WATER AND SANITATION PROGRAM: WORKING PAPER 64854 Global Scaling Up Handwashing Project Endline Assessment of the Enabling Environment in Peru Michael Favin June 2011 The Water and Sanitation Program is a multi-donor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. By Michael Flavin Global Scaling Up Handwashing is a Water and Sanitation Program (WSP) project focused on learning how to apply innovative promotional approaches to behavior change to generate widespread and sustained improvements in handwashing with soap at scale among women of reproductive age (ages 15-49) and primary school-aged children (ages 5-9). The project is being implemented by local and national governments with technical support from WSP. For more information, please visit www.wsp.org/scalinguphandwashing. This Working Paper is one in a series of knowledge products designed to showcase project �ndings, assessments, and lessons learned in the Global Scaling Up Handwashing Project. This paper is conceived as a work in progress to encourage the exchange of ideas about development issues. For more information please email Rocio Florez at wsp@worldbank.org or visit www.wsp. org. WSP is a multi-donor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP’s donors include Australia, Austria, Canada, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. WSP reports are published to communicate the results of WSP’s work to the development community. Some sources cited may be informal documents that are not readily available. The �ndings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its af�liated organizations, or to members of the Board of 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 work. The material in this publication is copyrighted. Requests for permission to reproduce portions of it should be sent to wsp@worldbank.org. WSP encourages the dissemination of its work and will normally grant permission promptly. For more information, please visit www.wsp.org. © 2011 Water and Sanitation Program Global Scaling Up Handwashing Project Endline Assessment of the Enabling Environment in Peru By Michael Favin June 2011 List of Acronyms and Abbreviations BCC Behavior Change Communication CARE Large social development NGO CESEM Implementation arm of the Arequipa Chamber of Commerce CIDA Canadian International Development Agency CORESAN Public-private coalition to combat child malnutrition, Cajamarca CRECER National initiative against child malnutrition, Prime Minister’s office DIRESA Health section of a regional government DRE Education section of a regional government EE Enabling environment EDSA Demographic and Family Health Survey FONCODES MIMDES poverty reduction program HW Handwashing HWI Handwashing Initiative (Iniciativa de Lavado de Manos) IRA Acute Respiratory Infection JUNTOS National conditional cash transfer program M&E Monitoring and Evaluation MDGs Millennium Development Goals MEF Ministry of Economy and Finance MIMDES Ministry of Women and Social Development MOE Ministry of Education MOH Ministry of Health MOU Memorandum of Understanding NGOs Non-governmental organizations PIP Public Investment Project PIN Integrated Nutrition Program PREDECI Cajamarca regional coalition to combat childhood malnutrition PRONAA MIMDES nutrition program PRONOEIS MOE preschool program PRISMA Large social development NGO PSP Private Sector Partners SNIP National System for Public Investment SJ Super Jaboncín (molded, plastic handwashing station) UGEL District education unit UNICEF United Nations Children’s Fund USAID United States Agency for International Development WB World Bank WSP Water and Sanitation Program www.wsp.org iii Endline Assessment of the Enabling Environment in Peru Contents Contents Executive Summary.................................................................. vi I. Introduction ............................................................................... 1 1.1 The Handwashing Initiative .................................................. 1 1.2 The Country Context: Peru................................................... 1 1.3 Assessment Methodology .................................................... 2 1.4 Assessment Objectives (as contained in the consulting TOR) .................................................................... 2 1.5 Assessment Dimensions ...................................................... 4 II. Findings by Dimension .............................................................. 5 2.1 Policy, Strategy, and Direction ............................................. 5 2.2 Partnerships ......................................................................... 8 2.3 Institutional Arrangements ................................................. 12 2.4 Program Methodology........................................................ 13 2.5 Implementation Capacity ................................................... 15 2.6 Availability of Products and Tools ...................................... 16 2.7 Financing ............................................................................ 18 2.8 Cost-Effective Implementation ........................................... 19 2.9 Monitoring and Evaluation.................................................. 20 2.10 Assessment Scores .......................................................... 21 III. Conclusion ............................................................................... 23 Background Reading............................................................... 26 Annexes A: Draft Question Guide in English ........................................ 28 B: Sampling Methodology ..................................................... 33 C: Summary of Major Findings and Recommendations by Dimension .................................................................... 34 D: Commitments and Results in Peru’s Decentralized System .............................................................................. 44 Figure 1: Spider Diagram to Monitor Progress in the Enabling Environment ..................................................................... 22 Boxes 1: Respondents for the EE Endline Survey ............................ 3 2: Key Public Sector Partners ................................................ 6 3: Buy-In from the Ministry of Woman and Social Development ...................................................................... 7 iv Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Contents 4: Key Private Sector Partners............................................. 10 5: Principal Training and BCC Materials Produced and Distributed ....................................................................... 14 Tables 1: Enabling Environment Dimensions ................................... vi 2: Children’s Respiratory Infections and Diarrhea in 2004 and 2009 ................................................................... 2 3: Definition of Enabling Environment Dimensions ................ 4 4: Examples of Private Company Social Responsibility Actions ............................................................................. 11 5: Enabling Environment Scores by Dimension ................... 22 6: Factors Favoring and Threatening Handwashing with Soap Sustainability .......................................................... 24 www.wsp.org v Executive Summary Background of HWI’s methodology; it does not mean continuation of The Water and Sanitation Program (WSP) is in the final phase HWI as a separate program or initiative. For WSP, the major of the Global Scaling Up Handwashing Project, implemented sign of success is that HWI is not frequently mentioned as a in Peru, Senegal, Tanzania, and Vietnam. In Peru, where the separate project or program but that its methodology, tools, project is known as Iniciativa de Lavado de Manos, or the and lessons have been adopted by institutions which will Handwashing Initiative (HWI), the specific target is to reach continue to assign resources in the future. 5.1 million women and children under the age of 12 with handwashing messages by the end of the four-year implemen- In 2007, WSP conducted a baseline assessment in Peru of tation period (November 2010). The ultimate goal is to have nine dimensions considered essential to scaling up hand- 1.3 million people practicing improved handwashing behaviors. washing with soap behavior change programs. This frame- work was developed by WSP, based on a review of relevant WSP developed HWI as a behavior-change package, with literature and a discussion with experienced subject matter methodologies, tools, and approaches intended for adoption experts, to indicate the feasibility of achieving program- by various public and private institutions engaged in differ- matic scalability and sustainability. Scale-up is defined as an ent fields related to poverty alleviation. These fields include: increase in the present scale and rate of behavior change, health promotion, school education, environmental educa- and sustainability of programs promoting handwashing tion, nutrition, and water and sanitation. Thus, sustainability with soap. Sustainability is defined as the ability to maintain means that handwashing with soap is a priority by differ- interventions after funding under this project has ended. ent institutions and that these institutions have ownership Table 1 includes definitions for each dimension. TABLE 1: ENABLING ENVIRONMENT DIMENSIONS Policy, Strategy, Policy: a set of procedures, rules and allocation mechanisms that provide the basis for programs and and Direction services. Strategy: guidance on how to implement a policy. Direction: a common understanding among interested parties of the goals of an intervention. Partnerships A relationship where two or more parties, having compatible goals, form an agreement to share the re- sponsibility for achieving the goals. Institutional The roles, responsibilities, relationships, and accountability arrangements among public and private or- Arrangements ganizations committed to reaching the handwashing goals. Program The approach agreed upon by partners and implementers to deliver the handwashing with soap program Methodology interventions in order to reach the handwashing with soap targets. Implementation The necessary resources (human and financial), skills, incentives, and materials/tools to deliver the full Capacity complement of interventions necessary to deliver a handwashing with soap program. Availability of Prod- The ready access of necessary products (e.g., soap, water, handwashing stations), that respond to con- ucts and Tools sumer demand to practice handwashing with soap. Financing Adequate funds are available to interested handwashing with soap organizations/agencies to cover the programmatic costs required to deliver their respective roles and responsibilities. Cost-Effective The cost of implementation as compared to the health and economic impacts to be measured in the im- Implementation pact evaluation. Monitoring and Systems and tools to capture progress on implementation and achievement of targets in a timely manner Evaluation to allow for analysis and prompt adaptation of implementation. Evaluation is defined as the assessment of the results of monitoring to identify what worked and what didn’t work. vi Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Executive Summary In 2010, WSP hired an international consultant to conduct regional levels, although there remain some general threats, an endline assessment of the same dimensions. This assess- and the EE is not as strong in some regions as in others. ment aimed to evaluate the robustness of the programmatic conditions for scale-up and sustainability as the project’s Likelihood that HWI interventions will continue to implementation phase was winding down. The objectives be implemented at a large scale: This is highly likely in for the assessment included: many regions. In addition to focusing on (1) integration of handwashing with soap within national programs for na- 1. Determine the current status of each dimension of tionwide scaling up and (2) integration within regional and the enabling environment. local programs to strengthen reach and impact at local level, 2. Identify strengths and weaknesses of each dimen- HWI’s sustainability strategy initiated a third approach: sion, with a focus on deficiencies. working to integrate the behavior-change package within 3. Describe the changes in the enabling environment WSP and wider World Bank programs. since 2007. 4. Determine which dimensions appear to be more or However, in Peru, as in most countries, some regions have less important to create conditions for scale-up and more resources/capacities than others. HWI’s approach to sustainability. this problem has been to encourage national programs (such 5. Make recommendations for improvements in the as PRONAA, Wawa Wasi, Sembrando, Juntos, and FON- enabling environment to the Country Task Man- CODES), which tend to focus on poorer regions. In some ager, WSP HQ staff and main in-country partners regions HWI has strong partnerships, in others strong sec- for the next six months. toral leaders, and in most of them strong national programs. 6. Obtain consensus among current partner organiza- tions for recommendations and next steps. There are potential threats to the sustainability of handwash- ing with soap promotion in Peru, including the upcoming Methodology turnover of political and technical officials throughout the Research followed a question guide used in the 2007 base- country (local officials will change in early 2011 and a new line EE assessment, with some modifications and additions president will be elected later in the year). There is also an based on program experience and learning. ongoing high turnover of teachers and, to a lesser extent, of health staff. Moreover, the length of HWI’s implementation The question guide was used to interview stakeholders period, the strength of political support for HWI, and the from the Government of Peru at national, regional and potential for private-sector support vary significantly among local levels; international agencies; national NGOs; private regions and districts, so the prospects for expansion and sus- sector partners; media; HWI regional coordinators; moth- tainability also vary. Although many of these threats cannot ers; preschool and primary school students; and the HWI be prevented, there are possible mitigation steps that HWI project manager and team. Most interviews were conducted or WSP can take, or in some cases, have already taken. in person, but several were done by telephone. The consul- tant visited three regions (Cajamarca, Arequipa, and Puno) Activities that have been most beneficial to the enabling and three districts (municipios) outside the capitals of those environment: Advocacy for permanently incorporating regions. handwashing with soap into numerous programs, engaging partners, facilitating financing, building capacity, and design- Research was conducted between October 18 and Novem- ing and making easily available a solid methodology. The cost- ber 5, 2010. effectiveness dimension does not show progress because the study was planned to be closely linked to the impact evalu- Findings ation endline. It is scheduled to be implemented during the Changes in the enabling environment since 2007: Over- second half of 2011. Several factors that do not fall easily in all the EE has been much strengthened at both national and any dimension are also potentially important for sustainability. www.wsp.org vii Endline Assessment of the Enabling Environment in Peru Executive Summary Recommendations to Strengthen the Enabling be adopted by the WSP Hygiene and Sanitation Environment: Alliance. • Encourage regional, provincial, and district coali- Policy, Strategy, and Direction tions addressing handwashing with soap to publicize • Request that each regional HWI coordinator or fa- their own work and results, including the contribu- cilitating agency propose a plan for strengthening tions of various partners, through local radio, news- the enabling environment for handwashing with papers, and public events. soap in 2011, and then discuss the proposed actions with the principal local partners and the WSP Hy- Institutional Arrangements giene. These plans are likely to include: providing Through their social-development projects in Peru, WSP information to the new regional and district au- and the World Bank should advocate for regional and local thorities on handwashing with soap methodology, governments to promote handwashing with soap, using experiences, and results; advocating with them to HWI’s methodology and tools. follow up on resolutions and other commitments to promote handwashing with soap; sharing impact evaluation results; and providing technical assistance Program Methodology on designing investment projects for future budget • Advocate and facilitate the BCC approach of HWI allocations. in all of WSP’s hygiene and sanitation integration • Maintain contact with the lead organization or co- projects. alition in each region that can carry out key func- • Continue collaborating with MIMDES (PRONAA, tions of advocacy, alliance-building, and training; Wawa Wasi, FONCODES) in finalizing the process offer suggestions as needed, learn about and share of adoption of HWI methodology for their pro- achievements and lessons learned. grams, and then prepare the print-ready adaptations • Prepare and implement a national event, or sev- of HWI materials. eral regional events, at which different-level ac- • Continue to work with the ministries of education, tors share their experiences of handwashing with health, and the environment to finalize the process soap promotion, including, for example, the An- of adoption of HW methodology, and then, time- cash experience with the Juntos program (educa- permitting, prepare print-ready joint guidelines for tional sessions are part of the conditions for cash the Healthy Schools program. payments). Also, share the findings of the impact evaluation endline survey with regional and mu- Implementation Capacity nicipal levels through various channels. • Provide technical assistance to public sector partners • Advocate for continued World Bank support for in planning, implementing, monitoring, and evalu- handwashing with soap in Peru by developing and ating multi-sector water, sanitation, and hygiene giving a presentation for World Bank staff about investments. HWI experiences and results, and the potential • Engage with new incoming authorities to explain the for handwashing with soap promotion through benefits of handwashing with soap promotion, the other World Bank programs, particularly the Hy- methodology, and implementation requirements; giene and Sanitation Alliance. and urge them to continue integrating hygiene BCC into their priority health, environmental, education, Partnerships and W&S programs. • If feasible, continue to publish and widely dis- • Advocate with partners to support capacity building seminate HWI bulletin, with a focus on cre- in regional and municipal governments in planning, ative and effective contributions by partners at project preparation, proposal writing, and other the regional and district level that could later basic skill areas. viii Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Executive Summary Availability of Products and Tools planning, budgeting management, and M&E (see • In the interest