Baseline Assessment
Transcripción
Baseline Assessment
Report Enabling Environment Assessment and Baseline for Scaling Up Handwashing Programs: Peru Michael Favin and Doris Alfaro Global Scaling Up Handwashing Project April 2008 This report is one in a series of products of the Water and Sanitation Program’s Scaling Up Handwashing Project funded by the Bill and Melinda Gates Foundation. The aim of the project is to test whether innovative promotional approaches can generate widespread and sustained increases in handwashing with soap at critical times among the poor and vulnerable. This series of reports documents the findings of work in progress about handwashing with soap in order to encourage the exchange of ideas and information and to promote learning. Please send your feedback to: [email protected] . The Water and Sanitation Program (WSP) is a multi-donor partnership of the World Bank. For more than 30 years, WSP has helped the poor gain sustained access to improved water supply and sanitation services (WSS). WSP works with governments at the local and national level in 25 countries. For more information, please visit: www.wsp.org . Credits Editorial Support: Hope Steele Production: Paula Carazo This report was reviewed by Rocio Florez, Lene Jensen, and Eduardo Perez. ABOUT THE AUTHORS Michael Favin Michael Favin has over 30 years of experience in international public health in more than 25 countries in Africa, Asia, and Latin America, and has worked periodically in environmental health since his time as a community organizer and health educator for the Peace Corps in Brazil in the early 1970s. Since joining the Manoff Group in 1987, he has served as a senior technical adviser or a consultant to numerous health and nutrition projects. For these projects and others, Mr. Favin facilitated behavior change and communication strategy design, planning, implementation, and evaluation. He has worked in many critical public health areas, including child health and nutrition, school health and nutrition, maternal and neonatal health, and environmental health and has supported innovative tool development in areas such as routine immunization, growth promotion, care-seeking, and community surveillance. Mr. Favin has written or contributed to more than 60 books, manuals and articles. Doris Alfaro Doris Alfaro is a communications specialist with 15 years of experience participating in and managing projects in the fields of hygiene promotion, behavioral change, social mobilization, and advocacy for local development as well as partnership building at the community level. She has coordinated, designed, and implemented communication plans for health and nutrition programs nationwide. She has been a communications consultant for the health sector in Peru, Latin America, and the Caribbean for projects in environmental and public health. She has worked with CEPIS-PAHO/WHO, PAHO, municipalities, and Ministries of Health as well as for NGOs such as CARE and PRISMA. The findings, interpretations, and conclusions expressed in this report are entirely those of the author. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations or those of the Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility whatsoever for any consequence of their use. The boundaries, colors, denominations and other information shown on any map in the document do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. ii Global Scaling Up Handwashing Project TABLE OF CONTENTS LIST OF ACRONYMS AND ABBREVIATIONS ………………………………………………………V SUMMARY........................................................................................................................................1 1. BACKGROUND..............................................................................................................................3 The Global Scaling Up Handwashing Project……………………………………………………..3 The Peru Handwashing Promotion Project………………………………………………………...4 Rationale for Enabling Environment Assessment …………………………………………………5 2. ASSESSMENT METHODOLOGY....................................................................................................6 Dimension Descriptions …………………………………………………………………………...6 The Assessment Process…………………………………………………………………………...7 Feedback on the Assessment Methodology………………………………………………………11 3. MAJOR FINDINGS BY DIMENSION.............................................................................................13 Policy, Strategy, and Direction…………………………………………………………………...13 Partnerships……………………………………………………………………………………….14 Institutional Arrangements………………………………………………………………………..18 Program Methodology……………………………………………………………………………19 Implementation Capacity…………………………………………………………………………20 Availability of Products and Tools……………………………………………………………….21 Financing………………………………………………………………………………………….21 Cost-Effective Implementation…………………………………………………………………...23 Monitoring and Evaluation……………………………………………………………………….23 4. RECOMMENDATIONS BY DIMENSION........................................................................................24 Policy, Strategy, and Direction…………………………………………………………………...24 Partnerships……………………………………………………………………………………….25 Institutional Arrangements………………………………………………………………………..27 Program Methodology……………………………………………………………………………29 Implementation Capacity…………………………………………………………………………29 Availability of Products and Tools……………………………………………………………….30 Financing………………………………………………………………………………………….31 Cost-Effective