WATER AND SANITATION PROGRAM: WORKING PAPER 74238 Global Scaling Up Handwashing Project Four-Country Synthesis of the Enabling Environment for Handwashing with Soap Endline Analysis Catherine O’Brien and Michael Favin October 2012 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. Global Scaling Up Handwashing is a Water and Sanitation Program (WSP) project focused on applying innovative behavior change approaches to improve handwashing with soap behavior among women of reproductive age (ages 15–49) and primary school-age children (ages 5–9). It is being implemented by local and national governments with technical support from WSP in four countries: Peru, Senegal, Tanzania, and Vietnam. 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 Catherine O’Brien or Michael Favin 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 and 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. © 2012 Water and Sanitation Program Global Scaling Up Handwashing Project Four-Country Synthesis of the Enabling Environment for Handwashing with Soap Endline Analysis Catherine O’Brien and Michael Favin October 2012 Glossary AGETIP Agence d’Exécution des Travaux d’Intérêt Public contre le sous- emploi: Public Works and Employment Agency, Senegal ARI Acute respiratory infection BCC Behavior Change Communication DCC Direct consumer contact DD Diarrheal disease DED District Executive Officer, Tanzania EE Enabling environment FLA Front line activator, Tanzania HWI Handwashing Initiative, Peru HWWS Global Scaling Up Handwashing Project IPC Interpersonal communication M&E Monitoring and evaluation MDGs Millennium Development Goals MEF Ministry of Economy and Finance, Peru MIS Management information system MM Mass media MoE Ministry of Education MoH Ministry of Health MoHSW Ministry of Health and Social Welfare, Tanzania MOU Memorandum of Understanding NGOs Non-governmental organizations NTP III National Target Program III, Vietnam PEPAM Programme d’eau potable et d’assainissement du Millénaire: Millennium Program for Drinking Water and Sanitation, Senegal PHAST Participatory Hygiene and Sanitation Transformation PPPHW Public Private Partnership for Handwashing TSSM Total Sanitation and Sanitation Marketing UNICEF United Nations Children’s Fund USAID United States Agency for International Development VEO Village Executive Officer, Tanzania VWU Vietnam Women’s Union WSP Water and Sanitation Program www.wsp.org iii Contents Glossary .................................................................................... iii Executive Summary................................................................... v I. Introduction ............................................................................... 1 1.1 Scaling Up Handwashing With Soap .................................. 1 1.2 The Enabling Environment.................................................... 2 II. Summary of Country Projects ................................................... 3 2.1 Peru ...................................................................................... 3 2.2 Senegal................................................................................. 3 2.3 Tanzania................................................................................ 4 2.4 Vietnam................................................................................. 4 III. Findings by Enabling Environment Assessment Dimension ... 5 3.1 Policy, Strategy, and Direction ............................................. 5 3.2 Partnerships ......................................................................... 6 3.3 Institutional Arrangements ................................................... 8 3.4 Program Methodology.......................................................... 9 3.5 Implementation Capacity ................................................... 11 3.6 Availability of Products and Tools ...................................... 13 3.7 Financing ............................................................................ 13 3.8 Cost-Effective Implementation ........................................... 15 3.9 Monitoring and Evaluation.................................................. 15 IV. Summary of Assessment Findings ......................................... 18 V. Summary of Recommended Activities to Strengthen the Enabling Environment ....................................................... 19 VI. Considerations for Programmers ........................................... 24 References ............................................................................... 25 Figure 1: Nine Dimensions Essential for Scaling Up Handwashing Behaviors................................................................................ 2 Tables 1: Handwashing Targets by Country .......................................... 1 2: Summary of Recommended Activities to Strengthen Enabling Environment in 2011 .............................................. 19 iv Global Scaling Up Handwashing Executive Summary The Water and Sanitation Program (WSP)’s Global Scaling • Implementation Capacity Up Handwashing Project (HWWS) has ended its four-year • Availability of Products and Tools implementation period (2007–2011). The project tested • Financing whether innovative approaches can generate large-scale and • Cost-Effective Implementation sustained increases in handwashing with soap at critical • Monitoring and Evaluation times among poor and vulnerable mothers and children in Peru, Senegal, Tanzania, and Vietnam. In 2007, baseline The definition of each dimension, the project’s original as- enabling environment (EE) assessments were conducted in sumptions for each dimension, as well as some specific find- each of these countries to better understand the program- ings and recommendations from the four EE assessment matic and institutional conditions needed to scale up, sus- reports, are provided in Section IV. tain, and replicate project interventions. The assessments were repeated after three years of project implementation Endline EE assessments were conducted in the four project to assess progress in strengthening the EE and to recom- countries in late 2010 and early 2011. Major findings con- mend additional steps to improve the EE as the projects cerning each of the nine dimensions across the four coun- wound down. The purpose of this report is to synthesize tries include: the main findings from the four endline EE assessment re- ports, including conclusions and lessons learned as well as Policy, Strategy, and Direction: This was a fairly strong recommended interventions and practices that can be used dimension in all four countries. HWWS Peru successfully to strengthen the EE in the future. advocated for promotion of handwashing with soap to become part of numerous programs and strategies of the HWWS developed a common conceptual framework ministries of health, education, women and social devel- within which the EE assessments were conducted. The opment, and regional and district governments, in part framework consists of nine dimensions that are considered by successfully promoting handwashing with soap as an to encompass the factors that support long-term, sustain- effective way to address the national priority of reducing able, at-scale handwashing with soap programming. They child malnutrition.1 In Vietnam, through its work with the reflect a series of assumptions underpinning the key ele- ministries of health and education, as well as the Vietnam ments that the project considers essential for sustaining Women’s Union (VWU), the HWWS project has helped improvements in handwashing promotion, and ultimately to raise the importance of handwashing with soap as a improved handwashing practice. HWWS believes that al- critical component of any sanitation and hygiene program. though there is no guarantee of sustainability, programs Although Tanzania lacks an approved sanitation policy can enhance the chances of sustained actions by assessing encompassing handwashing with soap, the government the EE at baseline and then, during implementation, tak- has included handwashing with soap in the national ing steps to improve key sustainability factors. growth and poverty reduction strategy and is working with partners to develop a sanitation policy and strategy that The nine dimensions of the conceptual framework are: includes handwashing with soap as a vital component. In Senegal, the project joined with the National Association • Policy, Strategy, and Direction of Midwives and the National Nutrition Program—two • Partnerships strong structures supporting the Millennium Development • Institutional Arrangements Goals (MDG) for sanitation. These agencies and programs • Program Methodology are considered strong enough to set an example for other 1 In Peru, the HWWS project was referred to as the Handwashing Initiative (HWI). www.wsp.org v A Four-Country Synthesis of the Enabling Environment Endline Analysis Executive Summary bureaus and agencies working on hygiene and sanitation on to reach the sanitation MDGs and PEPAM, tasked with how to effectively promote at-scale handwashing. awarding US$5 million in Global Sanitation Fund (GSF) money to improve hygiene and sanitation communication, Partnerships: The Peru project has successfully generated resulting in a commitment from both to always include partnerships with government at all levels, NGOs, soap handwashing with soap in their projects. companies, mining companies, a plastics manufacturer that produces a handwashing station to promote and facilitate Program Methodology: All country programs made great handwashing with soap, and other businesses. HWWS Viet- strides in developing and promoting the program method- nam helped to facilitate a public-private partnership that led ology, and opinions on the approach and materials were to the development of a model handwashing station (not generally quite positive. Most stakeholders in all countries yet marketed), and has trained staff of the VWU members appreciated the project’s approach to handwashing with to promote handwashing with soap at scale. In Tanzania, soap training and communication as practical, well devel- HWWS worked with the health, water, and education min- oped, and useful and were eager to adapt and use it. In Peru, istries, the Prime Minister’s Office of Regional Affairs and national programs of the ministries of health, education, Local Government (PMO-RALG), and other stakeholders to and women have officially adopted the project’s method- develop a process for the four ministries responsible for sani- ology (training and communication materials). The Viet- tation to work together on policy and strategy development nam MoH requested that HWWS assist them to develop to promote handwashing with soap. The Senegal program a handwashing with soap integration kit for use by MoH has worked closely with national partners to train their staff staff, as did the VWU. In Tanzania, stakeholders asked to incorporate handwashing with soap into their daily work. HWWS to help coordinate a review of all handwashing Government agencies such as the Millennium Program for with soap training and communication approaches cur- Drinking Water and Sanitation (PEPAM) look to the project rently in use, but the government has not yet agreed on a to help them forge partnerships with private companies to preferred model for promoting handwashing. Stakeholders promote improved sanitation, including handwashing. in Senegal expressed a desire to learn more about the proj- ect’s approach to training and developing communications Institutional Arrangements: HWWS Peru began with materials for promoting handwashing with soap. Concerns formal arrangements with key national governmental were raised in Vietnam about the cost of reproducing mate- ministries but later focused on specific institutional com- rials. In Tanzania, some local governments thought that the mitments in work plans and budgets of specific national promotional events component should have trained local programs and local governments. With increasing govern- cultural organizations rather than use a professional mar- mental decentralization, the overall focus has shifted to keting firm from Dar es Salaam. forming, or simply supporting, more local coalitions and programs. In contrast, HWWS Vietnam worked with ex- Implementation Capacity: Through advocacy, coordina- isting governmental networks (e.g., the VWU, Ministry tion, training of trainers, and provision of communication of Health (MoH), and other key ministries) with clearly and program-support materials, HWWS