. The Central American Handwashing for Diarrheal Disease Prevention Program showed that an effective approach to changing hygiene behaviors at large scale was to work with a broad partnership of public and private sector stakeholders that have a mutual interest in increasing handwashing with soap, to focus on the one behavior with largest potential health impact (handwashing with soap), and to promote it with cost-effective, consumer-centered marketing. The Scaling Up Handwashing Project In hopes of facilitating effective replication and scaling-up of future handwashing-with-soap behavior change programs, the new project will carry out a structured learning and dissemination process to develop and share evidence, practical knowledge, and tools. Specific project objectives are to: 1. design and support the implementation of innovative, large-scale, sustainable handwashing programs in four diverse countries (Peru, Senegal, Tanzania, and Vietnam); 2. document and learn about the impact and sustainability of innovative, large-scale handwashing programs; 3. learn about the most effective and sustainable approaches to triggering, scaling-up, and sustaining handwashing behaviors; 4. promote and enable the adoption of effective handwashing programs in other countries and position handwashing as a global public health priority through the translation of results and lessons learned into effective advocacy and applied knowledge and communication products. The project is designed to achieve key targets in each country at the end of two years of implementation. The specific handwashing targets for each country are in Table 1. The target audience is defined as poor women of childbearing age (15 49) and poor children ages Global PPPHW partners include the Water and Sanitation Program, USAID, World Bank, UNICEF, London School of Hygiene and Tropical Medicine, Centers for Disease Control, Academy for Educational Development, Water Supply and Sanitation Collaborative Council, Colgate-Palmolive, Procter & Gamble, and Unilever. 3

9 Country (population) Table 1. Handwashing Targets by Country Target population (millions) Peru (28 million) Senegal (11 million) Tanzania (37 million) Vietnam (84 million) Estimate target population adopting HWWS at critical times Source: World Bank (Water and Sanitation Program) Terms of Reference. Enabling Environment Assessment and Baseline to Scale up, Sustain and Replicate Handwashing with Soap Behavior Change Programs. March 9. The Peru Handwashing Promotion Project As in many countries, diarrhea and respiratory diseases are the leading causes of childhood illness and death in Peru, and malnutrition is a major underlying cause of child mortality. Handwashing with soap can significantly reduce all of these major causes of misery. Attention to hygiene and handwashing got a significant boost in Peru in the 1990s because of the cholera epidemic, but as shown by the Handwashing Initiative s 2004 baseline, practice levels were still woefully low: 11 percent of mothers and 6 percent of children washed hands with soap before eating, and 17.6 percent of mothers and 12 percent of children after going to the bathroom.2 The public-private partnership for handwashing developed in Peru over several years, as summarized in Table 2. Table 2. The Public-Private Partnership for Handwashing in Peru Year Activity 2003 Advocacy, handwashing practices study, development of a business plan 2004 Efforts to secure funding, funding commitments from the Japanese Fund, USAID, WSP (the Water and Sanitation Program), and COSUDE (Swiss aid) 2005 Selection of communication agencies, design of project strategy and work plan, first campaign and training workshops, monitoring activities, commitment of private sector funds 2006 Training workshops and promotional activities, monitoring, financial management, international advocacy, launching of second campaign, effort to establish local alliances, process evaluation, design of impact evaluation 2007 Financing from the Bill & Melinda Gates Foundation secured, local alliances strengthened, school program, mass media campaign, monitoring and evaluation Source: Flórez P., Rocío. Iniciativa de Lavado de Manos en el Perú. 17 de Octubre, 2006 (PPT). 2 AB PRISMA. Estudio de comportamiento de lavador de manos con jabón en zonas periféricas del Perú. Preparado como línea de base para la Iniciativa de Lavado de Manos en el Perú, liderado por PAS-Banco Mundial. Junio

