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United Nations Children’s Fund
The Story of a SuccessfulPublic-Private Partnershipin Central AmericaHandwashing for Diarrheal Disease Prevention
Authors
Camille Saadé
Massee Bateman
Diane B. Bendahmane
United Nations Children’s Fund
The
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Authors
Camille Saadé
Massee Bateman
Diane B. Bendahmane
The Story of a SuccessfulPublic-Private Partnershipin Central AmericaHandwashing for Diarrheal Disease Prevention
TheWorld BankGroupUnited Nations Children’s Fund
Recommended CitationCamille Saadé, Massee Bateman, Diane B. Bendahmane. The Story of a Successful Public-PrivatePartnership in Central America: Handwashing for Diarrheal Disease Prevention. Published by the BasicSupport for Child Survival Project (BASICS II), the Environmental Health Project, the United NationsChildren’s Fund, the United States Agency for International Development, and The World Bank. Arlington,Virginia, September 2001.
CreditPhoto credits are as follows: Cover photo, page 47, Servicios Estrategicos; page 1, UNICEF/90-0008/Ellen Tolmie; page 9, UNICEF/94-0948/Nicole Toutounji; page 15, Camille Saadé; pages 21, 29, 35, 55,Colgate Palmolive; page 67, UNICEF/Mainichi/Shinichi Asabe
About the PublishersThis document was supported by Basic Support for Institutionalizing Child Survival (BASICS II), theEnvironmental Health Project (EHP), The United Nations Children’s Fund (UNICEF), and The WorldBank. BASICS II and EHP are sponsored by the U.S. Agency for International Development, Bureau forGlobal Programs, Office of Health and Nutrition. BASICS II is conducted under the terms of Contract No.HRN-C-00-99-00007-00 by the Partnership for Child Health Care, Inc. Partners are the Academy forEducational Development, John Snow, Inc., and Management Sciences for Health. EHP is conductedunder the terms of Contract No. HRN-I-00-99-00011-00 by Camp Dresser & McKee International Inc. anda consortium of specialized subcontractors.
The views in this report are entirely those of the authors and do not necessarily reflect those of USAID,UNICEF, or the World Bank. This document may be reproduced if credit is properly given.
Office of Health and NutritionCenter for Population, Health, and NutritionBureau for Global Programs, Field Support, and ResearchWebsite: http://www.usaid.gov/pop_health/
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United Nations Children’s Fund
TheWorld BankGroup
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Table of Contents
Acknowledgments .............................................................................................................vii
Acronyms .......................................................................................................................... ix
Executive Summary ........................................................................................................... xi
Chapter IIntroduction: The Story of a Successful Public-Private Partnership ...................................... 1
The Concept ............................................................................................................... 2The “Nautilus”: An Approach to Public-Private Partnerships ........................................... 3A Promising Opportunity ............................................................................................. 6The Handwashing Initiative in a Nutshell ....................................................................... 6Overview of the Document ........................................................................................... 8
Chapter 2The Public Health Goal: Saving the Lives of Children ......................................................... 9
Diarrhea Morbidity and Mortality in Central America ..................................................... 10The Burden of Diarrheal Disease ................................................................................ 10Handwashing and Diarrhea Prevention ........................................................................ 10Handwashing Not Commonly Practiced ...................................................................... 11Private Sector Potential ............................................................................................. 12
Chapter 3The Catalyst: Bringing the Partners Together ................................................................... 15
BASICS Prepares to Play the Role of Catalyst ........................................................... 16Roles and Responsibilities ......................................................................................... 16Activities .................................................................................................................. 17
Phase One: Conceptualizing the Initiative ............................................................... 17Phase Two: Planning and Development ................................................................... 17Phase Three: Implementation ................................................................................. 19Phase Four: Assessment and Dissemination .......................................................... 19
Issues and Lessons Learned ..................................................................................... 20
Chapter 4The Private Sector Partners: Merging Business and Public Health Goals ........................... 21Commercial and Public Health Goals .............................................................................. 22Profiles of Participating Producers .................................................................................. 22A Non-Exclusive Partnership .......................................................................................... 23Roles and Responsibilities ............................................................................................. 24Activities of the Private Sector Partners ......................................................................... 25
Phase One: Conceptualizing the Initiative ................................................................... 25Phase Two: Planning and Development ....................................................................... 25Phase Three: Implementation ..................................................................................... 25Phase Four: Assessment and Dissemination .............................................................. 26
Issues and Lessons Learned .......................................................................................... 27
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Chapter 5The Public Sector and Other Partners: Joining Hands with the Soap Producers ................. 29
Targeted Groups ....................................................................................................... 30The Public Relations Blitz .......................................................................................... 30Activities of the Public Sector and Other Partners ....................................................... 31
The Follow-up Public Relations Event ..................................................................... 32Issues and Lessons Learned ..................................................................................... 32
Chapter 6Marketing Strategy Development: From Market Survey to Creative Concept ...................... 35
Consumer Research .................................................................................................. 36Selecting the Market Research Agency .................................................................. 36Designing and Testing the Questionnaire and Methodology ....................................... 37Implementing the Survey ....................................................................................... 37
Results .................................................................................................................... 39Diarrhea Prevalence and Detailed Analysis of Behaviors .......................................... 39Overall Stages of Key Behaviors ............................................................................ 40Key Attitudes and Constraints ................................................................................ 42Media Usage ........................................................................................................ 42
Implications for the Soap Producers ........................................................................... 42Advertising Strategy Development ............................................................................. 43
Advertising Brief ................................................................................................... 43Selecting the Advertising Agency ........................................................................... 43Developing the Communication Strategy ................................................................. 43The Design Concepts ............................................................................................ 44
Issues and Lessons Learned ..................................................................................... 44
Chapter 7The Advertising Campaign: The “How” and the “When” ...................................................... 47
Description of the Generic Handwashing Campaign ..................................................... 48Radio Spots .......................................................................................................... 48Television Spots .................................................................................................... 48Posters ................................................................................................................. 49
Strategy for Implementation ....................................................................................... 49Campaign Activities—March 1998 to April 1999 .......................................................... 50
Activities in Costa Rica ......................................................................................... 50Activities in El Salvador ........................................................................................ 50Activities in Guatemala .......................................................................................... 51
Continuing Project Activities ...................................................................................... 52Issues and Lessons Learned ..................................................................................... 53
Chapter 8Results: Return on Investments ...................................................................................... 55
Methods for Assessing Results ................................................................................. 56Follow-up Market Survey with Beneficiaries ............................................................ 56Interviews with Partners ......................................................................................... 56
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Results .................................................................................................................... 56Exposure to the Campaign ..................................................................................... 56Handwashing Behavior .......................................................................................... 57Attitudes Toward Handwashing and Soap ................................................................ 57Public Health Impact in Guatemala ......................................................................... 58Long-term Effects ................................................................................................. 59Other Key Findings ................................................................................................ 59
Resources Leveraged ................................................................................................ 59Soap Producers’ Evaluation of Results ....................................................................... 61Sustainable Change Among Partners ......................................................................... 63
Effect on the Private Sector ................................................................................... 63Effect on the Public Sector and Other Partners ....................................................... 63
Issues and Lessons Learned ..................................................................................... 64
Chapter 9Key Steps for Replication ............................................................................................... 67
Costs Versus Benefits ............................................................................................... 68Key Steps for Replication .......................................................................................... 68Issues ...................................................................................................................... 72Critical Success Factors ............................................................................................ 73
BoxesPast Experiences with Public-Private Partnerships for Child Health ..................................... 3Sample Studies of the Effectiveness of Handwashing ...................................................... 11Task Force Responsibilities of the Soap Producers .......................................................... 24The Public Relations Brochure ....................................................................................... 31Advertising Slogan and Logo .......................................................................................... 43Summary of the Handwashing Initiative Communication Strategy ..................................... 44Burbujita, the Mascot of the Handwashing Initiative ......................................................... 48The Generic Poster ........................................................................................................ 49Protex Handwashing Poster: An Adaptation of the Generic Campaign ................................ 52Protex Handwashing Promotion: A Program Targeting Schoolchildren ................................ 53Estimates of the Health Impact of the Handwashing Initiative in Guatemala ...................... 59
FiguresFigure 1. The Nautilus .................................................................................................... 5Figure 2. Handwashing Initiative Time Line ....................................................................... 6Figure 3. The Effectiveness of Interventions to Prevent Diarrhea ..................................... 11Figure 4. Diarrhea Prevalence Among Children by Handwashing Behavior
Stage of Surveyed Mothers, 1996 (all four countries) ........................................ 41Figure 5. Moving Families Up the Handwashing Steps .................................................... 42Figure 6. Generic vs. Branded Campaign Expenditures in 1998 ........................................ 51Figure 7. Stages of Handwashing Behavior in Guatemala, 1996 and 1999 ........................ 58Figure 8. Diarrhea Prevalence Among Children by Handwashing Behavior Stage of
Surveyed Mothers in Guatemala, 1996 and 1999 .............................................. 58
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TablesTable 1. Socioeconomic Targeting of Soaps .................................................................. 22Table 2. Products and Markets of Participating Producers .............................................. 23Table 3. Campaign Activities of Participating Producers ................................................. 26Table 4. Contributions of Public Sector and Other Partners ............................................ 33Table 5. Framework for the Market Survey .................................................................... 36Table 6. Focus of the Market Survey ............................................................................ 38Table 7. Observed Handwashing Technique: Percentage of Caretakers with Good
Reported Practices and Strength of Association with Lack of Diarrheain Children under Five in the Household, 1996 .................................................. 39
Table 8. Handwashing Occasions: Percentage of Caretakers with Good ReportedPractices and Strength of Association with Lack of Diarrhea in Childrenunder Five in the Household, 1996 ................................................................... 39
Table 9. Handwashing Place: Percentage with the Necessary Elements Present atthe Usual Place of Handwashing in the Household and Strength ofAssociation with Reduced Prevalence of Diarrhea among Childrenunder Five in the Household, 1996 ................................................................... 40
Table 10. Percentage of those Possessing and Using Soap, Guatemala, 1996 .................. 40Table 11. Handwashing Behavior Stage of Surveyed Mothers, 1996 (all four countries) ...... 42Table 12. Exposure to the “Lavo Mis Manos por Salud” Campaign .................................... 57Table 13. Catalyst Expenditures, 1996-1999 ................................................................... 60Table 14. Leveraged Resources, 1998-1999 .................................................................... 60Table 15. Costs and Benefits for Partners in the Handwashing Initiative ............................ 69Table 16. Key Steps for Replication ................................................................................ 70
AnnexesAnnex A. The Convenio ................................................................................................. 75Annex B. Persons Interviewed ....................................................................................... 81Annex C. Statistical Calculations for Estimates of the Health Impact of the Handwashing
Initiative in Guatemala .................................................................................... 83
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Acknowledgments
he authors gratefully acknowledge thecontributions of the partners in theInitiative and those who further
contributed to the documentation of ourexperience. Documenting the partnership wasitself a partnership among UNICEF, the WorldBank, and two USAID Projects—EHP andBASICS II.
We wish to express our appreciation firstfor the individuals who embraced our approachto building public-private partnerships andwho were willing to commit their time andresources to document it and allow its dis-semination to a wider audience: Rita Klees,Jennifer Sara, and Joana Godinho from TheWorld Bank and Lizette Burgers and VanessaTobin from UNICEF. Both organizations pro-vided support that made this publicationpossible. We also benefited from the thought-ful reviews and technical comments of a widespectrum of colleagues, including the above-mentioned colleagues from the World Bankand UNICEF, Hans Spruijt from UNICEF/Nepal, Paul Ickx and Renata Seidel fromBASICS II, Lisa Nichols and Frances Tainfrom EHP, and Valerie Curtis from the LondonSchool of Hygiene and Tropical Medicine.
Special thanks go to Karen Steele, whoconducted post-intervention interviews withkey players in the Handwashing Initiative fromthe public, private, donor, and NGO sectors.
We are especially grateful to Frances Tainat EHP who cheerfully managed the wholedocumentation process, coordinated theplanning among the four organizations, andkept the authors on schedule.
A warm thank you to our BASICS IIcolleagues Kathleen Shears, for her patientcopy editing, and Kathy Strauss, for layoutand design.
Finally, we thank all the partners in theCentral American Handwashing Initiative whocreated together and contributed to theexperience reported here. The individualsinvolved are too numerous to mention, so we
will simply thank their organizations forparticipating and continuing to use theInitiative as a model: Colgate-Palmolive,FUNDAZUCAR, La Prensa Libre, La Popular/PROFISA, the ministries of education inCosta Rica and El Salvador, the ministries ofhealth in Costa Rica, El Salvador, andGuatemala, NGOs and PVOs such as CAREand World Vision, the Office of the First Ladyof Costa Rica, Punto Rojo, TCS, Teletica,television channels 3,7,11, and 13 inGuatemala, Unisola/Unilever, and USAID andits missions in El Salvador, Costa Rica, andHonduras.
About the AuthorsCamille SaadéCamille Saadé is the public-private partnershipcoordinator at the Academy for EducationalDevelopment (AED), who works with theBASICS II and NetMark projects. Mr. Saadéhas developed and led the implementation of amethodology for mobilizing the commercialsector in mutually beneficial partnerships forsustainable interventions, such as the preven-tion of malnutrition, malaria and childhoodillness, promotion of health-enhancing behav-iors, hygiene education, and increasing thesupply and demand for appropriate treatments.
Prior to joining AED, Mr. Saadé spent 20years working in the pharmaceutical industryin different marketing and managementpositions in several international operationswith J&J, Upjohn, and Schering-Plough.
Mr. Saadé is the co-author of thepublication Mobilizing the Commercial Sectorfor Public Health Objectives. He was theeditor of the former quarterly Social MarketingMatters and has taught a course on socialmarketing at Boston University since 1997.
Massee BatemanMassee Bateman is the director of theEnvironmental Health Project. His career hasbeen dedicated to environmental health,
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disease prevention, and child survival issues.He has 18 years of experience in public healthand medicine; 16 years in international publichealth; and field experience in Antigua andBarbuda, Bangladesh, Bolivia, the DominicanRepublic, El Salvador, Ghana, Guatemala,Honduras, India, Indonesia, Nicaragua, Peru,Thailand, Uganda, and Zambia. Before joiningEHP, Dr. Bateman held positions as childsurvival advisor on the USAID managementteam for the BASICS I child survival project,epidemiologist and acting director, CommunityHealth Division, International Center forDiarrheal Disease Research, Bangladesh, andwas the associate director for environmentalhealth in the WASH Project in the early 1990s.
Dr. Bateman is the author or co-author of20 some publications on hygiene behavior,water supply and sanitation, family education,acute respiratory infections, HIV/AIDS and in-fectious diseases, nutrition, and reproductivehealth. He received his degree in medicinefrom the University of California and later
obtained a diploma in tropical medicine andhygiene from the Liverpool School of TropicalMedicine and Hygiene.
Diane B. BendahmaneDiane B. Bendahmane is a writer and editorwith extensive experience in publications ondevelopment assistance. Previously she wastechnical director for information services forthe Environmental Health Project (1994–2000)and for its predecessor, the Water andSanitation for Health (WASH) Project (1989–1994). She has carried out writing and editingassignments for the Inter-AmericanFoundation, the World Bank, the UnitedNations Foundation, the Foreign ServiceInstitute, Appropriate Technology International,and the Carnegie Endowment for InternationalPeace. Her interest in development grew fromher experiences as a Peace Corps volunteer(1966–68) and staff member (1969–1971) inMorocco.
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Acronyms
BASICS Basic Support for Child Survival
CARE Cooperative for Assistance and Relief Everywhere
DHS Demographic Health Surveys
EHP Environmental Health Project
INE Instituto Nacional de Estadística
MOE Ministry of Education
MOH Ministry of Health
NGO nongovernmental organization
ORS oral rehydration salts
ORT oral rehydration therapy
PAHO Pan American Health Organization
PRITECH Primary Health Care Technologies (USAID project)
PVO private voluntary organization
TCS Telecorporación Salvadoreña
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
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Executive Summary
The Project (principally ministries of health) would find itmutually beneficial to work in partnership toachieve complementary goals in promotinghandwashing for public health. Soapcompanies would use new messages andmethods of advertising soap designed toreach groups with low socioeconomic statusin rural areas where diarrheal disease rateswere high. These efforts would help eachcompany increase sales and enhance itscorporate image. The public sector wouldendorse the promotional campaign, assist indissemination, and collaborate in specialinterventions—such as distribution ofhandwashing kits. The partnership wouldprovide the public sector with new resources.
The ApproachThe Handwashing Initiative followed a 14-stepapproach developed and used by BASICS inother public-private partnership interventions.These steps fall into four distinct phases:
■ Conceptualization. The catalystorganization (usually a donor or NGO)identifies a public health goal that can bemarried with private sector objectives asthe basis for a public-private partnership.It also assesses the potential market forthe related product or service, tests theinterest and capabilities of companiesproducing the product, and selects thecompanies to participate. The companies,in turn, conduct their own feasibilitystudies before deciding to participate.
■ Planning and development. Thepartnership is formalized through amemorandum of understanding andformation of a task force to guide theeffort. The companies develop a generalmarketing plan, which is later fleshed outbased on market research. The researchfindings are used to create an advertisingand communication strategy. Then thetask force reaches out to involve the
he Central American HandwashingInitiative aimed to reduce morbidityand mortality among children underT
five through a coordinated communicationcampaign promoting proper handwashing withsoap to prevent diarrheal disease. TheInitiative was conceived and facilitated by theUnited States Agency for InternationalDevelopment (USAID) through two of itsprojects: Basic Support for InstitutionalizingChild Survival (or BASICS) and theEnvironmental Health Project (EHP).
The Initiative took place from 1996 to1999. The facilitator, or “catalyst” (the twoprojects) contacted soap producers from fiveCentral American countries—Guatemala,Costa Rica, El Salvador, Honduras, andNicaragua. Four companies eventuallylaunched handwashing promotion campaignsin 1998 in the first three countries. Ministriesof health and education, media companies,UNICEF, nongovernmental organizations(NGOs), and foundations also joined thepartnership. The campaign consisted of radioand television advertisements, posters andflyers distributed by sales personnel andthrough mobile units to communities; school,municipal, and health center programs;distribution of soap samples; promotionalevents; and print advertisements.
According to a follow-up assessment, tenpercent of the women surveyed improved theirhandwashing behavior. Based on observedrelationships between handwashing behaviorand diarrhea in these studies and supportingscientific literature, one can also estimate thatover the course of the intervention there wasan overall reduction in diarrheal prevalence ofabout 4.5 percent among children under five.(See Chapter 8 and Annex C.)
The ConceptThe effort was based on the belief that privatecommercial firms and public entities
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public sector and other organizations(such as media companies, NGOs,donors, and foundations), and thisexpanded partnership plans thecampaign.
■ Implementation. The advertisingcampaign is launched. As it unfolds,participants monitor implementation andlook for opportunities to expand andimprove it.
■ Assessment and dissemination. After aspecific period of time agreed upon inadvance (a year in the case of theHandwashing Initiative), an assessmentis conducted using essentially the sameinstrument used to collect baseline data.The analysis is incorporated into themarketing strategy, and results aredisseminated to guide continuation orexpansion of the campaign and otherefforts.
The approach varies depending oncircumstances. For example, it may be moreappropriate or even necessary for the catalystto involve public sector organizations first,rather than beginning with the privatecompanies. In the Handwashing Initiative,where no permissions or licenses—and thusno government approval—were needed, theprivate companies preferred to postpone theinvolvement of the public sector until acreative concept had been developed.
The Public Health GoalDiarrhea is a serious disease among childrenin developing countries, causing an estimated2.2 million deaths per year among those underfive, contributing to malnutrition, andincreasing the severity of other childhooddiseases. At the time of the intervention,UNICEF’s State of the World’s Children (1995)reported that diarrhea was the cause of 45percent of under-five mortality in Guatemalaand 20 percent in El Salvador.
Handwashing has been documented as aneffective means of preventing diarrhea if is itdone properly at appropriate times. Reductions
on the order of 35 percent may be expected(see Chapter 2). Yet in spite of its beneficialeffects, handwashing is not commonlypracticed or is ineffective because it is donewithout soap or not at the most crucial times.
The Catalyst ActivitiesThe role of the catalyst was to bring thepartners together, facilitate the work of thepartnership’s Task Force, finance a marketsurvey and development of an advertisingconcept, and provide technical assistance indesigning and implementing the campaignstrategy.
In the Central American HandwashingInitiative, the catalyst made preliminary visitsto soap manufacturers in the region to gaugetheir interest in the proposed project, broughtthose interested together in an organizationalmeeting, and facilitated the writing of amemorandum of understanding. The catalystalso formed a Task Force and called and ledperiodic meetings. It helped the marketresearch and advertising firms develop asound advertising strategy, worked with theproducers in each country to enlist thesupport of additional partners, and maintainedliaison with USAID missions in the targetcountries. BASICS provided expertise inmarketing and EHP in research and qualitycontrol of the campaign’s health-relatedmessages.
This report is part of the catalyst’sassessment and dissemination activities thatbegan with a follow-up market survey tomonitor the effects of the campaign andcontinued with presentations to manyorganizations to share the results and lessonslearned. The report aims to provide enoughdetail about the experience in Central Americafor project managers to understand what mightbe involved in carrying out such an effort.
The Private Sector PartnersThe five soap companies that joined theInitiative were La Popular and themultinational Colgate-Palmolive in Guatemala,Unisola/Unilever (another multinational) in El
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Salvador, Punto Rojo in Costa Rica, andCorporación Créssida in Honduras. Four ofthese companies eventually launchedcampaigns. (The Honduran firm had to dropout at the last minute because of financialproblems and the effects of Hurricane Mitch.The two Nicaraguan soap producers hadexpressed interest but were unable to committo the Initiative at that time.)
Each firm assigned its marketing directoror an official with similar responsibilities to theInitiative’s Task Force, which met seven timesand made important decisions about thedevelopment of the marketing strategy,selection of the market research firm andadvertising agency, scope of the marketsurvey, and design of the campaign. Once thecreative advertising concepts had beendeveloped, the companies joined with thecatalyst in contacting ministries of health,media organizations, UNICEF, nongovern-mental organizations, and others to expandthe partnership. They were able to attractconsiderable support for the campaign.
Which soap to advertise was an issue forthe producers. It was not financially feasiblefor any of the companies to develop a handsoap specifically for the campaign. On theother hand, those with multipurpose soaps—the bola used for laundry as well as personalcare—did not want to limit the positioning ofthese products to handwashing. Thosecompanies tended to use the basicadvertisements created by the advertisingagency, simply adding the logo of a brand oflaundry soap. The two major multinationals, onthe other hand, adapted the handwashingmessages to their existing brand advertising.
The campaigns varied widely. In ElSalvador, Unisola/Unilever worked with theMinistry of Health to complement andstrengthen its program for Healthy Schools. InCosta Rica, Punto Rojo leveragedconsiderable support from the media. Teletica(the major television station), matched theproducers’ paid advertisements one for one.La Popular’s efforts in Guatemala were highlyintegrated with the activities of its sales force,
which distributed materials in many smalltowns and villages. Colgate-Palmolive initiallysupported the efforts of UNICEF, NGOs, andfoundations and later organized a publicrelations event. Radio, television, and pressorganizations stepped forward and donatedtime and space for advertising.
Despite the formal conclusion of theBASICS/EHP intervention in 1999, several ofthe companies continued their ownhandwashing promotion. Colgate-Palmolivelaunched a school program reaching 450,000children regionwide and is using the creativeconcepts of the Initiative to advertise its best-selling brand, the antibacterial hand soap“Protex.” Unisola/Unilever is working with theMinistry of Health and BASICS to respond tothe threat of cholera in El Salvador. And at thepublic relations event in April 2000, theGuatemalan Ministry of Health andcommercial partners in Guatemala presentedplans for continuing activities through 2003,mainly through the MOH National Plan forHealthy Schools and Municipal HealthPromoters.