of sustainability, encourage local part- capacity building). In addition to training and men- ners (public and private) to plan for and finance toring, governments could be offered such tools as additional copies of materials. Private companies sample proposals and guidelines for social project may well be willing to assume this cost, particularly development along with planning, reporting, and if their logo can be placed on the material. A com- M&E formats. pany that purchases SJs, for example, could put a • Continue to facilitate PIPs that support handwash- sticker with its logo on each one, which would be ing with soap . seen by students and families numerous times each • Advocate with regional governments to include day. Private companies also have tax write-offs for funding and activities for promotion of handwash- such expenditures. ing with soap in annual work plans and in multi-year • Encourage homemade SJs, as have been made in one regional development plans. area of Cajamarca. Perhaps handwashing stations could be made from totora reed in the Lake Titicaca area. Cost-Effective Implementation • At the time of the WSP cost-effectiveness study, Financing discuss with the MEF the importance of cost- • Continue to advocate with the MEF to include a effectiveness data for its funding of handwashing line item in the national budget to build the capac- with soap promotion as well as other programs. If ity of regional and district governments in planning, such data will continue to be needed, organize an implementing, and monitoring of behavior-change orientation/training for key partner staff. methodologies. • Explore with the MEF and other partners how best Monitoring and Evaluation to offer training and other support in institutional • Meet with key national and regional partners to dis- strengthening (planning, budgeting, human re- cuss their satisfaction/comfort with current M&E sources management, etc.) to regional and district of handwashing with soap in their organizations. governments. If there is sufficient demand, and it is feasible, help • Work with allies and new partners to strengthen organize orientation/training on handwashing with regional governments’ capacity in social project soap for interested partners. www.wsp.org ix I. Introduction 1.1 The Handwashing Initiative to November 5, 2010, followed a 2007 baseline EE assess- The Water and Sanitation Program (WSP) is in the final ment. The same instrument was used in both assessments, phase of the Global Scaling Up Handwashing Project, im- with some modifications and additions made in 2010 based plemented in Peru, Senegal, Tanzania, and Vietnam. The on program experience and learning. An international con- project’s four objectives are: sultant carried out the assessment.1 1. To design and implement innovative, sustainable 1.2 Country Context: Peru handwashing programs in four countries resulting Peru is a large country with a heritage of indigenous civili- in large-scale adoption of handwashing with soap zations. Lima was a major capital of Spanish America and at critical times by the targeted population of poor today accounts for approximately a third of the national women and children; population. The country has tremendous diversity in ge- 2. To document and learn about the impact and sus- ography and population. Emerging from a long period of tainability of innovative large scale handwashing economic and political unrest, the country’s economic per- programs; formance has been remarkable over the last decade. Growth 3. To learn about the most effective and sustainable accelerated from 6.8 percent in 2005 to 9.8 percent in 2008, approaches to triggering, scaling up and sustaining reflecting both rising commodity prices that fueled export handwashing behaviors; and growth and sound economic management. Peru weathered 4. To promote and enable the adoption of effective the global economic crisis well, and preliminary numbers handwashing programs in other countries and posi- for 2010 indicate a rapid recovery. tion handwashing as a global public health priority through the translation of results and lessons learned Over the past decade Peru has made progress in reducing into effective advocacy and applied knowledge and poverty and improving health and education indicators. communication products. From 2005 to 2009 poverty fell from 48.7 percent to 34.8 percent. The percentage of institutional births has risen In Peru, where the project is known as Iniciativa de La- steadily to surpass the government’s goal of 75 percent. vado de Manos, or the Handwashing Initiative (HWI), the After stagnating for many years, child chronic malnutrition specific target is to reach 5.1 million women and children rates fell from 30 percent in 2000 to 23.8 percent in 2009, under 12 with handwashing messages by the end of the although rates remain significantly higher in rural areas of four-year implementation period (November 2010). The the Sierra (mountains). With the exception of preschool ultimate goal is to have 1.3 million people practicing im- education, enrolment figures are high; however, standard- proved handwashing behaviors. As of the first half of 2010, ized testing indicates low quality, which the government is the communication targets for reach by mass media had addressing through new policies. been significantly surpassed and for direct consumer con- tact (e.g., dramas, discussions, and health fairs) had almost The main health benefits of handwashing with soap are re- been reached. The target for interpersonal communication ductions in diarrheal and respiratory disease. Statistics from stood at 68 percent of the end of project target. the Peruvian Demographic and Family Health (EDSA) sur- veys indicate high rates of acute respiratory infection (ARI) This report summarizes the endline assessment of the en- among children younger than 5 in 2004 that were much abling environment (EE) for the Global Scaling Up Hand- reduced by 2009, but high rates of diarrhea show in both washing Project in Peru. This assessment aimed to evaluate surveys (see Table 2). the robustness of the programmatic conditions for scale- up and sustainability as the project’s implementation phase 1 WSP Scaling Up Handwashing Behavior Change Project: Terms of Reference, was winding down. Research carried out from October 18 Endline Assessments of the Enabling Environment, September 2010. www.wsp.org 1 Endline Assessment of the Enabling Environment in Peru Introduction TABLE 2: CHILDREN’S RESPIRATORY INFECTIONS AND DIARRHEA IN 2004 AND 2009 Percentage of ARI in Percentage of ARI in Percentage of Diarrhea in Percentage of Diarrhea in Age Last Two Weeks, 2004 Last Two Weeks, 2009 Last Two Weeks, 2004 Last Two Weeks, 2009 Less than 6 11.6 2.9 11.7 10.4 months 6–11 months 22.5 5.6 21.6 21.9 12–23 months 20.5 6.9 24.8 22.7 More than 5 17 6.4 15 14 years 1.3 Assessment Methodology Depending on the degree of a respondent’s involvement and The endline assessment was carried out using a revised ver- his or her time available, interviews lasted from 15 minutes sion of the original question guide from the 2007 EE baseline. to two hours or more. On average, interviews lasted 45 min- The question guide was used to interview stakeholders from utes to one hour. Asking all of the questions to a knowledge- the Government of Peru at national, regional and local levels; able respondent took at least two hours, so in most cases the international agencies; national NGOs; private sector part- consultant asked selected questions based on the respondent’s ners; media; HWI regional coordinators; mothers; preschool relationship to and knowledge of HWI and on his or her and primary school students; and others. Most interviews were time available. The scope of many of the questions needed to conducted in person, but several were done by telephone. The be clarified for particular respondents, depending on whether consultant visited three regions (Cajamarca, Arequipa, and their locus of knowledge was national, regional, or local. Puno) and three districts (municipios) outside the capitals of those regions. Annex A contains the English version of the 1.4 Assessment Objectives (as contained in question guide.2 the consulting TOR) The objectives for the assessment included: Prior to the assessment, WSP scheduled a majority of the interviews based on the sampling plan proposed in the EE 1. Determine the current status of each dimension of methodology. Criteria for selection included: (1) having the enabling environment. knowledge about the handwashing with soap program and/ 2. Identify strengths and weaknesses of each dimen- or of factors important to its success/sustainability; (2) rep- sion, with a focus on deficiencies. resenting a major respondent type; and/or (3) representing 3. Describe the changes in the enabling environment a particular level of an organization involved in the pro- since 2007. gram. Annex B contains the detailed sampling plan. 4. Determine which dimensions appear to be more or less important to create conditions for scale-up and Most of the interviews were summarized in a format by di- sustainability. mension and type and level of respondent, then analyzed 5. Make recommendations for improvements in the enabling and summarized for this report. Additionally, numerous environment to the Country Task Manager, WSP HQ reports and documents (see References). WSP staff helped staff and main in-country partners for the next six months. clarify contradictory or unclear information and provided 6. Obtain consensus among current partner organiza- very useful feedback and suggestions on the draft report. tions for recommendations and next steps.3 2 This question guide was subsequently translated into Spanish and shortened. 3 Ibid. 2 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Introduction BOX 1: RESPONDENTS FOR THE EE ENDLINE STUDY International Organizations • WSP: two key staff, HWI; four contracted regional HWI coordinators • USAID: Health Project Management Specialist National Government • Ministry of Health: Director of Health Promotion • Ministry of Education: two officials from Community Education and Environment • Ministry of Women and Social Development (MIMDES): the Minister of MIMDES; Manager of Food Secu- rity, PRONAA (nutrition program); Specialist, Wawa Wasi (daycare program) National NGOs • PRISMA: Executive Director and Director of Health and Sanitation • CARE: National Coordinator of Water Resources and the HWI coordinator for three regions Private Sector • BPZ Energy (Tumbes): Institutional Relations Director • Dale Foundation (Piura): Administrator • CESEM (implementation arm of the Arequipa Chamber of Commerce): President and HWI project manager • Inkabor Foundation (Arequipa): General Manager • Duraplast (manufactures handwashing stations): Sales Director Media • Peru Radio Programs (RPP): Executive Director • National Radio Coordinator (CNR): two sales managers Regional and Local Contacts • Arequipa Region: Coordinator, PRONOEIS (MIMDES preschool program); PRONOEIS teachers and stu- dents; representative of the DRE (regional education office); administrator and health promotion director, DIRESA (regional government health office); private sector representatives • Puno Region: Meeting with many staff from regional MIMDES programs; meeting with representatives from the DIRESA (health promotion), a private school, and the director and staff from the social security facility; various staff from the Chucuito health post; directors, teachers and students of Chucuito and nearby schools; Moho District: principal, teachers, and students of primary school; director and staff of health center • Cajamarca Region: Ichocán District: alcalde (district head), health and education officials, teachers, pri- mary students, health professional students, some mothers at home; attended meeting of CORESAN (coalition against child malnutrition), with about 45 persons representing organizations from throughout the region, mostly governmental, some NGOs, and a few from the private sector www.wsp.org 3 Endline Assessment of the Enabling Environment in Peru Introduction 1.5 Assessment Dimensions Following a discussion of findings and recommendations for The 2007 baseline EE assessments covered nine dimensions con- each dimension, this report summarizes the scores given each sidered essential to scaling up handwashing with soap behavior dimension in this endline EE assessment and compares them change programs. Developed by WSP based on a review of rel- to previous EE scores given by the WSP/Peru project staff. The evant literature and a discussion with experienced subject matter discussion of each dimension begins with bullets summarizing experts, the conceptual framework considers these dimensions to key points and with a small table comparing the 2007 with indicate the feasibility of achieving programmatic scalability and the 2010 situation; and ends with bullets offering one or more sustainability. Scale-up is defined as an increase in the present scale recommendations for strengthening that dimension. Annex C and rate of behavior change, and sustainability of programs pro- shows 2007 key findings and recommendations and 2010 key moting handwashing with soap. Sustainability is defined as the findings and recommendations, by dimension. ability to maintain interventions after funding under this project has ended. Table 3 describes the nine dimensions. TABLE 3: DEFINITION OF ENABLING ENVIRONMENT DIMENSIONS Dimension Definition 1. Policy, Strategy, and Direction Policy is a set of procedures, rules and allocation mechanisms that Respondents: GOP, international agencies, NGOs, do- provide the basis for programs and services; nors, and private sector Strategy is guidance on how to implement a policy; direction: a com- mon understanding among interested parties of the goals of an intervention 2. Partnerships A relationship where two or more parties, having compatible goals, Respondents: government, international agencies, form an agreement to share the responsibility for achieving the goals NGOs, donors, private sector 3. Institutional Arrangements The roles, responsibilities, relationships, and accountability arrange- Respondents: government, international agencies, ments among public and private organizations committed to reaching NGOs, donors, private sector the handwashing goals 4. Program Methodology The approach agreed upon by partners and implementers to deliver Respondents: government, international agencies, the handwashing with soap program interventions in order to reach the NGOs, donors, private sector handwashing with soap targets 5. Implementation Capacity The necessary resources (human and financial), skills, incentives, and Respondents: government, NGOs, private sector materials/tools to deliver the full complement of interventions neces- sary to deliver a handwashing with soap program 6. Availability of Products and Tools The ready access of necessary products (e.g., soap, water, handwash- Respondents: NGOs, private sector, donors ing stations), that respond to consumer demand to practice handwash- ing with soap 7. Financing Adequate funds are available to interested handwashing with soap Respondents: government, donors, NGOs organizations/agencies to cover the programmatic costs required to deliver their respective roles and responsibilities 8. Cost-Effective Implementation The cost of implementation as compared to the health and economic Respondents: government, NGOs, donors, interna- impacts to be measured in the impact evaluation tional organizations 9. Monitoring and Evaluation Systems and Tools to capture progress on implementation and Respondents: government, donors, NGOs, private achievement of targets in a timely manner to allow for analysis and sector prompt adaptation of implementation. Evaluation is the assessment of the results of monitoring to identify what worked and what didn’t work. 4 Global Scaling Up Handwashing II. Findings by Dimension 2.1 Policy, Strategy, and Direction The ministries of health, education, and the environment Virtually all respondents felt that handwashing with soap have reached agreement on unified evaluation indicators, had become an important national and local priority over including handwashing with soap, for the Sustainable De- the last few years, thanks in large part to advocacy and tech- velopment of Educational Institutions initiative. nical support from HWI. In HWI’s early years, political leaders supported handwashing with soap promotion with Handwashing with soap has a prominent role in the the intention of reducing cases of diarrhea and respiratory CRECER strategy, coordinated by the Prime Minister’s of- infection. Since 2007, political and practical support has fice, which commits 15 organizations to participate in an grown because of the widespread belief that handwashing Initiative against Child Malnutrition in Peru (CRECER). with soap can make a significant contribution to the pri- The CRECER strategy is said to have a very strong influ- ority national goal of reducing child malnutrition. Politi- ence on regional priorities, and it requires the collaboration cal will has also grown because of the local impact of some of agriculture, health, education, housing, and the private 22,000 teachers and other promoters of handwashing with sector. HWI has also worked with the Juntos conditional soap who have been trained. HWI activities have generated cash transfer program to incorporate handwashing with a lot of interest in regional and district (municipal) govern- soap promotion more solidly. ments, sometimes after they become aware of the activities elsewhere and then wanted the same programs and resources The MOE’s commitment to handwashing with soap pro- as their neighbors. Finally, people seem to like the fact that motion is official policy. Handwashing with soap is included the HWI offers practical solutions and tools for immediate in the national curriculum. A vice-ministerial resolution use, including training methods and materials, communica- designates the HWI methodology and tools as a compo- tion materials and activities, and handwashing stations. nent of the National Healthy and Safe [Schools] Program implemented in more than 3,000 pilot schools. Handwash- The raised profile for handwashing with soap has been of- ing with soap is also well integrated into the MOE pre- ficially recognized in over 120 organizational resolutions, school program (PRONOEIS, a program operated in poor norms, and directives of the ministries of health (MOH), communities by program staff and volunteer mothers). In education (MOE), and woman and social development Arequipa, PRONOEIS centers were observed to be fully (MIMDES) and their regional and district counterparts.4 involved in promotion of handwashing with soap in classes, 4 homes and communities. MOE resolutions have made These are listed in Iniciativa Lavado de Manos. Procesos y aprendizajes de la Iniciativa Lavado de Manos al 2010; see References. handwashing with soap one of two priority topics for the Key Findings: Policy, Strategy, and Direction Baseline Findings (2007) Endline Findings (2010) • There was good support among many government • Support has spread to other sectors and to regions officials, although multiple priorities limited action. and districts, and there is more follow-up. • The current national administration was very • The administration remains very supportive. supportive. • Several politically prominent national initiatives • HWI has successfully inserted handwashing with (re: malnutrition, healthy school, water and sanitation) soap and its methodology into these initiatives. offered natural links with handwashing with soap. • Support from key ministries varied over time, and the • The Ministries of Health, Education, and Women and Ministry of Education was a new partner. Social Development, have integrated the HWI meth- odology and tools within their programs. www.wsp.org 5 Endline Assessment of the Enabling Environment in Peru Findings by Dimension school year 2010 and mandated full MOE participation in Handwashing Week in 2009 and 2010. Another MOE res- olution requires at least monthly promotion of handwash- ing with soap in schools. Many local educational offices prioritize handwashing with soap, use HWI methodologies, appoint focal points, and certify teachers who complete a series of steps to promote handwashing with soap. Some district-level education units (UGELS) and schools have budgets allocated for promotion of handwashing with soap. HWI recently collaborated with the MOE in the prepara- tion of new national environmental education curriculum. Handwashing is included for preschool, primary and high school, across different areas of study. The HWI methodol- ogy, consisting of four sessions, is presented as the educa- In schools, soap is seldom at the right place. In Lambayeque, tional route to be followed in the classroom to promote a northern coastal region of Peru, children at a primary school HW behavior change in primary schools. line up to wash their hands with soap. The Ministry of Health (MOH) has long promoted hand- washing, but with added vigor and effectiveness in the last The Minister of MIMDES stated that her ministry was few years. A MOH resolution made handwashing with strongly committed to promoting handwashing with soap soap a priority theme for its involvement in the multi-sector through such programs as PRONAA (aimed at reducing healthy schools program. The topic is also well integrated infant malnutrition and anemia, the program includes a in the MOH’s Healthy Families and Homes project and school breakfast program, child feeding centers, distribu- its Healthy Municipalities and Cities program. The MOH tion of fortified bread, etc.); Wawa Wasi (a daycare program is working on directive to have a handwashing week every for children of poor working mothers); and FONCODES year and to promote handwashing with soap and access to (an infastructure program). She sees a very strong political water, in collaboration with the district alcaldes. will for social programs at the national level generally in the BOX 2: KEY PUBLIC SECTOR PARTNERS • Regional health units • Regional education units • Regional governments of Tumbes, Piura, Lambayeque, Cajamarca, Amazonas, San Martín, Ica, Huánuco, Arequipa, Tacna, and La Libertad • Ministry of Education • Ministry of Woman and Social Development • Ministry of Health • Ministry of Housing, Construction and Sanitation • Provincial and district governments in 21 regions • Juntos (conditional cash transfer) program • National Food Assistance Program (PRONAA) • National Basic Rural Sanitation Program (PRONASAR) Source: Procesos y aprendizajes, 2010 6 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Findings by Dimension BOX 3: BUY-IN FROM THE MINISTRY OF WOMAN AND SOCIAL DEVELOPMENT In 2009, PRONAA committed itself to implement HWI in the 318 poorest districts as part of the educational com- ponent of PIN (Integrated Nutrition Program). In July 2010, a proposal to institutionalize the HWI methodology in all MIMDES programs arrived at the desk of the Vice Minister for Social Development. At the time of this evalua- tion, PRONAA, Wawa Wasi, and FONCODES were preparing pilot projects under the public investment structure to integrate the HWI approach and methodologies. PRONAA is expected to incorporate handwashing with soap in mobilization events around in food distribution program in Ancash, Lima and Amazonas. In 2010, MIMDES zonal managers from 19 (of 25) regions were trained in the HWI methodology. MIMDES purchased 9,600 hygiene kits for classrooms. PRONAA developed various print materials, including a calendar, a flip chart and a poster, and instruction packet on handwashing with soap. Handwashing with soap is included in the PIN M&E system. regions also but suggested that advocacy for handwashing levels. Some regional respondents, including HWI consul- with soap must be maintained, or current gains could be lost. tants, expressed concern about sustainability in their own or other regions. Some respondents were concerned with PRISMA and CARE, two NGOs contracted by WSP to the impact of the end of the current WSP project, because facilitate handwashing with soap in many regions, appear regional leaders have many priorities and are often swayed to be dedicated to the task both within and beyond HWI. by the latest source of funding. Although they praise the Spokespersons stated that they will continue to promote project strategy and methodology, they feel that they need handwashing with soap, using the approach and methods more time to expand and solidify local buy-in; and they developed by HWI in their future projects. are concerned that the end of HWI implementation phase will make expansion to additional districts and communi- Radio Programas de Peru (RPP), by far the largest and ties difficult. They (and national respondents) are also con- most influential radio network, has implemented a three- cerned about the impact of turnover of political officials year campaign on infant nutrition. For many months the and of field staff (see below). campaign focused on handwashing with soap. RPP reaches six million listeners per month and has carried out track- Major reasons for the overall improvements in this dimen- ing studies that show significantly more healthful behaviors sion occurred because HWI has: among listeners than matched non-listeners. Initial funding came from the private company Alicorp, and now MIM- • Adjusted well to the country’s increasing decentral- DES makes a significant contribution. The national coali- ization of decisions and funding to the regional and tion of radio stations (CNR) also carried out handwashing district level. with soap campaigns in 2009 and 2010, utilizing funds, • Sought to insert handwashing with soap promotion spots, and other materials from HWI. and the HWI approach and methodology into na- tional and regional programs and strategies rather According to HWI staff, lessons from the project will in- than create a vertical or parallel program. form WSP’s work in hygiene across Latin America. • Focused on advocacy and recruiting partners at the regional level, while encouraging supportive national Annex D shows the strong commitment to handwashing government priorities and providing effective meth- with soap promotion in 20 of Peru’s 25 regions as of early odology, tools, and training. 2010. However, whereas political will is strong on the na- • Taken advantage of the national priority to reduce tional level, it naturally varies at regional and municipal child malnutrition. www.wsp.org 7 Endline Assessment of the Enabling Environment in Peru Findings by Dimension Recommendations for strengthening Policy, Strategy, and • Advocate for continued World Bank support for Direction: handwashing with soap in Peru by developing and giving a presentation for World Bank staff about • Request that each regional HWI coordinator or fa- HWI experiences and results, and the potential for cilitating agency propose a plan for strengthening handwashing with soap promotion through other the enabling environment for handwashing with World Bank programs, particularly the Hygiene and soap in 2011, and then discuss the proposed actions Sanitation Alliance. with the principal local partners. These plans will likely include: providing information to the new re- 2.2 Partnerships gional and district authorities on handwashing with Since concerted efforts to promote handwashing with soap methodology, experiences, and results; advocat- soap in Peru began in 2003, the country has evolved from ing with them to follow up on resolutions and other a highly centralized, top-down political structure to an in- commitments to promote handwashing with soap; creasingly horizontal and decentralized one. In 2003 the sharing impact evaluation results; and providing ministries were powerful structures with national reach, technical assistance on designing investment projects providing the last word on policy, planning, and budget for future budget allocations. allocation and spending. In the last two years, the regions • Maintain contact with the lead organization or co- have become more autonomous through the decentraliza- alition in each region that can carry out key func- tion process, although with varying degrees and effective- tions of advocacy, alliance-building, and training; ness due to various levels of local capacity and funding offer suggestions as needed, learn about and share sources. The national ministries are now better coordi- achievements and lessons learned. nated and more apt to define and implement their respec- • Prepare and implement a national event, or sev- tive responsibilities in joint initiatives. eral regional events, at which different-level actors share their experiences of handwashing with soap Particularly during HWI’s early years, the strength of promotion, including, for example, the Ancash ex- partnerships with national ministries varied over time. perience with the Juntos program (educational ses- The MOH was a very strong leader and owner of HWI sions are part of the conditions for cash payments). between 2004 and 2006. Starting in 2006 the MOE be- Also, share the findings of the cost-effectiveness came engaged and has continued a strong collaboration. study and the impact evaluation endline survey The multi-sector national conditional cash transfer pro- with regional and municipal levels through various gram (Juntos) incorporated handwashing with soap pro- channels. motion in 2008–2009, and MIMDES, which operates Key Findings: Partnerships Baseline Findings (2007) Endline Findings (2010) • This was a strong and innovative aspect of HWI. • Private participation has continued to grow; it is pri- marily, but not entirely, financial. • Some friction between public and private partners • This was not mentioned in 2010. was reported. • Maintaining commitment of ministries was challenging • The commitment now appears to be more solid in at times because of political changes and overbur- the institutions and not as dependent on particular dened officials. officials. 8 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Findings by Dimension several nutrition, daycare, and social programs, has been a While the project has involved an impressive number and strong partner since 2009. WSP considers that integration variety of partners (see Box 4), clearly there are additional of HWI within MIMDES as very important for sustain- partners that potentially could collaborate at the national ability. On the other hand, working with the Ministry of and local levels, NGOs and private companies in particu- Housing, Water, and Sanitation is a challenge still to be lar. One respondent made the interesting suggestion that to met, mainly because the life cycle of investments in in- truly make handwashing with soap a social norm, it would frastructure has a beginning and an end, while behavioral make sense for the ministries of tourism, transportation, change processes must continue in time. commerce, production, and others to be involved so that more public facilities for handwashing with soap would be Although the MOH’s national HW coordinating com- available. mittee has become inactive, ministries such as health and education are now working in coordination on health edu- One very experienced representative, a long-term partner cation in schools, which includes handwashing with soap. in HWI, stated, “It would be difficult to reverse the na- The ministries of education, health, and the environment tional support [for handwashing with soap] because of the created a joint indicators matrix for school health, which is alliances.� now used in around 20 percent of the 90,000 public and private schools. Another joint effort is the National Defense HWI is well represented in Cajamarca’s Regional Commit- Institute’s initiative on efficient use of water, with WSP, tee for Food Security and Nutrition (CORESAN), led by UNICEF, and other partners. the Social Development Unit of the regional government. CORESAN unites all sectors, public and private, national HWI has worked hard to facilitate or take advantage of and international, to coordinate and direct resources to- existing partnerships, particularly at the regional and dis- wards the reduction of child malnutrition, which is the in- trict levels. In some regions, HWI joined or strengthened dicator of poverty reduction for the region. Approximately partnerships already on the ground, as in Tumbes, Caja- 45 persons attended CORESAN’s most recent meeting in marca, and Piura; in others, with smaller groups at district October 2010. Working together, partners have produced level (in many regions). In Arequipa, HWI has allied itself manuals for preschool, primary, and secondary schools on with a coalition led by the Chamber of Commerce. Some, health and hygiene education and care of the environment. but not all, regions have strong coordinating groups, many Capacity building for HW promotion was done with all formed around CRECER, the national child malnutrition the institutional members of CORESAN that had field strategy—for example, the Regional Food Security Coun- promoters, resulting in activity throughout the region. One cil in Ancash and the District Technical Health Committee important partner is the PREDECI program against child in Junín. These may involve various government programs malnutrition in Cajamarca, funded by a group of mining and organizations, NGOs, and the private sector. Some al- companies. PREDECI has produced guidelines on strength- liances are formalized with memoranda of understanding ening municipal management for improved investments (MOUs) but many are informal. Responsibilities seem clear in young children, strengthening the work of community in either case. health agents, and local management of healthy schools. HWI provided technical support to Cajamarca regional HWI has done a much better job during the expansion authorities to design a Public Investment Project (PIP) to phase of keeping partners informed and motivated and support promotion of handwashing with soap, following in sharing innovations and lessons learned. Tools used include the footsteps of the Arequipa region. In Ichocán District, a bi-monthly newsletter with information and updates on a strong mayor is coordinating various public institutions the program in different regions, testimonies, interviews, and NGOs with focus on child malnutrition (water, hand- charts, and partnerships; a web site and blog; and a report washing with soap, food supplements, growth monitoring/ series and field notes. child development centers) throughout the municipality. www.wsp.org 9 Endline Assessment of the Enabling Environment in Peru Findings by Dimension Under the national CRECER initiative, regional govern- provinces. According to the Piura Regional Government Field ments have a coordination function and seek agreements Report, April 2010, the regional government spent $300,000 from civil society, government, churches, and NGOs to fa- of its own resources to implement the handwashing with soap cilitate resources for events or specific actions to address program in Huarmaca, obtaining a 25 percent reduction in child malnutrition. HWI launched the “Para Crecer Juntos� diarrhea among children. The municipality of Piura invested strategy, to bring together public and private regional institu- $20,000 in the implementation of a handwashing with soap tions to join efforts to reduce malnutrition rates. In March program at district level as well. HWI is supporting the orga- of 2008 HWI organized a workshop to update regional au- nization of a Regional Committee for Water, Sanitation, and thorities from Tumbes, Piura, Cajamarca, and Lambayeque Hygiene that brings together public and private institutions, on the regional processes and to design an action plan. Over building on networks developed by HWI. the following two years, this plan was implemented with the support of HWI’s regional coordinators and local partners.5 From 2003–2006 private companies provided marketing ex- BPZ Energy is a partner in the Tumbes regional plan for child pertise and disseminated information on handwashing with malnutrition, along with the Step by Step Foundation, HWI, soap through their own mass media (e.g., video broadcasts CIDA, and other partners. The company supports the pro- in banks) and interpersonal networks (e.g., house-to-house gram in one community and expects to move into others. It sales). Over time, their roles have shifted to provide financ- is encouraging other private companies to get involved. The ing at the regional and local level (e.g., through PREDECI WSP became a member of multi-sectoral regional committees in Cajamarca and CESEM, the technical arm of the Cham- in Tumbes and Cajamarca. In Piura it supported both pub- ber of Commerce, in Arequipa) and to direct local imple- lic and private institutions working in different districts and mentation of HWI methodology (e.g., Inkabor Association in Arequipa, BPZ Energy in Tumbes, and Campomar in La 5 WSP, unpublished concept note on partnerships, 2010. Libertad). Particularly in Arequipa and Cajamarca, mining BOX 4: KEY PRIVATE SECTOR PARTNERS Private mining and agricultural firms in Cajamarca, Tumbes, Piura, Ica, Lambayeque, La Libertad, and Arequipa fund handwashing with soap promotion. They have paid the honorarium for a nutritionist to give door-to-door education on handwashing with soap; paid for Super Jaboncine (SJ) handwashing stations in remote areas; dis- tributed, promoted, and monitored artisanal soap and SJ production for use in homes and schools; paid the costs of workshops; and assigned budgets to support monitoring. These firms include: Agrícola Chapi (Ica) Duraplast (national) Agrícola Saturno (Piura) Fundación Belcorp (national) Alicorp (national) Grupo Oviedo (Lambayeque) Asociación Civil Cerro Verde (Arequipa) Horizonte Corporativo Banco de Crédito del Perú (national) Inkabor Foundation (Ica) BPZ Energy (Tumbes) IMASEN (national) Buenaventura Mining (Arequipa) IOdebrecht (Lambayeque) CESEM (Arequipa) Pro Citrus—Duna Corp. (Huaral) Colgate Palmolive (national) Radio Programas del Perú (national) Campomar (La Libertad) Sunshine Exports DALE Foundation (Piura) Diarios Exreso y Extra Yanacocha Mining (Cajamarca) Source: Procesos y aprendizajes, March 2010. 