Public-Private Partnerships: A Handwashing and Hygiene Promotion Example

Slide 1:Public-Private Partnerships: A Handwashing and Hygiene Promotion Example

April 26, 2007 Sara Abdoulayi, David Hostler, Stacey Succop, and Sarah Wilkins ENVR 890 003

Slide 2:Presentation Outline

What is a public-private partnership? �Health in Your Hands� Handwashing Initiative Case studies from �Health in Your Hands� PPPs Problematic? Pros and cons of PPPs Recommendations and conclusions

Slide 3:What is a Public-Private Partnership?

��the combination of a public need with private capability and resources to create a market opportunity through which the public need is met and a profit is made.� According to the United Nations Development Program (UNDP), the broadest definition of a PPP includes agreement frameworks, traditional contracting, and joint ventures with shared ownership. At one extreme, government plays the role of a provider. At the other extreme, services are fully privatized and the role of government is limited to that of a regulator. At one extreme, government plays the role of a provider. At the other extreme, services are fully privatized and the role of government is limited to that of a regulator.

Slide 4:How does a public private partnership work?

Public and private organizations work together to: -determine a commonly-agreed upon goal for social benefit -produce consumer research -design and implement a promotional/educational campaign -evaluate the campaign

Slide 5:Global handwashing partnership

The World Bank and the Water and Sanitation Program $$ Bank-Netherlands $$ USAID $$ London School of Hygiene and Tropical Medicine Academy for Educational Development (AED) UNICEF CDC Colgate-Palmolive Proctor & Gamble Unilever National soap companies National governments NGOs Initiated in 2001 Composed of both public and private sectors The main funders are: Water and Sanitation Program, Bank-Netherlands, USAID Initiated in 2001 Composed of both public and private sectors The main funders are: Water and Sanitation Program, Bank-Netherlands, USAID

Slide 6:�Health in Your Hands�

Global initiative for promoting handwashing and hygiene through public-private partnerships around the world Functioning for more than 5 years Current projects in Ghana, Peru, Nepal Project in Senegal is planned, but delayed

Slide 7:�Health in Your Hands� Objectives

To reduce the incidence of diarrheal disease, in particular among children under five, by making handwashing with soap at critical times universally recognized, promoted, and practiced. To implement large scale handwashing interventions and use lessons learned to promote the approach at the global level. Transparency among and equality of partners

Slide 8:Why partner to promote handwashing?

Soap industry gains market expansion Public agencies benefit from the marketing expertise of the soap industry and thus have stronger capacity to relay health messages to target audiences via marketing campaign strategies Social responsibility

Slide 9:General Steps Followed by �Health in Your Hands�

Catalyst initiates discussion (this can be an organization in the host country, an organization pursuing new projects, or a private company) Formation of a steering committee Funds mobilization Conduct handwashing behavioral study (formative research) Design communications strategy Testing of communications strategy Execution, monitoring, and evaluation Countries are undertaking the following steps to implement a PPP handwashing initiative:  The catalyst is the global initiative (partners) Steering committee for individual country/region Handwashing Behavior Study (formative research: quantitative and qualitative) is used to identify the practices that are putting people at diarrhoea risk, and the ways we can change these practices. Specifically, the HWBS addresses the 4 following questions: What are the high risk practices? 2. Who is the target audience? 3. What motivates handwashing practices? 4. How do people communicate? M&E Programme Actors deployed and effective? Consumer research used in programme planning? Promotional activities (materials, media, etc.) reaching target population? Affordable soap available among target population (% of population with physical access to affordable soap) Distribution from central supply warehouse to point of sales established and increasing (increase in distributor demand of affordable soap) Soap sales of affordable soap increasing ( disaggregated by location of point of sale) Countries are undertaking the following steps to implement a PPP handwashing initiative: The catalyst is the global initiative (partners) Steering committee for individual country/region Handwashing Behavior Study (formative research: quantitative and qualitative) is used to identify the practices that are putting people at diarrhoea risk, and the ways we can change these practices. Specifically, the HWBS addresses the 4 following questions: What are the high risk practices? 2. Who is the target audience? 3. What motivates handwashing practices? 4. How do people communicate? M&E Programme Actors deployed and effective? Consumer research used in programme planning? Promotional activities (materials, media, etc.) reaching target population? Affordable soap available among target population (% of population with physical access to affordable soap) Distribution from central supply warehouse to point of sales established and increasing (increase in distributor demand of affordable soap) Soap sales of affordable soap increasing ( disaggregated by location of point of sale)