10 The Peruvian program implemented activities at the national level and developed partnerships and activities in 14 of Peru s 24 regions. Preliminary monitoring and evaluation showed mixed but promising improvements in knowledge, attitudes, and practices, particularly in handwashing before eating and preparing food. Fostering partnerships at the national, regional, and local levels has been a key project strategy. Although this has been difficult and demanding at times, it has also been a major reason for progress. Both interpersonal communication (in schools and communities) and mass media (mostly print and radio) made important contributions to changing knowledge, attitudes, and practices. M&E studies (these and other references are listed in Appendix A) indicate that all of the communication channels used (mass media broadcasts, print materials, training teachers and students, and training health staff and volunteers) contributed to reaching the target families, and that no one channel predominated. Rationale for Enabling Environment Assessment In each participating country, an Enabling Environment Assessment is being carried out to (1) assess the extent to which the programmatic conditions for scale up and sustainability are in place at the beginning of the project; and (2) on the basis of the assessment findings, recommend what should be done to address the gaps during project implementation. Toward the end of the project period in about 3.5 years a final assessment will be carried out to determine whether there is an enabling environment in place in each country that can continue after 2010 without the Gates Foundation/World Bank project assistance. The overall handwashing project is four years in duration with three distinct phases: Phase I is the 1.5-year start-up period for detailed planning at the global and country level. Several assessments, including a handwashing measures study and the baseline for the impact evaluation, will be carried out during this period. The baseline assessment of enabling elements will be carried out during Phase I. Phase II is the 2-year implementation period. Phase III is the 6-month wrap-up phase that will include the final evaluation and dissemination of lessons learned. The final enabling environment assessment will take place during Phase III. 5

11 2. ASSESSMENT METHODOLOGY In other to ensure consistency in the assessment findings, WSP constructed a conceptual framework for assessing scalability and sustainability. This framework was developed based on a review of relevant literature and discussions with key individuals. Dimension Descriptions The framework comprises nine dimensions that are considered essential to scaling up a handwashing-with-soap behavior change program. Policy, Strategy, and Direction: Establishing a shared vision and strategy and ensuring the political will to implement them is the starting point for scale up. Without political will and a shared vision and strategy among stakeholders at all levels, scale up will remain an elusive goal. Developing this shared vision and strategy in a collaborative manner is also the foundation for coordination and for creating motivation all levels. Partnerships: This handwashing-with-soap program model is based on a establishing a publicprivate partnership. A partnership is a relationship where two or more parties, having compatible goals, form an agreement to share the work, share the risk, share the power, and share the results or proceeds. Partnerships need to be built at all levels among public, private, and NGO sectors and between communities and local governments. Institutional Arrangements: Institutions at all levels must clearly understand their roles, responsibilities, and authority. They must also have the resources to carry out their roles. In addition to clear roles and responsibilities, institutional arrangements must include the mechanisms for actors at all levels to coordinate their activities. Program Methodology: Handwashing-with-soap programs have a seven-step program methodology. This methodology, adapted to each country context, should be clear and agreed upon by all key stakeholders. Implementation Capacity: In addition to clearly defined institutional roles and responsibilities, institutions at all levels must have the capacity to carry out their roles and responsibilities. Institutional capacity includes adequate human resources with the full range of skills required to carry out their functions; an organizational home within the institution that has the assigned responsibility; mastery of the agreed-upon program methodology, systems, and procedures required for implementation; and the ability to monitor program effectiveness and make adjustments. Availability of Products and Tools: A handwashing-with-soap behavior-change program is predicated on the existence of the soap that responds to consumer preferences and their willingness and ability to pay for them. In addition, handwashing station supplies that is, plastic basins, towels, and so on need to be easily available. Financing: This dimension is aimed at assessing the adequacy of arrangements for financing the programmatic costs. These costs include training, staff salaries, transportation, office equipment and supplies, and the development of communication and educational materials as well as programmatic line items in budgets for handwashing-promotion activities. Cost-Effective Implementation: The potentially high costs of promoting handwashing-withsoap behavior at scale make cost-effective implementation a key element. It is essential to understand how the unit costs change as activities are scaled up. Although it will not be possible to assess the cost-effectiveness of the approach and how best to achieve economies of scale until 6