Peru has contrib- defined responsibilities for sustained promotion of hand- uted to increasing handwashing with soap implementation washing with soap. HWWS Tanzania followed a strong capacity at regional and district levels. A remaining area of recommendation from the EE baseline to support institu- concern, related to the country’s rapid decentralization, is tional coordination among key ministries, donors, NGOs, the capacity of some regional and district governments in and other stakeholders to promote handwashing with soap planning, project preparation, proposal writing, efficient in policy, strategy development, and implementation. implementation, and other basic governing skills. HWWS HWWS Senegal focused institutional support on AGETIP Vietnam focused on training staff from the VWU, national (Agence d’Exécution des Travaux d’Intérêt Public contre le and provincial staff from various ministries, select NGOs, sous-emploi), which is responsible for coordinating efforts and World Bank water project staff to increase capacity to vi Global Scaling Up Handwashing A Four-Country Synthesis of the Enabling Environment Endline Analysis Executive Summary promote handwashing. Tanzania trained local government the efficacy and importance of promoting handwashing staff and volunteers to implement handwashing with soap with soap. In Tanzania, cost-effectiveness of handwash- at scale, and by 2010 turned to focus on supporting the ing was not a top priority, but there was interest in learn- Ministry of Health and Social Welfare’s (MoHSW) lead ing about the costs of running a large-scale handwashing role in the sanitation sector. Given the nature of the sector with soap intervention. In Senegal, HWWS has cost data in Senegal, HWWS’s MOUs with the National Association to share with stakeholders, although the 2011 EE end- of Midwives and the National Nutrition Program to train line did not find that cost-effectiveness was stakeholders’ national and local staff to promote handwashing with soap top priority. in their regular programs appear to be a viable way to create nationwide capacity to promote handwashing. Monitoring and Evaluation: HWWS Peru provided some capacity building in monitoring and evaluation to Availability of Products and Tools: Soap was found to be local partners, but found that there is demand for more. widely available in all four countries, although in Tanza- In Vietnam, HWWS’s work with the VWU resulted in nia and Senegal some families find it difficult to pay for the organization developing and inserting a handwash- soap and the 2008 formative research in Peru found that ing indicator into its monitoring system. In Tanzania, mothers were reluctant to “waste� soap on handwashing. stakeholders are working together to improve sanitation Communities in all countries have some access to water, and hygiene monitoring through national surveys and but access may be time consuming, seasonal, and/or only community-based systems. The project has experience for limited hours—a problem for sustaining the practice in monitoring handwashing with soap at-scale program- of handwashing. The HWWS projects in all four coun- ming that can be invaluable to this process, including a tries helped develop new handwashing station devices or system of record keeping that tracks uptake of improved promoted existing products that minimize water used for handwashing with soap behavior. The Senegal project de- handwashing, and encouraged people to provide a place for veloped a robust performance-monitoring system that has soap and water for handwashing in the house. enabled the program to monitor implementation progress closely. The project’s management information system Financing: By 2010 funding for handwashing with soap has proven to be attractive to partners; for example, as promotion in Peru had shifted from donors to national AGETIP develops its handwashing with soap programs, public and private organizations and programs. Peru is the HWWS has supported the development of a monitoring only one of the four project countries to have made this and evaluation system. shift. In Vietnam, by 2010 the government was discussing increased allocations for the communication support of Considerations for Programmers improved hygiene, sanitation, and water supply. HWWS The experience from this project demonstrates that it is found that in Tanzania in 2010, funding allocated for sani- difficult to make generalizations about which component tation and hygiene was moved from the Ministry of Water of the EE programmers should focus on first. This report to the MoHSW because of lack of progress in improving shows that each of the countries started and ended at differ- sanitation and hygiene. The major change found in Senegal ent places with respect to the EE. Additionally, key stake- was a shift away from emphasis on securing funding for holders in any given country may value or place a different the Public-Private Partnership for Handwashing (PPPHW) weight on any single EE components. to ensuring the HWWS project’s support for PEPAM and AGETIP’s roles in meeting the MDGs for sanitation. A key lesson from this project is that a programmer should assume that all components are equally important going Cost-Effective Implementation: The assessments found into EE assessment, and until an EE assessment is con- that partners in Vietnam and Peru felt no immediate ducted, it will be difficult to know where to prioritize re- need for cost-effectiveness studies to convince them of sources and efforts. www.wsp.org vii I. Introduction 1.1 Scaling Up Handwashing With Soap Launched in November 2006 (with implementation from mid-2007 to mid- 2011), handwashing with soap was implemented by the HWWS project and in-country partners in Peru, Senegal, Tanzania, and Vietnam (see Table 1).2 The project was created in response to evidence that effective interventions to pro- mote handwashing with soap could improve handwashing behaviors and dra- matically reduce diarrheal disease and acute respiratory infections—two of the leading causes of child mortality and morbidity. However, much of the evidence generated to date has been based on small-scale interventions, often in controlled settings. Larger handwashing initiatives, on the other hand, have not had rigorous evaluation of health outcomes, nor have they adequately addressed sustainability after the project ends. HWWS’s methodology was designed to learn what works to improve handwashing behaviors at large scale and to sustain the activities after the project ends. It is also designed to measure the impact of increased hand- washing with soap on health. The HWWS project is working with national and local governments to generate and sustain the handwashing with soap practices of 5.4 million women and primary-school-aged children. This report synthesizes the key findings of the endline assessments of the EE for HWWS projects in Peru, Senegal, Tanzania, and Vietnam. Aimed to gauge the robustness of the programmatic conditions for the continued scale-up and sustainability of program interventions as external funding for the projects end, the assessments were conducted from October 2010 through January 2011. The same basic instrument was used for the 2007 baseline EE assessments, with some modifications and additions made in 2010 based on program experience and learning. Objectives of the Endline Assessments 1. Determine the current status of each dimension of the EE. 2. Identify strengths and weaknesses of each dimension, with a focus on deficiencies. 3. Describe the changes in the EE since 2007. TABLE 1: HANDWASHING TARGETS BY COUNTRY Estimated Target Population for Washing Country (Population) Target Population Hands with Soap at Critical Times Peru (28 million) 5.1 million 1.3 million Senegal (11 million) 2.0 million 0.5 million Tanzania (37 million) 5.2 million 1.3 million Vietnam (84 million) 9.2 million 2.3 million 2 In Peru, the HWWS project was referred to as the Handwashing Initiative (HWI). www.wsp.org 1 A Four-Country Synthesis of the Enabling Environment Endline Analysis Introduction 4. Determine the level of importance for each dimension of the enabling environment to create conditions for scale-up and sustainability. 5. Make recommendations for improvements in the EE to the country task manager, HWWS headquarters staff, and main in-country partners cover- ing the next six months. 1.2 The Enabling Environment The 2007 baseline EE assessments covered nine dimensions considered essential to scaling up handwashing with soap behavior-change programs. Developed by the HWWS project based on a review of relevant literature and a discussion with subject matter experts, the conceptual framework considers these dimensions to be the essential indicators of the feasibility of achieving programmatic scalability and sustainability. Scale-up is defined as an increase in the present scale and rate of behavior change. Sustainability is defined as the ability to maintain interventions after funding under the project has ended. Section III describes the nine dimensions (see Figure 1) in detail and outlines the assumptions that underpin the definition of the EE from the start of the project. It also indicates the respondent groups for information on each dimension. FIGURE 1: NINE DIMENSIONS ESSENTIAL FOR SCALING UP HANDWASHING BEHAVIORS Policy, strategy & direction Monitoring Partnerships & evaluation Cost-effective Enabling Institutional implementation arrangements Environment Program Financing methodology Availability of Implementation products and tools capacity 2 Global Scaling Up Handwashing A Four-Country Synthesis of the Enabling Environment Endline Analysis Summary of Country Projects II. Summary of Country Projects 2.1 Peru HWWS3 in Peru was launched in 2003. For the first four years, the project focused on building robust partnerships, developing a sound implementation model, and creating evidence-based material for mass media (MM), direct consumer con- tact (DCC), and interpersonal communications (IPC). In 2007, HWWS started implementing activities in 24 of Peru’s 25 regions to improve the handwash- ing behavior of 1.3 million women and children.4 The project also focused on strengthening the EE to ensure that implementation of handwashing activities would continue after external funding through HWWS ends. The program in Peru has largely met or exceeded its programmatic targets for implementation and sustainability. The project’s approach to sustainability focused on promoting ownership of the HWWS methodology and raising handwashing with soap as a priority within different institutions. It did not seek to create or continue a standalone hand- washing program or initiative. HWWS recognizes that what needs to be sus- tained is the project’s technical added value to programs whose implementation will continue and that will use HWWS methodologies and tools and continue to assign resources to handwashing with soap in the future. HWWS considers it a major sign of its success that it is not frequently mentioned as a separate project or program but that its priority and methodology have been adopted by national and local programs and institutions, such as the ministries of health, education, and women, as well as regional, provincial, and local governments. 2.2 Senegal The Public-Private Partnership for Handwashing (PPPHW) was launched in Sen- egal in 2003. For several years, PPPHW focused on catalyzing and coordinating various organizations’ involvement in promoting handwashing with soap. The first phase of activities culminated with the 2007 launch of a 10-month commu- nications campaign that included TV and radio spots, DCC, and IPC. In 2008, HWWS expanded interventions to eight of the country’s 11 regions, with the ob- jective of improving the handwashing behavior of 500,000 women and children. In parallel, efforts were directed at strengthening the EE to ensure that activities and outcomes would be sustained after external funding through HWWS ended. The Senegal program exceeded all implementation targets. HWWS worked with PEPAM and AGETIP. AGETIP oversees the award of contracts for the GSF. In a move to further strengthen sustainability of handwashing with soap at the na- tional scale, HWWS provided training for the staff of the National Association of Midwives and the National Nutrition Program (CLTM), so these programs might successfully integrate the promotion of handwashing with soap into their activities throughout Senegal. 