The Market SurveyThe market survey financed by the catalystwas conducted by Generis Latina, a firmbased in Guatemala. Local surveyorscontacted 4,500 households in lowersocioeconomic strata in the four countries andasked mothers to answer about 50 questionsand give a demonstration of handwashing.Questions covered socioeconomic andhousehold characteristics, water availabilityand use, handwashing, soap use, attitudestoward handwashing, and diarrhealprevalence.
Times and technique are crucial inhandwashing for diarrheal disease prevention.Hands must be washed at a minimum of threecritical times: (1) before cooking or preparingfood, (2) before feeding a child or eating, and(3) after defecation, cleaning a baby, orchanging a diaper. The three elements ofproper technique are to use water and soap,rub one’s hands together at least three times,
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and dry them hygienically (e.g., with a cleantowel or by air drying).
The survey showed that only nine percentof those surveyed were in the “optimal”handwashing group. These peopledemonstrated all three elements of propertechnique and reported washing at all threecritical times. Sixty-five percent were in the“inadequate” group. (Their technique wasinadequate and/or hands were not washed atany of the critical times). The remaining 26percent were in the “intermediate” group,reporting adequate technique but at only oneor two of the critical times. Because of theimportance of correct handwashing behavior,the goal of the campaign was to move moremothers out of the inadequate group and intothe intermediate and optimal groups. Iftechnique is deficient, then handwashing isineffective, no matter how many times a dayhands are “washed.” The fact that there wasroom for improvement among 91 percent ofmothers surveyed indicated that there was awide scope for the campaign (and asignificant market potential for the soapproducers).
The survey also confirmed the expectedassociation between handwashing anddiarrheal disease: the better the handwashingpractices of mothers, the lower the rate ofreported diarrhea among children under fiveduring the previous two weeks. Diarrheaprevalence rates were 7 percent for theoptimal group, 15 percent for the intermediategroup, and 21 percent for the group withinadequate handwashing practices.
The Creative CommunicationConceptThe catalyst hired Servicios Estrategicos, anadvertising agency based in Guatemala, todevelop the campaign’s creative conceptsbased on the survey results and theInitiative’s goals, and to prepare genericmaterials for the producers to use or adapt.
The overall concept was based on the“how” and the “when” of handwashing: thethree elements of correct technique and three
critical times. The theme was “Manos limpias,evitan la diarrhea” (Clean hands preventdiarrhea), and the slogan was “Lavo mismanos por salud” (I wash my hands forhealth). The basic approach was to present amother as caretaker of the family and todescribe or illustrate the three critical timesand essential aspects of handwashingtechnique. The advertisements were upbeat,using popular music and actors in contextsfamiliar to the target population.
The ResultsThe market survey was repeated inGuatemala a year after the campaign hadbeen launched, with a few additionalquestions about exposure to the campaign. InCosta Rica and El Salvador, smaller follow-upsurveys were used mainly for tracking and toprovide information for further development ofthe campaign.
Key Results in Guatemala■ Handwashing behavior improved. Ten
percent of mothers moved out of theinadequate handwashing group into eitherthe intermediate or optimal group.
■ Diarrheal disease can be postulated tohave decreased. Based on observedrelationships between handwashingbehavior and diarrhea in these studiesand supporting scientific literature, onecan estimate that over the course of theintervention there was an overall reductionin diarrheal prevalence of about 4.5percent among children under five. (SeeChapter 8 and Annex C.)
Regionwide Results■ Catalyst activities leveraged significant
resources for public health. TogetherBASICS and EHP allocatedapproximately $389,000 to theHandwashing Initiative, which made itpossible for the soap companies andother organizations to carry outpromotional activities worth an estimatedvalue of $614,900 during the first year of
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the campaign. (It has not been possible toestimate contributions in subsequentyears.)
■ Soap company sales increased. Althoughthe soap companies provided no specificinformation, producers implied that saleshad increased in areas where projectactivities had taken place. Producerswere hesitant to share information suchas sales figures with the Task Forcebecause the group was composedprincipally of their competitors.
■ Sustainable changes achieved amongpartners. Private companies learned newapproaches and techniques for soappromotion and about the potential forworking in collaboration with the publicsector, media, and donor organizations.Public sector involvement in thecampaign led to increased competence ofpersonnel in handwashing promotion,improvements in hygiene programsthrough the contributions of the privatesector, and creation of new associationsand networks.
■ Experience disseminated to othercountries through the channels ofmultinationals. Subsidiaries ofmultinationals reported the success of theintervention to their headquarters, whichin turn disseminated the news to theirother subsidiaries, creating opportunitiesfor replication.
The Outstanding IssuesMore experience with the public-privateapproach used in the Central AmericanHandwashing Initiative may shed light on thefollowing unresolved issues:
■ Collaboration versus an exclusiveagreement. The Initiative invited allinterested soap producers to join, in theinterest of equity and campaign scope.However, some producers, preferringexclusivity, were not comfortable workingwith their competitors. Some later claimedthat they participated only “defensively,”
for fear of being left out. An exclusiveagreement with one company might haveprompted a greater effort.
■ Measuring impact. Because it isimpossible to have a control group, aproject operating at the scale of theInitiative cannot measure health impactthrough an experimental design thatallows for ironclad conclusions. Theinvolvement of an ever-widening group ofparticipants and more and more variedactivities also presents challenges forevaluation.
■ Feasibility of handwashing intervention.Environmental constraints, such aslimited access to water or affordablesoap, may threaten the feasibility of ahandwashing campaign.
■ Sustainability. It is encouraging thatactivities inspired by the Initiativecontinue. Nevertheless, the end ofcatalyst involvement has left a void. Timewill tell whether involved firms willincorporate elements of the campaign intheir soap advertisements in the long runand whether ministries of health willcontinue their support for the campaign.
Critical Success FactorsThe following factors proved to be essential tothe Initiative’s success:
■ Presence of a catalyst. Members of thepartnership said that the public andprivate sectors could not have beenbrought together without the catalyst. Inaddition, the catalyst brought to the tableexpertise in marketing, public health, andbehavioral research; financed the all-important market survey and advertisingconcepts; and assigned a localcoordinator to monitor activities.
■ Behavioral research. The market surveyprovided information that was vital todesigning the advertising strategy and abaseline for measuring progress inchanging behaviors and attitudes andbringing about health improvements.
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■ Public health backing. The Initiativereceived the enthusiastic support andendorsement of ministries of health in ElSalvador and Guatemala. This supportreassured the soap producers that theyhad made a wise decision in participatingin the campaign.
■ Road map. The catalyst used a well-defined approach to public-privatepartnership. This gave all partners a clearidea of the sequence of events andhelped keep the Initiative on track.
■ Roles, responsibilities, expectations. Amemorandum of understanding set out theroles and responsibilities of the partners,the goals, and the expected outcomes.The document was fairly open-ended as
to what resources the soap producerswere to provide. A too-specific documentwould not have been in keeping with thevoluntary nature of the Initiative.
The success of the HandwashingInitiative has been attributed to theenthusiastic support of the concept by thesoap producers and the availability of flexible,timely, technical assistance to keep theproject moving along. It is hoped that theexperience in Central America will bereplicated in other countries as a componentof integrated programs to prevent diarrhealdisease and that it can be used as a modelfor private sector involvement in other publichealth areas.
1
his chapter orients the reader to the HandwashingInitiative by…
IntroductionThe Story of a SuccessfulPublic-Private Partnership
Tn Explaining the concept behind the Initiative.
n Reviewing the approach used to plan, implement, and assess theInitiative.
n Telling the story of the Initiative—in abridged form.
n Giving a time line of activities.n Describing the contents of the rest of the chapters.
Chapter 1
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T he Central American Handwashing Initiative was a partnership ofprivate and public sector organizations working to promote the
use of soap for handwashing to reduce diarrhea-related morbidity andmortality among children. The Initiative was based on the belief that
private sector companies can positively influence consumers’ health-
related behaviors, while at the same time increasing their market shareof key products. Private sector involvement in public health can
leverage funds to reach those in need, as one component of a
comprehensive public health strategy.
The effort received funding from the UnitedStates Agency for International Development(USAID) through two of its projects: BASICS(Basic Support for Institutionalizing ChildSurvival) and the Environmental HealthProject (EHP). From 1996 to 1999, theseprojects served as the catalyst for theInitiative—mobilizing support from privatesoap companies, ministries of health andeducation, media organizations, donors, andnongovernmental organizations (NGOs).
This report tells the story of the Initiative,documents its successes and challenges,and offers lessons learned to guide futureactivities in Central America, as well assimilar programs in other regions.
The ConceptMaking a widespread and lasting impact onpublic health is a challenge for all in theinternational health community. In manydeveloping countries, the number of publichealth problems continues to grow, while theresources available to address them becomemore constrained because of economiccrises, changes in public and politicalpriorities, and complex bureaucraticprocesses. Even when donor funding isavailable, recipient governments often lackthe necessary infrastructure and personnel toreach at-risk populations efficiently andeffectively. Overextended ministries of healthmay collaborate with NGOs to deliver public
health-related products and services. Butthese NGOs, in turn, rely on limited funds fortheir operations.
Throughout the world, the commercialsector has managed to reach people at allsocioeconomic levels with a wide array ofproducts and services through consumer-drivenmarketing. These manufacturers, distributors,and marketers work within vibrant distributionand promotional networks that are effective inreaching and motivating consumers. Successfulcompanies also have a highly developedcapacity to influence customer behavior in themost cost-effective ways.
Normally, the public and the privatesectors work independently, and donors andministries of health have made only limitedefforts to seek partnerships with commercialfirms. Public-private partnerships have thepotential to reinforce and expand thecapabilities of donors and ministries of healthand to increase the use of essential productsin a sustainable and efficient way.
For public-private partnerships to work,they must be mutually beneficial and part ofan overall strategy to deliver needed productsand services. Bringing in the private sector tohelp achieve public health objectives does notmean replacing the public sector. Acoordinated approach helps rationalizespending on priority health needs at both thenational and the individual levels. Forexample, companies can relieve the burden
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Section 1
on public sector resources through marketsegmentation that targets those willing andable to pay for products and services throughprivate channels. Typically, the private sectorcan offer a wider range of choice, higherquality, and convenience.
The coverage of populations withdisposable income by the commercial sectoris obviously not an adequate solution to mostpublic health needs, since populations withthe heaviest health burden are often least ableto pay. However, public health deliverysystems often serve a disproportionatenumber of people who can afford to pay. Whenthese populations are offered convenient, highquality, affordable options through thecommercial sector, they are often eager toswitch, freeing public sector resources forthose most in need.
Public-private collaborations are moresuccessful in countries in which there is athriving commercial infrastructure and
governments view public health as a priority.Regional approaches also require favorableregulations and trade agreements.
The “Nautilus”: An Approach toPublic-Private PartnershipsThe Central American Handwashing Initiativefollowed an approach that BASICS hasdeveloped and applied in various settings topromote public-private partnerships. Theapproach is designed for a donor-fundedorganization that serves as a catalyst—toinitiate the partnership, provide technicalassistance and other resources, and keepthings moving.
The sequence of activities may varydepending upon the circumstances,particularly regarding the point at which thepublic sector is brought into the process.Figure 1 depicts the steps followed in theCentral American Handwashing Initiative asthe “chambers” in a nautilus.1
1. More details on the approach, and variations of it, may be found in Mobilizing the Commercial Sector for Public Health Objectives,published jointly by UNICEF and USAID (Slater and Saadé 1996).
The Regional Handwashing Initiative is not the first USAID-funded effort of its kind. In the early1990s, USAID’s PRITECH Project (Technologies for Primary Health Care) developed an approachto engage private sector companies in the prevention and treatment of diarrheal diseases. Theapproach was tested in Indonesia, where PRITECH involved major soap producers in acoordinated hygiene campaign in partnership with the government, media personnel, and theadvertising council. (There was no evaluation of the campaign impact, however.)
Several other public-private partnerships focusing on diarrheal disease and the promotion oforal rehydration therapy (ORT) also preceded and informed the Central American HandwashingInitiative:
■ a partnership among Sterling Beecham, UNICEF, USAID/PRITECH, and the government ofKenya to ensure nationwide availability of oral rehydration salts (ORS) and increase their usefor the prevention and treatment of dehydration due to diarrhea;
■ a collaboration brokered by PRITECH between ORS producers in Pakistan and the Ministry ofHealth to commercialize ORS and minimize the burden of procurement on the governmentthrough (tax-free) low-price, extended distribution to rural areas and promotion in conformitywith national policy;
■ a partnership among two ORS producers in Bolivia, the Pan American Health Organization(PAHO), UNICEF, BASICS, and the Ministry of Health to produce and market ORS inpharmacies and beyond to rural outlets.
Past Experiences with Public-Private Partnerships for Child Health
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Step 1 State relevant public health objective.The health objective identified must lenditself to private-sector involvement. Inpractical terms, this usually meansidentifying a key health-related behaviorconnected with a health care product(e.g., use of ORS to prevent and treatdehydration from diarrhea and use ofiodized salt and other fortified foods toimprove nutrition).
Step 2 Assess market potential. Both the sizeof the current market for a health-relatedproduct as well as the size of theuntapped potential market should beestimated. A dynamic market segmentattracts competition. Evaluating themarket share of each competitor helpsidentify the dominant forces andtrendsetters.
Step 3 Assess company capabilities.Information is gathered on all firmsmanufacturing or distributing the healthcare product. (What is their product?Where is it sold? How much does it cost?Who buys it? How is it advertised? Forwhom is it targeted?) An effective way toget answers to these and other suchquestions is to meet with a representativeof each company’s top management foran informational interview. This firstcontact also gives the catalyst a chanceto introduce the concept of a public-private partnership and gauge thecompany’s interest.
Step 4 Select partner companies. Establishcriteria for involvement and invite theappropriate company or companies toparticipate. Some partnerships mayinvolve just one company, while otherswill involve several. (An exclusivearrangement may be appropriate if thegoal is to provide a specific product fordistribution in a public health program.)
Step 5 Request feasibility study. Companiesconduct feasibility studies with well-considered projections of potentialrevenue, expenses, and profits over five
years to enable them to make a corporatedecision about whether or not to engagein the partnership. Such a study helps thepartnership avoid building unrealisticexpectations. It also forces an internalcompany discussion of the pros and consof participation.
Step 6 Finalize partnership. The partnership isformalized in a memorandum ofunderstanding outlining the goals, rolesand responsibilities, and contributions ofthe major partners. There should be ampletime for decision makers in theparticipating organizations to review andrevise the agreement before signing it.The agreement should provide for theformation of a task force made up ofrepresentatives from the partnerorganizations to guide the remainingsteps in the process.
Step 7 Prepare marketing plan. Together thepartners develop a preliminary marketingplan based on the public health goal. Forexample, the Handwashing Initiative’splan was to promote the beneficial healtheffects of handwashing with soap to low-income groups with high rates of diarrhealdisease, using appropriate communicationchannels involving media, communityactivities, and interpersonal communica-tion according to the combined andindividual resources of the partners.
Step 8 Carry out baseline market research.Before a marketing strategy can bedeveloped, the companies must find outhow much consumers know about thehealth problem being addressed and whattheir related practices and motivationsare. Market research techniques, such assurveys, focus group discussions, orobservation, can be used. Such researchcan also provide baseline informationabout knowledge, attitudes, beliefs, andbehaviors, so that results can bemonitored. It is usually advisable tocontract with a professional marketresearch agency for this work.
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Step 9 Raise public sector interest. After themarket survey has been completed andthe results analyzed, the task forcemeets with public sector organizations toinvite their involvement and collaboration.It is important to contact key publichealth officers, especially those who maybe enthusiastic about workingcollaboratively with the private sector. Inthe Handwashing Initiative, the soapcompanies preferred to postponeinvolvement of the public sector untilplans were fairly well developed. However,the public sector might be involved first,before private companies have joined theeffort. In such situations, the publicsector might play a role similar to thecatalyst’s, reaching out to the privatesector. International and regional lendinginstitutions, bilateral aid agencies,professional associations, and NGOs arealso contacted to expand the partnership
and help foster public-private collaborationfor health goals.
Step 10 Build consensus. Consensus is builtas the partners in the public and privatesectors discuss and address public healthand business concerns in a neutral wayand develop a joint work plan with anappropriate time frame and a cleardefinition of roles and responsibilities.
Step 11 Finalize marketing strategies. Usingthe market research data, the partnersfinalize the marketing plan, including thecommunication strategy. An advertisingagency develops the creative conceptsand reviews them with the partners. Theconcepts should be tested with theintended target audience before thepromotional materials are produced.
Step 12 Launch campaign. An advertisinglaunch provides a great opportunity tosolidify the commitment of each partner.
Figure 1. The Nautilus
Promoting Public/Private SectorPartnerships for Public Health
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A well-planned public relations event willcreate long-lasting promotional “noise” forthe benefit of the campaign.
Step 13 Monitor implementation. The catalystensures that the marketing plan isimplemented according to schedule byreviewing the plan regularly, monitoringeach partner’s activities, marshalingresources to solve problems, recognizingcontributions, and ensuring that sufficientdata are collected to measure impact.
Step 14 Evaluate and integrate results. Thecatalyst and public sector partners areusually responsible for measuring anddocumenting the partnership activitiesand determining their impact on publichealth. Commercial firms may collect theirown data to show the impact of thepartnership activities on their sales. Themain purpose of evaluation is to improvesubsequent efforts. Therefore, amechanism must be in place to documentresults, integrate them into futureactivities, and disseminate them tostakeholders.
A Promising OpportunityThe project described here was part ofUSAID’s attempt to hone an approach topublic-private partnerships and to document
its effect on the target population. The projectessentially began “at scale” because it wasimplemented at the national level in threecountries. Most handwashing studies in thepast have been aimed at relatively smallpopulations with levels of external inputs thatwere not generally sustainable.
Promoting handwashing is a natural goalfor a public-private partnership. The potentialfor combined public health and commercialbenefits promises that initial investments maylead to a partnership that is self sustaining—and that will bring lasting benefits.
The Handwashing Initiativein a NutshellBASICS/EHP began work on the CentralAmerican Handwashing Initiative in 1996 bycontacting all soap producers in five countries(Guatemala, Costa Rica, Honduras, Nicaragua,and El Salvador) to assess their interest.Eventually four companies—includingmultinationals as well as regional and nationalsoap producers—joined the collaborative effort.A Task Force made up of representatives fromeach company, BASICS, and EHP metperiodically to guide the Initiative.
The advertising strategy was based on amarket survey financed by BASICS, withtechnical assistance from EHP (see Chapter
Phase One: Conceptualizing The Initiative Phase Two:
Jan 95 – Jan 96 Jan 96 Mar 96 Jul 96
Nautilus Step #2: Step #3: Step #4: Step #5: Step #6: Step #7:Step #1: Assess Assess Select Request Finalize Prepare
State public market company partner feasibility partnership marketinghealth potential capabilities companies study plan
objective
Figure 2. Handwashing Initiative Time Line
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6). The survey results revealed that fewer thanten percent of mothers in low-income ruralareas washed their hands in an optimalfashion. The project defined this optimalbehavior as:
■ washing at three keytimes (before cooking orpreparing food, beforefeeding children or eating,and after defecatingand—for those withbabies—after changingbabies’ diapers)
■ with three correcttechniques (using soap,rubbing hands together at least threetimes, and drying with a clean towel).
The survey also confirmed a correlationamong survey participants between poorerhandwashing practices and a higherprevalence of child diarrhea.
BASICS financed preparation of ageneric advertising campaign based on themarket survey to communicate the “threetimes/three elements” message. The genericcampaign could be used as it was or adaptedby the companies in campaigns for their ownbrands of soap.
As soon as the creative strategy hadbeen developed, the Task Force presented itto ministries of health and education, donororganizations, and NGOs and asked them to
join the Initiative. Theresponse was very positive:ministries of health endorsedthe campaign and distributedmaterials to health centersand schools; mediacompanies donated time;UNICEF incorporated themessages in its localprograms; and USAID andUNICEF enlisted their NGOnetworks in distributing the
handwashing promotional materials.The intervention was carried out in three
of the five countries: Guatemala, Costa Rica,and El Salvador. Campaign elements includedtelevision and radio advertisements,distribution of posters and brochures, mobileunits distributing soap samples, and schoolprograms.
About a year after the launch of thecampaign, BASICS financed a follow-upmarket survey to assess impact. The secondsurvey, which was essentially a repeat of theearlier baseline survey, showed improve-ments in handwashing behaviors and beliefs
“The main reason for the
Handwashing Initiative was to
try to get the best of two
worlds.”
— Baudilio Lopez, USAID, Guatemala
Phase Four:Phase Three: Assessment &
Planning & Development Implementation Dissemination
Oct 99 –Nov 99
(some activitiesJun 96 – Sep 96 – May 97 – Mar 98 – Mar 98 – continuingSep 96 Feb 98 Sep 97 Oct 97 Sep 98 Sep 99 to present)
Step #8: Step #9: Step #10: Step #11: Step #12: Step #13: Step #14:Carry out Raise public Build Finalize Launch Monitor Conductbaseline sector interest consensus marketing campaign implementation evaluationmarket strategies, and integrate
research test and produce resultsmaterial
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and attitudes among the target population.Based on observed relationships betweenhandwashing behavior and diarrhea in thesestudies and supporting scientific literature,one can also estimate that over the courseof the intervention there was an overallreduction in diarrheal prevalence of about 4.5percent among children under five. (SeeChapter 8 and Annex C.) At a national level,such a reduction would represent asignificant impact on public health.
A relatively small amount of funds($389,000 over four years) from the donororganization for the catalyst activitiesleveraged resources for diarrheal diseaseprevention from the private sector valued atapproximately $614,900 in just the first yearof the campaign.
Figure 2 provides a time line for projectactivities, related to the steps of the Nautilus.
Overview of the DocumentThis report uses the story of a successfulproject as the jumping off point to describe thereplicable elements of a public-privatepartnership for achieving health goals. In thesepages, project planners from donororganizations, as well as ministry of healthofficials and representatives of commercialfirms, can learn about the essential elementsof public-private partnerships. How areactivities sequenced? Who must be involved—and how deeply? What resources must beavailable? What kind of expertise is needed?What results might be expected? What are thepitfalls and how can they be avoided?
Readers should find information to helpthem decide whether the approach mightenhance their programs, and understand thetime and resources such an approach wouldrequire.
Chapter 2: The Public Health Goal: Savingthe Lives of Children, explains the publichealth challenge addressed by the Initiative.
The next three chapters focus on theroles of the key players in the partnership:
■ Chapter 3: The Catalyst’s roles andresponsibilities, activities, and issues andlessons learned.
■ Chapter 4: The Private Sector Partners’goals, activities, interactions with thecatalyst and other partners, and issuesand lessons learned.
■ Chapter 5: The Public Sector and OtherPartners’ activities, and issues andlessons learned.
Three chapters describe theintervention itself:
■ Chapter 6: Marketing StrategyDevelopment covers the market survey,development of an advertising strategy,field-testing, the generic campaign, andissues and lessons learned.
■ Chapter 7: The Advertising Campaigndescribes the launch, breadth, and scopeof the campaign, variations from companyto company and country to country, andissues and lessons learned.
■ Chapter 8: Results summarizes what thecampaign achieved in terms of behaviorchange, diarrhea prevalence, andinstitutional changes among thepartners.
Chapter 9 : Key Points for Replication,includes critical success factors, outstandingissues, obstacles, and recapitulates keysteps.
Works CitedSlater, S, and C Saadé. 1996. Mobilizing the
Commercial Sector for Public HealthObjectives. A Practical Guide. New York andWashington, DC: UNICEF and USAID/BASICS.
9
his chapter establishes the significance and the appropriatenessof the public health goal of the Central American Handwashing
Initiative by . . .
