Public-Private Partnerships: A Handwashing and Hygiene

Promotion Example

April 26, 2007Sara Abdoulayi, David Hostler,

Stacey Succop, and Sarah WilkinsENVR 890 003

Presentation Outline

• What is a public-private partnership?

• “Health in Your Hands” Handwashing Initiative

• Case studies from “Health in Your Hands”

• PPPs Problematic?

• Pros and cons of PPPs

• Recommendations and conclusions

What is a Public-Private Partnership?

• “…the combination of a public need with private capability and resources to create a market opportunity through which the public need is met and a profit is made.”

• According to the United Nations Development Program (UNDP), the broadest definition of a PPP includes agreement frameworks, traditional contracting, and joint ventures with shared ownership.

How does a public private partnership work?

• Public and private organizations work together to:

-determine a commonly-agreed upon goal for social benefit

-produce consumer research

-design and implement a promotional/educational campaign

-evaluate the campaign

Global handwashing partnership

• The World Bank and the Water and Sanitation Program $$

• Bank-Netherlands $$• USAID $$• London School of Hygiene and Tropical Medicine• Academy for Educational Development (AED)• UNICEF• CDC• Colgate-Palmolive• Proctor & Gamble• Unilever• National soap companies• National governments• NGOs

“Health in Your Hands”

• Global initiative for promoting handwashing and hygiene through public-private partnerships around the world

• Functioning for more than 5 years• Current projects in Ghana, Peru, Nepal• Project in Senegal is planned, but

delayed

“Health in Your Hands” Objectives

• To reduce the incidence of diarrheal disease, in particular among children under five, by making handwashing with soap at critical times universally recognized, promoted, and practiced.

• To implement large scale handwashing interventions and use lessons learned to promote the approach at the global level.

• Transparency among and equality of partners

Why partner to promote handwashing?

• Soap industry gains market expansion

• Public agencies benefit from the marketing expertise of the soap industry and thus have stronger capacity to relay health messages to target audiences via marketing campaign strategies

• Social responsibility

General Steps Followed by “Health in Your Hands”

• Catalyst initiates discussion (this can be an organization in the host country, an organization pursuing new projects, or a private company)

• Formation of a steering committee• Funds mobilization• Conduct handwashing behavioral study

(formative research)• Design communications strategy• Testing of communications strategy• Execution, monitoring, and evaluation

Case Study - Nepal

• Population: 28.9 million

• 1/3 below poverty line

• 75% subsistence farmers

• Remote and landlocked

• Civil strife• Susceptible to natural

disaster

Case Study – Nepal (2)

• 2003• Child mortality 91/1000 due to diarrheal

disease (DHS 2001)• 1 in 5 children suffer from diarrhea• More prone to diarrhea in households

with well-water source for drinking water

Case Study – Nepal (3)

• Public partners: UNICEF, World Bank, USAID/EHP

• Private partners: Nepal Lever Ltd., market leader (subsidiary of Unilever Inc.) and Aarti Soap and Chemicals, local company

Case Study – Nepal (4)

• Goal: To contribute to the reduction of diarrheal incidence through handwashing with soap at critical times and using correct techniques

• Objectives:• To generate awareness on importance of

handwashing with soap• Reach 5 million people, including 500,000

school children

Case Study – Nepal (5)

• Phase I: Consumer Baseline Survey• Phase II: Marketing Strategy

• Mass media advertising including posters, brochures, radio spots, and tv commercials

• Community-based outreach: female health volunteers, sanitation motivators, door-to-doorvisits, demonstrations in schools

• Phase III: Program Lauch (2004)• National Sanitation Action Week in May

2005

Case Study - Peru

• Population: 28.7 million

• 54% below poverty line• IMR 35/1,000

• Urban slum population• Remote rural

population

• Arid coastal region• Andes mountains• Tropical rainforest

Case Study – Peru (2)

• Need:• Diarrheal disease was the 3rd leading cause

of childhood disease

• Rationale:• Past efforts to improve water infrastructure

have not reduced diarrheal disease• Peruvian government expressed interest in

a PPP at World Bank Water Forum

Case Study – Peru (3)

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

Case Study – Peru (4)

• Drivers• Mothers are judged by their children’s

grooming and health• Dirt, feces, and germs are widely

understood to cause disease

• Obstacles• “Soap and water are limited resources.”• “I’m careful when I defecate.”• “Doing laundry counts.”

Case Study – Peru (5)

• Public partners• Peruvian Ministry of Health (lead agency)• USAID (funds for formative research)• JSDF (funds for developing communications)

• Private partners• Colgate-Palmolive (printed materials/soap)• Boga Comunicaciones SA (cable TV)• Radio Programmas Peru (local radio)

Case Study - Ghana

• Population: 22.9 million

• Skewed towards young

• IMR 53/1,000

• 60% subsistence farmers

• Large refugee population from Liberia, Togo, etc.

Case Study – Ghana (2)

• Need: 25 % of deaths are due to diarrheal disease in children under age 5; 9 million cases of dd per year, and rising.