Implementation…………………………………………………………………...31 Monitoring and Evaluation……………………………………………………………………….32 5. NEXT STEPS...............................................................................................................................33 APPENDIX A: SELECTED DOCUMENTS.........................................................................................34 APPENDIX B: LISTA DE ENTREVISTADOS......................................................................................36 APPENDIX C: RESUMEN DE PUNTOS IMPORTANTES DE LAS ENTREVISTAS..................................42 APPENDIX D: ENCUESTA SOBRE LAS CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN: 10 RESPUESTAS.............................................................................................61 APPENDIX E: LAS CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN. GUÍA DE ENTREVISTA ....................................................................................................................69 APPENDIX F: ESTUDIO DE CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN (GUÍA DE ENTREVISTA PARA SOCIOS POTENCIALES) ........................................................75 iii Global Scaling Up Handwashing Project APPENDIX G: INFORME DE VIAJE A PIURA...................................................................................83 APPENDIX H: CONDICIONES PARA LA PROMOCIÓN DE LAVADO DE MANOS ................................88 APPENDIX I: SUMMARY OF MAJOR FINDINGS AND RECOMMENDATIONS BY DIMENSION.........93 APPENDIX J: MENÚ DE ACTIVIDADES PARA ALUMNOS (IDEAS PRELIMINARES)..........................97 APPENDIX K: MENÚ DE ACTIVIDADES PARA PROMOTORES DE SALUD (IDEAS PRELIMINARES).99 APPENDIX L: ACTION PLAN TO IMPROVE THE ENVIRONMENT FOR AN EXPANDED HANDWASHING PROJECT IN PERU..............................................................................................101 LIST OF FIGURES Figure 1. Partner Contributions to Interpersonal Communications……………………………...16 Figure 2. Partner Contributions to Mass Media………………………………………………….17 LIST OF TABLES Table 1. Handwashing Targets by Country……………………………………………………….4 Table 2. The Public-Private Partnership for Handwashing in Peru……………………………….4 Table 3. Dimension Addressed by Stakeholder Type …………………………………………….8 Table 4. Persons Interviewed by Organization Type…………………………………………….10 Table 5. Self-Reporting Questionnaire Responses by Organization Type………………………10 Table 6. Calendar of Assessment Team Activities, May–June, 2007…………………………...11 Table 7. Committee Participants…………………………………………………………………27 iv Global Scaling Up Handwashing Project List of Acronyms and Abbreviations CBO COSUDE DIRESA DREA FBO HWWS M&E MIMDES MOE MOH MOU NGO PAC/SEDAPAL PPPHW PRONASAR UGEL USAID WSP Community-based organization Swiss aid organization Regional health directorate Regional education directorate Faith-based organization Handwashing with soap Monitoring and evaluation Ministry of Women and Social Development Ministry of Education Ministry of Health Memorandum of understanding Nongovernmental organization Program in Lima to install/improve small water systems Public-Private Partnership for Handwashing National program to install/improve small water systems (Ministry of Housing) Local educational management unit U.S. Agency for International Development Water and Sanitation Program v Global Scaling Up Handwashing Project SUMMARY To follow up country work supported by the Public-Private Partnership for Handwashing, the World Bank Water and Sanitation Program (WSP) received funding from the Bill & Melinda Gates Foundation to support projects to scale up the promotion of handwashing with soap (HWWS) in Peru, Senegal, Tanzania, and Vietnam. The major project objectives of the Handwashing Initiative are: • • • inculcate the HWWS habit among millions of mothers and children in these countries, use a strong monitoring and evaluation (M&E) component to enhance the conceptualizing and management of such programs, establish sustainable programs that will continue and expand after this four-year grant ends. Enabling environment assessments were carried out in all four countries to assess current conditions for scalability and sustainability and to make recommendations for improving conditions that are not supportive. This report summarizes the study in Peru, which was carried out by an international and a national consultant during three and a half weeks in May 2007. All four county studies are following a similar methodology, developed by WSP, to examine nine dimensions of scalability/sustainability through individual and group in-depth interviews, an electronic survey in which respondents are asked to score various statements, and a review of documents (Appendix A). A partnership of many public and private organizations has supported handwashing promotion in Peru since 2002, achieving impressive results in advocacy, partnership development, tool development, and many other areas. The Initiative supported partnership formation, mass media, and capacity building for on-the-ground promotion in 14 of Peru’s 24 regions. Evaluation of actual impact on knowledge, attitudes, and practice regarding HWWS shows some positive and some inconclusive findings. However, the study team feels that much excellent groundwork for the expanded program in Peru has been solidly laid by efforts to date and that, in combination with strong 1 Global Scaling Up Handwashing Project political will from the national government and a certain level of