The Public Health GoalSaving the Lives of Children
Tn Presenting diarrheal disease morbidity and mortality figures for
Central America and for developing countries in general.
n Discussing handwashing as an effective intervention for diarrheal
disease prevention.n Explaining the potential role of the private sector in promoting
handwashing.
Chapter 2
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hen the Central American Handwashing Initiative began, anestimated 11 million children under five years of age were
Diarrhea Morbidity andMortality in Central AmericaIn Central America, frequent diarrhea has amarked impact on the lives of children.According to UNICEF’s State of the World’sChildren (1995), at about the time of theInitiative, diarrheal disease was the cause of19 percent of under-five mortality inHonduras, 23 percent in Nicaragua, 20percent in El Salvador, and 45 percent inGuatemala. Diarrheal disease is moreprevalent among children whose families’socioeconomic status and educational levelsare low and who live in remote areas.
The Burden of DiarrhealDiseaseDiarrhea-related deaths have been reduceddramatically over the past 25 years thanks toimproved treatment with oral rehydration salts(ORS), which prevents dehydration. However,diarrhea mortality remains high, and deathswill not continue to decline solely through theuse of oral rehydration therapy. Evidence isaccumulating that many of the children whodie with diarrhea today have dysentery,prolonged diarrhea, or diarrhea combined withmalnutrition (Victora et al. 1993, Bhan et al.1996, and Fauveau et al. 1991). A morecomprehensive approach to reducing suchdeaths is needed that also addresses thesource of the problem.
Diarrhea is the most frequent significantillness of children under five throughout theworld. In some parts of Latin America,children under three have an average of tenepisodes of diarrhea each year. InDemographic and Health Surveys (DHS)conducted in many countries throughout thedeveloping world, approximately 20 percent of
Wdying each year worldwide. About one-fifth of these—2.2 millionchildhood deaths—were due to diarrhea (Murray and Lopez 1996).
mothers report that a child under five has haddiarrhea in the two weeks before the survey.
Diarrhea—especially frequent andprolonged episodes and dysentery—is alsoone of the main causes of malnutrition(Martorell et al. 1975 and Alam et al. 2000).And even mild malnutrition is associated withincreased risk of death from a variety ofcommon childhood illnesses (Pelletier et al.1995). In addition, families face numerousdirect and indirect costs when a young childhas diarrhea: expenses for treatment, lostwork and wages for parents, older siblingskept out of school to care for the sick child,an additional strain on the resources ofalready overburdened mothers, and so on.Reducing the burden of diarrhea is clearly oneof the most important public health prioritiesin the developing world today.
Handwashing and DiarrheaPreventionThe means by which diarrhea is spread havebeen generally understood for many years.Minute quantities of fecal matter from a sickperson are ingested by a new host. Hands arean important vehicle in this fecal-oraltransmission route, especially the hands ofmothers and other caretakers of children. If amother’s hands are not free of fecalcontamination, the risk of spreading diarrhea tothe family through water and food is high.Enteric bacteria can survive on hands for atleast three hours and can easily be transferredto food and to other family members.
Likewise, the means to prevent diarrheahave been well documented. Esrey et al. in1991 and Huttly et al. in 1997 reviewed allrelevant studies on diarrheal diseaseprevention. Figure 3 summarizes what these
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studies revealed about the effectiveness ofvarious interventions. One remarkable findingis the effectiveness of improved handwashingto prevent diarrhea—both in developing anddeveloped countries. This should be nosurprise, as handwashing has long beenunderstood to be the key to preventing thespread of infection in hospitals—althougheven in hospitals this practice is poorlyimplemented (Boyce 1999 and Pittel andBoyce 2001). Most cultures considerhandwashing a fundamental aspect ofpersonal cleanliness.
The box on this page gives the findings ofseveral representative studies of handwashing.Effective programs to improve handwashing ofmothers and other caretakers of children, aswell as other hygiene behaviors, comparefavorably in cost-benefit to other specific childhealth interventions (Varley et al. 1998).
Handwashing Not CommonlyPracticedIn many parts of the world, handwashing isnot well recognized as a means to preventdiarrhea and is not commonly practiced. Toprevent diarrhea, at a minimum, people must
Source: Esrey et al. 1991; Huttly et al. 1997.
Figure 3. The Effectiveness ofInterventions to Prevent Diarrhea
Ten studies of handwashingwere included in a review ofinterventions to prevent diar-rhea (Huttly et al. 1997). Allreported a positive relationbetween improved hand-washing and diarrhealprevention, with a medianreduction of 33 percent(range 11-89 percent). Thefinding that improved hand-washing can preventdiarrhea was remarkably con-sistent in a variety of settings.For example, Black et al.(1981) cited reductions of 43percent in diarrhea amongday-care center children inthe United States resultingfrom a simple handwashing
wash their hands at certain critical timesusing proper technique. The critical times arebefore cooking or preparing food, beforefeeding children or eating and, afterdefecation, or cleaning babies or changingtheir diapers. The proper technique is to useclean water and soap, to rub hands together
Sample Studies of the Effectiveness of Handwashing
intervention. In Indonesia, im-proved handwashing behaviorby 65 mothers (who receivedsoap and explanations of thefecal-oral route of diarrheatransmission) reduced diarrheaincidence in their children by 89percent (Wilson et al. 1991).Similarly, handwashing andhygiene behavior interventionsreduced diarrheal disease by upto 39 percent in rural Thai vil-lages (Pinfold and Horan 1996).
Handwashing interventionsin urban Bangladesh reduceddysentery (shigella) by 35 per-cent and non-dysentericdiarrhea by 37 percent amongall age groups (Khan 1982). InMyanmar, childhood diarrhea
was reduced by 30 percentin urban households wherethe mother was given soapand handwashing education(Han and Hlaing 1989).
In more recent studiesnot included in the 1997review, soap distribution withhandwashing education wasassociated with a 33 percentdecrease in childhood diar-rhea in urban Bangladesh(Shahid et al. 1996) andsoap distribution alone wasassociated with a 27 percentreduction in diarrhea in arefugee camp in Malawi(Peterson et al. 1998).
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at least three times, and to rinse them welland dry them hygienically (Favin et al. 1999).Under ideal circumstances, additionalhandwashing is advisable; however, thecritical times and techniquesprovide a great deal ofprotection and are feasible forpeople whose time andresources may makeadditional handwashingexcessively burdensome.
Mothers in developingcountries often do not use theproper technique; the mostcommon failing is to washwith water alone—no soap.Likewise, they do notconsistently wash at criticaltimes. Many cultures perceivesoap as necessary only forwashing clothes, bathing, andwhen the hands feel or looksoiled.
Private Sector PotentialWhile the beneficial health effects of properhandwashing with soap have been welldocumented, public health sector efforts to
improve handwashing have not been showneffective. Educational campaigns conductedby the public health sector can be labor-intensive and time-consuming for busy health
care providers, may beineffective in terms ofinfluencing behaviors, maynot reach the most at-riskpopulations, and so on.Public education campaignsfor handwashing areexpensive to maintain at thelevel that may lead to lastingchanges, and may not be welldesigned in many cases.
The private sector offersan under-utilized resource fortransmitting healthinformation by advertisingsoap and its appropriate useas a means to preventdiarrhea. Involvement of the
private sector can significantly strengthen andsupplement the efforts of the public sector.The private sector can provide a valuablepublic service while developing the market forinexpensive soap for handwashing andincreasing market share.
“We genuinely believed in the
campaign and its cause. This
allowed us to keep in mind at
every moment that we were
perhaps saving a life . . .
We started to visualize the true
meaning of this project:
to save lives.”— Jorge Mario Lopez,
La Popular, Guatemala
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Murray, C, and A Lopez, eds. 1996. Global HealthStatistics: Volume 2. World Health Organization,World Bank and Harvard School of PublicHealth.
Pelletier, DL, EA Frongillo, Jr., DG Schroeder, andJP Habicht. 1995. The Effects of Malnutrition onChild Mortality in Developing Countries.Bulletin of the World Health Organization73(4):443-448.
Peterson EA, L Roberts, MJ Toole, DE Peterson.1998. The Effect of Soap Distribution onDiarrhoea: Nyanmithuthu Refugee Camp.International Journal of Epidemiology27(3):520-4.
Pinfold, JV, and NJ Horan. 1996. Measuring theEffect of a Hygiene Behaviour Intervention byIndicators of Behaviour and DiarrhoealDisease. Transactions of the Royal Society ofTropical Medicine and Hygiene 90(4): 366-371.
Pittet, D, and JM Boyce. 2001. Hand Hygiene andPatient Care: Pursuing the SemmelweisLegacy. Lancet Infectious Diseases April: 9-20;http://infection.thelancet.com/journal/review9.html.
Shahid, NS, WB Greenough 3rd, AR Samadi, MIHuq, N Rahman. 1996. Hand Washing withSoap Reduces Diarrhoea and Spread ofBacterial Pathogens in a Bangladesh Village.Journal of Diarrhoeal Disease Research14(2):85-89.
State of the World’s Children. 1995. New York:UNICEF.
Varley, RC, J Tarvid, DN Chao. 1998. AReassessment of the Cost-effectiveness ofWater and Sanitation Interventions inProgrammes for Controlling ChildhoodDiarrhoea. Bulletin of the World HealthOrganization 76(6):617-31.
Victora, CG, SR Huttly, SC Fuchs, FC Barros, MGarenne, O Leroy, O Fontaine, JP Beau, VFauveau, and H R Chowdhury. 1993.International Differences in Clinical Patterns ofDiarrhoeal Deaths: A Comparison of Childrenfrom Brazil, Senegal, Bangladesh, and India.Journal of Diarrheal Disease Research11(1):25-29.
Wilson, JM, GN Chandler, Muslihatun, andJamiluddin. 1991. Hand-Washing ReducesDiarrhoea Episodes: A Study in Lombok,Indonesia. Transactions of the Royal Society ofTropical Medicine and Hygiene 85:819-821.
Works CitedAlam, DS, GC Marks, AH Baqui, M Yunus, and GJ
Fuchs. 2000. Association Between ClinicalType of Diarrhea and Growth of Children under5 Years in Rural Bangladesh. InternationalJournal of Epidemiology 29:916-921.
Bhan, MK, N Bhandari, S Bhatnagar, and R Bahl.1996. Epidemiology and Management ofPersistent Diarrhoea in Children of DevelopingCountries. Indian Journal of Medical Research104:103-114.
Black, RE, AC Dykes, KE Anderson, JG Wells, SPSinclair, GW Gary, Jr., MH Hatch, and EJGangarosa. 1981. Handwashing to PreventDiarrhea in Day-Care Centers. AmericanJournal of Epidemiology 113(4):445-451.
Boyce, JM. 1999. It is Time for Action: ImprovingHand Hygiene in Hospitals. Annals of InternalMedicine 130:153-155.
Esrey, SA, JB Potash, L Roberts, and C Shiff.1991. Effects of Improved Water Supply andSanitation on Ascariasis, Diarrhoea,Dracunculiasis, Hookworm Infection,Schistosomiasis, and Tracoma. Bulletin of theWorld Health Organization 69(5):609-621.
Fauveau, VM, K Yunus, J Zaman, Chakraborty,and AM Sarder. 1991. Diarrhoea Mortality inRural Bangladeshi Children. Journal ofTropical Pediatrics 37(1):31-36.
Favin, M, M Yacoob, and D Bendahmane. 1999.Behavior First: A Minimum Package ofEnvironmental Health Behaviors to ImproveChild Health. EHP Applied Study No. 10.Arlington, Virginia: Environmental HealthProject.
Han, AM and T Hlaing. 1989. Prevention ofDiarrhoea and Dysentery by Hand Washing.Transactions of the Royal Society of TropicalMedicine and Hygiene 83:128-131.
Huttly, SRA, SS Morris, and V Pisani. 1997.Prevention of Diarrhoea in Young Children inDeveloping Countries. Bulletin of the WorldHealth Organization 75:163-174.
Khan, MU. 1982. Interruption of Shigellosis byHand Washing. Transactions of the RoyalSociety of Tropical Medicine and Hygiene76:164-168.
Martorell, R, C Yarbrough, A Lechtig, JP Habicht,and RE Klein. 1975. Diarrheal Diseases andGrowth Retardation in Pre-school GuatemalanChildren. American Journal of PhysicalAnthropology 43:341-6.
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hree types of organizations are involved in a public-private
partnership: catalyst, private sector, and public sector. This
The CatalystBringing the Partners Together
Tchapter takes an in-depth look at the catalyst by…
n Enumerating the roles and responsibilities of the catalyst (BASICS/
EHP) as outlined in the memorandum of understanding of theCentral American Handwashing Initiative.
n Describing the catalyst’s contribution to the planning,
implementation, and assessment phases of the Initiative.n Providing tips for carrying out the role of catalyst effectively.
Chapter 3
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successful public-private partnership is often initiated by anintermediary—a bilateral or multilateral donor organization or an
NGO. The intermediary brings resources and expertise to the table,but functions mainly to help the public and private sectors work
together, using their resources in innovative ways for public health
benefits. We call this partner a catalyst because, like a chemicalcatalyst, it is the “stimulus in bringing about or hastening a result.”
A
BASICS Prepares to Play theRole of CatalystIn 1995, USAID’s BASICS Project began toexplore the potential of the private sector inCentral America to assist the public sector inpreventing and treating the serious problem ofdiarrheal disease. The project’s private sectorspecialist traveled to theregion to identifyopportunities for mobilizingcommercial firms to produceand market products forpreventing and treatingdiarrhea. He focused onhandwashing with soap,disinfecting water withhousehold chlorine, and theprevention and treatment ofdehydration with ORS as themost appropriate areas forprivate-sector involvement.
This preliminary workrevealed that the soapcompanies were verysuccessful in getting their products into everysmall retail outlet in rural as well as urbanareas. They were intrigued by the idea ofpositioning a brand of soap for handwashing.BASICS concluded that providing thecompanies with evidence of market potentialthrough a market research study wouldinfluence their decisions about investing inthis new market “niche.”
USAID’s Environmental Health Project(EHP) was a natural partner because of itscommitment to preventing childhood disease
through environmental improvements andbehavior change and its specific experience inhandwashing promotion. EHP’s regionaladvisor in Central America was assigned tothe Initiative. He and the BASICS’ privatesector specialist visited soap producers andUSAID officials in Costa Rica, El Salvador,
Guatemala, Honduras, andNicaragua a second time in1996 to ask the producers tojoin the proposed Initiative.
The original idea hadbeen to promote both soapfor handwashing andhousehold chlorine for waterpurification, but the decisionwas made to focus on soapand then build on thatexperience, perhapsintroducing chlorine later.Important considerations thatweighed against includingchlorine were that (1) bleachand soap marketing were
segregated within companies; (2) developing,promoting, and evaluating bleach use forwater disinfection was more complex; and (3)a number of safety issues related to bleachpromotion were not relevant for soappromotion. The single focus of the Initiativemade it easier to design and evaluate.
Roles and ResponsibilitiesConceptualizing the public-private partnershipinitiative is perhaps the most importantresponsibility of the catalyst. Additional roles
“There is the possibility of
working together, even among
different institutions, but only if
there is communication. There
must also be an institution that
is capable of leading and
guiding the process.”— Jorge Mario Molina,
UNICEF, Guatemala
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and responsibilities were laid out during aBASICS-EHP meeting in February 1996, agreedupon by the producers in their first meeting inMarch 1996, and stated in the Convenio, thememorandum of agreement that all parties tothe Initiative signed (see Annex A).
The three main responsibilities weredivided among BASICS and EHP, the twoorganizations that comprised the catalystteam:
■ Facilitate the work of the Task Force setup to guide the Initiative;
■ Provide technicalassistance in developingthe campaign strategy;
■ Finance the marketsurvey, development ofgeneric creativeconcepts, and evaluationstudy.
BASICS provided overallleadership and support,technical leadership inmarketing and working withthe private sector, andsecretarial and administrative support. EHP’sspecific responsibilities were in research—design, data analysis, and presentation—andquality control of health-related messages forthe campaign. About midway into the effort,the catalyst team hired a local coordinator tofacilitate planning and implementation,especially in Guatemala, where she waslocated.
ActivitiesThe Initiative was divided into four phases:
■ Conceptualizing the Initiative (steps 1-3 ofthe Nautilus);
■ Planning and developing the advertisingcampaign (steps 4-11);
■ Implementing the campaign (steps 12and 13);
■ Assessing the effort and disseminatingfindings and lessons learned (step 14).
The Initiative was originally scheduled tobegin in January 1996 and end in September1998. However, it was completed in 1999because of delays along the way.
Phase One: Conceptualizing theInitiative (January 1995 – January 1996)Catalyst activities in the preliminary phaseconsisted of identifying the problem to beaddressed and making preliminary visits tothe countries to test the feasibility of a public-private partnership. All five countries—CostaRica, El Salvador, Guatemala, Honduras, and
Nicaragua—shared a thrivingcommercial infrastructure thatoffered excellentopportunities for contributingto child survival programs.Their governments wereconcerned about diarrhealdisease. Regulations andtrade agreements favored aregional approach, and mostsuccessful manufacturersalready had a regional scopeof operations.
Phase Two: Planning and Development(January 1996 – October 1997)Organizational Meeting. In March 1996,BASICS called a one-day meeting of the chiefexecutive officers (or other top managementofficials) of the interested soap companies inthe region. Five companies sentrepresentatives.
Participants agreed on the broad strategy,discussed their expectations, reviewed a draftmemorandum of understanding that set outthe goals, roles, and responsibilities of allparties and a general strategy. They alsomade a list of the information that theproposed market study should obtain,established a task force, and developed apreliminary work plan. The Task Forceincluded the marketing managers of each ofthe companies plus the catalyst team.
As a follow-up to this meeting, thecompanies were sent copies of the
“The catalyst also knew how to
balance the private competing
enterprises so that there was no
personal interest, but rather only
general interest present.”— Ileana Quiros,
Colgate-Palmolive, Costa Rica
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memorandum of understanding and asked tosign. Unlike a formal contract, thememorandum provided general guidelines andallowed flexibility forindividual implementation.Asking competingcompanies to agree tocollaborate when they wereused to working alone (andwhen several of them werequite open about preferringto work alone) was asensitive matter, raisingfears about confidentialityand proprietary information.The agreement had to alloweach company to define the specific terms ofits own participation.
Task Force Meetings. The first meeting of theTask Force took place in June 1996 to reviewthe memorandum of understanding and theplan for the baseline market survey.Subsequent meetings were held in October1996 (to review the baseline survey resultsand develop the communication strategy);May 1997 (to present the creative concepts);October 1997 (to test and select the finalconcept); July 1998 (to distribute mastercopies of the generic campaign); and January1999 (to review the status of the campaignlaunch). By the final Task Force meeting, theproject was in the implementation phase.
Support for Developing and TestingAdvertising Concepts. The catalyst providedtechnical support in developing theadvertising campaign to ensure that publichealth goals would be addressed. This supportincluded selecting and hiring consulting firms,providing technical assistance to those firms,and assisting each of the soap producers.
■ Selecting consulting firms. Using criteriaand other suggestions from the TaskForce, the catalyst team hired a marketresearch firm and an advertising agency.This task included preparing contractdocuments required by USAID, reviewing
bids, selecting contractors, andsupervising the contracts. Since thecatalyst paid the fees charged by these
firms, it had the final word inoversight. However, it wouldhave been counterproductiveto ignore the wishes of theTask Force. For example,some Task Force membersinsisted that the advertisingfirm selected be one that hadno other soap accounts, whichnarrowed the field significantly.This requirement and otherTask Force stipulations causeda significant delay in selecting
the advertising agency.■ Technical assistance for consulting firms.
The catalyst team met frequently with keypeople in the market research andadvertising agencies, helping them focuson the public health objectives as themarket survey was designed andconducted and the advertising strategydeveloped. In particular, the catalystprovided technical assistance to theagencies on health-related datarequirements, methods of data collection,and analysis. The catalyst also helpedboth agencies make effectivepresentations to the Task Force, otherpotential partners, public health officials,and USAID.
■ Assisting the soap producers individually.The soap producers hesitated to shareinformation about company operations inTask Force meetings. To respect thisdesire for confidentiality, the catalystteam kept in close individual contact withall producers throughout the developmentphase and assisted them in using thedata from the market research and theadvertising concepts.
Public Relations Efforts. One of the jobs ofthe advertising agency was to create a publicrelations package that could be used to makepresentations to additional partners from the
“The involvement of
international organizations was
also very important because it
helped us to sell the campaign
within our own company.”— Jorge Mario Lopez,
La Popular, Guatemala
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public and nongovernmental sectors. InFebruary 1998, the Task Force assisted thecatalyst team in a blitz public relations tour toGuatemala, El Salvador, and Honduras toconsult with soap producer personnel, theUSAID missions, and UNICEF on the bestapproach to reaching public sector decisionmakers who could influence the expansion ofthe campaign.
Liaison with USAID. The catalyst briefed theUSAID missions in each of the four countrieson every visit. The missions supported theInitiative by arranging meetings with keypeople in the ministries of health and byfacilitating the involvement of NGOs in thecampaign.
Phase Three: Implementation(March 1998 – September 1999)The Initiative was designed so that thecatalyst’s role would diminish greatly once theintervention was launched, leaving theproducers to continue their handwashingcampaigns in partnership with publicagencies. The goal was to create within thesoap companies a sustainable interest inpursuing public health goals congruent withtheir own sales targets.
Two Task Force meetingswere held for producers toshare their launchexperiences and ideas forenlisting additional partners.In addition, the catalyst teammet individually with eachproducer in September 1999to monitor the campaign andprepare for the evaluation.
To coordinate theactivities of the increasingnumber of local partners inGuatemala, the local coordinator organized anational task force that included the localsoap producers, the media, the Ministry ofHealth, USAID, UNICEF, PAHO, andrepresentatives of NGOs and foundations.(Local task forces were not formally organizedin the other countries.)
Except for work on phase four, BASICS’role changed from leading to coaching during1999 and, during 2000, from coaching toserving as an intermediary on retainer. A keyelement in this transition was developing andachieving consensus on a plan that specifiedpartners’ new roles as BASICS pulled away.
Phase Four: Assessment andDissemination (October 1999 – 2001)The principal activities under Phase Four werean assessment of the Initiative and analysisand presentation of the results.
Follow-up Assessment. The catalyst wasresponsible for conducting and analyzing thefollow-up survey. The original plan called foran assessment about a year after launch ofthe campaign. BASICS solicited a proposalfrom the same firm that had done the baselinemarket survey to conduct a study ofhouseholds in the same sample clusters andcompare the results. The second study wascarried out in October and November 1999.
Presentations. The catalyst team presentedthe results of the Handwashing Initiative inApril 2000 at an official event sponsored by theMinistry of Health in Guatemala. The event,
which was covered by themedia, was an excellentopportunity for public recog-nition of the soap producers,the partnering media, and thefunding agencies. Furtherpresentations were givenoutside the Central Americanregion to various groups: theGlobal Health Council, theSociety for InternationalDevelopment, the PanAmerican Health Organization,
UNICEF, the World Bank, the World Federationof Public Health Associations, and USAID. Thepurpose of the presentations was tocommunicate to USAID the results of itsinvestments and to interest other organizationsin the potential of public-private partnershipsfor achieving health goals.
“Both public and private sectors
brought to the table their own
experiences and strengths,
making the partnership a solid
team with a common vision.”
— Baudilio Lopez, USAID, Guatemala
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Issues and Lessons Learned■ A catalyst must offer more than mere
coordination to attract private sectorpartners. In this case, the catalyst wasable to put market research anddevelopment of the communicationstrategy on the table. The catalyst shouldoffer expertise and experience in both thecommercial sector and public health.
■ From the outset, the catalyst mustfoster a sense that the initiativebelongs to all the partners. If only onepartner claims ownership, the effort maybe stalled. The catalyst is not the owner.