• Partnership initiated by Ghanaian government agency- Community Water and Sanitation Agency (CWSA) in 2001

• Rationale: • Reduce infant morbidity and mortality with

the end goal of reducing poverty.• Compliments the rural H20 sector strategy:

H20, Sanitation, Hygiene

Case Study – Ghana (3)

• Lead Agency: CWSA- coordinator

• Public sector/World Bank: Ministries of Works & Housing, Women’s & Children’s Affairs, NCWSP II- World Bank- $$$Ministry of Health - local health servicesMinistry of Education: School Health Education Program

• Private sector: Unilever, PZ-Cussons, GETRADE, AGI-Provide technical assistance; in-kind.

• External Support Agencies:  UNICEF: Support to schools component.DANIDA: Support to schools component CIDA & WHO

Case Study – Ghana (4)

Drivers• HW after eating• HW after contact with public toilets.• Using soap to feel clean/ beautiful.  • Mothers prioritize their children’s health

Obstacles:• Children’s stools are not thought

dangerous• Soap is often kept hidden to prevent

misuse • Scented soaps- luxury items;

interfere with the taste of food

Case Study – Ghana (5)

Initiatives:

• Mass Media – aimed at mothers and school aged children

• Direct Consumer Contact- visits to 2 districts in each of the 6 regions- (health care facilities, schools) ….

• District Level Program (through schools, health centers and communities)

• Public Relations and Advocacy

Case Study – Ghana (6)

• Phase 1 carried out from September 2003 to August 2004

• August 2004 - Evaluation of media initiative looked successful

• Commercials re-aired in 2005 to reiterate message.

PPPs -Problematic?: Kerala (1)

Characteristics of Kerala as compared to rest of India:

• highest hygiene standards• lowest diarrheal deaths• highest awareness on prevention of diarrheal

diseases• lowest childhood mortality• highest female literacy.• highest access to safe water

SO WHY KERALA???

PPPs -Problematic?: Kerala (2)

Ethical Implications:

• Risk of privatization of traditional government responsibilities

• Destroying indigenous practices• Polluting environment with new

industrial products

Overall Pros of PPPs

• Financial and in-kind resources are contributed

• Local & international efforts are combined• Locals guide the development with expert

aid• Efforts are focused on a circumscribed

problem• Programs are compatible with the

population • Education is a durable good

Overall Cons of PPPs

• Selection of partners can be tricky• Conflicts of interest to ensure profit• Financial leverage affects decision-

making• Shifting of responsibilities from

governments• Sustainability is questionable• Ethical considerations• Bureaucracy

Recommendations

• Can PPPs be applied to capacity building and infrastructure strengthening?

• Ideals/values and grounds for rejecting partnership should be established before entering a PPP

• Third-party monitoring• Rigorous monitoring & evaluation

Conclusions

• “Health in Your Hands” has exhibited some success and evaluations continue

• Some keys to success include:• Partnership equality/transparency• Community involvement • Rigorous formative research• Comprehensive evaluation

• PPPs are a relatively new concept• PPPs have pros and cons and will

require more research to establish best practices

Example PPPs

• Health in Your Hands• Global Alliance for Vaccines and

Immunization• International AIDS Vaccine Initiative• Medicines for Malaria Venture• Global Alliance for TB Drug Development• Initiative on Public-Private Partnerships for

Health (database)• Public-Private Partnerships for the Urban

Environment (database)

References

• World Bank, 1994. World Development Report• Thomas A. Curtis V. Public-private partnerships for health; a review of

best practices in the health sector. July 2003• The global public-private partnership to promote handwashing with soap

[Online] [cited 2007 April 21]; Available from: URL:www.globalhandwashing.org

• Buse, K.; Waxman, A. “Public-Private Health Partnerships: A Strategy for WHO.” Bulletin of the World Health Organization. August 2001, 79 (8), 748-754.

• Roberts, M.J.; Breitenstein, A.G.; Roberts, C.S. “Chapter 4: The Ethics of Public-Private Partnerships.” Public-Private Partnerships for Public Health. April 2002, Harvard University Press, Boston, MA.

• Wheeler, C.; Berkley, S. “Initial Lessons from Public-Private Partnerships in Drug and Vaccine Development.” Bulletin of the World Health Organization. August 2001, 79 (8), 728-734.

• Widdus, R. “Public-Private Partnerships for Health: Their Main Targets, Their Diversity, and their Future Directions.” Bulletin of the World Health Organization. August 2001, 79 (8), 713-720.

• PRISMA. “Behavioral Study of Handwashing with Soap in Peri-urban and Rural Areas of Peru.” Joint Publication 11E. September 2004. 1-159.

• Shiva, V. "Saving lives or destroying lives? World Bank sells synthetic soap & cleanliness to Kerala: the land of health and hygiene”

• “PPPHW program: the story of Ghana.” Available at http://www.globalhandwashing.org/Country%20act/ghanapu.pdf.