12 the end of the project, data must still be collected during implementation to make this determination at the end of the project. Therefore, this assessment will try to ensure that information will be collected from the outset and that the capacity to collect the information is in place. Monitoring and Evaluation: A large-scale handwashing-with-soap behavior-change program requires regular monitoring and, perhaps more importantly, the willingness and ability to use the monitoring process to make adjustments in the program. Effective monitoring will identify strengths and weaknesses in the program methodology, implementation arrangements, and cost efficiencies. Overall monitoring responsibility must be at the highest level of the program, but must be based on information collected at the local government or district level. The Assessment Process The primary data sources comprised the main stakeholders/present partners for the in-country program work, including government agencies, international agencies, international NGOs, local NGOs, private sector organizations, and community-based organizations (CBOs) at national, regional, district, and local levels. In Peru, all members of the National Committee were sought for interviews, as well as other partners at the national level and local partners in two of the country s 24 regions. Piura was visited as an old region that had participated in the Handwashing Initiative, and Arequipa as a new region that will be included in the expanded program. In the expanded program, the number of participating regions will increase to approximately 20, depending on the requirements of the M&E plan. Secondary data sources comprised documents and additional potential implementers, such as media and ministries with no direct involvement to date. Appendix A lists the main documents consulted. Table 3 indicates the type of stakeholders interviewed on various dimensions. 7

13 Table 3. Dimension Addressed by Stakeholder Type Stakeholder Type Dimension Government agencies International agencies International NGOs & FBOs Local NGOs & FBOs Private Sector CBOs Media Advocacy groups Policy, Strategy, Direction X X X L X X X Partnerships X X X X X L X X X Institutional Arrangements X X X X L X X X Program Methodology X X X X X L X Implementation Capacity N,D X X X L Availability of Products & Tools X X X L Financing X X L Cost-Effective Implementation N,D X Bilateral projects Monitoring N,D, L X X L Note: Unless otherwise noted, an X means that it is appropriate to discuss this dimension at all levels: national, regional, district, and local; indicates that this stakeholder type was not questioned on this dimension; N = national, R = regional, D = district, L = local. In addition to reviewing documents on the program, both interviews and self-reporting were used to solicit individuals knowledge and opinions. Self-reporting consisted of responding to a grading-scale questionnaire that was ed to approximately 35 potential respondents, some of whom were identified at the end of the interviews with the primary informants. Self-reports allowed the triangulation of information as well as some quantitative analysis that can be easily compared to findings of the repeat of the assessment planned to take place near the end of the implementation phase. Sampling was purposive for all primary data sources. The team strived to interview persons who had participated in the handwashing program for at least six months. They also sought a good representation of decision makers, implementers, and midline supervisors/managers from different levels of organizations involved in the program that is, national, regional, district, and local (as indicated needed on the interview matrix of Table 3). Targets for the minimum sample size were: one interview and/or self-report (electronic questionnaire) with each current partnering stakeholder at any level three interviews in each dimension two self-reports in each dimension 8

14 two interview sets with two different present partnering agencies, within each of these two organizations, one of each work type one self-report set with two different present partnering agencies, within each of these two organizations, one of each work type two interview sets with two different present partnering agencies with one representative for each level at three levels minimum that is, national, district, local one self-report set with two different present partnering agencies with one representative for each level at three levels minimum that is, national, district, local three interviews with three potential partnering organizations (if appropriate). The team conducted 35 interviews in different organizations (Appendix B). The persons interviewed were from the organizations listed in Table 4. 9

15 Table 4. Persons Interviewed by Organization Type Types of organizations Persons interviewed Government agency 9 Bilateral project 3 Media company 3 Local NGO 4 Private sector 3 International agency 8 International NGO 5 TOTAL 35 Self-reporting questionnaires were sent to representatives of different institutions linked to the Handwashing Initiative, including some from the same institutions where the team interviewed. Table 5 shows the types of organizations that provided the 10 completed questionnaires. Table 5. Self-Reporting Questionnaire Responses by Organization Type Types of organizations Government agency 2 Bilateral project 3 Media company 0 Local NGO 1 Private sector 2 International agency 1 International NGO 0 Consultant 1 TOTAL 10 Persons responding The team carried out a qualitative analysis of the interviews, first by summarizing all respondents positive and negative comments by type of organization and dimension and also listing the respondents corresponding recommendations. Appendix C documents this step in the process. The team used many, but not all, of the respondents recommendations to develop its own recommendations. The major recommendations were then placed in an Action Plan, as required by the team s terms of reference. The team also did a quantitative analysis of the 10 self-reports received (see Appendix D) but did not attempt a further breakdown by stakeholder type because of the relatively small number of responses. 10