10 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Findings by Dimension companies are powerful and work well with government; In general, private companies have been motivated by the HWI has encouraged and benefited from their participation. desire to contribute to local development and to generate In Piura private companies’ participation has gradually grown local goodwill where they work, not to sell more soap or as active companies often influence others to get involved. other products. Those supporting HWI have incorporated HWI into their existing social-responsibility programs. HWI established a fruitful partnership with Duraplast, a Firms are providing a platform for sustainable develop- plastics producer that financed the design and production of ment as their long-term investments and vision lead to a the mold to make Super Jaboncin (SJ), the handwashing sta- long-term commitment with the region, the district and the tion. Various HWI partners in Peru have purchased and dis- local population surrounding, and their customers. There tributed around 80,000 SJs in Peru, and PAHO purchased are also tax incentives and legal requirements to contribute an additional 10,000 for use in Guatemala. to social programs. One respondent stated “HWI has made it easy for private companies to participate as they wish—in TABLE 4: EXAMPLES OF PRIVATE COMPANY SOCIAL RESPONSIBILITY ACTIONS Institution Sector Location Actions/Programs BPZ Energy (gas and Tumbes Collaborates with regional government on regional plan for youth and chil- oil) dren; strengthen capacities of women entrepreneurs; university scholar- ships; preschool programs Dale Foundation Agro-industrial Piura Allied with health and education authorities; capacity building of local (DOLE bananas) (Sultana) farmers health promotion Duraplast (Sam- Plastics National Loan program for health and education; donation of paper, plastic, and corp Group) glass; recycles toner cartridges Belcorp Cosmetics National Initiatives to empower women economically; scholarships Yanacocha Mining Cajamarca Investments in health posts; vaccination against rubeola; community edu- cation program; infant malnutrition project; participates in coalition for sus- tainable development Cerro Verde Mining Arequipa Women Entrepreneurs Program (jewelry and textiles); financing various regional government water and sanitation works; supports health and education Agrícola Chapi Agro-industrial Ica Project to strengthen community organization; environmental education; restoration of biodiversity of local forest El Diario (The Media Piura Training school reporters; campaign to raise awareness of need to conserve Times) water; operates local listserv on social and development issues Scotiabank Media National Donations, sponsorships, programs to help communities; support to health and education of women and children Piura University Education Piura Supports local development programs; supports nutrition, education, hy- giene and nutrition programs in communities; periodic hemoglobin and parasite screening Agua Limpia Water and La Libertad, Public education; technical assistance to the regional government; training of sanitation Ancash, specialist operators; sanitation education program Arequipa Southern Peru Mining Tacna, Sustainable development projects; infant malnutrition program; generic Moquegua improvement of alpacas Source: WSP Manos Limpias, NIÑOS SANOS, 03, September 2009. www.wsp.org 11 Endline Assessment of the Enabling Environment in Peru Findings by Dimension funding, implementation, etc. There is no bureaucratic process they need to go through.� Recommendations for strengthening Partnerships: • If feasible, continue to publish and widely dissemi- nate the HWI bulletin, with a focus on creative and effective contributions by partners at the regional and district level that could later be adopted by the WSP Hygiene and Sanitation Alliance. • Encourage regional, provincial, and district coali- tions addressing handwashing with soap to publicize their own work and results, including the contribu- tions of various partners, through local radio, news- papers, and public events. Schools that participate in a program coordinated by the Ministry of Education and Ministry of Health, have a “healthy corner� in every primary classroom. In Moho, Puno, children 2.3 Institutional Arrangements wash their hands before eating a morning snack. This dimension seems to be well addressed. Respondents pointed out no significant weaknesses. indicators (including ones on handwashing with soap) and As a result of the current government’s policy to encour- are preparing a national guide that includes an adaptation age an intersectoral approach in its programs, there has of the handwashing with soap methodology. been much stronger collaboration between the ministries of health and education, accompanied by more policies, At the regional and local levels, HWI has supported for- resources, and action in the field. In the last two years, mal agreements among local governmental and private the ministries of health and education have signed agree- partners that support promotion of handwashing with ments that spelled out in detail how they would integrate soap. National, regional, provincial and district govern- handwashing behavioral change methodology, technology, ments have approved over 120 ordinances, decrees, and and tools in schools. The ministries of health, education, agreements in support of handwashing with soap, some and the environment collaborate on implementing the directing activities of a particular organization and some healthy schools program; they have devised a unified set of outlining collaborative agreements. In Cajamarca, the Key Findings: Institutional Arrangements Baseline Findings (2007) Endline Findings (2010) • Key national partners were coordinated through • The committee is not currently active, which is support through a national HW committee. appropriate given recent governmental decentralization. • Major partners tended to promote handwashing with • There is much more collaboration in planning, imple- soap in their own organizations and programs. menting and M&E at national, regional, and local levels. • HWI tended to encourage formal agreements with pub- • The focus moved to encouraging formal commit- lic partners but not with private-sector ones. ments to promote handwashing with soap rather than agreements between the HWI and partners. 12 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Findings by Dimension institutional agreements are between many collaborating MOE, MIMDES), HWI’s BCC methodology has been organizations and programs with CORDESAN; responsi- passed on through cascade training, along with supportive bilities are clear but not formalized. The Tumbes five-year tools and materials, to teachers, health staff, and health vol- regional plan that includes promotion of handwashing unteers. At the end of their training, teachers sign an agree- with soap has the authority of law. The DALE Founda- ment to facilitate the six modules with their students, share tion has an agreement with the municipal health office in the methodology with the other teachers in the school, de- Sullana to promote handwashing with soap, and there are sign and implement mobilization activities in the school, many similar local arrangements. involve students’ families in the process, and present a re- port on these steps. On completion of the process, the DRE HWI has formal agreements with the MOE and MOH. (regional government education unit) awards the teachers a MIMDES expects to approve a formal policy supporting certificate, which adds points to teachers’ curricula and im- handwashing with soap promotion by July 2011. proves their job classification. The MOH has a similar pro- cess for health professionals, but the certificates are awarded Recommendation for strengthening Institutional from the national level. Arrangements: While the basic methodology has remained over time, • Through their social-development projects in Peru, there have been appropriate changes in emphasis on com- WSP and the World Bank should advocate for re- munication channels and in core messages. Feedback from gional and local governments to promote handwash- field promoters guided the HWI in making the modules ing with soap, using HWI’s methodology and tools. and manuals more concise. Another small change was the substitution of photos for drawings in some local materi- 2.4 Program Methodology als. (See Box 5 for the full list of materials.) At present the HWI’s intervention activities focus on promotion of modules for teachers and promoters are undergoing a thor- handwashing with soap and capacity building of trainers ough expert review within government ministries, which from many partner organizations so that they can orga- will probably lead to some revisions to have a stronger focus nize and carry out interpersonal sessions and promotional on HW stations, key moments, and motivators. events, as well as local mass media. In addition, the proj- ect contracted airtime to support local dissemination. Various respondents in the field felt that they needed more copies of materials, particularly to expand handwashing with Based on formative research, which was then tested and soap promotion to new districts and communities. They noted officially approved by major government ministries (MOH, that a huge supply of materials would be needed to cover Key Findings: Program Methodology Baseline Findings (2007) Endline Findings (2010) • Opinions on the methodology were generally quite • Opinions were strongly positive. positive. • Some respondents felt a need to focus more on in- • Interpersonal communication, along with group ac- terpersonal communication, while media representa- tivities, seems to play the leading role, with mass tives felt that mass media could play a stronger role. media used occasionally and strategically. • Some people noted that the approach seemed to work • This comment was not repeated, although great particularly well among children. enthusiasm was consistently observed among both teachers and pupils. • The ministries of health, education, and women are firm supporters now. www.wsp.org 13 Endline Assessment of the Enabling Environment in Peru Findings by Dimension BOX 5: PRINCIPAL TRAINING AND BCC MATERIALS PRODUCED AND DISTRIBUTED First Phase (2005–2007): • A module for facilitators to train health promoters on behavior change communication that targets women. • A module for facilitators to train teachers on behavior change communication that targets children. • An educational kit with educational games for children of different ages • Radio materials in Spanish and Quechua, including a 10-episode soap opera, spots, and jingle, along with in- structions on use • Posters to reinforce points from the radio series • A reminder poster on critical moments to wash • TV spots • Institutional (advocacy) video with testimonies from officials involved in HWI in various parts of the country Second Phase (2008–2010): • Parents’ manual—module for trainer to work with parents (nutrition and handwashing with soap) • Poster with guidelines for producing homemade liquid soap and SJ use • New radio materials—nine radio pieces on the superhero Super Jaboncín, including a new jingle, in two ver- sions, spots, and short programs • New print materials, including fliers, banners, press information, stickers, etc., all focused on the superhero Super Jaboncín all of the 50,000 public schools and 90,000 total schools. A few comments on limitations of the methodology WSP/HWI states that it has excess supplies of materials, so the concerned the need for materials in Quechua and problem may be that people in the regions and districts do not other local languages and the need for additional cop- know of the availability, or know how to request the supplies. ies of print materials and particularly of SJs. Some mothers in Puno claimed that they were too busy to Virtually all people interviewed praised HWI behavior- attend all three handwashing with soap orientation change methodology as more effective than and differ- sessions, so they dropped out before the third (and ent from most communication in Peru. Many praised its last) one. In response, the DIRESA (health unit of training as clear and simple, well-documented, and well- the regional government) is combining the last two supported by tools. It was recognized as participatory train- sessions. Some teachers agree that the process is long, ing that promotes active learning in contrast to traditional, and there has been some passive resistance from the didactic approaches. People like the handwashing stations militant teachers union in Puno. A minority of teach- (SJs) and the games, drama, and other group activities. ers in Cajamarca are also said to resist spending class Some also noted that the methodology has been adjusted on time on handwashing. the basis of monitoring findings. Some are aware that rather than merely giving people information, HWI methodology A few respondents suggested that this behavior-change- focuses on emotional motivations and reinforcement. Vari- oriented method has affected the educational approaches ous respondents noted that their organizations or programs of the various government agencies that have used it. had been promoting handwashing with soap with many A new regional-government project in Cajamarca to years but that HWI has brought a stronger methodology combat malnutrition has been designed using HWI’s and focus that they believe has led to more effectiveness. methodology. 14 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Findings by Dimension Recommendations for strengthening Program Methodology: themselves been effective trainers. The HWI has focussed on integration to face this challenge, under the assumption that • Advocate and facilitate the BCC approach of HWI the ministries, regional, and local governments will continue in all of WSP’s social development programs, in par- the capacity-building activities in the future. ticular the Hygiene and Sanitation Alliance. • Continue collaborating with MIMDES (PRONAA, The MOH now has regional health facilitators who train Wawa Wasi, FONCODES) in finalizing the process health staff and promoters and teach them to give effective of adoption of HWI methodology for their pro- demonstrations. Within the educational system, in particu- grams, and then prepare the print-ready adaptations lar, capacity building must be an ongoing process due to of HWI materials. the high turnover of teachers from year to year. Thus, even • Continue to work with the ministries of education, in places like Cajamarca, where there appears to be enough health, and the environment to finalize the process trained persons at present, capacity building must continue of adoption of HW methodology, and then, time- because of the turnover problem. PRISMA now targets local permitting, prepare print-ready joint guidelines for leaders who are permanent in the communities for training. the Healthy Schools program. HWI’s strategy for sustained capacity building is to advo- 2.5 Implementation Capacity cate for and support the integration of its behavior-change Through both support from HWI and their own internal methodology, including training, into key national pro- processes, the implementation capacity of major partners grams. The training methodology and tools have been at national and other levels has improved over the last few substantially integrated into the MOE and MIMDES, so years. HWI, in part through its contracted regional coordi- it is expected that they will allocate resources for training nators and NGOs, has made a major effort to build capacity new personnel as well as for refresher training to address in allied programs and organizations, mainly in: implemen- the problem of staff turnover. The effectiveness of capacity tation of the behavior-change communication (BCC) meth- building may be limited because some field sites have insuf- odology; advocacy for commitments, funding, and alliances; ficient staff to implement and report on multiple programs. and monitoring and evaluation. HWI has trained more than 22,000 teachers and health agents to promote handwashing Moreover, WSP’s transition strategy is to encourage and fa- with soap among women and children. While this training cilitate regional public investment projects (PIPs)*, such as of facilitators has been a strong point, some respondents feel the one approved in Arequipa and one likely to be approved that the subsequent cascade training is not always effective, in Cajamarca to continue HWI activities beyond the proj- because some of the persons trained to train others have not ect. WSP is sharing the approved PIP with other regional Key Findings: Implementation Capacity Baseline Findings (2007) Endline Findings (2010) • In general, effective skills and systems needed to • Through advocacy, coordination, training of trainers, implement the program existed at the national level and provision of communication and program- but were weaker in some regions and districts. support materials, HWI has contributed to increasing implementation capacity at regional and district levels. The main capacity gap affecting promotion of handwashing with soap is the governing and management skills of some local officials who have gained new responsibilities and access to resources. * Public Investment Project (PIP) is a tool used by regional and local governments to request funding for specific projects to the Ministry of Finance. www.wsp.org 15 Endline Assessment of the Enabling Environment in Peru Findings by Dimension governments to inform new authorities about what has been Advocate with partners to support capacity building in done, and what could be done in the future. Regional govern- regional and municipal governments in planning, project ments greatly value already developed PIPs, which can facili- preparation, proposal writing, and other basic skill areas. tate new resources, fast spending, and good management. PIPs that incorporate handwashing with soap normally have three 2.6 Availability of Products and Tools components: training, information and education, and SJs. The main products and tools needed for handwashing with soap are water and soap. Soap availability was already Several respondents mentioned that capacity building in high (above 98 percent) in 2004 and remains near the M&E is needed in many regions and districts. same level. The issue with soap, however, is affordability, as poor families may not want to buy as much soap as needed Finally, regional governments are still learning their new to wash hands at all key times. The project’s facilitation of roles, and their capabilities to plan and manage programs the development and distribution of the SJ (handwashing depend a great deal on the people in key positions. In many station) has been a good response to this problem, because cases, there is a clear need for capacity building in regional it uses liquid soap, which most people make by putting a and municipal governments in planning, project prepara- small piece of bar soap in hot water. tion, proposal writing, and other basic skill areas. Some regional governments are unable to spend a significant por- Access to water remains a problem in many poor neigh- tion of their budgets each year. borhoods and towns. Some neighborhoods in many urban areas have running water for only a limited number of Recommendations for WSP/HWI for strengthening Im- hours per day, and some rural communities have no access plementation Capacity: to water systems. The continued dissemination of SJs is a partial solution to poor access to water, as a two-or-three- • Provide