Slide 10:Case Study - Nepal

Population: 28.9 million 1/3 below poverty line 75% subsistence farmers Remote and landlocked Civil strife Susceptible to natural disaster Poor population may lack access Subsistence farming is a marker for being rural / no access to care or programs � big problem in Nepal 3 reasons why this country continues to be poor despite some natural resources: It is remote and landlocked Civil strife and border disputes occupy the government�s attention and detract from tourism $ Dealing with natural disasters takes up resources that could be used for infrastructure, welfare, etc.Poor population may lack access Subsistence farming is a marker for being rural / no access to care or programs � big problem in Nepal 3 reasons why this country continues to be poor despite some natural resources: It is remote and landlocked Civil strife and border disputes occupy the government�s attention and detract from tourism $ Dealing with natural disasters takes up resources that could be used for infrastructure, welfare, etc.

Slide 11:Case Study � Nepal (2)

2003 Child mortality 91/1000 due to diarrheal disease (DHS 2001) 1 in 5 children suffer from diarrhea More prone to diarrhea in households with well-water source for drinking water 1 in 5 children suffered from diarhoea in the 2 weeks before the survey Well water versus piped water 1 in 5 children suffered from diarhoea in the 2 weeks before the survey Well water versus piped water

Slide 12:Case Study � Nepal (3)

Public partners: UNICEF, World Bank, USAID/EHP Private partners: Nepal Lever Ltd., market leader (subsidiary of Unilever Inc.) and Aarti Soap and Chemicals, local company

Slide 13:Case Study � Nepal (4)

Goal: To contribute to the reduction of diarrheal incidence through handwashing with soap at critical times and using correct techniques Objectives: To generate awareness on importance of handwashing with soap Reach 5 million people, including 500,000 school children Soap companies provided free media airtime in prime time television and radio programs, soap samples, and school promotions Soap companies provided free media airtime in prime time television and radio programs, soap samples, and school promotions

Slide 14:Case Study � Nepal (5)

Phase I: Consumer Baseline Survey Phase II: Marketing Strategy Mass media advertising including posters, brochures, radio spots, and tv commercials Community-based outreach: female health volunteers, sanitation motivators, door-to-doorvisits, demonstrations in schools Phase III: Program Lauch (2004) National Sanitation Action Week in May 2005 National Sanitation campaign was only a public sector campaign National Sanitation campaign was only a public sector campaign

Slide 15:Case Study - Peru

Population: 28.7 million 54% below poverty line IMR 35/1,000 Urban slum population Remote rural population Arid coastal region Andes mountains Tropical rainforest

Slide 16:Case Study � Peru (2)

Need: Diarrheal disease was the 3rd leading cause of childhood disease Rationale: Past efforts to improve water infrastructure have not reduced diarrheal disease Peruvian government expressed interest in a PPP at World Bank Water Forum

Slide 17:Case Study � Peru (3)

Timeline Government expressed interest: May 2002 Project inception: March 2003 Formative research results: September 2004 Bidding for PPP design: July 2005 Formal launch of campaign: July 18, 2005 Evaluation: TBD

Slide 18:Case Study � Peru (4)

Drivers Mothers are judged by their children�s grooming and health Dirt, feces, and germs are widely understood to cause disease Obstacles �Soap and water are limited resources.� �I�m careful when I defecate.� �Doing laundry counts.�

Slide 19:Case Study � Peru (5)

Public partners Peruvian Ministry of Health (lead agency) USAID (funds for formative research) JSDF (funds for developing communications) Private partners Colgate-Palmolive (printed materials/soap) Boga Comunicaciones SA (cable TV) Radio Programmas Peru (local radio)

Slide 20:Case Study - Ghana

Population: 22.9 million Skewed towards young IMR 53/1,000 60% subsistence farmers Large refugee population from Liberia, Togo, etc. IMR = infant mortality rate 60% subsistence farmers = rural, remote population lacking access Refugee population placing strain on national resourcesIMR = infant mortality rate 60% subsistence farmers = rural, remote population lacking access Refugee population placing strain on national resources

Slide 21:Case Study � Ghana (2)

Need: 25 % of deaths are due to diarrheal disease in children under age 5; 9 million cases of dd per year, and rising. Partnership initiated by Ghanaian government agency- Community Water and Sanitation Agency (CWSA) in 2001 Rationale: Reduce infant morbidity and mortality with the end goal of reducing poverty. Compliments the rural H20 sector strategy: H20, Sanitation, Hygiene DD= $$ 33 million dollars annually. Doesn�t take DALY�s into account, nor cost to the family of a child sick with diarrhoea. Private Sector is # 1 spender on hygiene behavior change in countryDD= $$ 33 million dollars annually. Doesn�t take DALY�s into account, nor cost to the family of a child sick with diarrhoea. Private Sector is # 1 spender on hygiene behavior change in country

Slide 22:Case Study � Ghana (3)

Lead Agency: CWSA- coordinator Public sector/World Bank: Ministries of Works & Housing, Women�s & Children�s Affairs, NCWSP II- World Bank- $$$ Ministry of Health - local health servicesMinistry of Education: School Health Education Program Private sector: Unilever, PZ-Cussons, GETRADE, AGI- Provide technical assistance; in-kind. External Support Agencies: �UNICEF: Support to schools component.DANIDA: Support to schools component CIDA & WHO NCWSP - National Community Water and Sanitation Program (campaign design, testing, and management & implementation expertise, product samples); The programme will cost in the order of $4m over 30 months. 50% will come from the public sector 25% from industry and 25% from external support agencies. A sub-project of eighteen months� duration will seek to bring new products to the market through advocacy with the private sector as well as agreements for co-funding product research, development and consumer testing. change in behaviour = 2000 metric tonnes more of soap used in washing hands, amounting to ($1.25m) of sales per annum for full year of 2005. Ghana is a good choice for pilot b/c good health care infrastructure, local gov�t activity Ghana has a vibrant soap industry made up of two multinational soap companies, five large-scale local manufacturers, a number of small-scale soap manufacturers and over a thousand artisanal soap producers producing locally. NCWSP - National Community Water and Sanitation Program (campaign design, testing, and management & implementation expertise, product samples); The programme will cost in the order of $4m over 30 months. 50% will come from the public sector 25% from industry and 25% from external support agencies. A sub-project of eighteen months� duration will seek to bring new products to the market through advocacy with the private sector as well as agreements for co-funding product research, development and consumer testing. change in behaviour = 2000 metric tonnes more of soap used in washing hands, amounting to ($1.25m) of sales per annum for full year of 2005. Ghana is a good choice for pilot b/c good health care infrastructure, local gov�t activity Ghana has a vibrant soap industry made up of two multinational soap companies, five large-scale local manufacturers, a number of small-scale soap manufacturers and over a thousand artisanal soap producers producing locally.