■ The catalyst should always have a clearvision of the project’s goals and stayfocused on those goals. This is a vitalpart of the conceptualization process. It ismuch easier to get partners to participateif the goal is clearly understandable, easyto articulate, and generally consideredworthwhile. The catalyst must also presenta compelling case for the public good (inthis case, reduced diarrhea and improvedchild health) that can be achieved throughprivate sector participation.
■ The catalyst’s vision should be basedon a strong model, such as BASICS’public-private model (the Nautilus), sharedamong the partners as a basis forcollaboration.
■ A catalyst’s sponsoring organizationmust provide steady, flexible support.USAID created an environment in whichnew approaches could be tried out andadjustments and corrections could bemade as needed. An initiative like the onedescribed here must be flexible becauseit brings together organizations withdifferent motivations and priorities.
■ The catalyst should ensure that theroles, responsibilities, and
expectations of all are clearlyarticulated and that project processesare transparent. For example,agreements should be documented andface-to-face meetings held.
■ Technical assistance for the privatesector must retain an entrepreneurialspirit to enable the partnership to takeadvantage of new opportunities and reactquickly in times of crisis. For example, inGuatemala, using a network of relations,the catalyst won the support of the ownerof the main television channel, whodonated free time to air the genericcampaign for a full year.
■ A local coordinator makes it mucheasier for the catalyst to play its roleeffectively and to maximize theparticipation of all partners. Nothing cantake the place of regular personalcontacts and monitoring. Further, a localcoordinator can follow up after the projectis officially over to see how sustainablethe effort has been. The right person forthis job will know the local players in thedevelopment field and be familiar withmarket research and advertising.
■ Analyzing and documenting projectexperience and lessons learned willhelp ensure that innovative approachesare widely replicated. When a project iscompleted, managers often turn towardanother assignment, and it is difficult forthem to carve out time to look back to thelessons learned from the previous project.
■ A key issue is whether the partnership,once established, can continue whenthe catalyst draws back. In the CentralAmerican experience, new activities wereinitiated after the catalyst withdrew. Thelarger producers integrated handwashingpromotion in their brand advertising.
21
The Private Sector PartnersMerging Business and PublicHealth Goals
his chapter takes an in-depth look at the private sector partners
(the soap producers) by . . .Tn Reviewing the profile of potential partners.n Describing the nature of the partnership.
n Enumerating the producers’ roles and responsibilities as outlined in
the Initiative’s memorandum of understanding.n Describing their activities during the planning, implementation,
assessment, and follow-on phases of the Initiative.
Chapter 4
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n preparation for the HandwashingInitiative, the catalyst team contacted tensoap manufacturers—virtually all the
From the outset it was clear that theInitiative aimed to merge business and publichealth goals. As stated succinctly in thememorandum of understanding, the objective ofthe Initiative was “to promote the habit ofhandwashing with soap” and “increase themarket for soap” (see Annex A). Later, anexplicit connection between handwashing andprevention of diarrhea-related infant mortalitywas made in the Initiative’s mission statement:
The partnership aims to promote the habitof appropriate handwashing with waterand soap by means of an intensive,targeted, educative campaign focused onlowering the incidence of diarrhea toreduce infant mortality among populationsat risk in Central America.
Profiles of the ParticipatingProducersFive of the companies responded by attendingan organizational meeting at their own expense:
■ Punto Rojo from Costa Rica
■ Unisola/Unilever from El Salvador
■ Colgate-Palmolive from Guatemala
■ Fabrica La Popular from Guatemala
■ Corporación Créssida from Honduras
Iproducers in the region. Two weremultinationals, two were regional, and theremainder were local companies.
In Costa Rica – Punto Rojo (local)In El Salvador – Unisola/Unilever(multinational) and Summa (local)In Guatemala – La Luz (regional), LaPopular (local), Productos Finos (local), andColgate-Palmolive (multinational)In Honduras – Corporación Créssida(regional)In Nicaragua – Ind. Chamórro (local) andInd. Prégo (local)
Commercial and Public HealthGoalsCompanies were encouraged by the catalystto join the partnership for commercialreasons, such as increased sales volume andmarket share resulting from more frequenthandwashing. Joining would also demonstrategood corporate citizenship. The key for thecatalyst was to present the public healthobjectives in a way that made the benefits tothe private sector immediately apparent.
Note: A=Highest; E=Lowest
* Corporación Créssida was acquired by Unisola/Unilever in 2000, expanding Unilever’s representation to Honduras and potentiallybroadening its marketing to classes D and E.
Table 1. Socioeconomic Targeting of Soaps
Laundry Personal care
Country Company A B C D E A B C D E
Costa Rica Punto Rojo x x x x x x xEl Salvador Unisola/Unilever x x x
Summa x xGuatemala La Luz x x x
La Popular x x x
Productos Finos (PROFISA) x x xColgate-Palmolive x x x
Honduras Corporación Créssida* x x x x x x xNicaragua Ind. Chamorro x x x
Ind. Prego x x x
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Company
Punto RojoCosta Rica
Unisola/UnileverEl Salvador
La PopularGuatemala(La Popular andProductos Finosare sistercompanies withone owner)
Colgate-PalmoliveGuatemala
CorporaciónCréssidaHonduras
Market
Primarily Costa Rica butinterested in expandingregionally.
Local subsidiary of themultinational Unilever group.Recently acquired additionalcompanies in Panama andBelize.
Wants to position “Jabonito”as a handwashing productaimed at lowersocioeconomic groups.
Multinational corporation;marketing in all CentralAmerican countries.
Primarily oriented towardHonduran market but alsoworks regionally.
Interest in Initiative
Regional collaboration
Prefers an exclusiverelationship, but willcollaborate regionally.
Reservations aboutworking with companieswith competing markets.
Interested in an exclusiverelationship only.
Regional collaborationwith no reservations.
Soaps
Full line
Three personal caresoaps
La Popular produceslaundry soap anddetergent; ProductosFinos producespersonal care soaps.
Personal care soaps
Full line
The five participating companiesrepresented 72 percent of the laundry soapmarket and 71 percent of the personal caresoap market in the region. The personal caresoap was generally not targeted to the groupsthat the Initiative intended to influence.However, lower-income families do use“laundry soap”—in bars, cylinders, or morecommonly, balls (bola)—for laundry,dishwashing, bathing, general housecleaning,and handwashing. Thus, an important factor inpreliminary meetings with soap producers wasto find out to whom they marketed theirvarious brands. Companies selling to lower-income groups in rural areas were favored.
Table 1 shows how the producers targettheir markets by socioeconomic levels. Thehighlighted columns are the socioeconomicgroups that the Handwashing Initiative was totarget. Note that only three of the companiesmarketed personal care soap to the Initiative’starget groups. The others did not market eithertype of soap to the target groups, shown as“D” and “E.”
Table 2 summarizes the information thecatalyst team obtained about the soapproducers who joined the Initiative.
A Non-Exclusive PartnershipInitially the two multinational soap producerseach requested an exclusive arrangement forthe regional campaign. However, the catalystteam concluded that public health prioritieswould be better served by workingcollaboratively with the whole soap industry.(The companies both participated in the regionaleffort in the end, although they didn’t commituntil just before the organizational meeting.)
While an arrangement with a singlemultinational soap producer with the know-howand resources to run the regional promotionalcampaign would require less direct technicalassistance, such an arrangement would havedistinct disadvantages. Some of the largermultinationals concentrate on higher-incomeconsumers (as shown in Table 1), which werenot the target of the Handwashing Initiative.Also, involving only one company would have
Table 2. Products and Markets of Participating Producers
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raised issues of equity and coverage. In acollaborative arrangement, the expertise andresources offered by thecatalyst were available to allproducers who wished to join. Itwas hoped that participating inthe Initiative would encourageproducers to make lastingchanges in how and to whomthey advertised their soaps.From that perspective, themore firms involved, the better.
Roles andResponsibilitiesThe memorandum ofunderstanding outlined theroles and responsibilities ofthe soap companies for atleast the two-and-a-half years of the Initiative.
Participation in the Regional Task Force.Each producer selected a representative,preferably the marketing director, to serve onthe Initiative’s Task Force. This group, whichalso included the catalyst team, providedguidance for the effort and its members werethe points of contact for both internal andexternal communications. The list of Task
“Negative aspects? I could not
mention any major one, except
that I was sitting at the same
table as my competition. But
that pales next to the positive
things that were born of this
program.”
—Ileana Quiros,
Colgate-Palmolive, Costa Rica
Task Force Responsibilities of the Soap Producers
The memorandum of understanding, or Convenio, outlined the following responsibilities:
■ Design the general marketing strategy.
■ Establish a work plan with dates and responsibilities.
■ Identify the information necessary for the market research study.
■ Review the market survey questionnaire and advise on methodology.
■ Review and analyze the results of the market research study and translate them into acommunication strategy.
■ Set criteria for selection and offer advice on the selection of an advertising agency.
■ Review and approve the generic communication strategy.
■ Seek to obtain the participation of the local public sector to broaden the reach of the campaign.
■ Launch the campaign using company resources.
■ Assist in planning the follow-up market survey.
■ Interpret the final results of the communication strategy.
■ Advise on the dissemination strategy for each market.
Force responsibilities (see box) makes clearthat the group was to make all the major
decisions about the nature ofthe campaign.The Task Force met seventimes from March 1996 toJanuary 1999. Meetings tookplace at critical decisionpoints in the process. TaskForce members paid for theirown travel and lodging. Thecatalyst paid for the meetingspace and circulated reportson all the meetings.
Adapting the Initiative’sAdvertising Concepts. Oncethe generic advertisementshad been created by theadvertising agency, the
producers agreed to adapt them to their ownbrands using their own resources forproduction and dissemination.
Maintaining Communication. Producerspledged to keep in contact with the catalystteam and the other members of the TaskForce and to share information that wouldassist in assessing the impact of thecampaign.
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Activities of the Private SectorPartnersThe Initiative progressed in the plannedsequence, but several issues caused delaysthat pushed the launch date into the spring of1998—a year later than originally planned.Even with the delays, the Initiative proceededat a brisk pace.
Phase One: Conceptualizing theInitiative (January 1995 – January 1996)The catalyst used input from the soapproducers in designing the Initiative. Theirwillingness to meet with the BASICS’representative and share ideas contributedsignificantly to the catalyst’s assessment ofthe market potential and companycapabilities.
Phase Two: Planning andDevelopment(January 1996 – October 1997)Producers were involved inplanning through theirparticipation in the Task Force.They worked collaboratively toidentify the elements of amarket survey, develop criteriafor selecting a market researchfirm and advertising agency,formulate an overall strategy,and assist in developing thecreative concepts.
In addition to their workon the Task Force, theproducers had to carry theInitiative into their firms and integrate it intotheir marketing plans. Interestingly, when TaskForce members were asked to identifypotential partners that should be the target ofa public relations campaign to boost theInitiative, they identified their own topmanagement as the initial target.
Phase Three: Implementation(March 1998 – September 1999)
Campaigns. Four of the five original firmslaunched a campaign. Corporación Créssida in
Honduras canceled its campaign at the lastmoment because of internal financialconstraints and the devastating effects ofHurricane Mitch.
The campaigns varied widely, as shown inTable 3. (Chapter 7 describes the interventionin greater detail.) In El Salvador, Unisola/Unilever worked closely with the Ministry ofHealth to complement and strengthen itsprogram for Healthy Schools. In Costa Rica,Punto Rojo leveraged considerable supportfrom the media: Teletica (the major televisionstation) matched the producers’ paidadvertisements one for one. La Popular’sefforts in Guatemala were highly integratedwith the activities of its sales force, whodistributed samples and materials. Theirmobile units—pickup trucks equipped withmegaphones—reached many small towns andvillages. Colgate-Palmolive focused its initialefforts on organizing a public relations eventin April 2000 to recognize the support of a
wide range of organizationsand make a commitment tocontinue with the campaign(see Chapter 5). Since then,the company has integratedhandwashing messages intothe advertising of its best-selling soap, “Protex.”
Implementation Issues. Theproducers addressed theissue of territorial coverageby agreeing to carry out thecampaign in their homemarkets. This would focus
their efforts and avoid overlap that could leadto competition. Punto Rojo was to work inCosta Rica, Unisola/Unilever in El Salvador,Corporación Créssida in Honduras, and LaPopular and Colgate-Palmolive in Guatemala,through a segmented approach in which LaPopular worked mostly in rural areas andColgate-Palmolive in urban areas.
In launching their campaigns, producershad to face the issue of brand equity.Companies cannot change the positioning ofan established brand unless the change
“We got the people’s good will
towards the brand, and this is
very important. The media
coverage also more than
compensated for our efforts.”
—Jorge Mario Lopez,
La Popular, Guatemala
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reinforces the brand equity. In other words,an established laundry soap cannotimmediately be repositioned for handwashing;nor can the image of a personal care(“beauty”) soap be changed to that of a handsoap. Furthermore, creating and building anew brand specifically for handwashing wouldrequire a large financial investment andconsiderable lead time.
Personal-care-only soaps were not sold tothe socioeconomic groups that the Initiativesought to reach. What’s more, laundry soapproducers that reached the target populationwere reluctant to change the positioning oftheir established brands, and producers hadhad bad experiences marketing dual-usesoaps. Personal care soaps have a closerconnection to handwashing than laundrysoaps, which are usually more abrasive. Thisdilemma was not totally resolved. Theproducers settled on simply connecting theirbrand logos or names to the genericadvertising spots or printed materials, whichcommunicated the handwashing behaviormessage but said nothing about type of soap.(Colgate-Palmolive used the advertisingconcepts of the Initiative in a campaign for“Protex,” an antibacterial soap, even though it
was targeted at more affluent socioeconomicgroups.)
Another brand issue was related to theway advertising resources are allocated bythe companies. Funds for the handwashingcampaign had to be pegged to a specificbrand. The catalyst tried to link the campaignto a best-selling soap, or market leader, tobenefit from the substantial resourcesallocated to such brands. Integrating thehandwashing message within the advertisingof a major brand with a significant budget (amarket leader) would ensure greater impactand sustainability.
Reaching Out to Additional Partners.Producers were also instrumental inencouraging other organizations, both publicand private, to get involved in the campaign.
Phase Four: Assessment andDissemination(October 1999 – April 2000)Using results from the evaluation study,producers secured internal support from theirorganizations to bolster company support forthe campaign. In Guatemala, for example, thetwo companies co-sponsored a publicrelations event hosted by the MOH in April
Producer
Punto RojoCosta Rica
Unisola/UnileverEl Salvador
Colgate-PalmoliveGuatemala
La PopularGuatemala
Activities
Printed posters for distribution through WorldVision and the Office of the First Lady of CostaRica; advertised on television and radio and inprint; and obtained the agreement of a majortelevision station to double its media investment.
Devoted most of its efforts to collaborating withthe Ministry of Health’s Healthy Schools Programby providing video, audiotapes, banners, posters,soap samples, and coloring leaflets.
Organized public relations event involvingMinistry of Health and media, donated soap toschools, and funded handwashing kit prototype.
Supported radio advertisements, distributedposters and flyers, and broadcast radioadvertisements from mobile units traveling tosmall towns and villages.
Generic/branded
Used genericadvertisements withbrand name.
Used genericadvertisements withbrand name and logosof Ministry of Healthand TV station.
Generic.
Generic with brandlogos.
Dates
May ’98 –April ‘99
Sept. ‘98
’99 – ‘00
Mar. ’98 –Oct. ‘99
Table 3. Campaign Activities of Participating Producers
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2000. At this event, the soap companies andthe MOH presented their collaborative plan fortwo programs—”Healthy Schools” and“Healthy Communities”—which will beimplemented over three years.
Follow-on Activities. Colgate-Palmolivedeveloped and launched in 2001 a regionwideeducational program for schoolchildren. Inaddition, Unisola/Unilever plans to launch ahandwashing campaign in Honduras, basedon its acquisition of Corporación Créssida.
Issues and Lessons Learned■ A regional approach was preferred over
a lengthy country-by-country approachto take advantage of the regionalstructure of the commercial partners andthe economies of scale for the catalyst. Aregional approach also provided bettergeographic and socioeconomic coverage.
■ A key issue that wasnever resolved in theInitiative was whetheran exclusive agreementwould have beenpreferable to acollaborative approach.A more common model ofprivate sectorcollaboration in publichealth would call for onefirm to be selected on thebasis of well-developedcriteria to produce anddistribute a certainproduct for use by a ministry of health—usually a product that is not widelyavailable at an affordable price. Thepurpose of the Handwashing Initiative wasto change the way people use aubiquitous product. The more firmsinvolved, the wider the behavior changeand the greater the benefit to all firms interms of increased sales. Furthermore,there is synergy in working with a group ofproducers across a product line. It canencourage project advancement throughfriendly competition as well as economies
of scale in market research andproduction of campaign materials. In thiscase, the producers were concernedabout working with their competitors, butthey joined in because they were afraid tobe left out.
■ Encouraging collaboration amongfirms in fierce competition requiresfinesse on the part of the catalyst.Past a certain point, producers may feelthat to collaborate is to give away tradesecrets. Their desire to keep their plansconfidential may run counter to thedesire of the catalyst to encouragewider participation and disseminateresults.
■ Because of the potential for changes incompany leadership to cause delays inthe project, it is best not to base thepartnership on individual relationshipsbut instead to seek broad-based
acceptance of strategies andcommitments. During theInitiative, there were frequentchanges in personnel. In ahighly competitive industrysuch changes are notunexpected, but they didpresent difficulties. The newpeople had to be briefed onthe goals and status of theInitiative. In one instance, anewly assigned marketingdirector did not know that herfirm belonged to the Initiative.
The representative from one of the largestproducers had to withdraw from the TaskForce when he was promoted elsewhere.There was a long delay in assigning aproduct manager to prepare the campaignlaunch. Management changes in two othercompanies had similar effects.
■ The potential for a “clash of cultures”between the different organizations isever present. Within the typical catalystorganization, decisions are madethrough a slow process of developingconsensus, whereas businesses are
“The support we got from the
health department gave us great
credibility. But I believe that the
ones who really benefited were
the people.”—Gregory Hawener, Unisola/Unilever,
El Salvador
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more likely to operate through commandand control and are able to makedecisions and take action quickly.Furthermore, in this case the smallerlocal soap producers had the flexibilityto move rapidly, but the multinationalcompanies had complex approvalsystems, thorough budget planningprocesses, and acute concerns aboutbrand quality and positioning.
■ The timing and sequence forinvolvement of the public and privatepartners will differ depending on thenature of the partnership and the goalsto be achieved. In the HandwashingInitiative, attempts to engage the publicsector and other organizations werepostponed until the marketing conceptswere fully developed. The private sectorpartners believed it would be moreefficient to ask other partners toparticipate in a clearly delineated initiativeand feared that earlier collaboration wouldcause delays. One possible source ofconcern was inherent in the regionaldesign of the partnership, whichnecessitated involving different publicsector officials in each country—apotential cause of delays and a difficultand cumbersome process.
It must be pointed out, however, that itwas easy to postpone public sectorinvolvement because the Initiative couldgo ahead without licenses or waivers fromthe respective governments. In somecountries, it would have been impossibleto take any action without the initialinvolvement of the public sector.
■ The memorandum of understanding orother document outlining a public-private partnership should not be tooprescriptive. Some involved in the Initiativethought that there should have been adetailed plan that set specific targets foreach producer. The prevailing view was thatthe producers might back away from apartnership if the document formalizing thecollaboration appeared too prescriptive.
■ The public-private partnership was atool for implementing desired behaviorchange among the soap producers. Thehope is that advertising the health benefitsof handwashing will eventually beintegrated into the long-term strategy of aspecific brand, such as Protex for Colgate-Palmolive and Gold Pro for Unisola/Unilever. Thus, as the partnership evolves,the Task Force outlives its usefulness. TheInitiative will likely be continued asindividual company activities.
29
The Public Sectorand Other PartnersJoining Hands with the Soap Producers
his chapter takes an in-depth look at the public sector and other
partners by . . .Tn Describing the public relations efforts to recruit them.
n Listing who became involved from governments, media, donors,
foundations, and others.n Describing the contributions of these partners to the Initiative.
Chapter 5
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T he Task Force’s decision to postpone involvement of the publicsector until after the development of the creative concept was not
made lightly. The Task Force realized that additional partners might notfeel any ownership if they were invited to join too late. On the other
hand, if they were invited early, the Task Force would not have enough
information to provide concrete ideas about how the public sector andother partners could be involved. After some debate, the Task Force
decided that it would be more efficient to await the market research
results, develop the communication strategy, and then present theentire package to decision makers and opinion leaders in each country.
Once the planning process was completed,the producers and the catalyst began acontinuous public relations effort to recruitother partners to reinforce the advertisingcampaign and attract additional resources.Recruitment efforts reached out not only topublic sector organizations but also tointernational organizations, NGOs, and otherbusinesses, most notably the media.
Targeted GroupsFour groups were targeted in the publicrelations effort:
■ The public sectors in each country• Examples: ministries of health and
education• Purposes: To provide political support
through an official endorsement and todisseminate health messages throughhealth workers and teachers.
■ International organizations and NGOs• Examples: USAID, UNICEF, World
Vision, and CARE• Purposes: To diffuse the campaign
through their resources and communitynetworks and to increase the depth andcoverage of the campaign.
■ The mass media• Examples: Radio, television, and
newspapers
• Purpose: To disseminate the genericcampaign as a public service.
■ Other private companies• Examples: toilet paper and soap dish
manufacturers• Purpose: To associate good hygiene
practices with the use of theirproducts.
The key groups were the ministries ofhealth, to officially endorse the campaign, andradio and television companies, to disseminatethe generic campaign. For the audiences thatthe Initiative intended to reach—lowersocioeconomic groups in isolated rural areas—radio was the preferred medium, thentelevision, and finally newspapers.
The Public Relations BlitzThe catalyst team developed a public relationsbriefing kit including a briefing paper, the logoof the Initiative, examples of materials, and acustomized proposal. The kit was used inindividual contacts with potential partners.
A graphics art firm assisted with thedevelopment of an eight-page, four-coloredbrochure (9 inches x 12 inches) with a built-infolder for inserting other documents. It wasentitled “Lavo mis manos por salud: unainiciativa multisectorial para salvar vidasinfantiles” (I wash my hands for health: a
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multisectoral initiative to save children’s lives)and featured a photo of a mother and childwith soaped up hands. Topics includeddiarrheal disease; prevention throughhandwashing; the mission of the Initiative andits membership; the essential messages ofthe campaign; results of the marketing studyabout the correlation between properhandwashing and diarrheal prevalence; adescription of the campaign materials; and aninvitation to join the Initiative.
In February 1998, the catalyst team andTask Force members, each in his or her owncountry, went on a public relations blitz. Withthe help of USAID, they contacted companyexecutives and representatives of the media,governmental ministries, and internationalorganizations. They made professionalpresentations about the rationale for thecampaign; showed off the generic materials;and left behind the public relations brochure.
In each country, the ministry of healthimmediately agreed to support the campaign.The attempt to encourage media participationthrough donation of free media time andreproduction of tapes and video materials wasalso quite successful.
Activities of Public Sector andOther PartnersAdditional major partners joined the Initiativejust before or during the implementation phase:
■ Ministries of health. The Ministry of Healthwas a substantial partner in El Salvador,where Unisola/Unilever supported theministry’s Healthy Schools Program. InGuatemala the MOH created an Office ofHygiene Promotion within its Mother andChild Division.
■ UNICEF. In Guatemala and El SalvadorUNICEF distributed the campaign’sgeneric materials to support its water,sanitation, and hygiene activities.
■ NGOs. In Guatemala CARE disseminatedthe handwashing messages, using soapsamples and promotional materialprovided by soap producers.
■ Media. Although the media partners inGuatemala had not been involved inconceptualizing or planning theHandwashing Initiative, they were thefirst to step forward to launch theadvertising campaign on radio andtelevision. This campaign is scheduled tocontinue until at least 2003. In CostaRica a large television channelcontributed free generic advertisementsduring prime time for a year, matchingPunto Rojo paid advertisements one forone. A television station in El Salvadorcontributed free airtime for the genericadvertisement. The Guatemalan daily LaPrensa Libre used vignettes abouthandwashing as filler.