technical assistance to public sector partners liter bottle holds enough water for numerous good hand in planning, implementing, monitoring, and evalu- washes, if used correctly. ating multi-sector water, sanitation, and hygiene investments. In high Andean regions, very cold water can make it un- • Engage with new incoming authorities to explain the pleasant to wash hands. One solution that people use is to benefits of handwashing with soap promotion, the place the SJ in the sun so the water will warm. Another is methodology, and implementation requirements; to add a drop of castor or almond oil to the water. After and urge them to continue integrating hygiene BCC SJs were distributed to families in Moho, Puno, people into their priority health, environmental, education, complained that they could not obtain the plastic bottles to and W&S programs. complete the stations. The school organized a community Key Findings: Availability of Products and Tools Baseline Findings (2007) Endline Findings (2010) • Soap is available to more than 95 percent of families; • General availability of soap and water has not however, many poor communities have difficult, changed; however, some schools have installed long seasonal, or part-time access to water. sinks with multiple faucets for handwashing with soap and the invention and distribution of SJs to many schools and families have greatly facilitated handwashing with soap. 16 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Findings by Dimension budgets in the future for SJs; for example, funds for SJs are included in the project HWI is designing with MIMDES. The general consensus is that the SJ handwashing device has greatly facilitated handwashing practice. Placed in class- rooms or near latrines and kitchens, it reminds people to wash hands with soap, makes it very convenient to wash, and economizes both water and money spent on soap, since soap in liquid form goes further than in bar form. It also discourages the stealing of soap. Plastic basins and other small utensils can also facilitate handwashing with soap but are not absolutely essen- tial. Clean towels for drying also facilitate handwashing In Casacunca, Cusco, a daughter watches as her mother with soap, but are not essential if air-drying is used. It uses a piece of laundry bar soap to prepare a 3-liter bottle of is difficult to keep towels clean in poor environments, liquid soap. On average, a 3-liter bottle of liquid soap will last so in fact many experts recommend air-drying in such 21 days for a family of five. circumstances. collection of bottles, which appears to have solved the prob- Recommendations for strengthening Availability of Prod- lem, but there may be difficult access to large plastic bottles ucts and Tools: in some rural communities. • In the interest of sustainability, encourage local part- Some 80,000 SJs are in use in schools and homes, although ners (public and private) to plan for and finance ad- there is a potential demand for hundreds of thousands, if ditional copies of materials. Private companies may not millions, more units. The only significant constraint well be willing to assume this cost, particularly if their to additional production, distribution, and use of SJs is logo can be placed on the material. A company that securing funding for the production cost of $0.70 or less purchases SJs, for example, could put a sticker with its per unit, depending on the amount produced. According logo on each one, which would be seen by students to WSP, the problem has been the budgetary process—the and families numerous times teach day. Private com- public sector takes very long to have budgets approved (for panies also have tax write-offs for such expenditures. example, the regional government of Arequipa took one year). • Encourage homemade SJs, as have been made in In some cases, for rather small purchases (1,000 items), district- one area of Cajamarca. Perhaps handwashing sta- level education institutions and private firms have allotted tions could be made from totora reeds in the Lake resources to buy SJs. WSP expects large programs to assign Titicaca area. www.wsp.org 17 Endline Assessment of the Enabling Environment in Peru Findings by Dimension 2.7 Financing of mining profits and other contributions, exceeding their In recent years, the bulk of government implementation capacities to spend (the Arequipa regional government did funding has shifted from such ministries as health and not spend 45 percent of available funds in 2009). education to the regions and local governments: minis- tries’ roles are primarily to define national initiatives, Districts/municipios can receive budgetary support from the policies, guidelines, and tools. Implementation occurs at MEF through the Municipal Incentive Program, for which the regional and district (municipal) levels, with funding handwashing promotion is one of seven spending catego- coming from the regional and municipal governments, ries. A major purpose of the fund is to discourage muni- from local private companies, and through various fund- cipios from spending their entire budgets on construction ing mechanisms, particularly from the Ministry of the projects and specifically assign 5 percent of their budgets to Economy and Finance (MEF). HWI has adjusted well to activities related to reducing malnutrition. this new political scenario. Regional governments can also apply for approval of so- There is a mixture of positive and negative findings regard- cial projects from the MEF through a PIP. The Chamber ing financing for expansion and sustainability. On the one of Commerce and Cerro Verde mining company collabo- hand, officials in the field complain of a lack of financing rated with the Arequipa regional government to prepare a to enable them to expand the program to new districts, project plan to finance implementation of handwashing communities, and private schools. Money is needed for with soap promotion in several additional districts. After such expenses as training, SJs, communication and train- 14 months, the project was approved for a total budget ing materials, as well as the time and expense for staff to of $330,000 for capacity building, impact evaluation, train, manage, supervise, support, and evaluate handwash- and the acquisition and distribution of 30,000 SJs. Other ing with soap promotion. On the other hand, various pro- public and private organizations have agreed to contribute grams from the ministries of health, education, and women to the project. have funding for some of these costs, and regional and local governments have their own budgets plus the ability The Piura regional government has invested around to write proposals for additional funding. Some regional $300,000 for coordinated handwashing with soap pro- governments have large budgets to spend from their share motion in Huarmaca province. The project has measured Key Findings: Financing Baseline Findings (2007) Endline Findings (2010) • Financing mainly in the form of funding by • Funding mainly from the Peruvian government, international donors and in-kind contributions by through various mechanisms, as well as from private private companies to reach their staff and customers companies at regional and local levels. through existing channels. • Regional, provincial, and district governments have access to many government funds, and some in ad- dition have the potential to tap significant private funding; the main contraints are their ability to pre- pare solid proposals for funding and to spend allo- cated funds efficiently. 18 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Findings by Dimension a 25 percent reduction in diarrhea in a nine-month strengthening (planning, budgeting, HR manage- intervention. ment, etc.) to regional and district governments. • Work with allies and new partners to strengthen re- Various regional governments (such as Cajarmarca, Junin, gional governments’ capacity in social project plan- Ancash, La Libertad, Puno, Huancavelica, Apurimac, ning, budgeting management, and M&E (see capacity Moquegua, Tumbes, and Arequipa) and alliances have ef- building). In addition to training and mentoring, gov- fectively tapped contributions by private companies, par- ernments could be offered such tools as sample pro- ticularly mining companies. Large companies are often posals and guidelines for social project development willing to contribute because of their social responsibility/ along with planning, reporting, and M&E formats. public relations objectives. They also receive a reduction in • Continue to facilitate PIPs that support handwash- taxes in exchange for making social investments, and they ing with soap. are required by law to contribute a portion of profits to • Advocate with regional governments to include social programs. There remains much scope for more in- funding and activities for promotion of handwash- volvement of private companies in local partnerships that ing with soap in annual work plans and in multi-year promote handwashing with soap or more independent con- regional development plans. tributions or actions by private concerns. 2.8 Cost-Effective Implementation It is important to note, however, that some regions enjoy a We found there is a common perception, based on avail- wealth of large private enterprises, while others have few or able local data and feelings, that handwashing with soap none. Those regions with neither large private companies is cost-effective. One private sector respondent called it a nor public/private partnerships will need to rely on public “low cost, high impact� intervention because it contrib- and donor funding. utes to many health and social goals—it helps reduce mal- nutrition, diarrhea, and pneumonia, and improves child Recommendations to WSP/HWI for strengthening health and school performance. School staff seemed to Financing: share this idea. • Continue to advocate with the MEF to include a line The cost-effectiveness survey will be conducted during the item in the national budget to build the capacity of re- second half of 2011. It seeks to collect information on the gional and district governments in planning, implement- costs of implementation activities and attribution to spe- ing, and monitoring of behavior-change methodologies. cific sources. In Peru, many institutions, both public and • Explore with the MEF and other partners how best private, allocated resources to the HWI in different regions to offer training and other support in institutional of the country and nationwide. Key Findings: Cost-Effective Implementation Baseline Findings (2007) Endline Findings (2010) • WSP and its partners had collected extensive cost • WSP intends to carry out a cost-effectiveness study information but not yet calculated cost-effectiveness. in 2011. • Capabilities to collect and analyze needed data exist • Capabilities do not appear to have changed. at the national level, but technical support is seen as necessary at subnational levels. www.wsp.org 19 Endline Assessment of the Enabling Environment in Peru Findings by Dimension Because handwashing with soap promotion in Peru is in- one indicator is progress in implementing education on tegrated into many different programs, calculating cost- handwashing with soap. There are four implementation effectiveness may be difficult. The bulk of WSP’s expendi- levels ranging from the “school has soap and water� to tures have not been for direct implementation, but rather for “over 90 percent of students adequately wash their hands advocacy, coordination, information dissemination, M&E, with soap.� and for developing and facilitating the availability of key tools and approaches. There were some opinions that M&E training and assis- tance to local governmental units is needed. Government The one locus of interest in cost-effectiveness data is the officials have neither the time nor the skills to carry out MEF, for which such data is important in approving fund- good M&E; the number of activities for which they are ing at sub-national levels. responsible overwhelms them, and they cannot monitor everything. Recommendation for strengthening Cost-Effective Implementation: HWI has its own project M&E systems for tracking inputs, activities, outputs, and impact on practices and health and • At the time of the WSP cost-effectiveness study, social indicators. Data come from several sources, includ- discuss with the MEF the importance of cost- ing routine reports from coordinators and contractors in effectiveness data for its funding of handwashing the regions, longitudinal studies, and baseline and endline with soap promotion as well as other programs. If surveys. Key indicators are: such data will continue to be needed, organize an orientation/training for key partner staff. • Percent of reduction in diarrheal disease in children under 3 2.9 Monitoring and Evaluation • Percent change in the percent of the target popula- Handwashing with soap is included in the monitoring tion (children under 12 and mothers) who demon- and information systems of virtually all of the numerous strate correct handwashing with soap government programs with which it works; e.g., it is in the • Percent of the target population whose KAP and re- Wawa Wasi information system and in the healthy schools sources change positively due to HWI activities program, for which the ministries of health, education, • Cumulative number of social agents training in and the environment collaborated on a unified set of in- HWI methodology dicators. MIMDES programs employ a family informa- • Percent of the target population reached by interper- tion sheet, filled out annually, that includes handwashing sonal communication indicators. In the M&E system of the government’s Sus- • Percent of the target population reached by promo- tainable Development of Educational Institutions initia- tional events tive (ministries of health, education, and environment), • Percent of the population reached by mass media Key Findings: Monitoring and Evaluation Baseline Findings (2007) Endline Findings (2010) • Respondents generally agree that M&E is important, • HWI has done a better job of disseminating informa- but they are not aware of the results of HWI’s tion (monitoring progress, lessons learned, monitoring. innovations, etc.) through a web site, newsletters, and reports. Still, some respondents do not recall seeing documents and information that they should have received. 20 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Findings by Dimension Staff of schools, preschools, and health facilities use their own want to see evidence of impact as a condition for significant local statistics for assessing the impact of handwashing with investments. Hopefully the HWI’s endline survey will pro- soap promotion on child malnutrition, diarrhea, respiratory vide such evidence for handwashing with soap. disease, and school absenteeism. Many of the persons visited claimed improvements in these indicators. For example, in Recommendation for strengthening Monitoring and Ichocán district (which has addressed malnutrition as a prior- Evaluation: ity) health staff and teachers both reported almost no cases of diarrhea or lower respiratory infections following activities to • Meet with key national and regional partners to dis- treat water and handwashing with soap promotion. The dis- cuss their satisfaction/comfort with current M&E trict health center in Moho, Puno region reports only two or of handwashing with soap in their organizations. three cases of acute diarrhea this year and one case of pneu- If there is sufficient demand, and it is feasible, help monia, with no deaths from these causes. organize orientation/training on handwashing with soap for interested partners. The impact evaluation endline survey that HWI will imple- ment in 2011 will need to look very carefully at the micro- 2.10 Assessment Scores level of implementation. Although there has been some WSP developed a “spider diagram� (see Figure 1) to moni- handwashing with soap promotion in almost all regions, tor progress in the EE through categorical scales for each the intensity varies within regions and districts (as planned dimension. Each point on the scale (0–5) has defined in- by the evaluation methodology). For example, within a dis- dicators against which progress is assessed. Achievement of trict some communities may have received house-to-house an indicator is binary—either it has been achieved or not. education and SJs; there may have been handwashing with Each country has unique indicators, although the dimen- soap promotion in some, but not all schools; and some, but sions are consistent. For example, to assess Partnerships, not all communities may have had group “promotional� the EE in Peru is evaluated on the following indicators: events such as handwashing demonstrations or dramas. Within a region some districts may have had only short- • Stakeholders from public and private sectors term mass media coverage, but no interpersonal or group identified communication or activities. The other, unavoidable, issue • Partnership formalized, roles and responsibilities is some contamination of control areas by mass media and defined by some handwashing with soap promotion through na- • Partnership functioning according roles and respon- tional programs of the MOH and others. sibilities at national level • Partnership functioning according roles and respon- Several informants said they were puzzled by the design that sibilities at regional/local level requires control districts. They find it hard to understand • Partnership involves public, private and civil society why the program would deny the benefits of handwashing institutions at national and regional/local levels with soap to districts that want it (because they hear about the program activities in other districts) and to families that The following table summarizes the scores of each dimen- need it. sion of sustainability and scalability from the endline as- sessment and previous scoring by the project staff in Peru. It is important to note that the MEF, which plays a key role All scores were low in 2007, and every dimension but cost- in funding, setting priorities and approving projects, does effective implementation has reached a high level now. www.wsp.org 21 Endline Assessment of the Enabling Environment in Peru Findings by Dimension FIGURE 1: SPIDER DIAGRAM TO MONITOR PROGRESS IN THE ENABLING ENVIRONMENT Policy, Strategy and Direction 5 4 Partnership Institutional Arrangements 3 2 1 Monitoring and Evaluation Program Methodology 0 Cost-effective Implementation Implementation Capacity Key Endline 2010 Financing Availability of Products and Tools 2009 2008 2007 The spider uses categorical scales for each dimension. Each scale represents a dimension and each point on the scale ( 0-5) has defined indicators. Achievement of an indicator is binary—either it has been achieved or not. EE progress should not be considered linear, as scales may be achieved out of the order listed. For this reason, EE scores are cumulative and not sequential. TABLE 5: ENABLING ENVIRONMENT SCORES BY DIMENSION EE Dimension 2007 2008 2009 2010 Endline Percent Achieved 1 Policy, Strategy and Direction 1 2 4 4 5 100 2 Institutional Arrangements 1 2 4 5 5 100 3 Program Methodology 0 1 2 3 5 100 4 Implementation Capacity 1 2 3 4 4 80 5 Availability of Products and Tools 