3 HWWS is comprised of various partners such as government, private sector, and NGOs. WSP played a lead technical assistance role in developing evidence-based communication materials, building capacity of partners, brokering partnerships, and strengthening the enabling environment. 4 Devine and FlÓrez 2010 www.wsp.org 3 A Four-Country Synthesis of the Enabling Environment Endline Analysis Summary of Country Projects 2.3 Tanzania HWWS has supported the Government of Tanzania’s handwashing with soap promotion since 2005. The project’s initial support focused on conducting small- scale formative research and raising awareness of the importance of handwashing with soap as a key public health intervention. In 2007, HWWS began scaling up interventions to 10 rural districts, with the goal of improving handwashing be- haviors among 1.3 million women and children. At the same time, considerable effort went into improving the national EE to organize the sector and prepare for expanded implementation of handwashing with soap activities. These activities included using mass media (radio and print materials), DCC, and IPC inter- ventions. Additional efforts were directed at strengthening the EE at the local level through building capacity of local government authorities and community volunteers to implement and support various behavior-change activities. At the national level, efforts focused on getting buy-in to an evidence-based behavior- change approach, changes in policy to more explicitly support handwashing with soap, and the development of indicators to better track progress. 2.4 Vietnam In Vietnam, HWWS was launched in 2006. The initial phase consisted of a nine-month behavior-change campaign in 40 communes funded by the Danish Embassy utilizing MM, DCC, and IPC targeting mothers of children under five. In 2007, HWWS began to scale up activities, eventually carrying out activities in 540 communes in 10 provinces with more than two million mothers. Ad- ditionally, efforts were directed at strengthening the EE to ensure that activities and outcomes would be sustained after the project ended through a variety of partnership mechanisms at both the national and provincial levels to integrate handwashing with soap into ongoing partners programs. The MoH is responsible for promoting handwashing with soap within the Vietnamese government struc- ture. As a mass organization, the Vietnam Women’s Union (VWU) can reach households nationwide with messaging to promote and sustain behavior change. 4 Global Scaling Up Handwashing III. Findings by Enabling Environment Assessment Dimension This section summarizes key findings by EE dimension with soap among all key stakeholders in order to support from the 2007 and 2010–2011 EE assessments and also and sustain programming. A formal policy on handwashing summarizes how the HWWS project and others contrib- with soap, specifically accompanied by a well-articulated uted to changes in the EE. Each discussion begins with strategy, was also deemed necessary. Peru was thought to HWWS’s definition of the dimension, the assumptions that be farthest advanced along these lines in 2007, and in 2010 underpinned why each dimension is important to sustain- this was still the case. HWWS in Peru has had great success ing handwashing with soap, and a listing of the respondent inserting the promotion of handwashing with soap not into groups (“stakeholders�) interviewed in country for the EE. one national policy, but into numerous programs and strat- The discussion goes on to cite examples (from each of the egies, in part by successfully advocating for handwashing four countries) of change from the 2007 EE baseline to the with soap to be considered an effective way to address the 2010–2011 EE endline, and discusses the findings in brief. priority national goal of reducing child malnutrition. Some examples include: 3.1 Policy, Strategy, and Direction • Policy: a set of procedures, rules, and allocation mecha- • Handwashing with soap has a prominent role in the nisms that provides the basis for programs and services CRECER strategy, coordinated by the Prime Minis- • Strategy: guidance on how to implement a policy ter’s office, which commits 15 organizations to par- • Direction: a common understanding among inter- ticipate in an Initiative against Child Malnutrition ested parties of the goals of an intervention in Peru. • The multi-sector national conditional cash transfer Assumptions: program (Juntos) incorporated handwashing with • Having handwashing with soap represented in national soap promotion as one of their conditional behav- policy would necessitate implementing it at national iors in 2008/9. scale, increase the likelihood of funding activities, and • The MoE’s commitment to handwashing with soap force monitoring of handwashing with soap. promotion is official policy. Handwashing with • Having a handwashing with soap strategy would soap is included in the national curriculum. A vice- provide a common understanding of how to imple- ministerial resolution designates HWWS meth- ment handwashing with soap interventions, which odology and tools as a component of the National will increase the chances of continuing large-scale Healthy and Safe [Schools] Program implemented application post project. in 3,000 pilot schools. Handwashing with soap is • Having a common direction would require a shared also well integrated into the MoE preschool program vision of where handwashing with soap should go, (PRONOEIS, a program operated in poor commu- and would increase the likelihood that interventions nities by program staff and volunteer mothers). would be coordinated. • An MoH resolution made handwashing with soap a priority theme for its involvement in the multi- Respondents: sector healthy schools program. The topic is also • Government well integrated in the MoH’s Healthy Families and • International agencies Homes project and its Healthy Municipalities and • NGOs Cities program. • Donors • The Ministry of Women and Social Development • Private sector (MIMDES) is strongly committed to promoting handwashing with soap through such programs In 2007, findings from all four EE assessments noted the as PRONAA (aimed at reducing infant malnutri- importance of a shared vision and strategy for handwashing tion and anemia, the program includes a school www.wsp.org 5 A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension breakfast program, child feeding centers, distribu- with other stakeholders active in hygiene and sanitation, tion of fortified bread, etc.); Wawa Wasi (a daycare such as UNICEF and NGOs. These efforts addressed the program for children of poor working mothers); and four relevant Government of Tanzania offices—the min- FONCODES (a poverty reduction program). istries of Health and Social Welfare, Water and Irrigation, • The raised profile for handwashing with soap has and Education and Vocational Training, and the Prime been officially recognized in more than 120 orga- Minister’s Office of Regional Administration and Local nizational resolutions, norms, and directives of the Government—which together are responsible for sanita- ministries of health, education, and MIMDES and tion in the country. By 2010 the four offices, under the their regional and district counterparts. leadership of the Ministry of Health and Social Welfare, had signed a Memorandum of Understanding (MOU), outlin- In highly centralized Vietnam there was a favorable politi- ing a much-valued process for working on sanitation and cal environment for supporting handwashing with soap in hygiene policy and strategy, including handwashing with 2007, with opportunities for integration into ongoing pro- soap. At the time of writing the report, a draft policy, includ- grams and activities. At the same time, there was no na- ing handwashing with soap, was circulating for approval. tional strategy or policy on handwashing with soap, nor a shared vision of a national policy and strategy among hand- In Senegal, open discussions about handwashing with washing with soap stakeholders. By 2010 an objective for soap among stakeholders was found in 2007 and contin- handwashing with soap had been prepared and inserted ued in 2010 in the same project-focused and fragmented into the draft National Target Program III (NTP III), the environment. In 2007 there were too many one-on-one document following NTP I and II, that lays out national strategies with individual organizations and ministries and policy targets for the nation, the first time that any such no comprehensive national strategy and policy on hand- mention of handwashing had ever appeared in an NTP. washing with soap, although the project’s political and or- Most stakeholders interviewed agreed that handwashing ganizational priority had helped to establish the legitimacy with soap was considered an integral and important part of handwashing as an important hygiene intervention. By of hygiene and sanitation programming in Vietnam, and 2010 there were still many national ministries and bureaus that a standalone policy on handwashing with soap was not assigned partial responsibility for hygiene and sanitation required. HWWS has worked closely with the government programming, resulting in fragmented responsibility and ministries, including the ministries of Health, Education accountability for hygiene and sanitation. PEPAM, the na- and Training, Agriculture and Rural Development, as well tional platform for coordinating programming supporting as mass organizations and NGOS, to train their staff to in- the aim of achieving the MDGs, and AGETIP, the national tegrate handwashing with soap into their program using employment agency responsible for helping to select orga- what respondents uniformly deemed a sound, practical ap- nizations to receive funding from PEPAM, worked closely proach to training and a well-developed package of com- with HWWS to support the inclusion of handwashing with munication materials. This and efforts on the part of other soap in all hygiene and sanitation projects funded by the stakeholders, in combination with the MoH’s leadership in GSF. The GSF awarded Senegal US$5 million over five response to outbreaks of avian influenza and diarrheal dis- years to support improved sanitation programming, which ease, have helped to elevate the importance of handwashing in Senegal includes handwashing. PEPAM is committed to with soap as an integral component of hygiene and sanita- promoting handwashing with soap in all sanitation proj- tion programming in Vietnam without developing a spe- ects, which may help foster a strategy on handwashing with cific standalone policy. soap attractive to all players. On the other hand, in 2007 in Tanzania, it was found that 3.2 Partnerships in order to approach an ideal policy/strategy environment A relationship in which two or more parties, having compat- for promoting handwashing with soap, HWWS needed to ible goals, form an agreement to share the responsibility for commence advocacy immediately, which it did together achieving the goals. 