Slide 23:Ghana: Women�s Handwashing Behaviour Study -2002

Occasion Claims of Hand Claims of Hand Actual Washing Washing with Soap Observ (n=448) (n=436) (n=188) % % % After defecation/toilet 82 76 37 Before feeding a child 21 6 - Before preparing food 40 11 - Before eating 86 14 - After eating 85 53 - After farm work 15 8 - After Sweeping 13 5 - After cleaning up child�s feces. 0 0 31 Source: Clean Hands, Healthy Life- Ghana washes her hands: A Public-Private Partnership to save lives. Business plan Only 20% of children observed in schools during the Consumer Study washed their hands after using the latrine while a smaller number still, washed their hands with soap. Formative Research (RI) findings 1. Handwashing with soap after toilet is at about 16% 2. 95% of households have soap 3. 100% have water 4. Soap desired to remove smells and �contamination�, to make fresh and confident, to care for a child 5. HW is a habit, soap use is not 6. HW with soap is highly acceptable Only 20% of children observed in schools during the Consumer Study washed their hands after using the latrine while a smaller number still, washed their hands with soap. Formative Research (RI) findings 1. Handwashing with soap after toilet is at about 16% 2. 95% of households have soap 3. 100% have water 4. Soap desired to remove smells and �contamination�, to make fresh and confident, to care for a child 5. HW is a habit, soap use is not 6. HW with soap is highly acceptable

Slide 24:Case Study � Ghana (4)

Drivers HW after eating HW after contact with public toilets. Using soap to feel clean/ beautiful.� Mothers prioritize their children�s health Obstacles: Children�s stools are not thought dangerous Soap is often kept hidden to prevent misuse Scented soaps- luxury items; interfere with the taste of food Small sized liquid hand soap preferred. Multipurpose soap used for all activities including handwashing; Laundry soaps are thought better for use prior to eating; Toilet soaps are preferred post-defecation because of powerful smell Small sized liquid hand soap preferred. Multipurpose soap used for all activities including handwashing; Laundry soaps are thought better for use prior to eating; Toilet soaps are preferred post-defecation because of powerful smell

Slide 25:Case Study � Ghana (5)

Initiatives: Mass Media � aimed at mothers and school aged children Direct Consumer Contact- visits to 2 districts in each of the 6 regions- (health care facilities, schools) �. District Level Program (through schools, health centers and communities) Public Relations and Advocacy TARGETS: 90% of new mother gets soap and handwashing advice Handwashing advised in all child welfare clinic visits 50% of schoolchildren (primary and JSS) learn and practice handwashing with soap in school Road shows reach those not covered by mass media Reduce under 5 mortailty rate to 110/1000 in 2000 to 95/1000 in 2004 Mass Media- TV (show commercial) Radio,Posters, Billboards, Leaflets, Stickers, etc. 65% of mothers see TV 85% of women listen to radio (RI study) Direct Consumer Contact-event mgmt firm visits to 2 districts in each of 6 regions reach 103,313 school children, 2,930 teachers and 926 food vendors, and 132 events in health centres and communities for 11,500 mothers Audience had Q&A, concerns Disrtict Level $$$ for launch events, training & orientation for district steering committee members gov�t facilities, health centres, schools, community infrastructure deliver the handwashing with soap message; advocate for the provision of handwashing facilities and soap in public and school toilets, especially as over 60% of the target audience use public toilets. District-level activities to support the campaign continued throughout 2004 and the first half of 2005. Public Relations and Advocacy component that targets policy makers and opinion leaders and promotes the provision of handwashing infrastructure in schools and public latrines. TARGETS: 90% of new mother gets soap and handwashing advice Handwashing advised in all child welfare clinic visits 50% of schoolchildren (primary and JSS) learn and practice handwashing with soap in school Road shows reach those not covered by mass media Reduce under 5 mortailty rate to 110/1000 in 2000 to 95/1000 in 2004 Mass Media- TV (show commercial) Radio,Posters, Billboards, Leaflets, Stickers, etc. 65% of mothers see TV 85% of women listen to radio (RI study) Direct Consumer Contact-event mgmt firm visits to 2 districts in each of 6 regions reach 103,313 school children, 2,930 teachers and 926 food vendors, and 132 events in health centres and communities for 11,500 mothers Audience had Q&A, concerns Disrtict Level $$$ for launch events, training & orientation for district steering committee members gov�t facilities, health centres, schools, community infrastructure deliver the handwashing with soap message; advocate for the provision of handwashing facilities and soap in public and school toilets, especially as over 60% of the target audience use public toilets. District-level activities to support the campaign continued throughout 2004 and the first half of 2005. Public Relations and Advocacy component that targets policy makers and opinion leaders and promotes the provision of handwashing infrastructure in schools and public latrines.