1 3 3 5 5 100 6 Financing 2 3 3 3 4 80 7 Cost-effective Implementation 0 0 1 1 1 20 8 Monitoring and Evaluation 0 1 3 3 4 80 9 Partnerships 1 2 4 5 5 100 22 Global Scaling Up Handwashing III. Conclusion HWI’s strategic vision, as described by the national agents) who fulfilled their plans of interpersonal coordinator, is to identify opportunities to strengthen communication with the audience. the enabling environment and build upon them; share • While focusing on achieving regional and local com- ideas and lessons; focus on stimulating regional respon- mitment to handwashing with soap, the HWI has sibility; and support regions with tools, training, and advocated effectively at the national level with the guidelines. ministries that set national priorities and policies. It is in this spirit that HWI has consciously and successfully In general, HWI has done quite well on the dimensions of taken advantage of two strong national trends over the past sustainability defined by WSP. The chances of the sustain- several years: ability of handwashing with soap promotion are excellent in key ministries (health, education, and women) and in • A priority national effort to reduce childhood mal- certain regions and districts. However, an occurrence with nutrition, and an unknown impact is the impending end of the contracts • A gradual, but strong, move toward decentralizing of HWI’s consultants and contracted NGOs. Despite the funding and decision-making to regional, provin- significant institutionalization of handwashing with soap cial, and district governments. within key ministries, NGOs, and regions, there is still a need for some of the key functions of these coordinators: As mentioned, HWI’s strategy for sustainability has fo- advocacy for handwashing with soap, building and nurs- cused on integrating HWI’s methodology within national ing alliances, facilitating additional training (for new dis- (health promotion, school education, environmental edu- tricts and because of the high turnover of change agents) cation, nutrition, and water and sanitation) regional and and monitoring and adjusting the HW methodology. It is local programs to strengthen reach and impact. Currently unknown how people and partners in the regions will step WSP is working to integrate the behavior change approach up to the plate to effectively carry out these functions. to hygiene promotion within its programs and wider World Bank programs. Continuation of handwashing with soap promotion, how- ever, does not necessarily mean the full array of approaches HWI has also followed several other strategies that have en- in the HWI methodology. It is more likely that partners hanced both effectiveness and sustainability: will continue interpersonal communication in schools and communities and group activities to promote handwashing • A strong focus on children, built on the opportunity with soap (health fairs, dramas, discussions, and celebra- provided by the integration achieved within MOE tions) as well as mass media. In the decentralized situa- and MIMDES. Children have proven to be enthu- tion of Peru, mass media may play a relatively minor role, siastic participants and promoters of handwashing mainly during HW week and in regions where the private with soap and appear to be effective change agents sector is willing to fund broadcasts or radio or television within their families. stations are willing to give free airtime. HWI’s endline sur- • HWI has carried out effective internal project com- vey should indicate the extent to which people heard and munication activities through its newsletters, web remember mass media promotion. When asked about the site, reports, and meetings. Such actions provide both project methodology during this assessment, most respon- important information and motivation to partners. dents mentioned interpersonal and group activities only. The project has also worked hard with national and regional partners to facilitate certificates for change The project worked in specific districts and provinces in agents (teachers, health staff, and community health 24 of the 25 regions of the country achieving objectives of www.wsp.org 23 Endline Assessment of the Enabling Environment in Peru Conclusion reach. The project’s continuation in these and additional First, the Social Specialist in the MIMDES office in Puno is districts will depend on integration arrangements underway taking an initiative to address the issue of new officials tak- with the Ministry of Women and Social Development, and ing office who may not continue to support important social on future WSP hygiene and sanitation projects. programs. He has scheduled for late November a three-day workshop for the 39 newly elected mayors and the two re- Table 6 summarizes the main factors that favor and those gional government candidates, to provide orientation and that could threaten handwashing with soap sustainability. support on the management of social programs. This concept deserves to be replicated throughout the country, but it would Several steps to address the challenges have already been take some very rapid national coordination to organize this. taken: Certainly the HWI should lend its support where possible. TABLE 6: FACTORS FAVORING AND THREATENING HANDWASHING WITH SOAP SUSTAINABILITY Factors That May Favor Factors That May Threaten • A strong, shared priority at all levels to promote hand- • A change in the presidency in July 2011 could, over a pe- washing with soap as a way of addressing young child riod of a couple of years, lead to less priority, attention, and malnutrition resources for handwashing with soap and related social • Insertion of handwashing with soap promotion into regional issues. development and health plans, facilitating justification for • Changes in regional presidents and mayors in early 2011 resource allocation from different partners could lead to changes in local priorities. • A strategy of including promotion of handwashing with soap • The significant annual turnover of teachers, and to a lesser into numerous social development programs extent, health personnel, creates the need for regular • A strategy of encouraging and facilitating many strong re- training in handwashing with soap, which may be difficult gional alliances of organizations and programs for programs to do while expanding to new districts and • A focus on children, who have been exceptionally communities. enthusiastic • The rapidly approaching end of the implementation phase • A recognition of the strong impact of national policies that of the HWI will deprive regions of coordinators who play key require implementation and allocation of funds at the re- roles in advocacy, coordination, and facilitation of resources. gional and district levels The program in some regions has been institutionalized suf- • Private companies’ strong social responsibility programs, ficiently to move forward well, but other regions may have supported by tax incentives. Private funds are to be al- difficulty. located for the continuation of the program and scaling up • Success could breed complacency, as has happened with after project completion. many public health eradication campaigns (malaria, yaws, • A strong, well-received project methodology, based on a etc.). Once a problem seems almost “solved,� officials tend behavior-change process to move on to other priorities and the “solved� problem • Perceptions that handwashing with soap has contributed to re-emerges. improvements in child growth, and reductions in malnutri- tion, diarrhea and respiratory disease reduction, and school absenteeism • Authorities gathered evidence of diarrhea reduction among children and attribute it to the HWI—leads to national and regional policy. • HWI’s concern with sustainability from the beginning, con- ducting periodic assessments and making efforts to improve the environment for sustainability 24 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Conclusion Second, the MOH is leading a group, which includes the MOE and MIMDES, that has almost completed a booklet for mayors to explain HWI, its activities, costs, etc. The MOE and Ministry of Environment produced national guidelines for teachers on environmental education that include HWI’s training methodol- ogy for behavioral change In addition to the initial enabling environment assessment conducted in May 2007 and annual updates on scores for each of the nine dimensions, HWI under- took 18 regional assessments of scalability and sustainability in 2008. These were used as a baseline. Finally, from the beginning, the Peru team established several objectives related to sustainability: (1) To become part of national, regional and local policies related to health and nutrition, education, water and sanitation (2) to institutionalize the behavior-change methodologies and tools in these sectors; and (3) to insert handwashing behavioral change approach and methodologies into the MEF’s na- tional budget. The first two objectives have been largely achieved. The last one is still in process. www.wsp.org 25 Endline Assessment of the Enabling Environment in Peru Background Reading Background Reading Bossert, Thomas J. 1990. “Can They Get along without Impact Evaluation Baseline Survey in Peru. Water and Us? Sustainability of Donor-Supported Health Projects Sanitation Program. in Central America and Africa,� Soc. Sci. Med. 30(9), Iniciativa Lavado de Manos. Higiene y Salud. Manos pp. 1015–1023. Limipias, Niños Sanos. February 2010. Cogswell, Lynne and Lene Jensen. 2008. Guidelines for Iniciativa Lavado de Manos. Higiene y Salud. Manos Assessing the Enabling Environment Conditions for Limipias, Niños Sanos. July 2009. Large Scale, Effective, and Sustainable Handwashing Iniciativa Lavado de Manos. Higiene y Salud. Manos with Soap Behavior Change Programming. Guidance Limipias, Niños Sanos. August 2009. Document 01/2008. World Bank (Water and Sanita- tion Program). Iniciativa Lavado de Manos. Higiene y Salud. Manos Limipias, Niños Sanos. September 2009. Devine, Jacqueline. 2010. Insights from Designing a Handwashing Station for Rural Vietnamese House- Iniciativa Lavado de Manos. Higiene y Salud. Manos holds. Water and Sanitation Program. Limipias, Niños Sanos. October 2009. Devine, Jacqueline, Nat Paynter, and Hnin Hnin Pyne. Iniciativa Lavado de Manos. Higiene y Salud. Manos 2010. Scaling Up Handwashing with Soap Project Limipias, Niños Sanos. November 2009. Peru. Back-to-office report. May 10–14. Iniciativa Lavado de Manos. Procesos y aprendizajes de la Favin, Michael and Doris Alfaro. 2008. Scaling Up Hand- Iniciativa Lavado de Manos al 2010. washing with Soap Behavior Change Programs in Peru: Instituto de Estadística e Infomática (INEI), Agencia de Initial Assessment and Baseline of the Enabling Envi- los Estados Unidos para el Desarrollo Internacional ronment for Scaling Up and Sustainability. Working (USAID), and Programa Measure DHS+/ORC Macro. Paper. World Bank (Water and Sanitation Program). Perú Encuesta Demográfica y de Salud Familiar 2009. Florez, Rocio and Jacqueline Devine. 2010. Peru: A Hand- Visión nacional y departamental. Lima, May 2010. washing Behavior Change Journey. Water and Sanita- Instituto de Estadística e Infomática (INEI) and Programa tion Program. Measure DHS+/ORC Macro. Perú Encuesta Demográ- Galiani, Sebastian and Alexandra Orsola-Vidal. 2010. fica y de Salud Familiar. ENDES Continua 2004–2005. Scaling Up Handwashing Behavior: Findings from the Lima, November 2005. 26 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Annex A: Draft Question Guide in English Annex A: Draft Question Guide in English Interview Guide Definition: The questions included in this guide are not to be fol- lowed verbatim. Rather, they should serve as a guide to the • Policy: A set of procedures, rules, and allocation conversation. mechanisms that provide the basis for programs and services. Introductions (5 minutes) • Strategy: Guidance on how to implement a policy. • Introductions • Direction: A common understanding among inter- • Appreciation for time ested parties of the goals of an intervention. • Purpose of interview—follow up on baseline. Want to understand changes in the EE. Want to under- 1. How strong do you believe the political will is to stand what can be done to improve the EE before the support handwashing with soap is at the national project ends (Nov. 2011) [regional or local] level? • Definition of enabling environment 2. What organizations or leaders have most moved the • Confidential, won’t use name or other identifying program forward? information 3. Are there additional organizations or leaders whose • Participants will receive feedback from WSP on the political support is needed to strengthen the hand- findings and recommendations washing with soap initiative? If so, please explain. 4. What, if any, suggestions do you have for strength- Opening (10 minutes) ening the political will to support handwashing with • Please tell me briefly about your organization and soap? then what your organization does to support hand- 5. Is there a shared understanding among partner orga- washing with soap. nizations of the vision and goals of the handwashing • How committed do you believe your organization is with soap initiative? If yes, can you briefly describe to continuing to promote handwashing with soap in this vision? the future? Is promotion of handwashing with soap 6. Were this vision and goals developed in a participa- in your organization’s work plan objectives, budgets? tory manner? 7. How do you and your organization feel about this I. Policy, Strategy, and Direction vision/strategy? [Respondents from government, international agencies, 8. How well do you feel that national health and devel- international and local NGOs, private sector, advocacy opment policies and priorities support the promo- groups, bilateral donors/projects] tion of handwashing with soap? 9. What changes in policies or strategies related to the Overarching question: Do national priorities and priorities, handwashing with soap initiative have occurred dur- as well as a strong and shared handwashing with soap strat- ing the past three years? egy and direction, favor the continued implementation of 10. Who was responsible for these changes? handwashing with soap activities at scale after the project 11. Are they likely to be sustained? If so, why do you ends? believe that? If not, what can be done? 28 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Annex A: Draft Question Guide in English 12. What are the greatest barriers to sustaining these 12. What changes in partnerships for the handwashing changes? with soap initiative have occurred during the past 13. What, if any, policy issues still need to be addressed three years? for a national handwashing with soap program to 13. How did these changes occur? move forward? 14. Are they likely to be sustained? If so, why do you believe that? If not, what can be done? II. Partnerships 15. What, if any, additional improvements are needed in [Respondents from government, international agencies, in- partnerships during the next year? ternational and local NGOs, private sector, CBOs, media, 16. What roles do you see individual partners playing advocacy groups, bilateral donors/projects] in the coming years to maintain handwashing with soap implementation? Definition: A relationship where two or more parties, hav- ing compatible goals, form an agreement to share the re- III. Institutional Arrangements sponsibility for achieving the goals. [Respondents from government, international agencies, international and local NGOs, CBOs, media, advocacy Overarching question: Are there strong and active partner- groups, bilateral donors/projects] ships at national and regional levels that will continue to im- Definition: The roles, responsibilities, relationships, and plement large-scale handwashing with soap programming? accountability arrangements among public and private or- ganizations committed to reaching the handwashing goals. 1. What partnerships have been formed [at your level] to support the promotion of handwashing with soap? Overarching question: Are the roles, responsibilities, re- 2. How well are they functioning? lationships and accountability arrangements sufficiently 3. To what extent do partners actively participate in strong to support the handwashing with soap intervention discussions and decisions on strategies and plans? continuing at scale? 4. Does the partnership include an appropriate range of partners (e.g., public sector, private sector, NGOs, 1. How clear are the roles, responsibilities, and rela- etc.)? tionships of your organization for the handwashing 5. What, if any, important partners have not joined the with soap initiative? initiative? 2. [At your implementation level] are there clear imple- 6. In your opinion, how well have government and the mentation arrangements with all partners, including private-sector managed been able to work together? well-defined roles, responsibilities, and accountabil- 7. What are the greatest factors that have supported ity? If yes, please describe. If no, how might they be partners working well together? improved? 8. What are the greatest barriers to partners working 3. What types of resources do various partners contribute? well together? What type does your organization contribute? Do you 9. How well are partners’ roles, responsibilities, and believe that partners have the resources they need? mutual expectations clear and agreed upon? 4. Are the partnerships based on contracts, MOUs, or 10. How do partners coordinate efforts? How effective is simply understandings between people? the coordination among partners? 5. What, if any, mechanisms have been established 11. To what extent have partners integrated handwash- for national [or sub-national] level coordination/ ing with soap into their own organization’s objec- implementation among relevant national [or sub- tives, activities and budgets? national] partners? www.wsp.org 29 Endline Assessment of the Enabling Environment in Peru Annex A: Draft Question Guide in English 6. What changes in partners’ responsibilities and co- 8. Do you know if these changes were in response to ordination for the handwashing with soap initiative feedback from partners or monitoring results? If yes, have occurred during the past three years? please explain. 7. Are these changes likely to be sustained? If so, why 9. What, if any, additional improvements are needed in do you believe that? If not, what can be done? the program methodology? 8. What, if any, additional improvements are needed in institutional arrangements? V. Implementation Capacity [Respondents from government, international and local NGOs, private sector, CBOs] IV. Program Methodology [Respondents from government, international agencies, in- Definition: The necessary resources (human and financial), ternational and local NGOs, private sector, CBOs, advo- skills, incentives, and materials/tools to deliver the full cacy groups] complement of interventions necessary to deliver a hand- washing with soap program. Definition: The approach agreed upon by partners and im- plementers to deliver the handwashing with soap program Overarching question: Is there sufficient capacity for hand- interventions in order to reach the handwashing with soap washing with soap interventions to continue at scale? Is there targets. a structure to ensure that capacities continue to be developed? Overarching question: Is there a well-defined, evidence- 1. What strategies and activities exist to motivate, based, and tested approach to implementing hand- support, and encourage individuals’ and organiza- washing with soap that partners and collaborators tions’ continuing participation in the handwashing understand, accept, and desire to maintain in continued interventions? implementation? 