6 Global Scaling Up Handwashing A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension Assumptions: In Vietnam in 2007, there was strong interest among stake- • This dimension is about interested public and holders in cooperating and collaborating to promote hand- private-sector agencies partnering to promote and washing with soap, but the MoH did not see a need for a achieve the objectives of handwashing with soap PPP model to promote handwashing with soap as did other interventions. countries such as Peru and Senegal. Thus, HWWS focused • A strong partnership will bring together the skills and on bilateral partnerships with the private sector, NGOs, and resources no single organization or agency possesses. provincial departments of health and education. HWWS • Partners contribute resources—financial, human, carried out a rapid survey of handwashing with soap stake- knowledge, and/or goods/service—toward the holders in Vietnam and found during the EE endline assess- agreed-upon goals. ment that stakeholders agreed that the best way to promote • Partnerships may be among public and private handwashing with soap was to work with the MoH (respon- sectors—both profit and nonprofit—at national and sible for hygiene promotion), mass organizations such as the subnational levels. Vietnam Women’s Union (VWU), the Ministry of Educa- • Private-sector partners need not be soap tion and Training, and others. Stakeholders interviewed in manufacturers. the EE endline assessment commented that HWWS Viet- • A partnership is not contractually based (i.e., nam helped gather a public-private partnership that led to the HWWS does not pay for their services). development of a model handwashing station, although the station is not yet being manufactured and commercialized. Respondents: • Government The 2007 Tanzania assessment recommended that HWWS • International agencies work with ministries and other stakeholders, especially do- • NGOs nors, to organize a broad-based, public-private partnership • Donors (PPP), summit-type meeting where successes, challenges, • Private sector and approaches to promote handwashing were discussed. It also advocated collecting data from other countries to show In 2007 in Peru, HWWS focused on collaboration with the private sector how promotion of handwashing with soap national ministries and a few regional governments. It also might help expand their markets for soap. The baseline en- established arrangements with national private-sector part- couraged placing people’s handwashing stories in newspa- ners to promote handwashing with soap through their own pers, newsletters, and other media in order to create a buzz, networks. By 2010 Peru had become significantly more generating favorable publicity for promoting handwashing decentralized, and HWWS had generated an impressive to encourage actors from the public and private sectors to array of partners at both national and local levels, including become involved. By 2010 HWWS had helped create op- several dozen private-sector partners whose contributions portunities for peoples’ handwashing with soap stories to reach far beyond their own clientele. Partnerships include be told, particularly in newspapers. HWWS had also been government at all levels, NGOs, soap companies, mining asked by stakeholders to draw on its experience promoting companies, a plastics manufacturer that produces a hand- handwashing with soap at scale to coordinate the develop- washing station to promote and facilitate handwashing ment of a government and multistakeholder partnership to with soap, and other businesses in a decentralized system examine all handwashing with soap models in use in Tan- that favors development and implementation of local alli- zania and make recommendations for an effective Tanzania ances and strategies that promote handwashing as a way to model for promoting handwashing with soap. improve childhood nutrition and other goals. There are also numerous local partnerships at the regional (state) and dis- HWWS, in an important strategy for sustaining the pro- trict levels that address childhood malnutrition and other motion of handwashing with soap, worked closely with social goals that now include promotion of handwashing key Tanzanian government ministries, donors, NGOs, and with soap. other stakeholders to develop a mechanism with which the www.wsp.org 7 A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension challenge of and practical steps for improving sanitation, with the National Nutrition Program and the National As- including handwashing with soap, could be discussed and sociation of Midwives in 2010 to train their staff at na- consensus reached. This is documented in the MOU signed tional and local levels to promote handwashing with soap by the key ministries responsible for hygiene and sanita- in their programming. These strong partnerships will help tion. According to stakeholders interviewed during the EE to improve potential for the sustainability of at scale hand- endline assessment, the MOU and the process facilitated by washing with soap in Senegal. HWWS to help develop it, provides a place for the minis- tries to work on draft policy and implementation modali- 3.3 Institutional Arrangements ties. There was some limited engagement with the private The roles, responsibilities, relationships, and accountability ar- sector with one local soap company that co-branded its rangements among public and private organizations commit- hand soap product with the brand of HWWS: “Hands to ted to reaching the handwashing goals. be proud of.� It is still possible that private partners may join with the government on the draft national sanitation Assumptions: strategy, though their interest lies more at the implementa- • No single organization or agency can deliver large- tion level. scale comprehensive handwashing interventions. • To operate efficiently, the roles, responsibilities, and The 2007 baseline for Senegal reported diverse and sig- accountabilities for each agency (e.g., line ministries, nificant interest in participation in HWWS, with a part- NGOs, etc.) need to be well defined and understood. nership structure being formulated (PPPHW), but there • Institutional arrangements need to be defined at na- was more focus on individual organizations’ agendas than tional and subnational levels. on the group. There was a lack of common understanding • Institutional arrangements need to be articulated and vision of the partnership and its implications for pro- and coordinated for public and private sector actors. moting handwashing among the players, as well as insuf- • An institutional home is necessary for large-scale ficient collective and participatory decision-making. This sustainable handwashing initiatives. led to unilateral decision-making by individual partners. The endline assessment in 2011 found that the PPPHW Respondents: had gone dormant after the driving force behind it, a sin- • Government gle, dynamic individual, became involved in other work. • International agencies Even so, government institutions (PEPAM in particular) • NGOs expressed interest in learning how to work effectively with • Donors the private-sector companies to promote improved hygiene • Private sector and sanitation. Soap companies, insurance agencies, and media companies also indicated interest in learning how The Peru baseline assessment found that HWWS had for- to work more effectively with government to promote im- mal arrangements with key national governmental organiza- proved hygiene and sanitation, and handwashing in par- tions and generally more informal arrangement with private ticular. Both public and private groups look to HWWS partners. Respondents noted the increasing trend towards to facilitate the sectors working together in a sustainable decentralization and hence the need for local arrangements. way. Despite this shift away from a PPPHW project- They considered advocating for support of handwashing based approach to fostering partnership between the pri- with soap in work plans, budgets, institutional directives, vate sector and the government, there remains a concern and actual activities much more important than pursuing that individual organization’s goals and objectives could formal institutional arrangements. In 2010 there was less take priority over efforts to meet national sanitation goals emphasis on arrangements between HWWS and partners in a sector that is so fragmented. To forge partnerships and more on arrangements among the partners themselves with organizations capable of supporting handwashing at national, regional and district levels. Overall, there was with soap programming at scale, HWWS signed MOUs much more joint planning, implementing, and monitoring 8 Global Scaling Up Handwashing A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension at national, regional, and local levels. The focus had moved In Senegal, the 2007 baseline assessment found a lack of ef- to encouraging formal commitments to promote hand- fective guidance for implementing a decentralization pol- washing with soap rather than agreements between HWWS icy and little interest from local governments in sanitation and partners. and hygiene issues, including handwashing. Furthermore, institutional instability within the central government and Vietnam’s 2007 baseline assessment found that clear gov- lack of institutional leadership on handwashing, com- ernment networks existed with defined roles and respon- bined with poorly defined roles and responsibilities (for sibilities for promoting handwashing, and that HWWS’s hygiene and sanitation) and lack of coordination mecha- proposed project and approach had been only vaguely un- nisms among agencies, made for a weak EE for promoting derstood by most potential partners. The baseline assess- handwashing with soap behavior. On a positive note, there ment suggested that HWWS support existing government was a strong desire among stakeholders to clarify roles and structures—including the MoH, the VWU, and the Peo- responsibilities as well as strong interest from local NGOs ple’s Committee—to enhance capabilities and strengthen and from the environment and other sectors to integrate sustainability, cooperation, and collaboration on promot- handwashing with soap into topics/activities. As 2011 ap- ing handwashing with soap at all levels. According to re- proached and the PPPHW went dormant, HWWS and spondents during the endline assessment, HWWS did other stakeholders found themselves working in a sector work with the MoH, especially in the first year of the proj- where the same limitations remained and were widely ac- ect, and also worked closely with the VWU and the De- knowledged by stakeholders. HWWS is prioritizing work- partment of Education and Training at local levels. These ing with PEPAM and AGETIP to further strengthen and stakeholders reported increased capacity for planning for support these institutions’ abilities to coordinate Senegal’s and promoting handwashing with soap, although they also efforts to reach the MDGs (Senegal’s sanitation MDG in- mentioned a lack of funding to continue activities at the cludes handwashing), in part by strategic disbursement of same level without HWWS funding. This is a concern for money from the Global Sanitation Fund. sustainability of activities. The baseline also suggested that HWWS delineate a stakeholder map—who does what and 3.4 Program Methodology where. This was done and apparently used by the project The approach agreed upon by partners and implementers to for planning purposes. deliver handwashing with soap program interventions in order to reach the handwashing with soap targets. The main recommendations from the 2007 Tanzania baseline assessment were to focus on institutional arrange- Assumptions: ments to enable sustainability and scale-up of handwash- • Health education approaches are insufficient to ing with soap, and to support efforts to create effective change behaviors. coordination at the national level. By 2010, there had • A more systematic, consumer-focused, research- been a change in responsibility for sanitation within the based design will result in a methodology better able Water Sector Development Program5 (WSDP), with the to change behaviors. MOWI making the MoHSW the lead agency for sani- • The HWWS approach is an improvement over pre- tation and hygiene. This occurred because the MoHSW vious iterations. has the national mandate for sanitation and hygiene. The • The HWWS approach will prove to be more cost challenge for HWWS by 2010 was how to best support effective and impactful. the MoHSW in its new leadership role for sanitation and • The methodology need not follow the guidance hygiene in conjunction with stakeholders ranging from from The Handwashing Handbook. other donors, UNICEF, and NGOs, and utilizing the • Each country may need to develop/adapt a country- committees mentioned above. specific methodology. 