■ Office of the First Lady of Costa Rica.This office was instrumental in seeingthat handwashing promotion postersreached governmental offices all over thecountry.
The Public Relations Brochure(First Version)
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Other partners included PVOs such asWorld Vision, other businesses, andFUNDAZUCAR, the foundation of theGuatemalan sugarindustry (sugarcane growers andrefineries), whichis the country’slargest employer.Table 4 lists allpartners and theircontributions.
Several donororganizations alsocontributed to theassessment anddisseminationphase of theInitiative. USAID,the World Bank,and UNICEF havesupportedpublication anddistribution of thisdocument and are disseminating the findingsof the Initiative within their organizations.
The Follow-up Public Relations EventA public relations event was held in April2000. Organized in Guatemala under the jointsponsorship of Colgate-Palmolive, La Popular,and the local task force, it was an opportunityto publicly recognize the efforts of the variouspartners in that country. The Ministry of Healthhosted the event, which drew many peoplefrom governmental ministries and agencies,international organizations, foundations andassociations, NGOs, and private sectorcompanies. They were entertained by a choirfrom a nearby school, whose members sangthe campaign jingle and enacted skits abouthandwashing before the keynote speech ofthe Deputy Minister of Health.
A second public relations brochure wasprepared for this meeting. It carried the logosof all the partners in Guatemala: USAID, LaPopular (through the logo for “Ambar,” itsbest-selling laundry soap), Colgate-
Palmolive, La Prensa Libre daily newspaper,UNICEF, Camara de Radiodifusion deGuatemala, Channel 3, Super Channel,Televisiete (Channel 7), and the Ministry ofHealth. This second brochure presented theresults of the follow-up survey as evidenceof the effectiveness of the campaign’sapproach and outlined proposed campaignactivities until 2003.
Issues and Lessons Learned■ The catalyst has the necessary
credibility to communicate effectivelywith ministry of health officials andshould play an active role in recruitingpublic sector organizations. Someproducers did not feel comfortablecontacting health ministries without anintermediary. One producer was reluctantto interface directly with public sectorallies, stating that the government wouldbe more receptive to a health-relatedagency. BASICS therefore assisted inmeetings with UNICEF, the Ministry ofHealth, and education officials to obtainendorsements of the campaign.
■ The public-private partnership needs tobe sold to the public sector as anintegral partof its nationalstrategy. If thepublic sectorperceivesprivate sectorinterest inpublic healthactivities asan effort tousurp itsprerogatives,unnecessaryfriction canarise, and the partnership may bejeopardized.
■ It is not difficult to attract public sectorand other partners to a cause that isobviously good. The Initiative was
“The fundamental
reason that made the
Ministry of Health take
an active role in the
campaign was its vast
responsibility as health
manager. Handwashing,
if one looks at it closely,
is of vital importance to
everyone.”— Almeda Aguilar,
Ministry of Health, Guatemala
“Who better to work
with than those who are
responsible for the
health of that specific
country?”— Ileana Quiros,
Colgate-Palmolive, Costa Rica
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espoused readily by ministries of healthand education, media, foundations, andNGOs, not to mention the soapproducers. Not all health issues would beso free of political sensitivity.
■ The importance of public health inputin a public-private partnership seekingto achieve health goals cannot beoveremphasized. When ministries ofhealth joined in the HandwashingInitiative, the commitment of the privatesector partners was strengthened. The
epidemiologist on the catalyst team alsoadded authority and credibility. He wasable to reassure the producers that theInitiative was built on a solid public healthfoundation. However, he was not assignedfull time to the Initiative. Optimally, anactivity of the magnitude of theHandwashing Initiative should have twofull-time or almost full-time peopleassigned to it: one a private sectormanager and the other a public healthspecialist.
Television, Channel 7(Teletica)
TCS (channels 2, 4,and 6)
Television, channels 3,7, 11, and 13; radio(Central de Radios yCamara deRadiodifusion Nacional);and daily press (LaPrensa Libre)
Costa Rica
El Salvador
Guatemala
Contributed airtime equivalent to Punto Rojo’s budget fortelevision commercials.
Contributed free airtime during the first month of launch.
Radio and television stations donated airtime for thegeneric advertisement provided by BASICS and dailynewspaper used generic advertisements as filler whenspace allowed.
USAID
UNICEF
World Vision
CARE
NGOs
FUNDAZUCAR
El SalvadorGuatemalaHonduras
Costa RicaGuatemala
Costa Rica
Guatemala
Costa Rica
Guatemala
Facilitated contacts with governments, collaboratingagencies, and NGOs; accessed NGO network as a channelfor distributing handwashing materials.
Used generic materials in its rural sanitary educationalprograms and soap samples in handwashing kits.
Distributed posters donated by Punto Rojo.
Distributed leaflets and soap samples.
Used generic materials in community programs.
Introduced handwashing kits and handwashing corners inschools and health centers.
Office of the First Lady
Ministry of Health
Ministry of Health
Costa Rica
El Salvador
Guatemala
Distributed posters donated by Punto Rojo to healthcenters, schools, and other state offices and institutions,where they were used in hygiene programs.
Distributed educational materials provided by Unisola/Unilever and used them in the Healthy Schools Program.
Created an office of “Hygiene Promotion” within its Motherand Child Division.
Partner ActivityCountry
Table 4. Contributions of Public Sector and Other Partners
Public Sector
Media
International Organizations and NGOs
35
his chapter reviews the planning stage of the Central American
Handwashing Initiative by. . .
Marketing Strategy DevelopmentFrom Market Survey to Creative Concept
Tn Outlining the process for designing and implementing a marketing
survey.
n Describing the survey questionnaire.n Presenting the results.
n Showing how the results were used to develop an overall
communication strategy.
Chapter 6
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Table 5: Framework for the Market Survey
Decision Areas Specific Requirements
Information needs ■ Demographics■ Socioeconomic status■ Living conditions (including type of water and sanitation
systems)■ Behavior and attitudes toward handwashing■ Type of soap used■ Sources of information about handwashing■ Diarrheal disease prevalence among children under five
Characteristics of the study sample ■ Mothers of children under ten years of age■ Drawn from all four countries■ Stratified urban and rural■ Socioeconomic status of class “D” or “E”■ School-age children in household
Selection criteria for market ■ Demonstrated capability of performing a study in allresearch agency countries
■ High quality sample and information collection methods■ Ability to conduct study in a timely, expeditious manner■ Previous experiences in similar studies■ Reasonable cost■ Availability of additional data that could be incorporated
in the study at no additional cost
he Task Force’s first major task was to develop a regionalcampaign. This work was carried out in a relatively compressed
period, from March 1996 to May 1997, with the active participation ofmost Task Force members. The goal was to develop a generic market
strategy based on solid market research.
Consumer ResearchThe foundation of the communication strategywas a market survey. It provided a profile ofthe target consumer and was also intended toprovide baseline information for use inevaluating the Initiative. The soap producerswere no strangers to market surveys.However, the type of survey envisioned forthe Initiative was different from those usuallyconducted by the private sector (whichtypically include trade audits, store checks,quantitative research, and focus groups). Theproducers saw in-depth behavioral researchas an opportunity to learn about consumers’attitudes and behaviors regarding a then-neglected use of their product: handwashing.
Selecting the Market ResearchAgencyThe producers discussed the informationneeds for the marketing study, characteristicsof the study sample, and criteria for selectingthe research agency. Their decisions aresummarized in Table 5.
Guided by the producers’ criteria, thecatalyst selected a market researchagency through USAID’s competitiveprocess. Bids were solicited from fivecompanies. The agency selected wasGeneris Latina, a company based inGuatemala with a solid track record in theregion and the ability to respond effectivelyto the client’s needs.
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Section 1
1. A complete copy of the questionnaire can be found on the CD-ROM, The Story of a Successful Public-Private Partnership inCentral America: A Compendium of Resources. To obtain a copy of the CD-ROM or to find out how to access it through theInternet, contact the EHP Information Center, 1611 North Kent Street #300, Arlington, Virginia 22209, USA.
Designing and Testing theQuestionnaire and MethodologyFour main categories of information weresought through the study:
■ Information the Task Force andadvertising agency needed about thetarget audience profile to develop amarketing campaign.
■ Baseline information on handwashingpractices for subsequent evaluation of thecampaign.
■ Information on the observed relationshipsbetween handwashing behaviors anddiarrhea among children for the publichealth partners to use in advocacyactivities and to ensure that key riskfactors for diarrhea were addressed in thecampaign.
■ Information about water sources,availability, storage, and handling thatcould be used in a future campaign toaddress household water risks fordiarrhea, and, specifically, householdwater chlorination.
The Task Force reviewed the initial draftquestionnaire and methodology presented byGeneris Latina. In the next two weeks, thequestionnaire was revised, field tested inGuatemala, and revised again based onfindings from the field test. Interviewers weretrained. Within two months, the fieldwork forthe survey had been completed in fourcountries.
Implementing the SurveyA total of 4,500 households were surveyed:1,000 each from Costa Rica, El Salvador, andHonduras and 1,500 from Guatemala. A largersample size was used in Guatemala becauseof its relatively greater ethnic and geographicdiversity. In all cases, the sample size wassufficient to provide a summary descriptive
analysis by urban and rural strata and by themain geographic regions of the country with amargin of error of five percent.
The sample was drawn based on clustersselected from updated census trackscategorized as D and E (the lowestsocioeconomic levels). Within the clusters,interviewers selected households where therewas at least one child age ten years oryounger and applied standard criteria toeliminate households that displayedcharacteristics of a higher socioeconomiclevel. In Guatemala, each of the four mainMayan language groups was to be sampled,in addition to the Spanish-speakingpopulations. Ten households were randomlyselected from each rural cluster and fivehouseholds from each urban cluster. Allinterviews and observations were performedin the house or yard with the mother (or otheradult female family member in a smallnumber of cases), the male head ofhousehold, and children ages five to 10,when available.
Supervisors for each survey were trainedin Guatemala. They, in turn, trained a group ofinterviewers and local supervisors in each ofthe four survey countries. The trainingincluded conducting pilot interviews beforeactual data collection began. The catalystteam assisted in the training and field testingin Guatemala and Honduras.
The questionnaire consisted of about 50items. Interviewees were also asked todemonstrate how they washed their handsand were scored in a structured observation.At the request of the soap producers, childrenages five to ten present in the household atthe time for the survey were also asked todemonstrate how they washed their handsand to answer questions about when they hadwashed their hands in the past 24 hours. Table6 provides some details about the questionsasked.1
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Table 6. Focus of the Market Survey
Section Type of QuestionsSocioeconomic and ■ Languagehousehold ■ Education levels of mother and fathercharacteristics ■ Occupations
■ Number, relationship, and age of persons in household■ Presence of electricity, radio, television, refrigerator
Water availability Nature of water supply (household connection, community standpipe,and usage well or cistern, etc.)
For households without piped water. . .■ Who collects, how often, with what■ Usage (drinking, washing dishes, washing clothes, handwashing, etc.)For households with piped water. . .■ Hours of availability, outages, scarcity■ Usage (drinking, washing dishes, washing clothes, handwashing, etc.)For all households. . .■ Location in house where washing activities take place (sink, barrel,
wash basin, etc.)
Sanitation ■ Type of sanitation system (toilet, latrine, no system)■ Who uses
Handwashing ■ A 24-hour handwashing history was taken—from mothers and fathersand children (five to ten years old)—to determine on what occasions(typically before or after some recognizable event) and how many timesthey had washed their hands during the previous 24 hours
■ Handwashing demonstration: elements of technique observed—one ortwo hands, cleansing material (soap or ash), number of times rubbed,how dried, cleanliness of drying material (towel or rag)—for mothersand children present at the time of the interview
■ Presence of a handwashing place, defined as soap and wateravailable at a “usual” handwashing place where there is a basin orother arrangement for handwashing water
Soap Usage ■ Use or nonuse (if nonuse, why)■ Types (laundry bar, laundry powder, and hand soap)■ What used for■ If not used for handwashing, why not■ Where purchased■ Who in the household makes purchasing decisions■ Brands used
Attitudes toward Interviewee responds true or false to a number of statements,handwashing for example. . .
■ “Most times, handwashing with water alone is sufficient.”■ “It is impossible to see that children wash their hands after going to the
bathroom unless one is watching them all the time.”
Diarrhea prevalence ■ Presence or absence of diarrhea within the previous 14 days asreported by the mother for each child under five in the household
Communication profile ■ Literacy (tested)■ Exposure to radio, television, print media■ Preferred programs, times of listening, viewing
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ResultsDiarrhea Prevalence and DetailedAnalysis of BehaviorsDiarrhea prevalence in the last two weeksamong children under five was calculatedbased on 2,983 surveyed households (in allcountries) with a child under five. Overall, 19.3percent of households reported that at leastone child in the household had had at leastone day of diarrhea in the two weeks prior tothe survey. Prevalence figures varied fromcountry to country: Guatemala – 22.5 percent;Honduras – 24.9 percent; El Salvador – 19.5percent; and Costa Rica – 7.9 percent. (Thesurvey was conducted during the rainyseason when children are most prone to sufferfrom diarrhea.)
The percentages in tables 7–9 indicatethe proportion of those surveyed who reportedor demonstrated each of the critical elementsof proper handwashing. The number ofasterisks (*) indicates the strength of the
association with reduced risk of diarrhea in achild under five in the household.
Drying hands with a clean towel had thestrongest association with reduced risk ofdiarrhea of all of the handwashing elementsobserved (Table 7). At the same time, thiswas the least prevalent of the three “correcttechniques.” The low rates of practice broughtdown overall rates of both “good practices”and “optimal handwashing.”
The association between washing one’shands at critical times and reduced risk ofdiarrhea in children was confirmed, as shownin Table 8.
The findings in tables 7 and 8 were furtherexamined using logistic regression analysis tocontrol for potential confounding factors(country of residence, urban/rural residence,location of source of water, use of sanitarylatrine or toilet by all family members, testedability of the mother to read, and number ofchildren in the household) and to confirm
*P<.10 **P<.05 ***P<.01
Table 7. Observed Handwashing Technique: Percentage of Caretakers withGood Reported Practices and Strength of Association with Lack of Diarrhea inChildren under Five in the Household, 1996
Guatemala Honduras El Salvador Costa Rica Total
Both hands 99* 99 99 99 99
Uses soap 82 90 91 96 89
Rubs at least 3 times 85** 99 88* 88 90*
Dries with a clean towel 28*** 37*** 40* 69*** 42***
*P<.10 **P<.05
Table 8. Handwashing Occasions: Percentage of Caretakers with Good ReportedPractices and Strength of Association with Lack of Diarrhea in Children underFive in the Household, 1996
Guatemala Honduras El Salvador Costa Rica Total
Before eating/feeding 50* 77* 64* 56* 61*
Before cooking/foodpreparation 68** 63 67* 61* 65**
After defecation 65 74* 75 91** 75*
After changing orcleaning baby 29 18* 17 44* 26*
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which of these elements was most commonlylinked with reduced risk of diarrhea. In short,observed hand drying with a clean towel andreported handwashing before eating andpreparing food were confirmed to have thestrongest and most significant relationshipswith reduced risk of diarrhea.
Interestingly it appears that a dedicatedhandwashing place is necessary to supportthe practice of appropriate handwashing atcritical times. In three countries and overall,the presence of all three elements at ahandwashing place—water, soap, and a basinor place for water to fall—are more importantthan any one element, including soap alone(Table 9).
The use of soap was not found to have astrong association with reduced risk ofdiarrhea in this survey. The reason for thisfinding cannot be determined, but it could bedue to changes in behavior under observation(resulting in an over calculation of those whoactually use soap) or any number of other
factors (Cousens et al. 1996). The importanceof using soap to clean hands ofmicrobiological contamination and itsassociation with reduced risk of diarrhea havebeen demonstrated consistently in the past.
The importance of rubbing handssufficiently (Hoque et al. 1995, Bateman et al.1995) was confirmed. The importance ofhandwashing at times commonly found tocontribute to reducing diarrhea risk was alsoconfirmed in these settings, although theassociations were not strong.
The results clearly indicated that thecommunication strategy should address bothcorrect technique and critical handwashingtimes. The results also suggested that the roleof a dedicated handwashing place in ahousehold should be explored further.
Overall Stages of Key BehaviorsOf the 4,497 families surveyed in fourcountries, almost all regularly used and coulddemonstrate possession of some sort of soap
N= 1500
Table 10. Percentage of those Possessing and Using Soap, Guatemala, 1996
Laundry Soap Laundry SoapHand Soap (Bar) (Powder)
Have used in the past month (reported) 90 100 93
Used for handwashing (reported) 85 55 9
Had at the time of the interview 76 93 69(demonstrated)
*P<.10 **P<.05
Element Guatemala Honduras El Salvador Costa Rica Total
Water 98 99 99 99 99
Soap 86 94 97* 98* 93*
Basin or place forwater to fall 94 89 99* 97 94*
All three elements 82 84* 96** 95** 88**
Table 9. Handwashing Place: Percentage with the Necessary ElementsPresent at the Usual Place of Handwashing in the Household and Strength ofAssociation with Reduced Prevalence of Diarrhea among Children under Fivein the Household, 1996
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Intermediate Optimal
Diarrheal disease prevalence(percent)
Inadequate
Figure 4. Diarrhea Prevalence AmongChildren by Handwashing BehaviorStage of Surveyed Mothers, 1996(all four countries)
at the time of the interview. Table 10 presentsthe data for Guatemala, where soap was leastavailable.
Ideal handwashing behavior was definedin the survey as:
■ washing at three key times (beforecooking or preparing food, before feedingchildren or eating, and after defecating orchanging babies’ diapers) and
■ with three correct techniques (using soap,rubbing hands together at least threetimes, and drying with a clean towel).
The research segmented the targetaudience according to three behavior changestages:
■ Inadequate practice—technique isinadequate and/or hands are not washedat any of the critical times.
■ Intermediate practice—technique isadequate and hands are washed at one ortwo of the critical times.
■ Optimal practice—technique is adequateand hands are washed at all three criticaltimes.
Only 9 percent of the mothers surveyed inthe four countries were in the optimal group.(There were marked regional differences: moremothers in Guatemala were in the inadequategroup and more mothers in Costa Rica were inthe optimal group.) Regionwide, there was roomfor improvement in the handwashing behavior ofabout 91 percent of mothers surveyed. Two-thirds of mothers demonstrated poor techniqueor reported that they had not washed theirhands at any one of the three critical times onthe previous day—or both. Technique appearedto be less of a problem than timing.
Perhaps the most striking finding was thedirect correlation between the number ofcorrect handwashing times and theprevalence of diarrhea among childrenyounger than five. For example, diarrheaprevalence was less than 10 percent amongyoung children whose mothers washed their
hands correctly eight times or more during theday, compared to a prevalence of 23 percentamong those whose mothers never washedtheir hands correctly at critical times (seeFigure 4 and Table 11).
The finding of a strong associationbetween handwashing and the risk of diarrheawas confirmed by a logistic regressionanalysis that controlled for variables that hadan independent association with diarrhea. Aslisted above, these variables were country ofresidence, urban/rural residence, location ofsource of water, use of a sanitary latrine ortoilet by all family members, tested ability ofthe mother to read, and number of children inthe household.
In the analysis shown in Table 11, forexample, caretakers at the intermediate stephad a 1.5 risk (odds ratio 1.46, 95% confidenceinterval: 1.15-1.86) of having a child withdiarrhea within the past two weeks. Caretakersat the inadequate step had a 2.1 risk (odds ratio2.14, 95% confidence interval: 1.71-2.68)compared to families at the optimal stage.
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Figure 5. Moving Families Up theHandwashing Steps
Key Attitudes and ConstraintsThe market survey sought to learn about bothpositive associations with handwashing andthe primary constraints to good handwashingpractices.
Specifically, the survey looked at theconnection of handwashing to wateravailability; mothers’ perceptions of their ownability to influence children’s handwashingbehaviors; and perceived connectionsbetween handwashing and health.
Caretakers believed in an associationbetween handwashing and good health, but didnot think handwashing was sufficient to preventdiarrhea. In Guatemala, 51 percent of motherssaid “One gets sick even though we wash ourhands often.” A basic belief in the importance ofhandwashing was prevalent in all countries,however. For example, 94 percent said, “Peopleat home always told me I should wash myhands.”
Media UsageThe survey also looked at media use andinfluence. Eight out of ten mothers surveyedlistened to the radio daily—especially in themorning. Television was most common inurban areas, particularly after 6 p.m.Newspapers played a minor role in influencingthe target group. Other studies have shownthe importance of interpersonalcommunication to reinforce messagesdelivered by the mass media.
Implications for the SoapProducersTo the soap producers, the results of themarket survey highlighted the potential marketfor soap. People in the optimal group washedtheir hands an average of eight times per day.The remaining 91 percent washed their handszero to five times per day. If the campaignwere successful, these people would increasetheir handwashing by three to five times perday, thus increasing consumption of soap.The strategy adopted was to attempt to movefamilies up the “handwashing steps,”incrementally improving handwashing practiceand decreasing risk of diarrhea in children(see Figure 5).
N= 4497
Average daily % of childrenDescription occurrence of under age 5
% of those correct havingStage Technique Critical times interviewed handwashing diarrhea
Inadequate Incorrectand/or ➾ 0 65 0 23.1
Intermediate Good 1 or 2 26 4.5 13.1
Optimal Good 3 9 8 9.8
Table 11. Handwashing Behavior Stage of Surveyed Mothers, 1996(all four countries)
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Advertising StrategyDevelopmentLike the market survey, the advertisingstrategy was developed by a professionalagency hired by the catalyst. Task Forcemembers made decisions on the generalthrust and extent of the campaign—decidingto focus advertising on the “how” and “when”and to target those with “inadequate”handwashing behavior (the largest group).They also agreed to focus on healthychildren—and specifically prevention ofdiarrhea—as a positive campaign theme.(Some diarrhea campaigns have used fear orother negative motivators as a basic strategyfor promoting changes in practices.)
Advertising BriefAfter analyzing in detail the findings of themarket survey, the Task Force developed apreliminary marketing strategy, which formedthe basis for an advertising brief. The purposeof this brief was to guide the advertisingagency in developing messages and concepts.It analyzed the public health problem that theInitiative was to address, described thepartnership that had been formed, presented
the mission statement, and summarized theresults of the market research.
Selecting the Advertising AgencyBASICS issued requests for proposals to fiveCentral American advertising agencies,following USAID’s contracting procedures. TheTask Force set the following criteria forselecting the agency:
■ Strong creative capability■ Regional scope in Central America■ Neutral, i.e., no accounts with any Task
Force member or competitor, to avoid apotential conflict of interest
■ Affiliation with a multinational advertisingagency to benefit from sophisticatedtechnical support
The third criterion eliminated many top-rankedagencies that might have wished to bid,because of their handling of a soap companyportfolio.
The scope of work also specified that theagency chosen would develop the creativestrategy but would not place theadvertisements. Ad placement was to behandled by the in-house publicity departmentsof the soap companies. This arrangement wasunattractive to the advertising agencies,which usually derive substantial commissionsfrom ad placement. This delayed thesubmission of an adequate number of bids.Eventually, three companies did submit bidsand a Guatemala-based firm, ServiciosEstrategicos, was selected.
The original schedule called for selection ofan advertising agency by mid-December 1996for approval by USAID in mid-January 1997. Thecontract was finally awarded in April 1997.
Developing the CommunicationStrategyThe catalyst team met with ServiciosEstrategicos in late April to develop acommunication strategy. The strategy formedthe basis for developing materials andensuring consistency of the message.
Advertising Slogan and Logo
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Summary of the Handwashing Initiative Communication Strategy
Purpose: Develop the habit of handwashing with soap and water at critical times using correcttechnique among mothers of children ages five and under.