guaranteed funding, the outlook for effective expansion is very good. Nonetheless, the team has a number of suggestions, many of which expand ideas suggested by persons interviewed. Some of the key recommendations are the following: • • • • • • Plan and implement a dynamic advocacy strategy that begins immediately and that continues throughout implementation. Plan and implement a strong project communication strategy directed primarily to partners but also to decision makers at various levels and to the public. Materials, formats, and activities should be directly related to reaching one of the strategy’s objectives (for example, partner motivation, sharing good ideas) and audiences, which should be clearly defined. Develop and implement an exit strategy that includes steps for dissemination and sustainability of program activities and achievements. Continue to negotiate and sign more formal agreements on partners’ roles and responsibilities and develop systematic mechanisms to monitor the implementation of the agreements. Have the key national-level partners, including the implementing organizations (which will be contracted to manage local implementation), dedicate themselves to establishing the conditions and providing the tools and support for successful local implementation. In this decentralized vision, the team expects that key factors for program success will be strong and dedicated partnerships at local levels, with effective tools, methodologies, and support from the national level. Greater attention should be given to carrying out thorough regional, provincial, and district assessments of organizations, potential champions, resources, programs, and conditions and to establishing and encouraging strong local partnerships. The assessment methodology, findings, and recommendations are documented in this report and its many appendixes (a number of which are in Spanish). 2 Global Scaling Up Handwashing Project 1. BACKGROUND Funded by the Bill & Melinda Gates Foundation, the WSP Global Scaling Up Handwashing Project will follow the basic approach of the Public-Private Partnership for Handwashing (PPPHW), a global initiative established in 2001 to promote handwashing with soap at scale to reduce diarrheal and respiratory infections. 1 This approach draws extensively on lessons learned from two large-scale handwashing promotion programs. Programma Saniya, implemented in Bobo-Dioulasso, Burkina Faso, showed the importance of undertaking careful consumer research at the outset of a handwashing promotion program. The Central American Handwashing for Diarrheal Disease Prevention Program showed that an effective approach to changing hygiene behaviors at large scale was to work with a broad partnership of public and private sector stakeholders that have a mutual interest in increasing handwashing with soap, to focus on the one behavior with largest potential health impact (handwashing with soap), and to promote it with cost-effective, consumer-centered marketing. The Scaling Up Handwashing Project In hopes of facilitating effective replication and scaling-up of future handwashing-with-soap behavior change programs, the new project will carry out a structured learning and dissemination process to develop and share evidence, practical knowledge, and tools. Specific project objectives are to: 1. design and support the implementation of innovative, large-scale, sustainable handwashing programs in four diverse countries (Peru, Senegal, Tanzania, and Vietnam); 2. document and learn about the impact and sustainability of innovative, large-scale handwashing programs; 3. learn about the most effective and sustainable approaches to triggering, scaling-up, and sustaining handwashing behaviors; 4. promote and enable the adoption of effective handwashing programs in other countries and position handwashing as a global public health priority through the translation of results and lessons learned into effective advocacy and applied knowledge and communication products. The project is designed to achieve key targets in each country at the end of two years of implementation. The specific handwashing targets for each country are in Table 1. The target audience is defined as poor women of childbearing age (15–49) and poor children ages 5–9. 1 Global PPPHW partners include the Water and Sanitation Program, USAID, World Bank, UNICEF, London School of Hygiene and Tropical Medicine, Centers for Disease Control, Academy for Educational Development, Water Supply and Sanitation Collaborative Council, Colgate-Palmolive, Procter & Gamble, and Unilever. 3 Global Scaling Up Handwashing Project Table 1. Handwashing Targets by Country Country (population) Target population (millions) Estimate target population adopting HWWS at critical times Peru (28 million) 5.10 1.30 Senegal (11 million) 1.97 0.49 Tanzania (37 million) 5.20 1.30 Vietnam (84 million) 9.20 2.30 Source: World Bank (Water and Sanitation Program). 