5 The Water Sector Development Program (WSDP) is a basket fund comprised of government and donor resources for investment in water supply, sanitation, and hygiene. www.wsp.org 9 A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension • All participants in the HWWS program need to at the time followed traditional methods. The nature of have a shared understanding of the methodology. the proposed program methodology was not yet clear to • The partners and implementers agree that the ap- potential partners, so the HWWS project worked hard to proach adopted under this project is cost effective to develop a package of communication materials based on reach behavior change. sound behavior-change principles and shared the results through practical training based on adult learning meth- Respondents: odology. By 2010 the approach and communication ma- • Government terials had been shared with stakeholders, including the • International agencies VWU, ministries of health and education (at national and • NGOs provincial levels), NGOs, and other government minis- • Donors tries. Staff from World Bank water-infrastructure projects • Private sector also received training from the project that enabled them to integrate handwashing with soap into their activities. All four countries made great strides in developing and Stakeholders across the board consistently praised HWWS promoting the project’s program methodology, and opin- for its contribution to handwashing with soap methodol- ions on the approach and materials were generally quite ogy. The MoH asked that the project assist them in devel- positive. In Peru in 2007 respondents felt that the melding oping a handwashing with soap integration kit for use by of diverse partners’ strengths had produced an effective ap- MoH staff, a good sign that the government’s lead agency proach. Some mentioned that the project took too much of is interested in using HWWS’s methodology to promote a campaign approach, sometimes without follow-up, and handwashing. Concerns were raised in Vietnam during the with insufficient concern for institutionalization. Some EE endline assessment about the cost of reproducing ma- respondents mentioned the need to focus more on IPC, terials of the same quality. whereas media representatives felt that MM could play a larger role. Several of the individuals interviewed pointed Tanzania’s 2007 EE baseline assessment recommended out that it has been much easier to generate enthusiasm that the HWWS project emphasize the need to adapt the and behavior change among children than among moth- methodology for promoting handwashing to the Tanzanian ers, particularly in rural areas. In 2010, the methodology context. It also recommended that the project incorporate and tools had only changed slightly. Virtually all people feedback from stakeholders into its methodology to the ex- interviewed praised the methodology as more effective and tent possible. The baseline EE report recommended that action-oriented than most other communication efforts Tanzania develop a social marketing approach with core in Peru. Very importantly, the methodology is not just a concepts that could be delivered through multiple chan- communication strategy. It includes a training methodol- nels formulated with the technical assistance of the private ogy, and it facilitates the availability of handwashing sta- sector and partner inputs. By 2010, an evidence-based so- tions that (1) remind people to wash their hands with soap; cial marketing approach was developed using MM, DCC, (2) make it easy for them to wash; and (3) save soap, water, and IPC to influence handwashing with soap in the target and money. Ministries of health, education, and women’s population. However, many stakeholders expressed a need programs have officially adopted the methodology. Al- for a review of handwashing with soap promotion methods though the approach clearly incorporates IPC, DCC, and in use by various organizations and agencies in order to de- MM, local respondents were much more familiar with the velop a common approach. first two approaches than the latter. Stakeholders felt that with the MoHSW leading the de- Stakeholders in the 2007 baseline assessment for Vietnam velopment of a national policy and campaign, the time expressed interest in learning and applying new behavior- was ripe to support its leadership and that lessons learned change techniques to promote handwashing with soap, from HWWS could be useful in shaping the national cam- noting that most handwashing communication activities paign. The HWWS project is in a position to work with 10 Global Scaling Up Handwashing A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension the MoHSW to develop appropriate handwashing with staff, resulting in two national programs championing and soap interventions and policy guidance for implementa- promoting handwashing with soap at critical junctures at tion. Stakeholders expressed an interest in learning more scale using the HWWS methodology. It can be said that the and sharing with the project what they believe to be an in- HWWS approach is recognized by a few critical national tegrated BCC approach. To determine whether HWWS’s programs like PEPAM, the Nutrition program, the Global approach can and should be replicated in Tanzania, these Sanitation Fund (executed by AGETIP), and all programs lessons need to be documented and discussed with stake- that work with the project’s technical assistance (Midwives holders. Stakeholders have asked the project to help coor- and Nutrition). dinate a review of its current training and communication approaches as part of the process to reach a consensus on a It is interesting to note that stakeholders from Senegal and preferred Tanzania model for promoting handwashing in Tanzania were less interested in using MM approaches, per- the community. haps because of cost, but quite keen to use IPC materials. In Peru, where the project’s MM promotion of handwashing The 2007 baseline EE assessment for Senegal noted a lack with soap won an international prize, most people inter- of consensus on the handwashing with soap methodology viewed in 2010 focused on IPC and DCC. Stakeholders in among stakeholders and the implementation of numer- Vietnam expressed concern about their inability to replicate ous uncoordinated multimedia-communication activities. the materials produced by HWWS, fearing that they lacked The findings cited included inadequately individualized adequate funds to meet the standard set by the project. programs and insufficient understanding of the proposed HWWS approach and other approaches used by stakehold- 3.5 Implementation Capacity ers. There were also possibly complementary approaches The necessary resources (human and financial), skills, incen- that could potentially be explored. Among the few stake- tives, and materials/tools to deliver the full complement of holders familiar with the HWWS project, there appeared interventions necessary to deliver a handwashing with soap to be a broader knowledge of the project’s approach, program. methodology, training, and materials. Many stakeholders interviewed during the 2010 EE assessment, aside from Assumptions: government stakeholders, expressed interest in learning and • It is unlikely that sufficient capacity exists at the start applying the project’s methods, materials, and tools in their of a program, and so it will need to be built. programs. MOUs signed with the project indicate that the • Capacity building is not limited to training; it also Midwives Association and Nutrition Program are interested includes incentives, resources, and tools to deliver in learning and applying project methods, materials, and handwashing with soap interventions. tools in their programs. • Capacity may need to be built in all components of the program, including implementation of activities, Stakeholders appreciated how HWWS’s approach was de- planning, budgeting, monitoring, evaluating, pro- veloped using formative research (which included the role curement, etc. of fathers in promoting handwashing behavior). They were • Capacity may need to be built within public and pri- keenly interested in reviewing the IPC, DCC, and MM vate sectors, as well as in NGOs. materials for promoting handwashing with soap. Programs • The development of sufficient capacity to deliver a with MOUs include the National Association of Midwives, handwashing with soap program should increase the National Nutrition Program, Dakar City Municipality likelihood of sustainability. School Milk Program (132 primary schools), and Ministry of Education Pilot Teacher Training: Dakar and Thies. Ul- Respondents: timately, the project’s opportunity to contribute to sustain- • Government ability in the near future is through completing the training • NGOs for handwashing with soap for the Midwives and Nutrition • Private sector www.wsp.org 11 A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension The Peru findings from 2007 were that in general skills effective ways to market handwashing with soap to rural and systems needed to implement the program existed populations. The report also saw a need to clarify the most at the national level but were weaker in some regions important capacity-building opportunities for handwash- and districts. By 2010, through advocacy, coordination, ing with soap with partners. The baseline suggested limit- training of trainers, and provision of communication ing capacity building to what was needed to meet project and program-support materials, the project has helped objectives (for example, enabling the district government increase implementation capacity at region and district to sustain handwashing with soap activities). Turning to levels. HWWS had focused strongly on training of train- 2010, discussion on implementation capacity with stake- ers, mostly in the health and education units of regional holders touched on multiple areas, but in the end came governments. The facilitators in turn have trained some back to the basic need to concentrate on supporting the 22,000 individuals to promote handwashing with soap. MoHSW in coordinating a national hygiene and sanita- Major challenges to ongoing capacity building include the tion campaign. This encompasses many areas, especially large annual turnover of teachers as well as turnover in at regional and local levels, including planning, finance, the health sector. One area of concern, very much related monitoring and evaluation (M&E), and program meth- to the country’s rapid decentralization in the past several odology. It was difficult for the assessment to truly deter- years, is the capacity of some regional and district govern- mine how implementation capacity at the district level had ments for planning, project preparation, proposal writ- changed since the baseline. Aside from volunteers working ing, efficient implementation, and other basic governing with HWWS, district staff appeared to be capable of sup- skills. The 2010 assessment recommended that HWWS porting the handwashing with soap program, but several collaborate with partners to address this need for capacity district stakeholders expressed interest in and a preference building. for PHAST, and what they termed UNICEF’s WASH ap- proach used in schools. Some said that they believed these In 2007, the baseline assessment for Vietnam’s EE found models worked well in Tanzania, but it may also be the some capacity to implement the HWWS methodology, case that these are the models they know. It was interest- although training in its behavior-change approach was ing to note that many staff expressed a desire to develop needed in the initial provinces where the project proposed a Tanzanian model for promoting handwashing with soap to work. The baseline also found handwashing sessions in that used elements from these models, and perhaps others the curriculum and capacity for promoting handwashing that went unmentioned. in schools. Despite finding adequate technology and ca- pacity for evaluation and pilot program implementation, The key findings for Senegal in its 2007 baseline EE as- the assessment judged that capacity in Vietnam to go to sessment included the presence of existing regional and scale was limited. HWWS worked to build the capacity local structures with existing, albeit limited, personnel with of national and local VWU staff to promote handwashing some apparent competencies and expertise pertaining to with soap, but could not work as closely as hoped with handwashing. There was, however, inadequate involvement the MoH on handwashing until 2010. By 2010, HWWS of potential partners at all levels and sectors in promoting was developing handwashing with soap training and man- handwashing, and capacity to promote handwashing with agement manuals for MoH staff to promote handwashing soap weakened considerably at the very local level. In 2010 with soap and was taking steps to build the capacity of and 2011, HWWS began working to strengthen national key government ministries and the VWU to incorporate capacity to implement at-scale handwashing with soap the promotion of handwashing with soap into their non- through training of the Midwives Association and National water and sanitation activities. Nutrition Program and district staff. Smaller in scale, but no less interesting is HWWS’s work with city of Dakar pri- In 2007, Tanzania’s EE baseline assessment noted a need mary school staff, which prepares existing regional and local to build community and ward capacity for planning and school staff to promote at-scale handwashing with soap at working with the private sector to identify efficient and critical times. 