Desired Consumer Response: “I should always wash my hands with water and soap at criticaltimes, such as after coming in contact with fecal matter and before eating, to prevent illnesses, suchas diarrhea, which can cause the death of my children.”
Benefits: Preventing diarrhea.
Rationale: The market research study showed that, among the target population, the risk of diarrhealdisease was inversely associated with the frequency of appropriate handwashing.
Target Groups: Primary group: Mothers with a low level of education and socioeconomic status whohave children under five, principally in the interior of the country. Secondary group: Elementaryschoolchildren living under the same conditions.
Tone: Project an image that is positive, cheerful, memorable, direct, and natural.
The Design ConceptsServicios Estrategicos developed roughdesign concepts and presented them to theTask Force. The package consisted of acampaign logo and two versions of acampaign, each consisting of a radio spot, astoryboard for a television spot, and a poster.Version one centered on handwashingbehavior technique and critical times. Itfeatured a young mother in a rural setting—atypical representative of the primary targetaudience. Version two conveyed the samemessage but showed young children washingtheir hands correctly at appropriate times, asinstructed by their mother. ServiciosEstrategicos also suggested alternativecommunication channels, includingcommunity activities at fairs or markets, andschool activities.
The Task Force approved both designconcepts as complementary. The “mother”version would be used for the introductorycampaign and the “children” version in afollow-up round. It agreed to pretest the radiospot and poster in Guatemala and CostaRica—two countries at opposite ends of theregion’s socioeconomic range. Approval of thecreative concept marked the end of the all-important planning phase. The next chapterdiscusses implementation, beginning with amore detailed description of the advertisingcampaign.
Issues and Lessons Learned■ A well-conducted market survey is
essential for an initiative of this kind. Itserves two purposes: as formativeresearch to develop a profile of thepotential customers and to create abaseline for measuring the impact of theintervention on behaviors. Without such asurvey, an advertising campaign cannotbe designed or evaluated.
■ The catalyst must be prepared toprovide technical backstopping to themarket research and advertising firms.Working with a good local marketresearch firm can be a very efficient wayto get a high-quality product. However,market research firms are unlikely to haveexperience and personnel with priortraining in the behavioral aspects of theresearch required. Examples includehandwashing demonstrations, questionsabout diarrhea, or just about anything todo with children (from selectinghouseholds based on the presence ofchildren to enumerating the children in ahousehold and their ages). Specifictechnical backstopping on the training ofsurvey personnel is essential to ensure auniform approach and high-quality results.These firms also may be unfamiliar withpublic-private partnerships and may, forexample, need help presenting
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Works CitedBateman OM, RA Jahan, S Brahman, S Zeitlyn,
SL Laston. 1995. Prevention of DiarrheaThrough Improving Hygiene Behaviors.ICDDR, B Special Publication No. 42, Dhaka,Bangladesh: International Centre for DiarrhealResearch, Bangladesh.
Cousens S, B Kanki, S Toure, I Diallo, V Curtis.1996. Reactivity and Repeatability of HygieneBehavior: Structured Observations fromBurkina Faso. Social Science and Medicine43(9):1299-308.
Hoque BA, D Mahalanabis, MJ Alam, MS Islam.1995. Post-defecation Handwashing inBangladesh: Practice and EfficiencyPerspectives. Public Health 109(1):15-24.
Shahid NS, WB Greenough 3rd, AR Samadi, MIHuq, N Rahman. 1996. Hand Washing withSoap Reduces Diarrhoea and Spread ofBacterial Pathogens in a Bangladesh Village.Journal of Diarrhoeal Disease Research14(2):85-9.
information in a way that will beconvincing to all partners. Anotherchallenge of working with a marketresearch firm is the compressed timeschedule typically allowed for such asurvey. Technical assistance and qualitycontrol input from the catalyst requiresintensive commitment of resources duringthe planning phase.
■ It is important to establish thecommunication strategy as thereference document for all advertisingdesigns and media. Adhering to thecommunication strategy ensures thatclear, consistent messages are conveyedto consumers.
47
his chapter reviews the implementation phase of the Central
American Handwashing Initiative by. . .
The Advertising CampaignThe “How” and the “When”
Tn Describing the promotional materials (radio and television spots
and posters).
n Recounting how the campaign was implemented in each country.
n Highlighting ongoing activities.n Reviewing future plans for continuing the campaign.
Chapter 7
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The implementation phase of the Handwashing Initiative began inOctober 1997, when all producers in the Task Force received
master copies of the campaign materials created by ServiciosEstrategicos. The plan was to launch all of the country campaigns
simultaneously (in February 1998) for maximum impact. In actuality,
launch dates were staggered from March to September 1998.
Description of the GenericHandwashing CampaignThe campaign theme was “Manos limpias,evitan la diarrhea” (Clean hands preventdiarrhea), and its slogan was “Lavo mismanos por salud” (I wash my hands forhealth). Servicios Estrategicos also designeda campaign logo (shown in Chapter 6) and amascot, “La Burbujita.”
Radio SpotsBased on information from the market surveyabout media usage, radio was identified asthe primary medium for reaching the targetaudience. Servicios Estrategicos created twospots with easy-to-remember lyrics set to themusic of traditional songs that would be
Burbujita, the Mascot of theHandwashing Initiative
known by all family members. The first wasaimed at mothers and the second at children.Only the first spot was produced in ready-for-broadcast format. The second was created innon-final prototype format, intended for afollow-up campaign. The spots were asfollows:
■ Version 1 (finalized): “Uno, dos, y tres”(One, two, and three)—a 30-second spotto the tune of “Cielito Lindo” (a verypopular old song transmitted throughgenerations). The mother sings a songtelling happily why it is important to washone’s hands at critical times. “Uno, dos, ytres” refers to the three critical times (aftergoing to the bathroom, after changing ababy, and before preparing food) and thethree critical techniques (use soap andwater, rub hands three times, and dry inthe air or on a clean towel).
■ Version 2 (prototype): “Dice mi mama” (Mymama says)—a 15-second spot withvariations to the tune of “Tengo unamuneca vestida de azul” (another popularsong). The child sings about what hismother has told him. There are threevariations: wash before eating, wash aftergoing to the bathroom, and my mamawashes after cleaning my little sister. Thethree aspects of correct technique arealso included.
Television SpotsTelevision was the secondary medium. Again,two spots were created. Both were short andupbeat, using actors and contexts the target
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population could identify with to portray goodhealth, and featuring the same popular tunesas the radio spots.
■ Version 1 (finished master copy): “Uno,dos, y tres,” a 30-second spot—similarto version one of the radio spot,presenting the cheerful mother as theauthority for maintaining the health ofthe family as she demonstrates theproper handwashing technique at criticaltimes during the day.
■ Version 2 (prototype storyboard): “Dice mimama,” a 15-second spot with threevariations, similar to the second versionof the radio spot.
PostersPosters were created to support and
reinforce the radio and television campaign.They were to be displayed in public placessuch as schools, health centers, stores, andpharmacies. One version depicted thecheerful mother carrying out all of thecampaign behaviors (the three “techniques” atthe three “times”). The poster carried the logoand slogan as well as the main message:“Manos limpias evitan la diarrea.”
Task Force members had thoroughlydiscussed the design elements of thecampaign. Hand soap producers wanted ascene showing a modern bathroom sink, whilelaundry soap producers insisted on a ruralsetting, showing the pila (laundry tub) withlaundry hanging on a line in the background.The poster Servicios Estrategicos designedrepresented the best compromise, targetingthe primary audience of rural mothers insocioeconomic categories D and E.
Strategy for ImplementationServicios Estrategicos gave each of theproducers in the Task Force master copies ofthe advertising materials. These materialscould be used as they were for promotinghandwashing with no brand identification (ageneric campaign). Or producers couldassociate the campaign with a product by (1)
adding the trademark and logo of the productto the materials or (2) incorporating themessages and graphics into a company’s ownadvertisements for a specific brand. The basicimplementation strategy of the HandwashingInitiative was to launch a two-prongedcampaign in each country: a genericcampaign on radio and television (presumablywith time donated by media organizations),followed or accompanied by the individualcompany’s brand advertising through massmedia, educational activities, and point-of-sale promotion.
The local coordinator prepared a genericmedia plan detailing the radio-television mix,the number of radio stations, programs, andspots, date of launch, and duration of thecampaign for each country, and presented itto the Task Force. For the producers,acceptance of this plan raised issues ofownership, budget, confidentiality, and brand
The Generic Poster
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positioning adaptation. Most of themdeveloped their own media plans instead ofadapting the generic plan.
Campaign Activities—March 1998 to April 1999Activities in Costa RicaPunto Rojo set aside approximately $114,900to spend on media for the HandwashingInitiative (about $82,400 on television and$26,000 on radio). The company contactedChannel 7 (Teletica), the television station withthe widest national coverage (90 percent)broadcasting the most popular programs forhousewives. Teletica was so enthusiastic aboutthe campaign that, for every paidannouncement, they offered at least one freeannouncement during prime time.
For the generic campaign, televisionspots were run on Channel 7, and printedmaterials and tapes of the radio spots or theposter were distributed toNGOs with direct reach tocommunities (for example,World Vision). The brandedcampaign consisted oftelevision and radiocommercials of the “Fortuna”brand—an inexpensive toiletsoap with high distribution inrural areas—andmerchandising through thedistributor sales force.
Punto Rojo did not renewthe agreement with Teleticawhen it ended in April 1999.The producer felt that thespot was targeted more to thepoorer Central American neighboring countriesand that it did not adequately reflect the CostaRican setting. The producer agreed with themessage but preferred a more upscale modelin a more urban setting—more in keeping withthe local population.
Despite Punto Rojo’s reservations,independent media audits indicated that thecompany’s advertising campaign for “Fortuna”in connection with the Handwashing Initiative
was one of the country’s most active soapadvertising campaigns. Thanks to theagreement with Teletica, the campaignoutspent even the big names, such as“Palmolive,” “Bactex,” “Lux,” “Dove,” and “GoldPro” soaps, in television advertising.
The Office of the First Lady of Costa Ricaalso contributed to the campaign by providinga total of 3,500 posters to all governmentministries and directorates for distribution tohealth centers, post offices, and the like.Punto Rojo printed a special batch of posterscarrying the logo of the Office of the FirstLady along with the “Fortuna” brand logo.
Activities in El SalvadorThe Directorate of Social Programs of theMinistry of Health, which had introduced theconcept of Escuelas Saludables (HealthySchools) several years before, expressedinterest in the Handwashing Initiative as
soon as its director heardabout it. Unisola/Unilever hadbeen seeking Ministry ofHealth endorsement of thehandwashing advertisingcampaign and agreed to putits full effort into a jointarrangement with theministry. Under theagreement, “Plan decooperación ‘Lavo misManos por Salud,’ ” Unisola/Unilever developedhandwashing materials to beused in schools, healthcenters, prisons, andmarkets. The school
program, which reached 3,500 schools,consisted of educational modules onhandwashing for schoolchildren anddistribution of “Gold Pro” soap samples,educational posters, banners, and leaflets.Within the health centers, the TV spot wasshown as a video in waiting rooms,accompanied by posters and leaflets. Thesoap company mass-produced materials fordistribution to selected schools and health
“We joined the campaign
because it involved the
company in a social outreach
program, something we had not
participated in before, and to
decrease the number of children
who die due to disease.”—Arnoldo del Valle,
La Popular, Guatemala
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posts. USAID and UNICEF also distributedmaterials through NGO networks.
Following the positive collaborativeexperience with Unisola/Unilever, the Ministryof Health reached out to ask Colgate-Palmolive to supply additional soap samplesfor the school program and to Helsal, a majortowel manufacturer.
Unisola/Unilever, with the Ministry ofHealth and the major Salvadoran televisionbroadcasting corporation (TCS—Channels 2,4, and 6), cosponsored free broadcasting ofthe generic spot, though only for a limitedtime. The “Gold Pro” brand advertising ontelevision was preceded and followed by thehandwashing message and logo, reinforcingthe link between the generic campaign andthe brand advertising.
Activities in GuatemalaThe campaign was launched in Guatemala inMarch 1998 with airtime for the generic “Uno,dos y tres” television and radio spots donatedby the largest media company and the radioassociation. The television spot has beenaired mostly on Channel 6, the station withthe largest audience, and the radio spots havebeen broadcast in several areas of thecountry. In addition, La Prensa Libre, thelargest daily newspaper in the country, agreedto run generic advertisements withhandwashing vignettes as filler. Thenewspaper is also considering other ways toparticipate, such as reporting on handwashingthrough interviews of experts in the field andfeaturing handwashing as a topic in theSunday children’s section. The localcoordinator was responsible for contacting themedia companies and persuading them toparticipate in the Initiative.
Two producers, La Popular and Colgate-Palmolive, shared responsibility for thecampaign in Guatemala. Colgate-Palmolivewas not able to launch its branded campaignduring the first year of the Initiative, mainlybecause of the delay in assigning a newrepresentative when the company’s TaskForce member was promoted. As of August
2001, the advertising agencies of Colgate-Palmolive had developed and begundisseminating handwashing kits in schools.
La Popular launched its activities in May1998. The company wavered betweenassociating the handwashing campaign withits line of personal care soaps or its line oflaundry soaps. The original position was tolaunch the campaign along with the laundrysoaps, where La Popular, with its four brands,holds more than 50 percent of the market. LaPopular ultimately followed the BASICSprivate sector advisor’s recommendation tostick with that position because the primarytarget for the Initiative uses laundry, not hand,soap. La Popular’s laundry brands areidentified with the campaign—for example,their logos are on the posters—but themessages of the Initiative have not beenintegrated into the company’s advertising.(One “Ambar” advertisement touted the soap’sthorough cleaning of clothes but gentlenesson hands. Beyond this mild mention, thecompany did not wish to include dedicatedmessages on handwashing in itsadvertisements.)
Figure 6. Generic vs. BrandedCampaign Expenditures in 1998
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La Popular carried out field activitiesthrough its mobile units, playing the radio spoton a loudspeaker, distributing soap samplesand leaflets, and displaying posters aroundthe country. And to celebrate the fiftiethanniversary of “Ambar,” the country’s leadinglaundry soap, the company provided 14,000samples of the soap for handwashing kits forprograms in 400 schools—a program alsosupported by UNICEF.
FUNDAZUCAR, an organization fosteringeducation, health, housing, and municipaldevelopment for those working in the sugarcane plantations and plants, introducedhandwashing kits and handwashing corners inthe schools and centers it sponsors.
Figure 6 compares the implementation ofthe campaign in the three countries.
Continuing Project ActivitiesSince the follow-up market survey at the endof 1999, which marked the official conclusionof the BASICS/EHP intervention, producersand other partners have carried out additionalactivities. These activities are not officiallypart of the campaign, but grew out of theactivities of the partnership and are evidenceof sustainability.
■ In the aftermath of the earthquake in ElSalvador in January 2001, Unisola/Unileverworked with BASICS and the Ministry ofHealth to launch a promotional campaign toaddress the high risk of diarrheal disease incommunities damaged or destroyed by theearthquake. Through press, radio, posters,calendars, and stickers, the partnersconveyed three important messages:disinfect drinking water, wash hands withwater and soap at three key times, andwash fruits and vegetables. USAID financedthe production of materials, and Unisola/Unilever provided bars of soap and tabletsfor disinfecting water. The strategy waslaunched at the community level throughthe Department of Health. The companyhas proposed repeating the campaign butfocusing exclusively on handwashing.
■ CARE/Guatemala continued to distributeleaflets and place posters in strategiclocations.
■ Colgate-Palmolive has donated soap andpromotional material to the ministries ofhealth in Guatemala, Nicaragua, ElSalvador, and Honduras.
■ Colgate-Palmolive is using the messagesof the handwashing campaign toadvertise its antibacterial soap, “Protex,”to the general public.
■ Colgate-Palmolive has also developed a newregionwide campaign targeting elementaryschool children in Guatemala, El Salvador,Panama, and Costa Rica. Materialsdeveloped for the school program include ahandwashing story told by Manolo, a cartoonoctopus character, a board game about whento wash one’s hands, a poster forclassrooms with accompanying notes for
Protex Handwashing Poster:An Adaptation of the GenericCampaign
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teachers, and a take-home calendarstudents can use to keep a daily record ofwhen they wash their hands.
■ At the April 2000 public relations event,the partnership announced that it haddrawn up plans to continue the campaignin Guatemala through 2003. Two types ofactivities were anticipated:• Educate the population about the
critical times and techniques forhandwashing through television, radio,press, mobile units in local markets,and posters in health centers,hospitals, and schools.
• Integrate the “Lavo Mis Manos PorSalud” program with the Ministry ofHealth’s National Plan for HealthySchools and Municipal HealthPromoters through:
Protex Handwashing Promotion: A Program Targeting Schoolchildren
– handwashing clinics in markets,– handwashing kits for health
centers and schools,– a “Handwashing Week.”
Colgate-Palmolive pledged a donation of20,000 soap samples and 10,000 postersand stated that it would lead the effort incoordination with the Ministry of Healthand other partners.
Other future plans are discussed inChapter 8 in the section on sustainability.
Issues and Lessons Learned■ The diversity of implementation
methods underlines the importance offlexibility on the part of the catalyst.However, if the methods diverge toosharply, the campaign materials may not
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be completely appropriate. In the case ofEl Salvador, for example, a schoolprogram was adopted, yet the genericmaterials were clearly addressed tomothers, not children. The constant in allimplementation approaches was that thesoap companies financed or leveragedfunds for the campaign without donorfinancial support.
■ Internal issues of the soap producersand competitive stresses among themcan have a significant impact on theimplementation of a regionaladvertising campaign. For example,management and personnel changes attwo companies slowed down campaign
implementation and ruled out asimultaneous launch, which would havegenerated regional and local momentum.Competitive factors also explain thefailure to launch the campaign in acoordinated manner. The smaller firmswanted to wait for the larger firms tolaunch to benefit from the “tempo” thelarge firms would create. There was alsoan element of defensive competition: “Iwon’t launch until the others launch.” Andregional leaders were afraid of losing theiredge: “If I launch in one country, I cannotreplicate regionwide because the localfirms have the market.” There was noleveraging of regional capabilities.
55
his chapter reviews the assessment phase of the CentralAmerican Handwashing Initiative by. . .
ResultsReturn on Investments
Tn Describing the assessment efforts—including the follow-up
marketing survey.
n Detailing positive results in three categories: public health,
resources leveraged, and sustainable change among partners.n Reviewing the Initiative’s results from the soap producers’ point
of view.
Chapter 8
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1. The complete report, Impacto del Campana Lavo Mis Manos por Salud: Reporte Final, is also available in the CD-ROM, The Storyof a Successful Public-Private Partnership in Central America: A Compendium of Resources.
he Central American Handwashing Initiative yielded three kindsof results. Foremost were the public health results—including
changes in attitudes and actual handwashing behaviors known toprevent diarrheal disease. To some extent it is also possible to
estimate changes in the burden of diarrheal disease itself. Second, the
Initiative leveraged considerable resources for handwashingpromotion, not only from producers but also from other partners.
Finally, the Initiative had a positive and—the evidence suggests—
sustainable effect on the organizations that participated in it.
Methods for Assessing ResultsFollow-up Market Survey withBeneficiariesPublic health results were assessed bymeans of a second survey conducted byGeneris Latina. The questionnaire wasidentical to the one used in 1996, with theaddition of questions to capture campaignexposure. Due to funding limitations, thisfollow-up survey was carried out only inGuatemala. There, a total sample of 1,500households was once again selected withinthe same clusters that were sampled in thebaseline survey. The supervisors and, to theextent possible, survey team members, werethe same as those who performed thebaseline survey. The second survey wasconducted in November 1999, a little morethan a year after the launch. Smaller trackingsurveys of 500 mothers were conducted inurban areas of Costa Rica and El Salvador toprovide information for further development ofthe campaign in those countries. Thesesurveys were not designed for strictcomparison to the baseline, and they differsignificantly from the baseline in terms ofsample design and implementation.
Generis Latina prepared a reportcomparing the results of the baseline and final
surveys (Evaluación del Impacto CampanaLavo, 2000). Key features of this analysis arepresented below.1
Interviews with PartnersPartners in the Initiative were also contactedto assess the collaboration. In April 2001, thelocal coordinator interviewed ten people whohad been involved in the Initiative inGuatemala, Costa Rica, and El Salvador (seeAnnex B). She questioned them on theirreasons for involvement, expectations,impressions of the partnership, benefits totheir organization, problems and issues, andcontinuing related activities.
ResultsExposure to the CampaignThe campaign most effectively reached capital-dwelling, non-indigenous populations withaccess to television, but also reached rural andindigenous populations—albeit at a lower rate(see Table 12). In Guatemala, about 25 percentof the total population recalled campaignmessages on the radio—a key element of thestrategy for reaching rural indigenouspopulations via Mayan-language radio stations.
The survey also looked at exposure to“any” messages about handwashing during the
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N (Guatemala) = 1500; N (El Salvador) = 500; N (Costa Rica) = 500
“At a local level, the campaign
had a great impact; people
were even saying, ‘I wash my
hands for my health.’”— Almeda Aguilar,
Ministry of Health, Guatemala
campaign period. Because the Initiativeencouraged soap companies to promotehandwashing but did not dictate exactly how(or even whether) the graphics specificallyprepared for the campaignwere to be used, it is helpfulto look at broader exposure tohandwashing messages aswell. For example, inGuatemala, exposure to anymessages abouthandwashing during thisperiod was mentioned by 42percent of those surveyed; inEl Salvador, by 49 percent,and in Costa Rica, by 74percent. The distribution of those exposed(urban vs. rural, indigenous vs. non-indigenous) was similar to the exposurepatterns for the campaign-specific messages.
Handwashing BehaviorThe behavioral objectives of the Initiativewere to improve handwashing techniques andincrease the frequency of handwashing at
critical times. As in the first market study in1996, the follow-up survey categorizedinterviewees as being in one of three stagesvis a vis good handwashing practice: optimal
practices, intermediatepractices, and inadequatepractices (see Chapter 6).
Figure 7 compares the firstand second survey results interms of handwashing behaviorin Guatemala. Considerableprogress was made: tenpercent moved from theinadequate to the intermediateor optimal stages.
Attitudes Toward Handwashingand SoapA number of important attitudes improvedfollowing the campaign. In Guatemala, forexample, the proportion of mothers who said,“One still gets ill even with regularhandwashing,” fell from 51 percent to 37percent. The percentage of mothers whoagreed with the statement, “We should wash
Recall “Lavo MisManos por Salud” Guatemala El Salvador Costa Rica
Campaign (urban & rural) (urban) (urban)
Prompted and unprompted recall of campaign:
All interviewees 18% 23% 65%
Urban 24% 23% 65%
Rural 14%
Capital 30% 26% 68%
Rest of Country 15% (rural and urban) 20% (urban only) 63% (urban only)
Indigenous 10%
Nonindigenous 22%
Medium recalled:
TV 70% 81% 97%
Radio 25% 4% 7%
Newspaper 6% 3% 1%
Flyers and Posters 20% 18% 2%
Table 12. Exposure to the “Lavo Mis Manos por Salud” Campaign
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our hands before eating only if our handsappear dirty,” decreased from 43 percent to 32percent. There was also a 10 percent drop inthe percentage who agreed that “Most times,washing hands with water is sufficient.” At thesame time, the number of mothers agreeingwith the statement: “When I don’t use soap, Ifeel that I am not clean” rose from 78 percentto 88 percent. Mothers perceiving themultipurpose use of the bola soap increasedfrom 39 percent to 50 percent, reflecting theintensive efforts of laundry soap producers tolink their brands with the handwashingcampaign.
At the same time, changes in attitude werenot uniformly positive. For example, inGuatemala there was no reduction in thepercentage of mothers who said it was difficultto get their children to wash their hands aftergoing to the bathroom or before eating.