2007. “Terms of Reference. Enabling Environment Assessment and Baseline to Scale up, Sustain and Replicate Handwashing with Soap Behavior Change Programs.” March 9. The Peru Handwashing Promotion Project As in many countries, diarrhea and respiratory diseases are the leading causes of childhood illness and death in Peru, and malnutrition is a major underlying cause of child mortality. Handwashing with soap can significantly reduce all of these major causes of misery. Attention to hygiene and handwashing got a significant boost in Peru in the 1990s because of the cholera epidemic, but as shown by the Handwashing Initiative’s 2004 baseline, practice levels were still woefully low: 11 percent of mothers and 6 percent of children washed hands with soap before eating, and 17.6 percent of mothers and 12 percent of children after going to the bathroom.2 The public-private partnership for handwashing developed in Peru over several years, as summarized in Table 2. Table 2. The Public-Private Partnership for Handwashing in Peru Year Activity 2003 Advocacy, handwashing practices study, development of a business plan 2004 Efforts to secure funding, funding commitments from the Japanese Fund, USAID, WSP (the Water and Sanitation Program), and COSUDE (Swiss aid) 2005 Selection of communication agencies, design of project strategy and work plan, first campaign and training workshops, monitoring activities, commitment of private sector funds 2006 Training workshops and promotional activities, monitoring, financial management, international advocacy, launching of second campaign, effort to establish local alliances, process evaluation, design of impact evaluation 2007 Financing from the Bill & Melinda Gates Foundation secured, local alliances strengthened, school program, mass media campaign, monitoring and evaluation Source: Flórez P., Rocío. “Iniciativa de Lavado de Manos en el Perú.” 17 de Octubre, 2006 (PPT). 2 AB PRISMA. Estudio de comportamiento de lavador de manos con jabón en zonas periféricas del Perú. Preparado como línea de base para la Iniciativa de Lavado de Manos en el Perú, liderado por PAS-Banco Mundial. Junio 2004. 4 Global Scaling Up Handwashing Project The Peruvian program implemented activities at the national level and developed partnerships and activities in 14 of Peru’s 24 regions. Preliminary monitoring and evaluation showed mixed but promising improvements in knowledge, attitudes, and practices, particularly in handwashing before eating and preparing food. Fostering partnerships at the national, regional, and local levels has been a key project strategy. Although this has been difficult and demanding at times, it has also been a major reason for progress. Both interpersonal communication (in schools and communities) and mass media (mostly print and radio) made important contributions to changing knowledge, attitudes, and practices. M&E studies (these and other references are listed in Appendix A) indicate that all of the communication channels used (mass media broadcasts, print materials, training teachers and students, and training health staff and volunteers) contributed to reaching the target families, and that no one channel predominated. Rationale for Enabling Environment Assessment In each participating country, an Enabling Environment Assessment is being carried out to (1) assess the extent to which the programmatic conditions for scale up and sustainability are in place at the beginning of the project; and (2) on the basis of the assessment findings, recommend what should be done to address the gaps during project implementation. Toward the end of the project period—in about 3.5 years—a final assessment will be carried out to determine whether there is an enabling environment in place in each country that can continue after 2010 without the Gates Foundation/World Bank project assistance. The overall handwashing project is four years in duration with three distinct phases: • • • Phase I is the 1.5-year start-up period for detailed planning at the global and country level. Several assessments, including a handwashing measures study and the baseline for the impact evaluation, will be carried out during this period. The baseline assessment of enabling elements will be carried out during Phase I. Phase II is the 2-year implementation period. Phase III is the 6-month wrap-up phase that will include the final evaluation and dissemination of lessons learned. The final enabling environment assessment will take place during Phase III. 5 Global Scaling Up Handwashing Project 2. ASSESSMENT METHODOLOGY In other to ensure consistency in the assessment findings, WSP constructed a conceptual framework for assessing scalability and sustainability. This framework was developed based on a review of relevant literature and discussions with key individuals. Dimension Descriptions The framework comprises nine dimensions that are considered essential to scaling up a handwashing-with-soap behavior change program. Policy, Strategy, and Direction: Establishing a shared vision and strategy and ensuring the political will to implement them is the starting point for scale up. Without political will and a shared vision and strategy among stakeholders at all levels, scale up will remain an elusive goal. Developing this shared vision and strategy in a collaborative manner is also the foundation for coordination and for creating motivation all levels. Partnerships: This handwashing-with-soap program model is based on a establishing a publicprivate partnership. A partnership is a relationship where two or more parties, having compatible goals, form an agreement to share the work, share the risk, share the power, and share the results or proceeds. Partnerships need to be built at all levels among public, private, and NGO sectors and between communities and local governments. Institutional Arrangements: Institutions at all levels must clearly understand their roles, responsibilities, and authority. They must also have the resources