16 The assessment team was comprised of one international consultant and one local consultant who worked together during the final 3.5 weeks of May Table 6 summarizes their activities in Peru. Table 6. Calendar of Assessment Team Activities, May June, 2007 Date May 8 11 Peru In-Country Activities Met with country team manager (CTM) to plan the activity Reviewed the stakeholder list and developed the interview list Scheduled interviews Organized logistics Modified and translated instruments Sent out self-report questionnaires by Began interviews May 14 June 1 Conducted interviews (in Lima, Piura, Arequipa) Summarized responses Received and tabulated self-reported questionnaires Drafted findings, recommendations, action plan June 4 30 Prepared and gave debriefing to global WSP team and Peru program coordinator Read additional documents Debriefed for global WSP and drafted this assessment report Feedback on the Assessment Methodology The team had to make some adjustments to the general assessment methodology proposed for all four countries, starting with translating all instruments into Spanish. In addition, they found that the standard interview questionnaire contained many single questions that contained multiple issues, so they separated these out. The first few interviews showed that there were too many questions to ask knowledgeable respondents and that there was some redundancy in questions under the different dimensions. The team therefore prepared a shortened version of the interview guide to try to address these concerns. Also, the team was unsure about the degree to which it should seek information from regions that had already participated in the program compared with areas where the program would expand. In the end they visited one region of each type, but they had to prepare another version of the question guide for the new region. (Appendixes D and E contains these question guides in Spanish. Appendixes F and G contain summaries of the visits to Piura and Arequipa.) The persons interviewed varied tremendously by level and nature of their involvement in the program. Although the methodology anticipated some of this challenge, the interviewers still had to make on-the-spot decisions on which questions were relevant to the particular respondent and 11

17 whether the respondent should focus on the past or the future of handwashing promotion activities. Many of the respondents of the self-reported questionnaires participated in the Initiative as locallevel implementers or supervisors, so they were really not in a good position to comment on some of the broader program questions. Nonetheless, there was a fairly strong congruence in scores for the different questions, which gives some confidence regarding general opinions. Since it is planned that this assessment will be repeated near the end of the expansion phase, the team would recommend that different versions of the question guides be prepared for representatives of key national partners, key regional partners, local implementers, and national organizations that implemented promotional activities within their own organizations. 12

18 3. MAJOR FINDINGS BY DIMENSION Based on documents, interviews and questionnaires, the team prepared a summary of findings and recommendations in table format (see Appendix I). This section presents a narrative of key findings. Policy, Strategy, and Direction The National Committee served as a key venue for manifesting high-level national commitment to promotion of HWWS. Government and other organization officials have a strong, positive political will toward handwashing promotion and child health, although some government officials find it hard to give these areas special attention because of so many other priorities. The current national administration has embraced the Initiative and seems well disposed to collaborate. Key partners feel that they understand the approach used in the first phase and feel ownership, but they do not yet have a good understanding of the expanded project (which is still being designed). There are several politically prominent national initiatives (regarding malnutrition, healthy schools, and water and sanitation) that offer natural links with handwashing. Although the Ministry of Health (MOH) signed a ministerial decree in 2004 in support of the Handwashing Initiative, its enthusiasm has waxed and waned with frequent changes of officials; current officials appear to be quite supportive. At the beginning of the Initiative, national Ministry of Education (MOE) involvement was minimal, but now the MOE is actively engaged. There appears to be a strong and positive attitude toward the promotion of handwashing and an appreciation of its link to child health, in part due to the country s experience with handwashing as an effective way to control cholera. This common perception of handwashing promotion as a key action for improving child health is a major factor favoring program expansion. The current national government has made a public commitment to improving health and education, and in turn to supporting several specific programs to which HWWS can directly contribute. The handwashing program has been successful in promoting the concept that the Initiative is a true partnership of many organizations and not a program of, for example, the World Bank or the MOH alone. There has been a shared vision of the partnership that transcends any particular member, which was no doubt fostered by the National Committee (in particular), as well as the consultative committee and communication committee. At the same time, the interviews strongly indicated the need to strengthen dissemination of results and to maintain clarity regarding roles in the partnership and to nurture partners sense of active participation. Important steps have been taken toward institutionalization, but much work remains to be done. The Initiative first focused on identifying and engaging with partners to form a public-private alliance, conducting a study on handwashing practices, and designing a business plan. The MOH issued Ministerial Resolution No in support of the Handwashing Initiative, and in 2005 the ministry assumed a stronger leadership role with the initiation of the communication activities, providing some resources and a resolution in support of a national program of information dissemination. The MOH also established a sectoral committee comprised of key ministry offices, but its function was limited to receiving information, and it did not evolve into making proposals to strengthen the institutionalization of the Initiative. 13