Public Health Impact in GuatemalaAs discussed in Chapter 6, diarrheal diseaseprevalence among children under five wasclosely associated in the first survey withmothers’ handwashing practices. In the
second survey conducted in Guatemala, thisassociation was still marked (see Figure 8).The final survey was conducted during aseason when diarrhea rates are normallylower. As one would expect, optimalhandwashing behaviors were associated witha stable, low prevalence of diarrhea. And,given the reduced risk of diarrhea during thisseason, intermediate and inadequatebehaviors were associated with about half therisk of diarrhea seen in the baseline, whichwas conducted in the high-diarrhea season.
The improvement in mothers’handwashing behavior in Guatemala betweenthe baseline and follow-up surveys wasapparently small, but on a population basis itmay have translated into an important publichealth impact. According to the NationalStatistics Institute in Guatemala, the totalpopulation of under-five year olds in the year2000 was 1,845,317, and about 85 percent ofthem lived under the lowest socioeconomic
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30
40
50
60
70
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Inadequate Intermediate Optimal
19961999
Percent
Figure 7. Stages of HandwashingBehavior in Guatemala, 1996and 1999
Handwashing behavior change after12-month campaign in Guatemala(1500 mothers)
Figure 8. Diarrhea PrevalenceAmong Children by HandwashingBehavior Stage of Surveyed Mothersin Guatemala, 1996 and 1999
N =1500
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Estimates of the Health Impact of theHandwashing Initiative in Guatemala2
After one year of the campaign in Guatemalaamong the 1,572,395 children under fivenationwide in the two lowest socioeconomicstrata, there were:
■ 14,500 fewer children with diarrheaduring any two-week period during therainy (high diarrhea) season
■ 7,000 fewer children with diarrhea duringany two-week period during the dry (lowdiarrhea) season
■ 322,000 fewer cases of diarrhea a year
■ 1,287,000 fewer days of diarrhea a year
2. See Annex C for calculations used to produce these estimates. These estimates were calculated using information in Figures 7and 8 and population estimates from the National Institute of Statistics of Guatemala (INE 2000), assuming a mean of 4.5 casesof diarrhea per year, with a mean duration of four days per incident case, for children under five in socioeconomic strata D and Ein Guatemala.
conditions (INE 2000). That means that thechanges in handwashing behavior and thecorresponding 4.5 percent overall reductionin diarrhea risk2 had an effect on a largepopulation of under-five year olds—about1.57 million children. What does this mean interms of reducing the burden of diarrhealdiseases? Some estimates of this impact arepresented in the box on this page.
Long-term EffectsThe campaign fostered proper handwashingbehavior now and with a promise into thefuture. Mothers modified their behavior toreduce the current rate of diarrheal disease.And as schoolchildren targeted by thecampaign become parents, another seed forproper handwashing techniques among futuregenerations will already have been laid. (Asimilar long-term vision has been realized inSri Lanka, where an oral hygiene program forchildren begun 20 years ago by Unilever hasbeen associated with the highest oral hygienerate in the region—and a strong market fortoothpaste companies as well.)
Other Key FindingsAdditional findings on exposure to thecampaign, changes in attitudes, and otherfactors emerged from the market survey.Differences in findings among countries aredifficult to interpret because the sampledesign and implementation of the finalsurveys in Costa Rica and El Salvadordiffered from those of the baseline in thosecountries and from both surveys inGuatemala.
■ Handwashing on Critical Occasions: InGuatemala and urban Costa Rica, therewas little change in reported handwashingon critical occasions among the mothers,fathers, and children five to ten years ofage, whereas in El Salvador, there was a
consistent increase in reported frequencyof handwashing on critical occasionsamong all three groups.
■ Handwashing Technique: Observedhandwashing technique improvedsignificantly among both mothers andchildren in Guatemala, but there were nosuch improvements in El Salvador orCosta Rica.
■ Soap Usage: Reported soap use anddemonstrated presence of soap in thehousehold at the time of the interviewremained very high and unchanged in allthree countries.
■ Movement up the Handwashing Steps:Overall improvement in handwashing—movement up the handwashing steps(Figure 7)—was significant in both urbanand rural Guatemala, but with muchgreater improvements in urban settings.
Resources LeveragedA relatively modest level of effort on the partof USAID, through funding to BASICS andEHP, prompted soap companies and media to
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Table 13. Catalyst Expenditures, 1996-1999
Item
Technical assistance
Travel and per diem
Task Force meetings
Marketing studies:baseline and follow-up
Advertising designconcept
Description
Three technical experts (meet with soap producers andother partners, keep USAID apprised of status of theInitiative, attend Task Force meetings, analyze data,etc.) Approximate level of effort: 70 person days for EHPand 260 person days for BASICS.
Facilitators, meeting room rental, refreshments, etc., forseven Task Force meetings.
Contract with Generis Latina
Contract with Servicios Estrategicos
TOTAL
Cost
$177,000
$20,000
$6,000
$153,000
$33,000
$389,000
Table 14. Leveraged Resources, 1998-1999
Item Description Amount
Guatemala
Radio Donated commercials, May to December 1998, 6,336 spots $110,000(Central de Radios y (198 per week), Guatemala City and the Altiplano y Camara deRadiodifusion Nacional)
Television Donated commercials, May to December 1998, 589 spots, $200,000(Channels 3, 7 18 per week, national coverage11, 13)
Print media Vignettes in black and white and color, April to December 1999 $5,000(La Prensa Libre)
Colgate-Palmolive Reprinted 10,000 posters for distribution through UNICEF and $4,000NGOs, August 1998
Developed protocols for handwashing kits and school program $10,000materials (coloring books, flyers), April to August 1998
Donated soap samples $3,000
La Popular Radio commercials, October 1998, in Guatemala City and September $9,5001998 to October 1999, mobile unit promotion in the interior of the country
Printing and distribution of 5,000 posters in markets, October 1998 $2,000
Distribution of banners in markets, September 1998 to October 1999 $1,500
Donation of 3,000 bars of soap for handwashing kits distributed $1,400in Quiche
Printing and national distribution of 10,000 flyers through the mobile units $2,000
FUNDAZUCAR Introduced handwashing kits and handwashing corners in schools $3,500and health centers
UNICEF Radio commercial, August to October 1998, in the Altiplano $8,000
Printing and distribution of posters and handwashing kits in the $2,000Altiplano, July 1998
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spend resources that would not otherwisehave been spent on handwashing promotion.
BASICS/EHP expenditures for theHandwashing Initiative totaled $389,000 fortechnical assistance, travel and per diem,development of the marketing strategy, andmarket research (baseline and follow-up) fromJanuary 1996 to December 1999. Table 13itemizes these expenditures.
This investment by USAID leveraged anestimated $614,900 for public health in thethree countries in just the first year of thecampaign. Table 14 itemizes the leveragedresources and puts a dollar value on them.
The information in Table 14 does notprovide the whole picture because it presentsonly the total for one year and does not includeongoing handwashing promotional efforts thatbegan after the official end of the Initiative.
Soap Producers’Evaluation of ResultsKey executives from three of the four soapcompanies involved in the Initiative wereinterviewed. Their overall impression of thecampaign was positive, and two of theproducers are involved in activities that grewout of the handwashing campaign.
In the producers’ view, the Initiative hadnumerous pluses:
■ Helping people. Most often mentionedwas the satisfaction of being involved in acampaign designed to help people. Therepresentative from Colgate-Palmolivesaid that the company views helpingcommunities and governments improvethe health conditions of populations as acorporate responsibility. The producers
Table 14. Leveraged Resources, 1998-1999 (cont’d)
Item Description Amount
Work groups distributing handwashing kits in rural communitiesand schools in the Altiplano, March 1998 to the present $5,000
Total for Guatemala $366,900
Costa Rica
Television - Teletica Matched Punto Rojo advertisements on TV7, May to December 1998 $82,400
Punto Rojo Radio commercial, May to December 1998, national coverage $26,000
Print advertisements, May to December 1998, national coverage $3,500
Printing and distribution (through World Vision and the Office of theFirst Lady of Costa Rica) of 6,600 posters $3,000
Television commercials, May 1998 to April 1999, national coverage $82,400
Distribution of soap samples at events $2,000
Total for Costa Rica $199,300
El Salvador
Unisola/Unilever Distribution of television advertisement via videocassette, Healthy $600Schools Program (3,500 schools)
Distribution of radio commercial via audiocassette to 31 health posts $100
Distribution of banners to 150 health fairs $1,000
Printing and distribution of 30,000 posters, Healthy Schools Program, $22,000health posts, and Healthy Markets, and various NGOs
Donation of 25,000 soap samples, Healthy Schools Program, Healthy $15,000Markets, and health posts
Television (TCS) Aired commercial during initial launch $10,000
Total for El Salvador $48,700
Grand Total $614,900
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also named the public as the majorbeneficiary of the campaign. Said one:“We genuinely believed in the campaignand its cause. This allowed us to keep inmind at every moment that we wereperhaps saving a life.”
■ Advantages of working with the publicsector and international organizations.Producers appreciated the value ofteamwork and the involvement of thepublic sector and internationalorganizations. They gave high marks tothe level of communication amongpartners. All remarked that theinvolvement of ministries of health andorganizations such as UNICEF and CAREgave the advertising campaign morecredibility—not only with the public butalso within their own companies to “sellparticipation in the campaign.” “When wesay, ‘GoldPro recommends you wash yourhands,’ it doesn’t have the same weightas when the Health Department, USAID,and BASICS say, ‘Wash your hands forthe sake of your health,’” noted theUnisola/Unilever representative. “We needa partner that can give us some authorityso that people will believe what we say.”In a similar vein, the Colgate-Palmoliverepresentative said, “What is better thanto have the country’s health departmentitself next to you?”
■ The catalyst role. BASICS/EHP’s role asa catalyst was highly appreciated,particularly the ability of the catalyst teamto be neutral toward competingcompanies and a variety of organizationsand to react quickly to changingcircumstances. The companiesrecognized that BASICS, in particular, isvery interested in private sectorcollaboration.
■ Increased sales. The producers madereference to sales but only to say that it isvery difficult to tease out what effect therelatively modest advertising campaign ofthe Handwashing Initiative had. Twoproducers implied that sales had increased
in areas where project activities had takenplace. While public-private partnerships arebuilt on the assumption that involvementwill benefit the bottom line for commercialfirms, it may be a challenge to documentthe increases because of the sensitivity ofsuch information.
The producers also raised issues andproblems:
■ Competition. The difficulty of working withcompetitors—even for a good cause—was recognized. Throughout the Initiativecertain producers never wavered in theircontention that an exclusive arrangementwould have been better.
■ Tight resources. Lack of funds for publicservice efforts was identified as aproblem. Apparently, not all top managerswere willing to allocate resources to thecampaign unless it was compatible withthe positioning of their brands.
■ Lack of follow-up after the formalcampaign. When BASICS/EHP reducedthe level of catalyst involvement, thepartners were left without a formalcoordinator and raised the question ofwho would step forward to lead the effort.Colgate-Palmolive expressed the desire tokeep its national Task Force going withmonthly meetings. (“We have enoughmomentum to keep communicating thissimple message in hopes of improvingchildren’s health.”) Some criticized thegovernment for not remaining moreinvolved or supporting the companiesmore, with compensation through taxbreaks, for example.
■ Creative concept. The genericadvertisement was criticized for not beingculturally appropriate in all countries. Oneproducer said, “A Costa Rican woman maynot identify with a commercial showing aGuatemalan mother worrying about herson’s diarrhea.” Another producer felt thegeneric advertisement was “too heavy withinformation” and would have been better
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“I insist that this campaign be a
lasting one, not something that
ends abruptly, because through
the soap campaign, we are
promoting a health change in
people’s habits.”— Lucrecia Mendez, CARE, Guatemala
with a simpler message. It was mentionedthat radio could have been used to betteradvantage. However, the producers feltthat the campaign was generally welltargeted to the people in need.
Sustainable Change AmongPartnersEffect on the Private SectorOne of the major benefits of the HandwashingInitiative was building awareness among theprivate sector that public health objectives arecompatible with business opportunities. Thesoap producers learned that soap could beadvertised in ways to promote its correct useto achieve health benefits. They also gainedvaluable experience in reaching out to themedia, ministries of health, and other partners.
A vivid example of this new awarenesswas Unisola/Unilever’s response to adevastating earthquake in El Salvador in early2001. Within a week the company was able toput together an advertising campaign toaddress the emergency, in partnership withBASICS and the Ministry of Health. Theadvertisements focused on handwashing withsoap at key times in addition to othermessages for choleraprevention.
Colgate-Palmolive islaunching a regionalcampaign with elementsbased “100 percent”(according to a companyrepresentative) on theHandwashing Initiative. Theplans include a schoolprogram in Guatemala, ElSalvador, Costa Rica, andPanama to teach children thecorrect technique, timing, andfrequency of handwashing.The program planned to reach 450,000 schoolchildren in 2000-2001 and will be extended toHonduras and Nicaragua the following year.The motivation is to replicate the company’sexperience of the highly successful, 20-year,“Bright smiles, bright futures” oral hygiene
campaign with the “Lavos mis manos porsalud” diarrheal disease prevention campaign.Colgate-Palmolive planned to invest $150,000in this program.
Unfortunately, the catalyst has nomechanism for following ongoing activitiesfrom a public health point of view. Thecompanies continually monitor theircommercial activities in terms of return oninvestment but are unlikely to assess publichealth impact.
Effect on the Public Sector and OtherPartnersRepresentatives from the public sector andother organizations were also interviewed andreported that participating in the HandwashingInitiative had a positive effect on theirorganizations.
■ Increased competence of personnel.Involvement with the Initiative helpedhealth workers learn to speak easily andclearly about handwashing.
■ Improvements in hygiene programs.UNICEF Guatemala mentioned that theexperience with the handwashingcampaign materials was helping the
organization to revise themessages in its sanitary andenvironmental educationprograms. “The campaign hada single message,” theUNICEF official said, “not avolley of messages. ‘One,two, and three’ is very easyfor people to remember andapply. It is a handwashingmessage stressing practicalresults.” The representativefrom CARE/ Guatemala saidinvolvement in the campaign
had strengthened its program by helpingCARE unify its efforts, enabling theorganization to respond to one of theHealth Department’s top priorities, andfortifying work done by its Maternal andInfant Health Program.
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■ Creation of new associations andnetworks. Involvement as a partner in theInitiative opened up new channels ofcollaboration that can be used in otherefforts. For example, it appears thatUnisola/Unilever, the Salvadoran MOH,and BASICS/El Salvador are poised tocollaborate in a sustained way to addresschild health problems.
Several issues were identified by thepublic sector and other partners that mayhave limited the success of the Initiative inbringing about sustainable change:
■ Length of the campaign. As oneinterviewee remarked, “To talk impact, wehave to talk years.” The campaign was tooshort, and BASICS and EHP should havebeen involved longer. Now, with the twoprojects playing a very limited role, theministries and international organizationshave to find ways to continue and extendthe campaign on their own. Lack ofresources may make that difficult.CARE’s representative said that thecampaign should be a lasting one, notsomething that ends abruptly.
■ Community involvement. TheHandwashing Initiative did not include acommunity participation component.There is room for involving key people inthe community and people who couldserve as models to reinforce handwashingbehavior change.
Issues and Lessons Learned■ The most salient feature of a private
sector initiative for public healthobjectives is that financial and technicalsupport rests with the companiesthemselves, and continued activities arenot predicated on continued injections offunds and technical assistance.
■ Subsidiaries communicate successfulexperiences to their headquarters,which in turn spread messages to the restof a global network.
■ Even a small improvement on a largescale translates into a big impact, butgreater impact may be achievedthrough broader partnerships. InGuatemala alone, the national campaignpotentially benefited over 1.5 millionchildren, and handwashing improvementswere seen at a national scale. The largestpreviously documented handwashingimprovement intervention had a targetpopulation of about 60,000 children, andmost documented experiences had muchsmaller populations.
■ Public-private sector partnership canbe routinely considered among publichealth tools. This experience shows howsuch a partnership can work. On the otherhand, the reduction in diarrhea ratesestimated here are much less than thoseseen in many reported studies. However,this activity does not represent acomprehensive approach either todiarrhea prevention or to handwashingbehavior change. What has beendemonstrated here is that public-privatesector partnerships can play a useful rolein promoting handwashing.
Opportunities for expanding thepartnership and achieving greater impactinclude more participation of NGOs andPVOs (with community-level interventionsand more opportunities for interpersonalcommunication), integration withinfrastructure programs, assessment ofbarriers to handwashing, and inclusion ofpartners to address those barriers.Additional partnerships can be key toinfluencing the most affected and difficult-to-reach populations.
■ There are many obstacles to assessingpublic health impact where theintervention happens at the scale seenhere.
• Other interventions that may affect thetarget behavior must be monitored. Ifthey exist to any significant degree,then any evaluation will be difficult.
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Likewise, the effects of an interventioncan be difficult to distinguish from asecular trend and behaviorimprovements.
• It is impossible to have a control groupwith national-level campaigns, so thequestion of whether any effects onbehavior can be attributed to theintervention can never be fullyresolved.
• Comparing two surveys with randomlyselected populations presents limitationswhen the real interest is finding out whathappened to individuals or families. Inthe Handwashing Initiative, the realinterest was evaluating specificallywhether individual families moved fromone step to the next in improvinghandwashing behavior and then tryingto discover whether the movement wasrelated to exposure to the intervention.The latter issue implies that a cohortdesign, perhaps with periodic monitoringof a smaller number of families and atime series analysis, should beconsidered for the survey. In any event,survey design will present difficultiesand tradeoffs. The design used in thisactivity was chosen because it balancedmarket research and evaluation needs,could be applied within the availablebudget by a local firm with limitedexternal assistance, and could bepresented to the private sector partnersin a format to which they areaccustomed.
• While the relationship betweenhandwashing and risk of diarrhea iswell documented, demonstratingbehavior change alone may not besufficient for the needs of somepartners. The more difficult task ofestimating health impact may benecessary for both continued supportand advocacy.
• Sufficient support from the publichealth interests in the partnershipmust be provided early and
consistently throughout the process ifan evaluation of public healthimprovements is contemplated. Asnoted in Chapter 6, the design andimplementation of surveys oftenmoves rapidly when one is workingwith private sector partners. The publicsector and/or catalyst team needs tobe prepared to invest resourcesintensively for a short period of time atthe outset to assure that the criticalaspects of evaluation design andimplementation are sufficientlyaddressed. Likewise, sufficient supportwill be needed throughout for themonitoring and final informationcollection and analysis.
■ Private companies were unable orunwilling to share information abouthow their participation in theadvertising campaign affected sales.Thus, it was difficult to document the fullimpact of the Initiative.
■ The Initiative tried to integratehandwashing promotion into thebudget of a winning brand (marketleader). If handwashing promotion is notpart of the promotional program of amarket leader, it will not be sustained. If itis integrated into the promotion of a minorbrand (with a small budget) it will not havean impact.
Works CitedEvaluación del Impacto Campana Lavo Mis
Manos Por Salud: Reporte Final. 2000.Prepared for Generis Latina de Grupo deServicios de Información, Guatemala,Guatemala, CA, Febrero.
Encuesta de Ingresos y Gastos (1998-1999) andPopulation Projections. 2000. Instituto Nacionalde Estadística (INE), Guatemala, Guatemala,CA
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Key Steps for Replication
his chapter identifies the key elements of the Central AmericanHandwashing Initiative for organizations that may wish toT
replicate a similar effort by . . .n Examining overall costs and benefits for the participants.
n Describing the critical path and key actions for replication.
n Identifying “red flag” issues.
Chapter 9
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T he success of the Central American Handwashing Initiativesuggests the potential inherent in partnerships that bring the
public and private sectors together to achieve complementary goals.Similar efforts in other countries or regions would multiply the
resources available to fight diarrheal disease—and many other
diseases. The Initiative also suggests that the private sector’stechniques for getting messages out can be marshaled to change
behavior.
Costs Versus BenefitsAn attractive feature of the public-privatepartnership described in this report is its lowcost and high benefits. For reasonsdescribed below, it is not possible to put adollar value on all costs and benefits;however, Table 15 indicates the extent andkind of resources required and the type ofbenefits obtained.
The catalyst organization underwrote thecosts of encouraging and facilitating theparticipation of the private firms and ofcarrying out essential planning activities—themarket study and creative design. Theestimated value of the catalyst’s contributionhere was $389,000 over four years. This is notan insignificant amount, but, considering thechild health benefits—both estimated short-term and potential long-term benefits—it isactually a modest investment.1
Costs and benefits from the soapproducers’ perspective are difficult toestimate. The concept behind the project wasto encourage the private sector partners tospend resources that they would spendanyway to advertise soap in a different way(to promote correct handwashing) andexpand and open up new markets. Theassumption is that the soap producers soldmore soap during the HandwashingInitiative—based on the documented
increases in handwashing. However, such anincrease would be difficult to track, given thesize of the companies and their variedproduct lines. Also, companies may not wishto divulge information about sales increases.(When interviewed, two producers impliedthat their sales had increased as a result ofthe campaign.)
The investment of the producers, media,international organizations, and others(estimated at $614,900 in the first year of thecampaign alone) may not be large in absoluteterms. But it is very large from the point ofview of the catalyst and the public sector,which have limited funds to spend on diarrheaprevention. It is not known whether thecompanies allocated additional resources forthe Initiative or simply reassigned resourcesfrom their regular advertising budgets.
The principal benefit of the Initiative is theestimated decrease in diarrheal diseaseprevalence at the end of 1999. However, thecampaign has continued since then and willcontinue through 2003—and perhaps beyond.The documented contribution of the Initiativelikely understates its true benefits.
Key Steps for ReplicationTable 16 (pp. 70–72) presents the key stepsfor replicating a public-private partnership forpublic health. It is aimed mainly at catalyst
1. See Varley et al. 1998 for a discussion of the cost-effectiveness of hygiene activities – including handwashing promotion – com-pared with other diarrhea prevention and treatment interventions.
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organizations as initiators and facilitators ofthe process. The steps reflect the actualexperience of the Handwashing Initiative.
The first column of Table 16 shows thecritical path of steps and indicates who isresponsible for carrying them out. The secondcolumn adds detail by listing key decisions oractions for each step. The third column listsissues to be considered when taking theactions or making the decisions.
Benefits
■ Leverages resources to achieveorganizational goals.
■ Brings about sustainable changes in privatesector’s advertising messages andapproaches.
■ Demonstrates to other potential catalystsand public sector partners, such asministries of health, the benefits of public-private collaboration.
■ Provides an approach that otherorganizations can use.
■ Increases soap sales.■ Receives kudos/media recognition for
public service in good cause.■ Creates new alliances with the public sector
and other organizations.■ Learns new methods of marketing research
and advertising for behavior change.
■ Lowers diarrheal disease prevalence.■ Learns about the potential of public-private
partnerships for public health.■ Learns new techniques for social marketing.■ Improves school hygiene programs.
■ Reinforces healthy behavior at householdand community level.
■ Improves and strengthens its ownprograms.
Costs
■ Facilitates the partnership.■ Provides technical assistance.■ Guides development of
advertising strategy and designconcept.
■ Assigns personnel toparticipate in the Task Forceand guide the effort.
■ Implements the advertisingstrategy (this could be anadditional cost or part of thenormal advertising budget).
■ Carries out some pro bonoactivities to spread genericmessage.
■ Assigns personnel to work withprivate sector.
■ Assists in distributingadvertising messages/materials.
■ Motivates involvement at locallevel (e.g., public schools).
■ Assists in distributingadvertising messages andmaterials.
■ Organizes activities atcommunity level.
Partner
Catalyst
Private Sector
Public Sector
NGOs
The Initiative was supposed to have beena two-and-a-half year effort, and that is areasonable pace for such a project. Theplanning phase was to take about a year,followed by a year for implementing thecampaign, and then six months forassessment. Delays over the selection of theadvertising agency and a lag in the launchschedule of the producers postponed thecampaign launch about a year.