to carry out their roles. In addition to clear roles and responsibilities, institutional arrangements must include the mechanisms for actors at all levels to coordinate their activities. Program Methodology: Handwashing-with-soap programs have a seven-step program methodology. This methodology, adapted to each country context, should be clear and agreed upon by all key stakeholders. Implementation Capacity: In addition to clearly defined institutional roles and responsibilities, institutions at all levels must have the capacity to carry out their roles and responsibilities. Institutional capacity includes adequate human resources with the full range of skills required to carry out their functions; an “organizational home” within the institution that has the assigned responsibility; mastery of the agreed-upon program methodology, systems, and procedures required for implementation; and the ability to monitor program effectiveness and make adjustments. Availability of Products and Tools: A handwashing-with-soap behavior-change program is predicated on the existence of the soap that responds to consumer preferences and their willingness and ability to pay for them. In addition, handwashing station supplies—that is, plastic basins, towels, and so on—need to be easily available. Financing: This dimension is aimed at assessing the adequacy of arrangements for financing the programmatic costs. These costs include training, staff salaries, transportation, office equipment and supplies, and the development of communication and educational materials as well as programmatic line items in budgets for handwashing-promotion activities. Cost-Effective Implementation: The potentially high costs of promoting handwashing-withsoap behavior at scale make cost-effective implementation a key element. It is essential to understand how the unit costs change as activities are scaled up. Although it will not be possible to assess the cost-effectiveness of the approach and how best to achieve economies of scale until 6 Global Scaling Up Handwashing Project the end of the project, data must still be collected during implementation to make this determination at the end of the project. Therefore, this assessment will try to ensure that information will be collected from the outset and that the capacity to collect the information is in place. Monitoring and Evaluation: A large-scale handwashing-with-soap behavior-change program requires regular monitoring and, perhaps more importantly, the willingness and ability to use the monitoring process to make adjustments in the program. Effective monitoring will identify strengths and weaknesses in the program methodology, implementation arrangements, and cost efficiencies. Overall monitoring responsibility must be at the highest level of the program, but must be based on information collected at the local government or district level. The Assessment Process The primary data sources comprised the main stakeholders/present partners for the in-country program work, including government agencies, international agencies, international NGOs, local NGOs, private sector organizations, and community-based organizations (CBOs) at national, regional, district, and local levels. In Peru, all members of the National Committee were sought for interviews, as well as other partners at the national level and local partners in two of the country’s 24 regions. Piura was visited as an “old” region that had participated in the Handwashing Initiative, and Arequipa as a new region that will be included in the expanded program. In the expanded program, the number of participating regions will increase to approximately 20, depending on the requirements of the M&E plan. Secondary data sources comprised documents and additional potential implementers, such as media and ministries with no direct involvement to date. Appendix A lists the main documents consulted. Table 3 indicates the type of stakeholders interviewed on various dimensions. 7 Global Scaling Up Handwashing Project Table 3. Dimension Addressed by Stakeholder Type Stakeholder Type Media X L X – – X X Partnerships X X X X X L X X X Institutional Arrangements X X X X – L X X X Program Methodology X X X X X L – X – Implementation Capacity N,D – X X X L – – – Availability of Products & Tools – – X X X L – – – Financing X – X – – L – – – Cost-Effective Implementation N,D – X – – – – – – Monitoring N,D, L – X – X L – – – Bilateral projects CBOs X Advocacy groups International NGOs & FBOs X Private Sector International agencies Policy, Strategy, Direction Local NGOs & FBOs Government agencies Dimension Note: Unless otherwise noted, an X means that it is appropriate to discuss this dimension at all levels: national, regional, district, and local; — indicates that this stakeholder type was not questioned on this dimension; N = national, R = regional, D = district, L = local. In addition to reviewing documents on the program, both interviews and self-reporting were used to solicit individuals’ knowledge and opinions. Self-reporting consisted of responding to a grading-scale questionnaire that was e-mailed to approximately 35 potential respondents, some of whom were identified at the end of the interviews with the primary informants. Self-reports allowed the triangulation of information as well as some quantitative analysis that can be easily compared to findings of the repeat of the assessment planned to take place near the end of the implementation