12 Global Scaling Up Handwashing A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension 3.6 Availability of Products and Tools The 2007 baseline for Vietnam recommended that the The ready access of necessary products (e.g., soap, water, hand- project assess existing information on the availability and washing stations), that respond to consumer demand to practice potential markets for products to facilitate handwashing handwashing with soap. with soap. The baseline also suggested that HWWS re- consider how to best integrate handwashing work into Assumptions: other projects and programs, for example, combine some • Easy access to these products is necessary to sustain handwashing activities with an ongoing water program. the practice of handwashing with soap and turn it By 2010, HWWS in Vietnam had helped lead forma- into a habit. tive research that resulted in the development of a model • Consumers will not use the products that do not re- handwashing station considered a viable candidate for spond to their needs. promotion via a public-private partnership with govern- • Consumer-responsive products can be developed. ment and business partners. Respondents: Tanzania’s 2007 baseline called for HWWS to address the • NGOs lack of handwashing facilities in schools. However, because • Private sector the schools could not be used in the program owing to the • Donors design and impact evaluation, the school component was dropped. By 2010 the project trained community volun- Soap was found to be widely available in all four coun- teers to motivate families to construct and use tippy taps tries, although in Tanzania and Senegal some families made from plastic bottles at the household level. People find it difficult to pay for soap. Communities in all coun- were encouraged to use soap with their tippy taps. The use tries have some access to water, but access may be time- of tippy taps was also promoted through DCC events con- consuming, seasonal, and/or only for limited hours—a ducted by marketing agencies. problem for sustaining the practice of handwashing. All four country programs developed handwashing stations, The Senegal baseline found that soap was widely avail- although Senegal promoted the use of a basin and vessel able and affordable and that access to water was generally for handwashing. good. HWWS promoted the use of a handwashing station comprised of a vessel and basin to help ensure there was In 2010, as in 2007, many communities in Peru continued an established place to carry out the behavior. The govern- to have difficult or part-time access to water. More than ment is working to improve access to water, even for the 95 percent of homes had access to soap. Formative research in very poor, with the assistance of donors, NGOs, and other 2008 showed, however, that many mothers were concerned stakeholders. with wasting soap on handwashing, and therefore did not make it available to family members for that purpose. This 3.7 Financing was a major incentive to devise the handwashing stations Adequate funds are available to organizations/agencies inter- (Super Jaboncines), which facilitate handwashing with soap ested in promoting handwashing with soap to cover the pro- using liquid soap made from a small piece of a bar soap. As of grammatic costs required to deliver their respective roles and October 2010, about 80,000 handwashing stations had been responsibilities. distributed in Peru (and 10,000 in Guatemala). These both encourage and facilitate handwashing with soap, conserving Assumptions: both water and soap in the process. Many more handwashing • Inadequate resources greatly constrain the ability to stations are needed as the project expands further. To increase deliver and sustain a large-scale handwashing with production and distribution, partners need to arrange fund- soap program. ing for the approximately $0.70/unit cost. A small number of • Sufficient funds need to be allocated to all com- families have made homemade versions. ponents of a handwashing with soap program, www.wsp.org 13 A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension including training, implementing activities, moni- of 2010 the NTP III was still under development, with the toring, transportation, office supplies, development Ministry of Agriculture and Rural Development discussing of materials, and so forth. increasing the allocation for communication in support of • Having dedicated handwashing with soap budget improved hygiene, sanitation, and water supply to as high lines in partners’ budgets increases the likelihood of as 20 percent of the total budget. HWWS’s higher profile sustained implementation. activities, such as training, development of a communica- • Having a financing plan based on realistic costs is tion materials package, and the model handwashing sta- important. tion, together with MoH and other efforts, helped raise awareness of the importance of investing in handwashing Respondents: with soap as part of an overall hygiene and sanitation com- • Government munication effort. Private soap companies continue to col- • Donors laborate with the MoH on handwashing communication • NGOs and promotion activities. In Peru in 2007 most financing came from international Tanzania’s 2007 baseline suggested that the HWWS proj- donors and in-kind contributions by private companies ect help districts increase their capacity to effectively pro- that reached their staff and customers through existing gram and use their hygiene-promotion funds, and work channels. By 2010, the focus had shifted from donor fund- with the Ministry of Education and Vocational Training ing to funding by national public and private organizations and District Executive Directors to ensure that funding and programs. Peru is the only one of the four HWWS is allocated for handwashing facilities in schools. The countries to have made this shift in focus. Although lack baseline noted that funding was mainly donor driven but of funding is clearly perceived as a barrier to expansion in that it was allocated through government mechanisms: some regions and districts, well-managed regional and dis- the Prime Minister’s Office for Regional Affairs and Local trict governments and partnerships that prioritize reducing Government, down to the districts. In 2010 this was still malnutrition or promoting handwashing with soap can the case. However, the US$20 million allocated for sanita- access several sources of funding. Various national govern- tion and hygiene under WSDP was moved from MOWI ment financing schemes are available to those regions, prov- to MoHSW. HWWS and partners are coordinating sup- inces, and districts that have the skills to tap into them. port to the MoHSW to help districts effectively program Regions that have mining and other large companies can and use funds allocated for hygiene and sanitation pro- establish projects that can attract private funding. motion. As previously noted, HWWS did not focus on promoting handwashing in schools due to the design of Vietnam’s 2007 baseline noted a mix of internal, project- the impact evaluation. focused needs and broader-based needs outside of the proj- ect. The baseline found insufficient attention paid to fi- The Senegal baseline focused on ways to obtain adequate nancing such products as handwashing facilities, water, and funding for the PPPHW to cover activities and expand. By soap. The baseline noted the need for increased private-sec- 2010, the HWWS project’s focus had shifted to support- tor investments in handwashing programs and for encour- ing PEPAM and AGETIP in their role of coordinating aging each partner, including the Government of Vietnam, sanitation programming aiming to reach the MDGs. By to establish a handwashing promotion and/or product line 2010, the GSF had also agreed to provide US$5 million items in their organizational budgets. It also called for the (over five years) to support projects promoting improved development of a budget format for the PPHW that makes hygiene and sanitation behavior. AGETIP, the govern- clear that handwashing with soap is explicitly funded. By ment employment agency working with the PEPAM 2010 HWWS had helped bring together partners to de- framework, is awarding contracts for GSF funding and is velop and potentially market a model handwashing station working with HWWS to help ensure that a handwashing through a multistakeholder, public-private partnership. As with soap component is included in all awards. 14 Global Scaling Up Handwashing A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension 3.8 Cost-Effective Implementation standard cost-effectiveness study. Given what is known The cost of implementation as compared to the health and eco- about the effectiveness of handwashing with soap and the nomic impacts to be measured in the impact evaluation. need for improved hygiene in Vietnam, partners currently feel no need to have a cost-effectiveness study to convince Assumptions: them of the efficacy and importance of promoting hand- • HWWS wants to sustain only cost-effective washing with soap. interventions. • Useful for advocacy in order to sustain financing and The 2007 Tanzania assessment recommended that HWWS implementation. describe clear incentives for tracking cost data, including costs averted due to decreases in diarrheal disease (DD) and Respondents: acute respiratory infections (ARI), and simplify the col- • Government lection of cost data. The baseline also suggested that the • NGOs project try to raise awareness within government about the • Donors cost-effective impact of handwashing with soap on DD • International organizations and ARI reduction targets. During the 2010 assessment, this issue did not appear to be a major concern to stake- In Peru in 2007 it was found that HWWS and its part- holders, but even so, HWWS has some data on the cost ners had collected extensive cost information but had not of handwashing with soap as recommended by the 2007 yet calculated cost-effectiveness. Capabilities to collect and baseline to share with stakeholders. This may be of inter- analyze needed data existed at the national level, but techni- est to the ministries as they spell out the details of their cal support was seen as necessary at subnational levels. The national sanitation strategy. 2010 assessment found that some government stakeholders already perceived handwashing with soap as a cost-effective Senegal’s 2007 baseline assessment reported finding in- intervention, and therefore measuring cost-effectiveness sufficient expertise to gather and utilize cost-effectiveness was not a top priority. Many informants have a strong be- information. The 2011 endline assessment found limited lief—sometimes based on local data—that handwashing interest expressed by stakeholders, although HWWS will with soap is a “low-cost, high-impact� intervention, in the have cost-effectiveness data that they propose to share with words of one respondent. People cited local data on child stakeholders. growth, child malnutrition, diarrhea and pneumonia cases, and school absenteeism. It was noted that because hand- 3.9 Monitoring and Evaluation washing with soap promotion in Peru is integrated into Monitoring is the process of capturing progress on implementa- so many different programs, calculating cost-effectiveness tion and achievement of targets in a timely manner to allow for might be difficult. analysis and prompt adaptation of implementation changes. Evaluation is defined as the assessment of the results of monitor- The 2007 Vietnam baseline assessment found existing ca- ing to identify what worked and what didn’t work. pacity and expertise to conduct a cost-effectiveness study. At the 2010 endline assessment, however, there did not appear Assumptions: to be much interest in this issue, and many interviewees • Ongoing monitoring of handwashing behaviors is required probing. It is important to note that when probed, necessary to keep the topic on the national policy some stakeholders thought that cost-effectiveness is “not agenda. quantifiable, cannot be analyzed, and that handwashing • Monitoring needs to continue in order to track with soap can have huge impact and is effective. We do not changes in the target population that may require a need to have proof that this should be supported.