19 In some of the regions, there has been progress in institutionalizing handwashing activities into public and private institutions work plans (for example, Lambayeque and Ica) and into training curricula (in Cusco, for teachers). Continuing to encourage such steps is a key to sustainability of the Initiative. Although before 2006, the MOE was not linked to the Initiative, MOE offices in various regions, provinces, and districts were active partners, taking advantage of the Initiative s communication tools and using the training modules with children in their classrooms. Today the MOE is actively engaged in planning for the expanded phase, and it will include handwashing in schools as part of its national Social Mobilization Program. For this purpose, it has assessed and pretested the Initiative s school materials. The current national MOE support should facilitate strong involvement of local MOE offices. There is good political will at the regional level also, but not as strong or cohesive as the political will at the central level. The regional and provincial levels are in a transition to decentralization, in which authorities are uncertain about their functions, roles, and resources. Local decision making and regional organizations working together on a common objective are new ways of working, and local governmental units are in the process of trying to establish their regional priorities from among a plethora of needs. The regional governments are working on their development plans and documents on regional health priorities. The Initiative and its partners should work to make improving child health and reducing diarrheal diseases prominent in these plans. At all levels, there are additional avenues for the expansion and sustainability of the project by linking it with current national political initiatives such as Reduction of Infant Malnutrition, Healthy Schools, and Water for Everyone, which do or could incorporate handwashing promotion. Despite this positive situation, converting political will into program actions remains a challenge because, as various persons interviewed noted, it is difficult to give special attention to one particular theme such as handwashing because there are so many other public sector priorities. Decrees published by government agencies at national, regional, and local levels are very important since they represent the main door leading to public funding of activities. They also define a period of time in which the strategy and activities will be implemented. So, as several respondents pointed out, although a decree does not guarantee further action (rules, regulations, and activities in work plans and in the field), without them there is no public spending. Following the MOH decree in 2004, the ministry financed a one-month handwashing campaign and direct consumer contact (local promotional events) in 24 regions in Partnerships In general this has been a successful and innovative aspect of the program, in particular with private sector partners. Public and private organizations have generally worked well together, but not without some minor friction. Private partners sometimes become impatient because the public sector tends to be more formal and bureaucratic and to have more changes in personnel. Some local public officials consider private organizations to be too interested in receiving individual credit. Keeping key government ministries (particularly health, education, and housing) involved is essential, even though this can be difficult at times because of political changes and overburdened officials who are too busy to participate in meetings. 14