phase. Sampling was purposive for all primary data sources. The team strived to interview persons who had participated in the handwashing program for at least six months. They also sought a good representation of decision makers, implementers, and midline supervisors/managers from different levels of organizations involved in the program—that is, national, regional, district, and local (as indicated needed on the interview matrix of Table 3). Targets for the minimum sample size were: • • • one interview and/or self-report (electronic questionnaire) with each current partnering stakeholder at any level three interviews in each dimension two self-reports in each dimension 8 Global Scaling Up Handwashing Project • • • • • two interview sets with two different present partnering agencies, within each of these two organizations, one of each work type one self-report set with two different present partnering agencies, within each of these two organizations, one of each work type two interview sets with two different present partnering agencies with one representative for each level at three levels minimum—that is, national, district, local one self-report set with two different present partnering agencies with one representative for each level at three levels minimum—that is, national, district, local three interviews with three potential partnering organizations (if appropriate). The team conducted 35 interviews in different organizations (Appendix B). The persons interviewed were from the organizations listed in Table 4. 9 Global Scaling Up Handwashing Project Table 4. Persons Interviewed by Organization Type Types of organizations Persons interviewed Government agency 9 Bilateral project 3 Media company 3 Local NGO 4 Private sector 3 International agency 8 International NGO 5 TOTAL 35 Self-reporting questionnaires were sent to representatives of different institutions linked to the Handwashing Initiative, including some from the same institutions where the team interviewed. Table 5 shows the types of organizations that provided the 10 completed questionnaires. Table 5. Self-Reporting Questionnaire Responses by Organization Type Types of organizations Persons responding Government agency 2 Bilateral project 3 Media company 0 Local NGO 1 Private sector 2 International agency 1 International NGO 0 Consultant 1 TOTAL 10 The team carried out a qualitative analysis of the interviews, first by summarizing all respondents’ positive and negative comments by type of organization and dimension and also listing the respondents’ corresponding recommendations. Appendix C documents this step in the process. The team used many, but not all, of the respondents’ recommendations to develop its own recommendations. The major recommendations were then placed in an Action Plan, as required by the team’s terms of reference. The team also did a quantitative analysis of the 10 self-reports received (see Appendix D) but did not attempt a further breakdown by stakeholder type because of the relatively small number of responses. 10 Global Scaling Up Handwashing Project The assessment team was comprised of one international consultant and one local consultant who worked together during the final 3.5 weeks of May 2007. Table 6 summarizes their activities in Peru. Table 6. Calendar of Assessment Team Activities, May–June, 2007 Date Peru In-Country Activities May 8–11 Met with country team manager (CTM) to plan the activity Reviewed the stakeholder list and developed the interview list Scheduled interviews Organized logistics Modified and translated instruments Sent out self-report questionnaires by e-mail Began interviews May 14– June 1 Conducted interviews (in Lima, Piura, Arequipa) Summarized responses Received and tabulated self-reported questionnaires Drafted findings, recommendations, action plan June 4–30 Prepared and gave debriefing to global WSP team and Peru program coordinator Read additional documents Debriefed for global WSP and drafted this assessment report Feedback on the Assessment Methodology The team had to make some adjustments to the general assessment methodology proposed for all four countries, starting with translating all instruments into Spanish. In addition, they found that the standard interview questionnaire contained many single questions that contained multiple issues, so they separated these out. The first few interviews showed that there were too many questions to ask knowledgeable respondents and that there was some redundancy in questions under the different dimensions. The team therefore prepared a shortened version of the interview guide to try to address these concerns. Also, the team was unsure about the degree to which it should seek information from regions that had already participated in the program compared with areas where the program would expand. In the end they visited one region of each type, but they had to prepare another version of the question guide for the new region. (Appendixes D and E contains these question guides in Spanish. Appendixes F and G contain summaries of the visits to Piura and Arequipa.) The persons interviewed varied tremendously by level and nature of their involvement in the program. Although the methodology anticipated some of this challenge, the interviewers still had to make on-the-spot decisions on which questions were relevant to the particular respondent and 11 Global Scaling Up Handwashing Project whether the respondent should focus on the past or the future of handwashing promotion activities. Many of the respondents of the self-reported questionnaires participated in the Initiative as locallevel implementers or supervisors, so they were really not in a good position to comment on some of the broader program questions. Nonetheless, there was a fairly strong congruence in scores for the different questions, which gives some confidence regarding general opinions. Since it is planned that this assessment will be repeated near the end of the expansion phase, the team would recommend that different versions of the question guides be prepared for representatives of key national partners, key regional partners, local implementers, and national organizations that implemented promotional activities within their own organizations. 