� Some change in intervention design. stakeholders said that there are many benefits to handwash- • Ideally, M&E systems are not parallel, but are incor- ing with soap that are intangible and immeasurable in a porated into existing monitoring systems. www.wsp.org 15 A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension • M&E for handwashing is likely to be poor, and so could be accessed by all partners. It suggested that HWWS systems and capacities will need to be developed. help provide evidence of how monitoring would benefit • Monitoring data need to be received quickly enough partners, and work with an experienced research group to allow for program adjustment if necessary. to measure health outcomes. By 2010, the government, • Collaborative development of targets keeps national HWWS, and stakeholders in Tanzania planned to address and subnational actors focused on results. M&E needs by incorporating handwashing with soap into the planned National Sanitation Campaign. Stakehold- Respondents: ers (particularly the MoHSW, WaterAid, UNICEF, and • Government HWWS) are making efforts to improve M&E by strength- • Donors ening national surveys, definitions, and targets along with • NGOs testing ways to improve routine monitoring and how to in- • Private sector centivize reporting. In the 2007 Peru assessment, respondents generally agreed The government of Tanzania is working with stakeholders that M&E was important, but they were not aware of the to develop a national performance-monitoring framework. results of HWWS’s monitoring. This led to the recommen- No firm decisions have been made on a handwashing indi- dation that the project share monitoring and other experi- cator yet, but national stakeholders expect to continue to ence among partners in Peru. The endline assessment found work with HWWS on this issue. It was clear from meetings that HWWS had done a much better job of disseminating with district and village officials during the endline assess- information on progress, lessons learned, and innovations ment that HWWS has worked through many iterations of through a website, newsletters, and reports. Still, some re- a community-based M&E system for tracking progress on spondents did not recall seeing documents and informa- the HWWS project. The project developed several forms tion that they should have received. There are now one or for front line activators (FLAs) for tracking the number of more handwashing with soap indicators in the information meetings held to promote handwashing with soap behav- systems of the many government programs that promote ior change, and the types of groups and activities that were handwashing with soap. HWWS has provided some capac- conducted. Village registers—inventory lists of household ity building in M&E to local partners, but there is demand sanitation and hygiene indicators—were also introduced. for more. These registers have been placed with village executive of- ficers (VEOs), who collect the FLA reports. FLAs use the The 2007 Vietnam assessment found existing capability to forms submitted to track their progress in carrying out develop, apply, use, and maintain a monitoring system, but their IPC work. Some VEOs were clearly informed about, there was a lack of consistent handwashing behavior-change supportive of, and active in the project, but others just indicators found among potential players. By the 2010 end- collected the reports to forward to HWWS staff. line assessment, HWWS had helped build capacity in the VWU to monitor handwashing with soap activities in its Senegal’s 2007 baseline found that there was expertise in regular programming, and the VWU had drafted a specific operating existing, albeit limited, monitoring systems. By handwashing with soap indicator for its M&E system. As early 2011, HWWS had developed a robust monitoring mentioned earlier, the NTP III was still in draft stage in system for close tracking of handwashing with soap that 2010, with the inclusion of a handwashing with soap in- it needed to share with stakeholders. The best succinct de- dicator defined as the presence of soap and a handwashing scription of HWWS’s M&E system is drawn from the proj- station in homes. ect’s annual report: Tanzania’s 2007 baseline recommended using the mini- The project has developed a robust performance monitoring mum number of indicators necessary to guide and evaluate system which has enabled the program to closely monitor im- the project, and building on an existing M&E system that plementation progress. The MIS has proven to be attractive 16 Global Scaling Up Handwashing A Four-Country Synthesis of the Enabling Environment Endline Analysis Findings by Enabling Environment Assessment Dimension to boundary partners, for example, as AGETIP develops its handwashing with soap programs, WSP has been supporting the development of a monitoring and evalua- tion system. AGETIP’s MIS will potentially include the same indicators as WSP— presence of a handwashing facility with soap and water, frequency of improved handwashing at critical times, distance of handwashing facility to kitchen/latrine, and changes in some handwashing determinants. Additionally, the National Nu- trition Program has approached WSP to help strengthen the handwashing section of their MIS to include handwashing indicators. The proposed indicators are pres- ence of a handwashing station, distance of the handwashing station to latrine/ kitchen, and practice of handwashing with soap at critical times through structured observations. www.wsp.org 17 IV. Summary of Assessment Findings The EE endline assessments in all four countries found increasing demand from the project’s partners to support and strengthen the development of handwash- ing components within national programs. HWWS provided technical assistance in planning, training to improve performance on monitoring, capacity build- ing for program implementation (IPC and MM in particular), facilitating pol- icy development and dialogue, and strengthening partnerships. Interviews with stakeholders (government, NGOs, private sector, media companies, international organizations, HWWS, World Bank operations staff, and donors) during the EE endline assessments underscored the degree to which stakeholders valued hand- washing as an integral component of a solid hygiene and sanitation strategy, or in Peru as part of a strategy to reduce childhood malnutrition. The indications are that handwashing interventions stand a good chance of continuing. Important outcomes drawn from the EE endline reports included: • Inclusion of handwashing indicators in national monitoring systems. Including feasible indicators of handwashing with soap increases the likeli- hood that program activities will be funded to make progress against the indicator. This is a critical contribution to increasing the likelihood of sustainability of handwashing with soap programming. • Development or strengthening of handwashing in national policies. Having a strong policy on handwashing—or ensuring that handwashing with soap is incorporated into other national policies such as reducing childhood malnutrition or improving water and sanitation—helps in- crease the likelihood that handwashing will become part of the national routine programming, and lessens the chance that it will be ignored. • Increased funding for handwashing. Each country team has convinced partners to increase funding for handwashing programming, a critical step toward continuing handwashing interventions. • Improved national capacity. The projects have focused on building im- plementation resources in country. These resources are housed in national agencies such as ministries of health and education in all countries as well as regional and local governments, and the VWU. The private sector’s ca- pacity has been improved through collaboration with HWWS in develop- ing behavior-change communications. These resources can be drawn on by subsequent initiatives to carry out the handwashing programming and help train local agencies to promote handwashing themselves using local resources. • Development of handwashing programs. In each country, stakeholders are developing handwashing components for national programs and have requested support from HWWS to help design the programs. 18 Global Scaling Up Handwashing V. Summary of Recommended Activities to Strengthen the Enabling Environment Table 2 lists the recommended actions in each of the countries to further progress on strengthening the EE. Either HWWS or other sector partners could carry out these activities in each country. TABLE 2: SUMMARY OF RECOMMENDED ACTIVITIES TO STRENGTHEN ENABLING ENVIRONMENT IN 2011 EE Dimension Peru Vietnam Tanzania Senegal Policy, • Maintain contact with • Compile a fully devel- • Support the MoHSW to • Use HWWS participation Strategy, and the lead organization or oped advocacy pack- lead in hygiene promo- in PEPAM subcommittee Direction coalition in each region age of lessons learned tion through the broad- and UNICEF coordinated that can perform key from the HWWS project, ening of the evidence WASH subcommittee to functions of advocacy, ranging from baseline base for promoting share lessons learned alliance-building, and and endline assessment; handwashing with soap about handwash- training; offer sug- compile a package doc- at critical times through ing with soap at scale gestions as needed, umenting handwashing the sharing of the Tan- implementation to sup- learn about and share with soap methodology, zania Behavior Change port improved hygiene achievements and les- training approach and Journey in a series of programming. sons learned. materials, management national and district • Provide technical assis- • Prepare and implement guidance, and BCC sharing workshops. tance to PEPAM so that a national event or sev- materials to share with • Contribute to the devel- the GoS framework for eral regional events, at stakeholders. opment of guidelines implementing sanitation which different-level • Advocate with stake- to promote hygiene and hygiene program- actors share their holders the continued improvement with a ming is designed to in- experiences around importance of hand- focus on handwashing clude handwashing with handwashing with soap washing with soap tar- with soap in the National soap. promotion, including, for gets and indicators in Sanitation Campaign. example, the Ancash ex- national policy. • Support the MoHSW perience with the Juntos in its responsibility to program (educational provide clear guidance sessions are part of on implementing policy the conditions for cash at the district level in payments). concert with, and via the PMO-RALG. (continued) www.wsp.org 19 A Four-Country Synthesis of the Enabling Environment Endline Analysis Summary of Recommended Activities to Strengthen the Enabling Environment EE Dimension Peru Vietnam Tanzania Senegal Partnerships • If feasible, continue to • Continue to work with • Take the lead in helping • Organize a meeting or publish and widely dis- the VWU on integrat- stakeholders develop workshops with potential seminate HWWS bul- ing handwashing with a partnership based on private sector partners letins, with a focus on soap activities within the UNICEF coordinated such as soap companies creative and effective the VWU’s own program School WASH to help and PEPAM and other contributions by part- planning through the define the best, most interested stakeholders ners at the regional and provision of techni- appropriate mix of meth- as appropriate, with the district levels that could cal assistance as per odologies for promoting objective of understand- later be adopted by the HWWS’s 2010 Transition handwashing with soap ing how to determine HWWS Hygiene and Strategy. at scale in Tanzania. cooperation objectives, Sanitation Alliance. • Continue to support budgeting, partner roles • Encourage regional, stakeholder business and responsibilities, provincial, and district plans under develop- outcomes, and planning coalitions address- ment to market hand- cycles. ing handwashing with washing stations, and soap to publicize their remain active in the own work and results, partnership using the including the contribu- project’s convening tions of various partners, power to help facilitate through local radio, development as pro- newspapers, and public jected need arises. events. Institutional • Through their social- • Support MoH leader- • Support the MoHSW • Continue to work with Arrangements development projects ship on the promotion of and PMO-RALG in de- GoS and development in Peru, the HWWS handwashing with soap veloping instructions for partners to help define project and the World at scale at critical junc- allocation of financing roles and responsibilities Bank should advocate tures through the devel- priorities at the district for hygiene. for