Table 15. Costs and Benefits for Partners in the Handwashing Initiative
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IssuesKey Decisions/ActionsCritical Path
CONCEPTUALIZATION PHASE (Nautilus steps 1-3)
Catalystconceptualizesproject
➩ Selects relevant public healthneed from epidemiological data,locally or regionally.
➩ Contacts firms; gauges theirinterest.
➩ Assesses competitive market.
Public health need should be met in partthrough private sector activities.
Companies should be willing to workcollaboratively, if that is the plan.
All companies should be invited to participate.
There should be room for substantial growth inthe market so that companies have an incentiveto participate.
PLANNING PHASE (Nautilus steps 4-11)
Catalystselects firm(s)to participate.
Catalyst andprivatepartnersformalize thepartnership.
Catalystconductsmarketresearch.
➩ Selects companies according totransparent and clear criteria.
➩ Holds organizational meeting,sets goals and overall approach.
➩ Sign agreement or memorandumof understanding.
➩ Establish task force.
➩ Develop work plan.
➩ Selects market research firm.
➩ Reviews draft survey, with TaskForce.
➩ Approves survey forimplementation.
➩ Assists market research agencyto implement, analyze, interpret,and present results.
➩ Develops general marketing planon basis of research, with TaskForce.
Companies selected should have the capacityto produce and distribute the producteconomically.
Transparent participatory meeting norms shouldbe established.
Agreement should be flexible enough toaccommodate variations in company styles/goals/resources but specific enough to provideclear direction and focus.
The roles and responsibilities and expectationsof the partners should be clearly spelled out.
Work should be completed in a compressedtime frame to keep up momentum and interest.
The task force should help set selection criteria.
Survey must address need for both marketresearch and baseline for evaluation and mustbe kept to a manageable size to maintain dataquality.
Market research objectives require more inputfrom the agency and private sector partners; theevaluation objectives are primarily theresponsibility of the catalyst.
Intense technical support from the catalyst isneeded.
Additional technical resources may have to bebrought in at significant cost to the catalyst.
Intense technical support from the catalystneeded to assure the quality of the data and theusefulness of the analysis and presentation toserve both sets of objectives.
Results should be presented in a way that isunderstandable to non-specialists.
Table 16. Key Steps for Replication
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Catalystdevelopscreativeconcept.
Catalyst andPrivate Sectorexpand thepartnership.
➩ Writes advertising brief, with TaskForce participation.➩ Selects advertising agency.➩ Provides technical assistance toagency during development ofcreative concept and promotionalmaterials.
➩ Approves creative concept, withTask Force.➩ Develop strategy for seekingcollaboration of additional partnersfrom the public sector and otherorganizations.➩ Design promotional materials ora presentation to use in recruitingother partners.➩ Recruit public sector and otherpartners: media, internationalorganizations, foundations, NGOs.➩ Carry out a public relations eventto recognize partners and publicizethe project.
Task Force should help set selection criteria.The creative concept should be consistent withpublic health principles and the findings of theresearch. (The importance of this point cannotbe overemphasized if the campaign is toachieve public health goals.)
A close relationship between the public healthspecialist and the task force and private sectorpartners is needed.
Cultural issues should be considered.Decisions should be made on use of creativeconcept for generic and branded advertising.Strategy should be based on comparativeadvantages of the catalyst and the private firms.
Private sector partners should be offeredsupport in dealing with ministries of health andother governmental agencies.Decisions should be made on when (orwhether) to hold an event: before the campaignbegins or after the campaign has beencompleted so that results can be shown?
IMPLEMENTATION PHASE (Nautilus steps 12-13)Private andOtherPartnersimplement thecampaign.
Catalystmonitorsimplementation.
➩ Plan for a coordinated launch formaximum impact and mediasaturation.
Internal or external events that might make acoordinated launch impossible should beidentified.Ways should be found to keep privatecompanies involved in spite of personnelchanges and shifts in company priorities andstrategies.The catalyst should make every attempt to havea local presence during the monitoring phase.The functions of the catalyst are to:■ Monitor the campaign activities and level of
resources expended by the partners (forevaluation and advocacy).
■ Monitor and support expansion of thepartnership.
■ Monitor the content of new activities that spinoff from the original campaign (to ensure thatthe content is consistent with the campaign).
■ Stay in close contact with the partners toassist in identifying and solvingimplementation problems, including the needfor internal advocacy within a company.
IssuesKey Decisions/ActionsCritical Path
Table 16. Key Steps for Replication (cont’d)
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IssuesKey Decisions/ActionsCritical Path
ASSESSMENT PHASE (Nautilus step 14)
Catalystconductsassessmentactivities.
➩ Carries out follow-up marketingsurvey to evaluate impact.
➩ Assists market research firm toanalyze, interpret, and presentresults.
➩ Identifies opportunities anddesigns materials for presentingresults to organizations that couldserve the catalyst role in the future.
➩ Designs mechanisms forincorporating assessment resultsinto development of the model andplanning for future activities.
Follow-up survey should replicate the baseline(sample and instrument design andimplementation), with additional questionsrelated to campaign exposure.
Follow-up survey should not be carried out untilat least a year after the launch of the campaign(optimally after two years of consistentcampaign activity).
Results should be targeted to decision makers,who include:
■ Current and potential new partners—toadvocate for engaging in a public-privatepartnership,
■ Potential catalysts,
■ Task force members and marketing managersof each private sector partner—to assist themin adjusting their marketing strategies.
Diverse private and public sector audiencesmay require a variety of presentations in orderfor these to be effective.
IssuesAt the conclusion of the HandwashingInitiative, several issues were still unresolved.Additional experience with partnerships likethe Initiative will shed more light on theseissues.
■ Dynamics of competition. While thedecision was made to work with a groupof producers rather than to enter into anexclusive arrangement with one company,not all producers were happy with thisarrangement. However, even those whowere unhappy did participate. With anexclusive agreement, a producer mightfeel that there was more to be gained inincreased sales and might put forth agreater effort.
■ Role of Task Force. Participation in theTask Force was good at the beginning ofthe Initiative but fell off precipitously asimplementation began. This meant thatthe catalyst had to travel directly to thefirms to get their input and to keep themengaged—a fairly time-consumingprocess. There are several possibleexplanations for the drop-off in interest:simple lack of time, lack of interest insharing information about the campaignwith competitors, changes in personnelthat brought less engaged members tothe Task Force, and loss of momentumdue to delays.
■ Measuring Impact. A project operating atthe scale of this Initiative cannot measurehealth impact through an experimental
Table 16. Key Steps for Replication (cont’d)
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design that allows for ironcladconclusions on the impact of thecampaign. Where the partnership model ishighly successful, more and morepartners get involved over time and bringan ever more diverse set of activitiesunder the broadest umbrella of theinitiative. For example, in the CentralAmerican Handwashing Initiative, schoolprograms were not anticipated to be aprimary intervention and thus the surveywas not well designed toevaluate the effort in ElSalvador, which wasalmost completelyoriented toschoolchildren. Diversityin campaigns presentsadditional challenges,such as ensuringconsistency with thecontent of the campaignand public health goals,describing the numerousactivities, and carryingout the follow-up survey.In a dynamic andseemingly organicprocess of burgeoningpartnerships, over timethe limits of an initiativecan become difficult todefine with precision.
■ Sustainability. Plans areafoot to continue the handwashingcampaign in Guatemala until 2003.However, it will be interesting to seewhether the effort will survive thetransition as the catalyst team withdrawsfrom an active leadership role. Theproducers may or may not have a long-term commitment to reorienting some oftheir advertising dollars for diarrheaprevention or to working with the publicsector. That may depend upon howsuccessful the campaign ultimately wasin increasing their sales.
Critical Success FactorsThe catalyst team, with the help of otherpartners, has identified several factors thatwere critical to the success of theHandwashing Initiative:
■ Presence of catalyst. Partners agreedthat the public and private sectors couldnot have been brought together toachieve complementary goals unlessBASICS/EHP had assumed the role of
catalyst. The catalyst alsobrought to the tableexpertise in marketing,public health, and behavioralresearch and was able tomaintain an on-the-groundpresence for providingtechnical assistance,monitoring, and follow-up.Hiring a local coordinator isa crucial element insuccessful public-privateinitiatives. Flexible,consistent support for theInitiative was the key.■ Good cause. There was anatural link between thepublic health goal andcommercial interests.Because the link was strong,both halves of the partnershipsaw benefits for themselves.
This perception of mutual benefits is thelinchpin of private sector participation.Media, foundations, and NGOs neededlittle encouragement to rally around thepublic health benefits of the Initiative.
■ Road map. The catalyst used a clear,tested approach as a road map forimplementing the Initiative (the “Nautilus”model). Thus, all concerned knew how thepartnership would evolve. The Initiativekept going partly because all partners hada clear understanding of the mainelements and logical progression ofsteps.
“We got the people’s good will
toward the brand, and this is
very important. The media
coverage also more than
compensated for our efforts. I
believe that if we communicated
to the rural areas of the country
that handwashing was a way to
prevent diarrhea, and if this
saved a life, we are more than
satisfied.”—Jorge Mario Lopez,
La Popular, Guatemala
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■ Market research. The advertising strategywas based on the findings of marketresearch that included information notonly about the actual and potential marketfor the product but also about thebehavior and attitudes of the targetpopulation toward the product and the keypractice. The research in turn wasdesigned with an understanding of theepidemiology of diarrheal disease and therole of specific behaviorsin its prevention. Withsolid information in hand,it was possible to developadvertising messagesthat led to behaviorchange and greater useof the product.
■ Public health backing.The Initiative received theenthusiastic support andendorsement of ministriesof health in all fourcountries, and in ElSalvador the ministries ofhealth and educationwere highly involved inthe campaign. Thissupport from publichealth officials gave theInitiative credibility andreassured the producers that they hadmade a wise decision.
■ Roles, responsibilities, expectations.The memorandum of understandingensured that partners’ expectations wererealistic. It did not specify precisely whatresources the producers would providebut was open-ended, making it possiblefor the producers to take advantage ofopportunities as they emerged.
■ Decision making. Critical decisions weremade jointly so that all partners feltownership of the project. Some of thegroup’s decisions caused delays, but hadthe catalyst overruled them, it could havedestroyed the whole Initiative. Strongdifferences of opinion between public and
private organizations are to be expected,given their different orientations. Jointdecision making was facilitated bytransparent processes, clearcommunication, documentation ofagreements, and effective face-to-facemeetings.
■ Timing and sequence. The HandwashingInitiative got off to a good start becausethe catalyst approached the soap
producers first, got theminvolved, and rapidly movedthrough the planning stage.The effort started small andstrategic, later involvingadditional partners asnecessary and useful.
The success of thehandwashing campaign inCentral America has beenattributed to the enthusiasticsupport of the soap producersand the availability of flexible,timely technical assistance bythe catalyst team to keep theprocess moving along. Giventhe potential impact of a public-private partnership like the onedescribed here, donororganizations should make
every attempt to work with the private sector inthe cause of proper handwashing in countrieswhere diarrheal disease continues to be aserious problem, as well as in other areas ofcommon interest and public health need.
“What we got in return was that
people are now aware that we
are not only a commercial
company, but that we care for
the health of the people of El
Salvador. The support we got
from the health department also
gave us great credibility. But I
believe that the ones who really
benefited were the people.”—Gregory Hawener,
Unisola/Unilever, El Salvador
Works CitedVarley, RCG, J Tarvid, and DNW Chao. 1998. A
Reassessment of the Cost-Effectiveness ofWater and Sanitation Interventions inProgrammes for Controlling ChildhoodDiarrhoea. Bulletin of the World HealthOrganization 76(6):617-631.
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Annex A. The Convenio
Annex A
Agreement Between Private Producers of Hand Soap and BASICS/EHPWe, the undersigned, meeting in GuatemalaCity, on the first day of March of nineteenninety-six, have studied the health situationin our countries and the project“PROMOTION OF HANDWASHING WITHSOAP IN CENTRAL AMERICA” promotedby BASICS/EHP and concluded that thishelps improve health conditions and has anacceptable design.
Based on our study, WE DECLARE ourcommitment to participate in the project in ajoint and collaborative manner. We haveagreed to work for at least 2 years and 6months (Phase I, Initiation of the Self-sustainable process) beginning on this date.Our participation shall be limited to the
statement of Reference Terms, which isincluded in Appendix No. 1.
Also, we have determined that in order tocarry out the project, we shall use theelements of the General Marketing Strategy,which is detailed in Appendix No. 2, “GeneralMarketing Strategy.”
Finally, we have established a Task Force.The names of its members and theirassigned tasks are shown in Appendix No. 3,“Task Force.”
In confirmation of our discussions anddecisions, we sign this document, formalizingour commitment to participate.
Appendix 1 of the AgreementRules of the Game or Reference TermsWho should participate in the project?
All institutions whose representative[s] attended the Seminar-Workshop for the Promotionof Handwashing with Soap in Central America project (March 1), plus the representative ofIndustria Chamorro de Nicaragua, subject to their reconfirmation.
Agreements on the tasks to be carried out jointly:
■ Planning and development of the market study
■ Planning and development of generic promotional campaign
1. We agree to develop a generic promotional campaign (institutional) for handwashing withsoap that does not benefit one specific brand.
2. We agree to seek funding (public and private) for production and dissemination of acampaign.
3. We agree that each company should use the concepts of the generic campaign through thesponsorship of the campaign by product.
4. We agree to jointly conduct a market study funded by BASICS/EHP.
5. We agree to disseminate the experience and follow up the Initiative.
6. The cost for the companies mainly involves launching the campaign (February 1997). It isexpected that the cost of the campaign will be reasonable in terms of each company’s normalinvestment in advertising.
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Roles and Responsibilities1. Companies
■ Name one representative to the Task Force (commitment to participate, communicationlink with his company).
■ Respect the agreements/rules of the game.■ Share with BASICS/EHP information to help measure the impact of the campaign in a
confidential manner.■ Commitment to continue the project in accordance with the general design (2 years and 6
months).
2. BASICS/EHP
Technical role
■ Plan, coordinate, and facilitate the activities carried out jointly (including the Task Force).■ Carry out specific technical responsibilities for conducting studies and for the generic
communication strategy.
Role with respect to funding
■ Market studies■ Development of the generic creative strategy■ Costs of the representatives of BASICS/EHP■ Contribution to the costs of meetings
Support for establishing contacts with the public sector and eventually sources of funding with theobjective of reinforcing execution of the generic campaign.
3. Task Force
General role
■ Provide guidance, review, and follow-up of the activities that are carried out jointly.
Specific role
■ Design the general marketing strategy.■ Establish the work plan.■ Identify the information needed for market studies.■ Review the questionnaire / suggestions on methodology.■ Review / analyze the results of the market study and transfer the results to the
communication strategy.■ Establish selection criteria and advise on the research and advertising agencies.■ Review and approve the generic communication strategy.■ Review and approve the generic creative concepts.■ Establish the strategy for involving the public sector.■ Design and review market study no. 2 (similar to no. 1).■ Interpret results in terms of the communication strategy.■ Advise on the dissemination strategy (and active participation).
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Methods of carrying out the process:
■ Maintain constant communication between BASICS/EHP and other Task Force membersvia fax and Internet.
■ Hold Task Force meetings at critical times (to make decisions) on the work plan.■ The Task Force members are the points of contact for internal and external
communication.
Appendix 2 of the AgreementGeneral Marketing StrategyObjective
■ To encourage the habit of washing hands with soap.■ To expand the market for soap use.
Strategy/direction
■ Principal segment socioeconomic level D and below■ All members of the family (men, women, and children)■ Investigate behavior in connection with handwashing with soap
Critical path
1) Written confirmation of the agreement March 15, 19962) Market research No. 1 March – July 19963) Evaluation of study results August 19964) Determination of communication strategy
Presentation of other participants September – December 19965) Execution – production of campaign material January 19976) Launch February 19977) Market research No. 2 March 19988) Evaluation of results June 19989) Determination of long-term strategy July 1998
Geographic dimension
All countries in Central America can participate in a coordinated manner.
Coordinating companies by country
GUATEMALA – Colgate Palmolive / La PopularEL SALVADOR – Unisola / UnileverHONDURAS – Corporación CréssidaNICARAGUA – (Chamorro) / Colgate PalmoliveCOSTA RICA – Punto Rojo
Total time of the process
March 1996 – July 1998
Method■ It is preferable to conduct the market research with a company that has regional coverage in
Central America.
■ The launching of the campaign will be simultaneous.
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Appendix 3 of the AgreementTask Force in Connection with the AgreementComposition
One representative of each company, one representative of BASICS, and onerepresentative of EHP
Who constitutes the task force?
Ricardo Mejía-Aoun/ Colgate Palmolive – Guatemala
Arnoldo del Valle / Fábrica La Popular – Guatemala
Rafael Chinchilla / Corporación Créssida – Honduras
Viviane Dechamps / Unisola – El Salvador
Federico Quezada / Punto Rojo - Costa Rica
(Representative of Industria Chamorro – Nicaragua)
Massee Bateman / EHP
Camille Saadé / BASICS
CoordinatorsMassee Bateman and Camille Saadé
Meetings at critical points1. Approval of market study questionnaire: The meeting will be held in May or June of 1996. The
questionnaire should be sent out before the meeting. The next meeting will be held inHonduras (Tegucigalpa).
2. Evaluation of results: August 1996
3. Establishment of objectives and creative strategy: October 1996
4. Approval of messages, material, and coordination of launch, development of meeting plan for1997-98: November 1996
Preferred time for meetings: Friday, first two weeks of the month. Provide (at least)two weeks notice.
DraftInformation for Marketing Research
Objectives
1. Establish the profile of the target consumer for a campaign in connection with handwashingwith soap.
2. Establish a reference point for handwashing behaviors in the target population.
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Characteristics of the sample to be chosen
■ Country-wide, in each of the five Central American countries (there may be a regionallevel under each country)
■ Urban and rural■ Class D and below■ Families with small and school-age children
Required Information
1. Socio-demographic characteristics
■ Family structure■ Level of income■ Education/children in school■ Occupation of husband and wife■ Language spoken at home
2. Living conditions
■ Availability of water (inside or outside the house and how far away)■ Source of water■ Storage of water and type of container■ Electricity■ Radio or television■ Latrines or places for defecation
3. Behavior and attitudes towards handwashing
■ Perceived relationship between cleanliness and health
■ Handwashing techniques:– Demonstration of six elements: use of water, two hands, soap or other material, rinsing,
washing, drying– Availability of soap: type, kind– Place for handwashing– Specific uses of soap
■ Frequency of handwashing– Number of times per day– At critical times
■ Handwashing behavior of other family members– Demonstration with children– Number of times– Reasons for washing hands– Reasons for not washing hands– Which other family members wash their hands with soap
■ Impact– Presence of diarrhea in children under five in the last two weeks (total number of days)
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4. Soap for any use
■ Source for obtaining soap■ Kind of soap used■ Where to buy soap■ Decision-making for buying soap: who buys the soap, who decides■ Weekly usage of soap■ Cost■ Obstacles to obtaining soap
5. Soap for handwashing
■ Preferences with respect to soap for handwashing: size, color, appearance, cost,presentation
■ Reasons for not using soap
6. Information on handwashing■ Source of information■ Preferred methods■ Influences
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Annex B
Annex B. Persons Interviewed
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Name of the Contact Company Date of the Interview
Soap Companies
Ileana Quiros Colgate-Palmolive, Costa Rica 04-06-01
Arnoldo Del Valle La Popular, Guatemala 04-06-01
Jorge Mario Lopez La Popular, Guatemala 04-04-01
Gregory Hawener Unisola/Unilever, El Salvador 05-02-01
Public Sector
Lcda. Almeda Aguilar Ministerio Salud, Guatemala 04-06-01
International Organizations
Jorge Mario Molina UNICEF, Guatemala 04-17-01
Stan Terrell USAID, Guatemala 03-27-01
Dra. Patricia Quinteros BASICS II, El Salvador 04-17-01
Baudilio López USAID, Guatemala 04-17-01
Dra. Lucrecia Mendez CARE, Guatemala 04-05-01
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Annex CAnnex C. Statistical Calculations for Estimatesof the Health Impact of the HandwashingInitiative in Guatemala
Note: The model for calculating the effect of changes in handwashing behavior on diarrhea rates was developed specifically for thisactivity. It is based on changes in population proportions along behavioral steps and the proportion of children with diarrhea at eachstep. As the population moves up the “handwashing steps” from baseline to final survey, a higher proportion of the population is in thesteps associated with lower rates of diarrhea. These translate into an estimated 4.365 reduction in diarrhea using the 1999 associationsbetween diarrhea prevalence and handwashing steps (low diarrhea season) and a 4.73 percent reduction in diarrhea using the 1996associations between diarrhea prevalence and handwashing steps (high diarrhea season) for an overall average of a 4.5 percentreduction in diarrhea from 1996 to 1999.
Code Formula
Total No. Children under five in Guatemala, 2000 1,845,317Proportion of Children under five in SE levels D and E 0.8521Total No. Children under 5 in Guatemala in SE Level D and E NUM 1,572,395
Proportion with Diarrhea by Step 1996 (Figure 8) 1996 Inadequate 96DD1 0.211996 Intermediate 96DD2 0.151996 Optimal 96DD3 0.07
Proportion with Diarrhea by Step 1999 (Figure 8) 1999 Inadequate 99DD1 0.111999 Intermediate 99DD2 0.071999 Optimal 99DD3 0.06
Population Proportion by Step 1996 (Figure 7) 1996 Inadequate 96POP1 0.781996 Intermediate 96POP2 0.191996 Optimal 96POP3 0.03
Population Proportion by Step 1999 (Figure 7) 1999 Inadequate 99POP1 0.681999 Intermediate 99POP2 0.251999 Optimal 99POP3 0.07
Total No. DD cases, 2 weeks, Hi season, A NUM((96DD1*96POP1)+ 1996 POP proportions (96DD2*96POP2)+(96DD3*96POP3)) 305,674Total No. DD cases, 2 weeks, Hi season, B NUM((96DD1*99POP1)+ 1999 POP proportions (96DD2*99POP2)+(96DD3*99POP3)) 291,207Total No. DD cases, 2 weeks, Low season, A’ NUM((99DD1*96POP1)+ 1996 POP proportions (99DD2*96POP2)+(99DD3*96POP3)) 158,655Total No. DD cases, 2 weeks, Low season, B’ NUM((99DD1*99POP1)+ 1999 POP proportions (99DD2*99POP2)+(99DD3*99POP3)) 151,736
Total No. Diarrhea cases avoided 2 weeks, (A-B) 14,466 Hi seasonTotal No. Diarrhea cases avoided 2 weeks, (A’-B’) 6,919 Low season Proportion of Diarrhea cases avoided (A-B)/A 0.0473 2 weeks, High season Proportion of Diarrhea cases avoided (A’-B’)/A’ 0.0436 2 weeks, Low season Mean proportion of Diarrhea Cases PREVENT ((A-B)/A)+(A’-B’/A’))/2 0.0455 prevented, High and Low Seasons
Total No. Cases per year (@ 4.5 per child NUM*4.5 7,075,776 under five years of age, SE D&E) Total No. of days of Diarrhea days per year (NUM*4.5)*4 28,303,103 (@ mean 4 days per incident case)
Reduction in number of cases per year (NUM*4.5)*PREVENT 321,709Reduction in number of days of diarrhea ((NUM*4.5)*4)*PREVENT 1,286,838 per year
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United Nations Children’s Fund
The Story of a SuccessfulPublic-Private Partnershipin Central AmericaHandwashing for Diarrheal Disease Prevention
Authors
Camille Saadé
Massee Bateman
Diane B. Bendahmane
United Nations Children’s Fund
The
Sto
ry of a
Su
cc
essfu
l Pu
blic
-Priva
te P
artn
ersh
ip in
Ce
ntra
l Am
eric
a: H
an
dw
ash
ing
for D
iarrh
ea
l Dise
ase
Pre
ven
tion