Slide 26:Case Study � Ghana (6)

Phase 1 carried out from September 2003 to August 2004 August 2004 - Evaluation of media initiative looked successful Commercials re-aired in 2005 to reiterate message. The programme is phased over 30 months. The first half year will be spent setting up and testing and revising approaches and materials. A full year of activities in 44 districts will then be followed by a second year of activities focused on the remaining 66 districts. To optimise impact, districts and activities will be chosen and phased so as to concentrate contact via mass media and other channels into the same time period at the beginning of each year, followed by maintenance at a lower frequency. The programme is phased over 30 months. The first half year will be spent setting up and testing and revising approaches and materials. A full year of activities in 44 districts will then be followed by a second year of activities focused on the remaining 66 districts. To optimise impact, districts and activities will be chosen and phased so as to concentrate contact via mass media and other channels into the same time period at the beginning of each year, followed by maintenance at a lower frequency.

Slide 27:PPPs -Problematic?: Kerala (1)

Characteristics of Kerala as compared to rest of India: highest hygiene standards lowest diarrheal deaths highest awareness on prevention of diarrheal diseases lowest childhood mortality highest female literacy. highest access to safe water SO WHY KERALA??? Importance of doing formative research highest knowledge of prevention of diarrhoea because of high female literacy and local health practices such as use of jeera water and high use of fluids during diarrhoea. Possible misuse of formative research Importance of doing formative research highest knowledge of prevention of diarrhoea because of high female literacy and local health practices such as use of jeera water and high use of fluids during diarrhoea. Possible misuse of formative research

Slide 28:PPPs -Problematic?: Kerala (2)

Ethical Implications: Risk of privatization of traditional government responsibilities Destroying indigenous practices Polluting environment with new industrial products Need to pay special attention to the potential impacts that interventions may have--- Weigh the benefits against the possible negative impactsNeed to pay special attention to the potential impacts that interventions may have--- Weigh the benefits against the possible negative impacts

Slide 29:Overall Pros of PPPs

Financial and in-kind resources are contributed Local & international efforts are combined Locals guide the development with expert aid Efforts are focused on a circumscribed problem Programs are compatible with the population Education is a durable good

Slide 30:Overall Cons of PPPs

Selection of partners can be tricky Conflicts of interest to ensure profit Financial leverage affects decision-making Shifting of responsibilities from governments Sustainability is questionable Ethical considerations Bureaucracy Selection of partners � private organizations may be governed by non-representative boards Conflicts of interest � for example focusing on affluent, easily-accessed communities rather than marginalized, to ensure profit Financial leverage � not-for-profits may be at the mercy of their wealthier partners in decision-making Shifting of responsibilities � national governing bodies may see PPPs as an excuse for not keeping commitments to protect the health of their citizens Sustainability � if the project does not exhibit the potential for future profit it may be terminated; lack of evidence Ethical Considerations � the goals of the PPP should be ethical and should be equitable in who the product/program reaches Bureaucracy � dealing with boards, administration, and leaders from multiple partners can be cumbersome and very time-consuming Selection of partners � private organizations may be governed by non-representative boards Conflicts of interest � for example focusing on affluent, easily-accessed communities rather than marginalized, to ensure profit Financial leverage � not-for-profits may be at the mercy of their wealthier partners in decision-making Shifting of responsibilities � national governing bodies may see PPPs as an excuse for not keeping commitments to protect the health of their citizens Sustainability � if the project does not exhibit the potential for future profit it may be terminated; lack of evidence Ethical Considerations � the goals of the PPP should be ethical and should be equitable in who the product/program reaches Bureaucracy � dealing with boards, administration, and leaders from multiple partners can be cumbersome and very time-consuming