regional and local opment of handwashing level. governments to promote with soap program handwashing with soap, management and train- using HWWS’s method- ing manuals for training ology and tools. MoH staff. • Provide stakeholders, especially GoV stake- holders, with packages of planning, manage- ment, training, and com- munications material needed to train staff to promote handwashing with soap. 20 Global Scaling Up Handwashing A Four-Country Synthesis of the Enabling Environment Endline Analysis Summary of Recommended Activities to Strengthen the Enabling Environment EE Dimension Peru Vietnam Tanzania Senegal Program • Continue collaborating • Offer stakeholders the • Continue collaborating • Hold workshops to Methodology with MIMDES (PRONAA, opportunity to form with all stakeholders to expose the stakehold- Wawa Wasi, FONCODES) learning alliances with develop a process to ers, beyond those in finalizing the process of HWWS to examine share lessons learned having signed MoUs adopting HWWS meth- the HWWS approach, in hygiene improvement with HWWS, to the odology for their pro- methodology, training and decide on a process handwashing with soap grams, and then prepare materials, and commu- for selecting the best Behavior Change Jour- the print-ready adapta- nications materials, and approach for Tanzania. ney, and tell the story of tions of HWWS materials. determine how best to at-scale promotion of • Continue to work with sustainably adapt and handwashing with soap the ministries of educa- use them in their ongo- in Senegal from both the tion, health, and the ing programming. perspective of the environment to finalize • Ensure that packages of community and the the process of adopt- materials, reports, stud- community-based orga- ing the handwashing ies, and manuals are niztions and media com- methodology, then, completely prepared for panies who implemented time-permitting, prepare sharing with stakehold- the handwashing with print-ready joint guide- ers in a workshop or soap methodology and lines for the Healthy series of workshops. developed IPC and DCC Schools program. tools. Implementation • Through the Hygiene • Ensure that handwash- • Advocate with national • Provide support and Capacity and Sanitation Alliance, ing with soap man- and regional government monitor training planned provide technical as- agement and training partners to include train- with national midwives sistance to public sector manuals for MoH staff ing on the handwashing and nutrition programs, partners in planning, im- are developed in close with soap methodol- and document progress plementing, monitoring, coordination with the ogy and tools in their of training and imple- and evaluating multisec- MoH. workplans. mentation plans. tor water, sanitation, and • Coordinate with MoH, • Explore options for • HWWS should follow, hygiene investments. MARD, and MOET on strengthening the use support, monitor, and • Advocate with partners appropriate methods for of volunteers in hygiene report in ongoing HWWS to support capacity sharing HWWS learning promotion and develop- documentation on the building in regional and with GoV stakehold- ing alternatives to mon- handwashing with soap municipal governments ers comprehensively etary incentives; and training provided to in planning, project through a workshop, look at integrating hand- the midwives, nutrition preparation, proposal series of workshops, washing with soap into program, Dakar Primary writing, and other basic and learning notes, as other community-based Schools, and MoE in skill areas. appropriate. interventions. Thies. (continued) www.wsp.org 21 A Four-Country Synthesis of the Enabling Environment Endline Analysis Summary of Recommended Activities to Strengthen the Enabling Environment EE Dimension Peru Vietnam Tanzania Senegal Availability • In the interest of sustain- • Ensure on-time, well- • Review qualitative find- • Stakeholders from GoS of Products ability, encourage local researched handwashing ings from program imple- and NGOs expressed and Tools partners (public and with soap intervention out- mentation to develop an interest in HWWS private) to plan for and lines including approach, recommendations for lo- facilitating a meeting finance additional cop- methodology, training and cally suitable and sustain- between private sector ies of materials. Private tools, communications able handwashing with companies to figure out companies may well be material, staffing, financ- soap products including how to work together willing to assume this ing, and monitoring re- soap and tippy taps. in an organized, well- cost, particularly if their quirements, are prepared This is an essential part planned way to promote logo can be placed on for insertion into World of telling the story, and hygiene and sanitation. the material. Bank water projects under developing the evidence Judging from what • Encourage homemade preparation. base for handwashing stakeholders said, both SJs, as have been made • Using the convening with soap promotion. sides would benefit from in one area of Caja- power of the HWWS Such a review can help a discussion on shar- marca. Perhaps hand- project, promote con- inform other dimensions ing goals, objectives, washing stations could tinued multistakeholder of the EE such as policy projected outcomes, be made from totora participation in market- and strategy, program and learning when and reed in the Lake Titicaca ing plans for the hand- methodology, financing, how to plan together and area. washing station model and even implementation budget, so that collabo- developed with IDEO. capacity and training. ration can occur. Financing • Continue to advocate with • Continue to advocate for • Continue to advocate • Share the Behavior the Ministry of Economy the inclusion of a strong within the MoHSW for Change Journey meth- and Finance (MEF) to communication com- the incorporation of odology, tools, story, and include a line item in the ponent for hygiene im- hygiene and sanitation results with stakeholders. national budget to build provement that includes components in other Sharing results will help the capacity of regional handwashing with soap health areas such as GoS, donors, and other and district governments in the NTP III. maternal health, malaria, stakeholders decide in planning, implementing, HIV/AIDS and child sur- how to spend money al- and monitoring behavior- vival in order to position located for hygiene and change methodologies. handwashing with soap sanitation software, for • Explore with the MEF and as an important compo- developing BCC pack- other partners how best nent of their program- ages and approaches to offer training and other ming versus a rival for from the national to the support in institutional funds. community and house- strengthening (plan- • Advocate to govern- hold levels. This, com- ning, budgeting, human ment stakeholders for bined with information on resources management, a better understanding costs, could potentially etc.) to regional and dis- of the evidence base for provide powerful mo- trict governments so they and efficacy of including tivation, in addition to can include funding and handwashing with soap existent support (PEPAM, activities for promotion of in ongoing programs by AGETIP, NGOs) for hand- handwashing with soap telling the story of hand- washing with soap, to in annual work plans and washing with soap. continue to strengthen in multiyear regional de- hygiene and sanitation velopment plans. behavior change. 22 Global Scaling Up Handwashing A Four-Country Synthesis of the Enabling Environment Endline Analysis Summary of Recommended Activities to Strengthen the Enabling Environment EE Dimension Peru Vietnam Tanzania Senegal Cost-Effective • Discuss with the MEF • Share cost-effectiveness • Share cost-effectiveness • Share cost-effectiveness Implementation the importance of cost- data results and data data results and data data with stakeholders effectiveness data for its with stakeholders after with stakeholders after at venues to include funding of handwashing study is completed. study is completed. workshops, PEPAM with soap promotion as Hygiene subcommittee, well as other programs. and UNICEF WASH sub- If such data will continue committee, where and to be needed, organize as appropriate. an orientation/training for key partner staff. Monitoring • Meet with key national • Support the inclusion • Support MoHSW, • Increase HWWS and Evaluation and regional partners to of a handwashing with regional, and local efforts to share its learn- discuss their satisfac- soap indicator in draft governments with imple- ing on monitoring and tion/comfort with current NTP III in conjunction mentation of village reg- evaluating handwashing M&E of handwashing with other partners. ister system to monitor with soap at scale with with soap in their or- • Share lessons learned sanitation and hygiene, stakeholders through a ganizations. If there is from the implementa- and assist in evaluating skill-building workshop sufficient demand and it tion of handwashing its effectiveness. targeting different seg- is feasible, help organize with soap at scale with • Work with MoHSW to ments of stakeholders orientation/training on stakeholders as part of a include a handwashing (GoS, NGO, donors) handwashing with soap lessons-learned presen- with soap indicator in as well as in presenta- for interested partners. tation that includes the other national surveys tions to selected totality of the experience that collect household hygiene and sanitation across dimensions. data. subcommittees. www.wsp.org 23 VI. Considerations for Programmers We recommend that any organization interested in implementing large-scale handwashing with soap interventions with government counterparts undertake an EE assessment to understand the context in which programmers will be work- ing. The EE assessment should help practitioners identify and address key fac- tors that ultimately support or hinder the service delivery of behavior-change interventions. The experience from this project demonstrates that it is difficult to generalize about which of the nine EE components is most important for programmers to focus on first. As this report shows, each of the countries started and ended at different places with respect to the EE. Additionally, stakeholders in any given country may value or place a different weight on anyone of the EE components. For example, in Vietnam stakeholders did not think developing a specific policy around handwashing with soap was essential to prioritize it in the country, be- cause they saw the inherent value of promoting handwashing with soap. Cultural and political differences and levels of economic development between countries will influence the EE of different countries, and some components may require more attention. The key learning coming out of this project is that a programmer’s assumption going into EE assessment should be that all components are equally important, and until an EE assessment is conducted, it will be difficult to know where to prioritize resources and efforts. 24 Global Scaling Up Handwashing A Four-Country Synthesis of the Enabling Environment Endline Analysis References References Coombes, Y., and N. Paynter. 2011. Tanzania: A Handwashing Behavior Change Journey. WSP Learning Note. www.wsp.org/wsp/sites/wsp.org/files/ publications/WSP-Tanzania-Behavior-Change-Journey-HWWS.pdf. Devine, J., and R. Flórez Peschiera. 2010. Peru: A Handwashing Behavior Change Journey. WSP Learning Note. www.wsp.org/wsp/sites/wsp.org/files/ publications/WSP_PeruBehaviorChange_HWWS.pdf. Devine, J., and S. Koita. 2010. Senegal: A Handwashing Behavior Change Jour- ney. WSP Learning Note. www.wsp.org/wsp/sites/wsp.org/files/ publications/WSP_SenegalBCJourney_HWWS.pdf. Favin, M., 2011. Endline Assessment of the Enabling Environment in Peru. WSP Working Paper. www.wsp.org/wsp/sites/wsp.org/files/publications/WSP- Peru-Handwashing-Enabling-Environment-Endline.pdf. Koita, S., 2010. Involving Men in Handwashing Behavior Change Interventions in Senegal. WSP Learning Note. www.wsp.org/wsp/sites/wsp.org/files/WSP_ InvolvingMen_HWWS.pdf. Nguyen, N., N. Paynter, and M.-H. Thi Nguyen. 2011. Vietnam: A Handwash- ing Behavior Change Journey for the Caretakers’ Program. WSP Learning Note. www.wsp.org/wsp/sites/wsp.org/files/publications/WSP-FA-Vietnam- LN-HWWS-lowres-DEC-2011.pdf. WSP. 2011. Handwashing with Soap (HWWS) Project. Semi-Annual Progress Report: Peru, Senegal, Tanzania, and Vietnam; July 1, 2010 – December 31, 2010. www.wsp.org 25