2. [At the appropriate level] are there enough motivated persons with needed skills, as well as the program 1. Is there clearly defined program methodology for support such as training programs and communica- implementing the promotion of handwashing with tion materials, to maintain or even expand the hand- soap? washing with soap initiative? 2. [If so] can you please describe it briefly? 3. Has capacity been built in the private sector to pro- 3. Has the methodology been well documented and vide quality goods and services (i.e., handwashing disseminated to partners? stations, direct consumer-contact activities, etc.) at 4. How well has the methodology been supported by different levels of service? the dissemination of program tools, documents, and 4. Has capacity been developed at national/state and training? local government levels to oversee and monitor pro- 5. Is the program methodology widely understood and gram implementation at the community level? accepted by program implementers? What is your 5. What changes in implementation capacity for the opinion of it? handwashing with soap initiative have occurred dur- 6. Do you feel that the methodology is simple and ef- ing the past three years? fective enough to be used as other organizations take 6. How did these changes occur? Are they likely to be on the implementation roles? Is it affordable? Or are sustained? If so, why do you believe that? If not, some changes needed? what can be done? 7. What, if any, changes in the program methodology 7. What, if any, additional improvements are needed in for the handwashing with soap initiative have oc- implementation capacity during the next year? curred during the past three years? If changes have 8. What systems are in place to ensure ongoing capac- occurred, what is your opinion of them? ity development (e.g., institutionalizing training)? 30 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Annex A: Draft Question Guide in English VI. Availability of Products and Tools for? For what time period do you have secure fund- [Respondents from international and local NGOs, private ing? What are the prospects for continued financing sector, CBOs] after that period? 2. In general do you feel that the partners have suffi- Definition: The ready access of necessary products (e.g., cient funding to pay for their program costs (such as soap, water, handwashing stations), that respond to con- staff salaries, training, transport, etc.)? sumer demand to practice handwashing with soap. 3. [At the national or regional level] is there a clear un- derstanding and commitment among stakeholders Overarching question: Are there sufficient handwashing with regarding financial responsibilities? soap products readily available to allow for HW behavior 4. What, if any, additional sources of financing might among the target group? be available at [the appropriate level]? 5. Do you believe that there is enough funding to 1. Do families—even poor families—have convenient ac- maintain activities once funds from WSP are no lon- cess to important handwashing with soap products— ger available? Is there funding to expand activities to such as soap, handwashing stations, and water? new parts of the country? 2. To what extent do you feel that the products offered 6. What, if any, funding gaps remain? Where might respond to consumer preferences? the partners find funding to fill these gaps? 3. Are poor families willing and able to pay for these 7. How have private-sector partners contributed, with products? cash or in-kind financing, to the sustainability of the 4. What changes in access to appropriate products for HW campaigns? What do you think has motivated the handwashing with soap have occurred during the private sector contributions? the past three years? 8. How has the financing situation changed over the 5. How did these changes occur? past three years? How did these changes occur? 6. Are they likely to be sustained? If so, how and by 9. Do you have any suggestions for improving the whom? If not, what can be done? funds committed to support the continued promo- 7. What, if any, additional improvements are needed tion of handwashing with soap? in access to appropriate products for handwashing with soap? VIII. Cost-Effective Implementation [Respondents from government, international NGOs] VII. Financing [Respondents from government, international NGOs, Definition: The cost of implementation as compared to the CBOs] health and economic impacts to be measured in the impact evaluation. Definition: Adequate funds are available to interested hand- washing with soap organizations/agencies to cover the pro- Overarching question: Is there robust evidence that the grammatic costs required to deliver their respective roles handwashing with soap interventions are worth the cost, and responsibilities. and can this evidence be used to secure additional resources, partners, and political support? Overarching question: Is there sufficient funding available (from the government, NGOs, CBOs, donors, etc.) to de- 1. Is your organization, or other handwashing with liver handwashing with soap program objectives? soap partners, collecting information on program expenditures? Is your organization using (or will it 1. Does your organization have sufficient funds to ful- use) this information to calculate cost-effectiveness? fill your commitments to the handwashing with soap 2. Is your organization, or other handwashing with initiative’s objectives? What are your main expenses soap partners, collecting information on program www.wsp.org 31 Endline Assessment of the Enabling Environment in Peru Annex A: Draft Question Guide in English achievements, for example the number of people or evaluate the handwashing with soap initiative? If who were reached by program activities or the num- yes, what you have heard? ber who actually changed their handwashing with 3. Have you received, either from the regional or na- soap practices? If so, have you or other partners used tional level, the results of handwashing with soap this information to calculate costs/output or costs/ monitoring or evaluation studies? impact? 4. Are you aware of any changes in the handwashing 3. What, if any, information are you aware of concern- with soap activities that were made because of the ing the handwashing with soap initiative’s costs and/ findings from monitoring or evaluation studies? If or achievements? yes, what you have heard? 4. How important do you consider such information 5. Do you feel that there are persons with the needed in your decision to continue to invest in promoting skills at the national and local levels to monitor and handwashing with soap even after the current WSP evaluate the handwashing with soap initiative? If support ends? not, what suggestions do you have for increasing ca- 5. What, if any, additional improvements are needed in pacity? If yes, please explain your response. improving cost effectiveness? 6. Have these capabilities changed during the past three years? If yes, how? IX. Monitoring and Evaluation 7. Can you please summarize your feelings on how [Respondents from government, international NGOs, pri- important getting feedback from monitoring and vate sector, CBOs] evaluation is for your organization’s decision to con- tinue to fund or otherwise support handwashing Definition: with soap in the future? 8. What, if any, additional improvements are needed • Monitoring: the systems to capture progress on im- for improving monitoring and evaluation? plementation and achievement of targets in a timely manner to allow for analysis and prompt adaptation Closing (5 minutes) of implementation. • What is your assessment of the chances that the • Evaluation: The assessment of the results of monitor- handwashing with soap program will continue effec- ing to identify what worked and what didn’t work. tively for several more years? • What factors do you think will be most important Overarching Question: Is there a strong monitoring system for enabling this to happen? in place in order to assist those implementing handwashing • Which of the topics that we discussed do you think with soap interventions to adjust program interventions as is the weakest area for the handwashing with soap necessary and evaluate results to determine what worked initiative (and why)? and what did not? • Which of the topics that we discussed do you think is the strongest area for the handwashing with soap 1. Regarding your organization’s contribution to pro- initiative (and why)? moting handwashing with soap initiative, are you • What are your recommendations for what WSP and monitoring your organizations inputs, outputs, or partners should do to improve likelihood of sustain- their impact? ing interventions into the future? 2. Are you aware of any actions by the broader partner- ship, either on the local or national level, to monitor Thank the respondent for his/her time. 32 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Annex B: Sampling Methodology Annex B: Sampling Methodology The matrix below indicates which type of stakeholders will be as determined essential and as time permits. The first should be interviewed on what dimensions. Use your dis- data collection with secondary data sources should be through cretion as the interview progresses to adjust or adapt with self-reporting (see Methodology in Annex C) if possible. More whom you discuss what dimensions. specificity will be required within each stakeholder type, e.g., government agencies would be broken down by ministry, First priority will be the primary data sources and document re- MOH, MOHSW, MOE, MOW, etc. view, any secondary data source interview and/or self-reporting Stakeholder Type [unless otherwise noted, an X means that it is appropriate to discuss this dimension at all levels—national, regional, district, local] International Local Government International NGOs and NGOs Private Advocacy Bilateral Dimension Agencies Agencies FBOs and FBOs Sector CBOs Media Groups Projects 1. Policy, Strategy, Direction X X X L X — — X X 2. Partnerships X X X X X L X X X 3. Institutional Arrangements X X X X — L X X X 4. Program Methodology X X X X X L — X — 5. Implementation Capacity N,D — X X X L — — — 6. Availability of Products and Tools — — X X X L — — — 7. Financing X — X — — L — — — 8. Cost-Effective Implementation N,D — X — — — — — — 9. Monitoring N,D,L — X — X L — — — [N=National, R=Regional, D=District, L=Local] Source: Cogswell, Lynne and Lene Jensen. 2008. Guidelines for Assessing the Enabling Environment Conditions for Large Scale, Effective, and Sustainable Handwashing with Soap Behavior Change Programming. Guidance Document, January. World Bank (Water and Sanitation Program). www.wsp.org 33 34 Annex C: Summary of Major Findings and Recommendations by Dimension 2007 Findings 2007 Recommendations 2010 Findings 2010 Recommendations Policy, Strategy, and Direction • There was generally strong, posi- • Develop an advocacy strategy with • Informants described a tremen- • Request that each regional HWI tive political will towards hand- arguments and materials for differ- dous political will in Peru to pro- coordinator or facilitating agency washing with soap promotion and ent levels of decision-makers that mote handwashing with soap, propose a plan for strengthen- child health among organizations describes the importance of hand- often based on its ability to con- ing the enabling environment for Endline Assessment of the Enabling Environment in Peru and government officials, although washing with soap for achieving tribute to the national priority of handwashing with soap in 2011, some government officials found many social and health goals. reducing child malnutrition. and then discuss the proposed ac- it hard to follow up because of so • Hold individual and group meet- • Handwashing with soap promotion tions with the principal local part- many other priorities. ings with the key partners to clarify is firmly entrenched in policies and ners and the WSP Hygiene and • National partners manifested their their expectations and the proj- programs of ministries of health, Sanitation Alliance. (This new proj- support through a national hand- ect’s intentions and constraints. education, and women, and above ect will be active in 10 regions— washing with soap committee. In preparation for these meetings, the ministerial level in the national Ancash, Arequipa, Cajamarca, • The current national administration prepare and disseminate a brief CRECER (child nutrition) strategy. Cuzco, La Libertad, Lambayeque, was very supportive. description on the new project. • Handwashing with soap promo- Piura, San Martin, Tumbes, and • Several politically prominent na- • Carry out a similar process to tion also has strong support in the Ucayali). These plans are likely tional initiatives (re: malnutrition, introduce the new project at the regions, but is stronger in some to include: providing information healthy school, water and sani- regional, provincial, and district regions than others. to the new regional and district tation) offered natural links with levels, once the intervention dis- • Project staff have clear vision authorities on handwashing with handwashing with soap. tricts have been selected. for sustainability. They consider soap methodology, experiences, • MOH support had varied over time • Develop an exit strategy that ad- this not as an independent proj- and results; advocating with them and the MOE was a new partner. dresses both sustainability and ect but rather HWI as a support to follow up on resolutions and • Key partners feel that they under- expansion issues. mechanism that advocates for other commitments to promote stood the approach used in the handwashing with soap as a pro- handwashing with soap; sharing Annex C: Summary of Major Findings and Recommendations by Dimension first phase and feel ownership, gram priority and for the project impact evaluation results; and but they did not yet have a good methodology to become owned providing technical assistance on understanding of the expanded by multiple programs and organi- designing investment projects for project (still being designed). zations at all levels. future budget allocations. Global Scaling Up Handwashing 2007 Findings 2007 Recommendations 2010 Findings 2010 Recommendations www.wsp.org Policy, Strategy, and Direction, continued • Many officials remembered the role Maintain contact with the lead of handwashing with soap during organization or coalition in each the cholera epidemic and were region that can carry out key func- therefore well disposed to promote tions of advocacy, alliance-building, handwashing with soap. and training; offer suggestions as needed, learn about and share achievements and lessons learned. • Prepare and implement a na- tional event, or several regional Endline Assessment of the Enabling Environment in Peru events, at which different-level actors share their experiences of handwashing with soap pro- motion, including, for example, the Ancash experience with the Juntos program (educational ses- sions are part of the conditions for cash payments). Also, share the findings of the cost-effectiveness study and the endline survey regional and municipal levels through various channels. • Advocate for continued World Bank support for handwashing with soap in Peru by developing and giving a presentation for World Bank staff about HWI experiences and results, and the potential for Annex C: Summary of Major Findings and Recommendations by Dimension handwashing with soap promo- tion through other World Bank programs, particularly the Hygiene and Sanitation Alliance. continued 35 36 2007 Findings 2007 Recommendations 2010 Findings 2010 Recommendations Partnerships • The extensive, diverse partner- • Invite the MOE’s environmental • The HWI has done a superb job of • If feasible, continue to publish and ships were a strong and innovative health program and the Ministry engaging public and private part- widely disseminate the HWI bul- aspect of the HWI. of Housing’s PRONASAR (small ners at national and local levels. letin, with a focus on creative and • Some friction was reported be- water systems) program to join the • At the national level MIMDES has effective contributions by part- tween public and private partners. Initiative’s Executive Committee, become a key partner in the past ners at regional and district level • Keeping key government minis- as well as a strong private sector two years. that could later be adopted by tries (health, education, housing) partner. • Private participation has continued the WSP Hygiene and Sanitation Endline Assessment of the Enabling Environment in Peru involved was challenging at times • Assess the interest of potential to grow, encompassing more than Alliance. because of political changes and new partners in joining the Initia- 20 private firms at national and • Encourage regional, provincial, overburdened officials. tive (e.g., UNICEF, PAHO, Save the regional levels. Public and private and district coalitions addressing • Different partners’ roles varied Children, etc.). institutions are jointly funding and handwashing with soap to pub- from being fully engaged as a • Focus on providing guidelines, implementing handwashing with licize their own work and results, member of the coordinating com- tools and strategic technical assis- soap activities in various regions including the contributions of vari- mittee, to providing short-term tance to local partnerships. (e.g., Tumbes, Piura, Cajamarca, ous partners, through local radio, messages on HW, to co-financing • At the regional, provincial, and Lambayeque, La Libertad, Ica, and newspapers, and public events. and/or managing local activities. district levels, identify, encourage, Arequipa). and support existing public/pri- • The HWI no longer prioritizes for- vate coordination groups to take mal coordination among national responsibility for the HW activities, partners but does encourage for- such as the mesa de concert- mal and official commitments and ación or regional multi-sectoral the adoption of the handwash- committee. ing with soap priority by regional coalitions. • Institutional commitment now ap- pears to be more solid and not Annex C: Summary of Major Findings and Recommendations by Dimension to be as dependent on particular officials. Global Scaling Up Handwashing www.wsp.org 2007 Findings 2007 Recommendations 2010 Findings 2010 Recommendations Institutional Arrangements • Key national partners coordinated • Continue to pursue formal insti- • National partners coordinate pro- • Through their social-development their support through a national tutional arrangements supporting motion of handwashing with soap projects in Peru, WSP and the HW committee. promotion of handwashing with through various joint national ini- World Bank should advocate for • Major partners tended to promote soap at the national level and local tiatives and programs, no longer regional and local