20 Different partners have played very different roles, from being fully engaged as a member of the national coordinating committee to providing short-term messages on handwashing and co-financing and/or managing local activities. This is fine as long as expectations are clear. The Initiative engaged with diverse organizations and persons, including regional and municipal governments, communication media, and health and education offices and organizations. Many partner organizations were able to insert handwashing promotion into existing strong and efficient networks. In general, the organizational partners were of three types: (1) WSP, donor organizations, and governmental organizations that managed the program (through the national committee); (2) national-level implementation partners from various types of organizations (public and private), most of which collaborated on the basis of informal agreements and some on the basis of memoranda of understanding or contracts; and (3) regional and local implementing partners, also both public and private, and some with financial or material support from the Initiative. The different roles of partners at the national level that the team identified include: providing funding (for example, the Japan Social Development Fund) providing funding and participating in planning and management of the Initiative (for example, COSUDE, USAID) providing funding and participating in planning, management, and national implementation (for example, the MOH and the MOE, more recently) implementing communication activities directed to their personnel and customers (for example, Belcorp, CARE) carrying out M&E activities and playing a major role in preparing training and trainers (as, for example, PRISMA, which worked under contract) supporting a specific activity, such as dissemination or printing, based on its resources (for example, Banco de Crédito, Transportes Ormeño). At the regional level, the Initiative established strong relationships with various types of organizations, usually via the Regional Health Directorates (DIRESA), that made various contributions. Some examples are: providing funds and participating in the planning and management of the Initiative (for example, the Regional Government of Lambayeque) providing funds and participating in local planning, management, and implementation (for example, the DIRESA, Regional Education Directorate [DREA], or MOE s Local Educational Management Unit [UGEL]) implementing communication activities directed to their staff and beneficiaries (for example, local NGO offices) getting involved in a specific activity (for example, dissemination or printing) appropriate to its resources (for example, Radio PROMUDEH in San Martín). Figures 1 and 2 show organizations that have done person-to-person promotion and mass media promotion. 15

21 Figure 1. Partner Contributions to Interpersonal Communications PUERTA A PUERTA Socios Actividad / Impacto MINSA Promoción de la Salud PAC SEDAPAL Ampliación de cobertura AGAP Programa Mi Barrio CARE Belcorp Asociación de Agricultores Desarrollo público local Programa Promoción de la Salud Venta de cosméticos Peace Corps Prisma Voluntarios ONG Talleres Talleres itinerantes Talleres y réplicas Scouts Actividades de Scouts Source: Flórez P., Rocío. Iniciativa de Lavado de Manos en el Perú. 17 de Octubre, 2006 [PPT] 16

22 Figure 2. Partner Contributions to Mass Media MEDIOS MASIVOS Socios RPP Banco de Crédito Luz del Sur Expreso Extra Ormeño Interbank Terra Radios y TV Local SEDAPAL Actividad / Impacto Serie Radial, avisos Circuitos interno de TV220 agencias Aviso en recibo de electricidad Avisos en periódicos de circulación nacional Circuito de TV en buses Circuito interno de TV, 40 agencias Avisos en página Web 25 regiones Aviso en recibo de agua Source: Flórez P., Rocío. Iniciativa de Lavado de Manos en el Perú. 17 de Octubre, 2006 [PPT]. The process of participating in such a public-private partnership has allowed government and company staff to learn about other ways of working together for public health, in a participatory way, with support that they could offer with their own resources. The public institutions, the companies, and the NGOs interviewed indicated their interest in continuing their involvement. In the case of NGOs, officials are pleased to collaborate to the extent that their goals and funding address reducing diarrhea and respiratory disease among children. At the central level, the Initiative worked to achieve financing from the Ministry of Women and Social Development (MIMDES) for disseminating broadcast materials in the Clean Hands, Healthy Kids campaign, 15 times a day, mostly in the preferred early morning hours. This dissemination included four regions where the project was active: Ayacucho, Cusco, Lambayeque, and San Martín. In Ayacucho, the Regional Health Council stimulated the formation of a regional Handwashing Initiative by establishing an implementation committee in which the MOH and DIRESA joined the regional government to prepare guidelines for health programs and projects. The objective of the committee is to safeguard the logic and consistency in the implementation of all health programs in the region. The local partners achieved the collaboration of the army for the temporary storage of training materials. In Cusco, the provincial municipality of Canchis participated in inter-institutional agreements with the UGELs of the Ministry of Education of Cusco and Canchis to train local trainers and health promoters. 17

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