Slide 31:Recommendations

Can PPPs be applied to capacity building and infrastructure strengthening? Ideals/values and grounds for rejecting partnership should be established before entering a PPP Third-party monitoring Rigorous monitoring & evaluation 1. PPPs need to find a way to contribute not just to product development and delivery but also capacity building and infrastructure strengthening 2. Organizations considering entering a PPP should ensure that their ideals/values are explicit and establish guidelines dictating when and why potential partnerships should be rejected 3. PPPs should consider establishing a third-party monitoring group to ensure that common goals are being met and that no fundamental ideals/values established by the participants are being violated throughout the partnership 4. PPPs should incorporate rigorous M&E procedures for their programs in order to be able to evaluate the extent of the benefits of the programs and whether or not they should continue 1. PPPs need to find a way to contribute not just to product development and delivery but also capacity building and infrastructure strengthening 2. Organizations considering entering a PPP should ensure that their ideals/values are explicit and establish guidelines dictating when and why potential partnerships should be rejected 3. PPPs should consider establishing a third-party monitoring group to ensure that common goals are being met and that no fundamental ideals/values established by the participants are being violated throughout the partnership 4. PPPs should incorporate rigorous M&E procedures for their programs in order to be able to evaluate the extent of the benefits of the programs and whether or not they should continue

Slide 32:Conclusions

�Health in Your Hands� has exhibited some success and evaluations continue Some keys to success include: Partnership equality/transparency Community involvement Rigorous formative research Comprehensive evaluation PPPs are a relatively new concept PPPs have pros and cons and will require more research to establish best practices

Slide 33:Example PPPs

Health in Your Hands Global Alliance for Vaccines and Immunization International AIDS Vaccine Initiative Medicines for Malaria Venture Global Alliance for TB Drug Development Initiative on Public-Private Partnerships for Health (database) Public-Private Partnerships for the Urban Environment (database)

Slide 34:References

World Bank, 1994. World Development Report Thomas A. Curtis V. Public-private partnerships for health; a review of best practices in the health sector. July 2003 The global public-private partnership to promote handwashing with soap [Online] [cited 2007 April 21]; Available from: URL:www.globalhandwashing.org Buse, K.; Waxman, A. �Public-Private Health Partnerships: A Strategy for WHO.� Bulletin of the World Health Organization. August 2001, 79 (8), 748-754. Roberts, M.J.; Breitenstein, A.G.; Roberts, C.S. �Chapter 4: The Ethics of Public-Private Partnerships.� Public-Private Partnerships for Public Health. April 2002, Harvard University Press, Boston, MA. Wheeler, C.; Berkley, S. �Initial Lessons from Public-Private Partnerships in Drug and Vaccine Development.� Bulletin of the World Health Organization. August 2001, 79 (8), 728-734. Widdus, R. �Public-Private Partnerships for Health: Their Main Targets, Their Diversity, and their Future Directions.� Bulletin of the World Health Organization. August 2001, 79 (8), 713-720. PRISMA. �Behavioral Study of Handwashing with Soap in Peri-urban and Rural Areas of Peru.� Joint Publication 11E. September 2004. 1-159. Shiva, V. "Saving lives or destroying lives? World Bank sells synthetic soap & cleanliness to Kerala: the land of health and hygiene� �PPPHW program: the story of Ghana.� Available at http://www.globalhandwashing.org/Country%20act/ghanapu.pdf.