governments to handwashing with soap in their levels. through a national committee. promote handwashing with soap, own organizations and programs. • Seek more formal agreements with • There is much stronger inter- using the HWI’s methodology and • The HWI tended to encourage for- private sector partners also, to ministerial collaboration in 2010 tools. mal agreements with public part- clarify roles and expectations and than in 2007, primarily as a result Endline Assessment of the Enabling Environment in Peru ners but not with private-sector support sustainability. of the government’s policy to en- ones. • Periodically assess the implemen- courage an intersectoral approach tation of these agreements. in its programs. • To build and maintain a positive • HWI is pleased to formalize com- program image, to motivate part- mitments if requested by the col- ners and supporters, and to share laborating organization. The HWI useful technical and strategic in- has formal agreements with the formation, create a strong project MOH and MOE and works well but communication program directed informally with MIMDES. at both collaborating organizations • Many private-sector collaborators and the outside world (political have no formal agreements with leaders, donors, the public). At a the HWI or regional groups. minimum it should include an elec- tronic newsletter, information on the WSP/Peru and MOH web sites (with links to partners’ sites), and specific efforts to obtain radio and press coverage of accomplish- Annex C: Summary of Major Findings and Recommendations by Dimension ments and activities. continued 37 38 2007 Findings 2007 Recommendations 2010 Findings 2010 Recommendations Program Methodology • Opinions on the methodology • Focus on supporting local • HWI developed a behavior change • Advocate and facilitate the BCC were generally quite positive. implementation. communication (BCC) methodol- approach of the HWI in all of • Some respondents felt a need to • Allow local partners flexibility in ogy based on formative research WSP’s social development pro- focus more on interpersonal com- implementing the methodology. and testing (by a contracted NGO, grams, in particular the Hygiene munication, while media represen- • Urge local partners to avoid a PRISMA), in 2005 and later revised and Sanitation Alliance. tatives felt that mass media could focus on short campaigns with no it in 2007. • Continue collaborating with MIM- play a stronger role. clear follow-up. • Virtually all persons interviewed DES (PRONAA, Wawa Wasi, FON- • Some persons noted that the ap- • Develop a standard methodology praised the methodology as more CODES) in finalizing the process of proach seemed to work particu- and instruments for assessment effective and action-oriented than adoption of HWI methodology for Endline Assessment of the Enabling Environment in Peru larly well among children. visits at the provincial and district and different from most communi- their programs, then prepare the • Some respondents mentioned that levels to identify existing activities cation in Peru. print-ready adaptations of the HWI the Initiative (or its local partners) in which HW promotion could be • Very importantly, it is not just a materials. focused too much on short-term added or strengthened, the stron- communication strategy. It in- • Continue to work with the minis- promotional campaigns, with- gest partner organizations, and cludes a training methodology, tries of education, health, and the out follow-up in some places, potential handwashing with soap and it facilitates the availability of environment to finalize the process and with insufficient concern for champions. handwashing stations (SJs) that of adoption of HW methodology, institutionalization. • Emphasize interpersonal com- (1) remind people to wash hands then, time-permitting, prepare munication; use mass media when with soap; (2) make it easy to print-ready joint guidelines for the possible, emphasizing local radio wash; and (3) save soap, water, Healthy Schools program. in local languages and interactive and money. formats (call-in shows, radio lis- • The methodology has been of- tening groups, etc.). Ensure good ficially adapted by ministries of coordination between mass media health, education, and women’s promotion and on-the-ground programs. activities. • If possible, develop separate com- munication materials for the coast, Annex C: Summary of Major Findings and Recommendations by Dimension mountains, and jungle areas of Peru and make other needed ad- aptations for local conditions. Global Scaling Up Handwashing www.wsp.org 2007 Findings 2007 Recommendations 2010 Findings 2010 Recommendations Program Methodology, continued • For both effectiveness and sus- tainability, encourage and support HW promotion within existing pro- grams such as health promotion by the MOH, Escuelas Saludables, Viviendas Saludables, Municipios Endline Assessment of the Enabling Environment in Peru Saludables, PRONASAR (new water and sanitation systems), PRONOEIS (preschool), initiatives directed at malnutrition, JAAS (water and sanitation boards), NGOs doing health promotion, etc. • The contracted “implementing organizations� should collaborate to prepare an operational guide for the district level. • Take advantage of children’s enthusiasm by suggesting ac- tivities for students to promote handwashing with soap at home and in their communities. Sup- port change agents to work with individual mothers on solving Annex C: Summary of Major Findings and Recommendations by Dimension problems such as (perceptions of) limited water, soap, or time. continued 39 40 2007 Findings 2007 Recommendations 2010 Findings 2010 Recommendations Implementation Capacity • In general effective skills and sys- • Develop implementation guide- • Through advocacy, coordination, • Through the Hygiene and Sanita- tems needed to implement the lines and tools to support imple- training of trainers, and provision tion Alliance, provide technical as- program existed at the national mentation at the provincial and of communication and program- sistance to public-sector partners level but were weaker in some re- district levels. support materials, the HWI has in planning, implementing, moni- gions and districts. • Work with local partners to fund contributed to increasing imple- toring, and evaluating multi-sector transportation and food costs so mentation capacity at region and water, sanitation, and hygiene local promoters can make more district levels. investments. Endline Assessment of the Enabling Environment in Peru home visits. • HWI has focused strongly on train- • Engage with new incoming au- • Where the local assessments ing of trainers, mostly in the health thorities to explain the benefits show particular weaknesses, the and education units of regional of handwashing with soap pro- responsible implementing agency governments. The facilitators in motion, the methodology, and should provide training, mentoring turn have trained some 22,000 implementation requirements; and and/or exchange visits with other persons to promote handwashing urge them to continue integrat- districts, and technical assistance. with soap. ing hygiene BCC into their priority • Major challenges to ongoing ca- health, environmental, education, pacity building include the large W&S programs. annual turnover of teachers and • Advocate with partners to sup- as well as turnover in the health port capacity-building in regional sector. and municipal governments in • To become more effective in their planning, project preparation, newly decentralized environment, proposal-writing, and other basic regional and district governments skill areas. require capacity building in basic functions such as conducting assessments, planning, writing Annex C: Summary of Major Findings and Recommendations by Dimension proposals, project management, monitoring and evaluation, and reporting. Global Scaling Up Handwashing 2007 Findings 2007 Recommendations 2010 Findings 2010 Recommendations Availability of Products and Tools • There was little concern with the • Collect usable soap from hotels in • Soap is available to almost all • In the interest of sustainability, www.wsp.org availability of soap, although ac- big cities and distribute the soap families; some families and com- encourage local partners (public cess to water was difficult in some in the poorest communities; pro- munities lack convenient access and private) to plan for and finance communities. mote tippy taps and similar water- to water, although with a tippy tap additional copies of materials. • Respondents considered the pro- conserving devices where needed; or Super Jaboncín (SJ) station, Private companies may well be vision of plastic washing bowls promote hand-drying on clean handwashing requires little. willing to assume this cost, par- and pitchers to have been useful cloths or towels in dusty regions • About 80,000 SJs have been ticularly if their logo can be placed in the first phase. (where air drying would not be distributed in Peru (and 10,000 in on the material. A company that recommended); and promote use Guatemala). To increase produc- purchases SJs, for example, could of ash, sand, or quinua oil where tion and distribution, partners put a sticker with its logo on each soap is not available. need to arrange funding for the one, which would be seen by stu- Endline Assessment of the Enabling Environment in Peru • Prepare local change agents to approximately US$0.70/unit cost. dents and families numerous times counsel families that lack essen- A small number of families have teach day. Private companies tial products and, where needed, made homemade versions. also have tax write-offs for such local partners should address • Some regional informants said that expenditures. shortages. they lack enough SJs to expand • Encourage homemade SJs, as • Partners at the district level should into new districts. have been made in one area of consider purchasing and providing Cajamarca. Perhaps handwashing bowls, pitchers, and even soap to stations could be made from to- the poorest families. tora reed in the Lake Titicaca area. Financing • Financing was mainly in the form • Continue to explore a co-financing • The focus has shifted from donor • Continue to advocate with the of funding by international donors agreement by the Fund of the funding to funding by national MEF to include a line item in and in-kind contributions by pri- Americas (FONDAM), which has public and private organizations the national budget to build the vate companies to reach their staff expressed interest in supporting and programs. capacity of regional and district and customers through existing handwashing with soap in Peru. • Although lack of funding is clearly governments in planning, imple- channels. • Obtain information on USAID’s perceived as a barrier to expan- menting, and monitoring, and • The assessment team believed small grants program and then sion in some regions and districts, behavior-change methodologies. that some external funding would decide if it wants to share this with well-managed regional and district • Explore with the MEF and other Annex C: Summary of Major Findings and Recommendations by Dimension be needed after 2010, particularly local partners. governments and partnerships partners how best to offer training to support advocacy. • Lobby national and regional gov- that prioritize reducing malnutrition and other support in institutional ernment officials for budgetary or promoting handwashing with strengthening (planning, budget- funds directed towards HW and/or soap can access various sources ing, HR management, etc.) to re- hygiene education. of funding. gional and district governments. continued 41 42 2007 Findings 2007 Recommendations 2010 Findings 2010 Recommendations Financing, continued • Continue to seek donated air time • Various national government fi- • Work with allies and new partners and publicly acknowledge the nancing schemes are available to strengthen regional governments’ donation of free air time by private to those regions, provinces and capacity in social project planning, media companies. districts that have the skills to tap budgeting management, and M&E into them. (see capacity building). In addition to • Regions that have mining and training and mentoring, governments other large companies can estab- could be offered such tools as sam- lish projects that can attract pri- ple proposals, guidelines for social vate funding. project development; and planning, reporting, and M&E formats. • Continue to facilitate PIPs that Endline Assessment of the Enabling Environment in Peru support handwashing with soap • Advocate with regional govern- ments to include funding and activities for promotion of hand- washing with soap in annual work plans and in multi-year regional development plans. Cost-Effective Implementation • WSP and its partners had col- • Identify needs and contract in- • This issue is not on most respon- • At the time of the WSP cost- lected extensive cost informa- dividuals or companies that can dents’ radar. effectiveness study, discuss with tion but not yet calculated meet them. • Many informants have a strong the MEF the importance of cost- cost-effectiveness. belief—sometimes based on local effectiveness data for its funding • Capabilities to collect and analyze data—that handwashing with of handwashing with soap promo- needed data existed at the na- soap is a “low-cost, high-impact� tion as well as other programs. tional level, but technical support intervention, in the words of one If such data will continue to be was seen as necessary at sub- respondent. People cite local data needed, organize an orientation/ national levels. on child growth, child malnutrition, training for key partner staff. diarrhea and pneumonia cases, Annex C: Summary of Major Findings and Recommendations by Dimension and school absenteeism. • Because handwashing with soap promotion in Peru is integrated into so many different programs, calculating cost-effectiveness may be difficult. Global Scaling Up Handwashing www.wsp.org 2007 Findings 2007 Recommendations 2010 Findings 2010 Recommendations Monitoring and Evaluation • Respondents generally agreed • Assign M&E responsibility to • The HWI has done a much better • At the time of the WSP cost- that M&E was important, but they persons outside of WSP/HWI job of disseminating information effectiveness study, discuss with were not aware of the results of staff, so this work does not inter- (e.g., monitoring progress, les- the MEF the importance of cost- the HWI’s monitoring. fere with their ability to manage sons learned, innovations) through effectiveness data for its funding implementation. a web site, newsletters, and re- of handwashing with soap promo- • Maintain partner and public mo- ports. Still, some respondent do tion as well as other programs. tivation through the timely dis- not recall seeing documents and If such data will continue to be Endline Assessment of the Enabling Environment in Peru semination of achievements and information that they should have needed, organize an orientation/ results. received. training for key partner staff. • Handwashing with soap is an indi- cator in the information systems of the many government programs in which it is included. • HWI’s own M&E system for track- ing inputs, activities, outputs, and impact on practices and health and social indicators seems to be working well. • Various respondents complained about the control districts. They cannot understand why the pro- gram would deny such an effec- tive intervention to districts that request it. • HWI has provided some capacity Annex C: Summary of Major Findings and Recommendations by Dimension building in M&E to local partners, but there is demand for more. 43 Endline Assessment of the Enabling Environment in Peru Annex D: Commitments and Results in Peru’s Decentralized System Annex D: Commitments and Results in Peru’s Decentralized System Trained Teachers/ Mothers/ Participating Health Children Region Policies Schools Staff/Vols. Reached Partners Tumbes Letter of commitment of HWI and 22 117/29 166 BPZ and regional government districts agreeing to work together strategy to improve child and ado- lescent health Lima Regional directive on training of 158 902/225 4,009 Partners include regional govern- teachers in handwashing with soap ment, Colgate Palmolive, Pro promotion Citrus—Duna Corp., Santiago de Surco District government Tacna Office of Environmental Education 49 231/58 946 Partners include CESEM resolution implementing hand- washing with soap promotion in schools Piura Regional ordinance creating re- 20 762/191 10,234 Regional government, DRE, Piura gional council on poverty and in- District government, JUNTOS, fant malnutrition DALE Foundation, Sunshine Ex- ports, Caña Brava Ica Regional ordinance institutional- 70 786/197 38,628 The methodology is included in the izing handwashing with soap in regional education policy CRECER and educational plans Cajamarca Regional education resolution to 89 2,118/546 21,697 CORESAN (regional food security include handwashing with soap in and nutrition committee) units nu- several school programs merous partners Lambayeque Regional ordinance incorporates 436 871/204 28,815 Work is led by a very active re- CRECER in regional development gional education unit (UGEL) plans Arequipa Regional agreement and resolu- 338 806/201 6,938 Public/private alliance has gener- tion, regional govt and university ated US$300,000 funding to pro- agree to collaborate to combat mote handwashing with soap respiratory diseases Huánaco — 105 351/88 3,785 — La Libertad — 140 281/70 1,451 — 44 Global Scaling Up Handwashing Endline Assessment of the Enabling Environment in Peru Annex D: Commitments and Results in Peru’s Decentralized System Trained Teachers/ Mothers/ Participating Health Children Region Policies Schools Staff/Vols. Reached Partners Moquegua — 56 254/64 1,150 — Junín Plan of Chanchamayo Province 8 640/160 3,720 Chanchamayo Province to develop a regional directive on government handwashing with soap �ncash — 34 497/124 4,302 — Huancavalica Sub-regional education resolution 56 338/85 8,745 DRE, regional government, CARE incorporates handwashing with soap in school programs, names pilot schools, and designates focal points Apurímac Regional environmental educa- 44 422/105 9,609 Regional government, CARE tion office includes handwashing with soap in Safe, Clean, Healthy schools program Puno Regional education resolution 21 414/104 3,191 Regional education unit, CESEM makes handwashing with soap an official program in the regional education unit Ayacucho Regional environmental educa- 72 323/81 6,500 Regional government, CARE tion office includes handwashing with soap in Safe, Clean, Healthy Schools program Cusco Municipal ordinance creates 116 862/215 17,931 Anta Province has a provincial pol- inter-institutional committee on icy on environmental management handwashing with soap in Anta Province Amazonas Regional ordinance to imple- 12 234/59 1,306 Regional government ment CRECER, another declares handwashing with soap a regional priority San Martín Executive resolution declares insti- 0 80/20 1,000 Regional government tutionalization of handwashing with soap a priority Source: Iniciativa Lavado de Manos. Procesos y aprendizajes de la Iniciativa Lavado de Manos al 2010. www.wsp.org 45