12 Global Scaling Up Handwashing Project 3. MAJOR FINDINGS BY DIMENSION Based on documents, interviews and questionnaires, the team prepared a summary of findings and recommendations in table format (see Appendix I). This section presents a narrative of key findings. Policy, Strategy, and Direction • • • • • • • The National Committee served as a key venue for manifesting high-level national commitment to promotion of HWWS. Government and other organization officials have a strong, positive political will toward handwashing promotion and child health, although some government officials find it hard to give these areas special attention because of so many other priorities. The current national administration has embraced the Initiative and seems well disposed to collaborate. Key partners feel that they understand the approach used in the first phase and feel ownership, but they do not yet have a good understanding of the expanded project (which is still being designed). There are several politically prominent national initiatives (regarding malnutrition, healthy schools, and water and sanitation) that offer natural links with handwashing. Although the Ministry of Health (MOH) signed a ministerial decree in 2004 in support of the Handwashing Initiative, its enthusiasm has waxed and waned with frequent changes of officials; current officials appear to be quite supportive. At the beginning of the Initiative, national Ministry of Education (MOE) involvement was minimal, but now the MOE is actively engaged. There appears to be a strong and positive attitude toward the promotion of handwashing and an appreciation of its link to child health, in part due to the country’s experience with handwashing as an effective way to control cholera. This common perception of handwashing promotion as a key action for improving child health is a major factor favoring program expansion. The current national government has made a public commitment to improving health and education, and in turn to supporting several specific programs to which HWWS can directly contribute. The handwashing program has been successful in promoting the concept that the Initiative is a true partnership of many organizations and not a program of, for example, the World Bank or the MOH alone. There has been a shared vision of the partnership that transcends any particular member, which was no doubt fostered by the National Committee (in particular), as well as the consultative committee and communication committee. At the same time, the interviews strongly indicated the need to strengthen dissemination of results and to maintain clarity regarding roles in the partnership and to nurture partners’ sense of active participation. Important steps have been taken toward institutionalization, but much work remains to be done. The Initiative first focused on identifying and engaging with partners to form a public-private alliance, conducting a study on handwashing practices, and designing a business plan. The MOH issued Ministerial Resolution No. 062-2004 in support of the Handwashing Initiative, and in 2005 the ministry assumed a stronger leadership role with the initiation of the communication activities, providing some resources and a resolution in support of a national program of information dissemination. The MOH also established a sectoral committee comprised of key ministry offices, but its function was limited to receiving information, and it did not evolve into making proposals to strengthen the institutionalization of the Initiative. 13 Global Scaling Up Handwashing Project In some of the regions, there has been progress in institutionalizing handwashing activities into public and private institutions’ work plans (for example, Lambayeque and Ica) and into training curricula (in Cusco, for teachers). Continuing to encourage such steps is a key to sustainability of the Initiative. Although before 2006, the MOE was not linked to the Initiative, MOE offices in various regions, provinces, and districts were active partners, taking advantage of the Initiative’s communication tools and using the training modules with children in their classrooms. Today the MOE is actively engaged in planning for the expanded phase, and it will include handwashing in schools as part of its national Social Mobilization Program. For this purpose, it has assessed and pretested the Initiative’s school materials. The current national MOE support should facilitate strong involvement of local MOE offices. There is good political will at the regional level also, but not as strong or cohesive as the political will at the central level. The regional and provincial levels are in a transition to decentralization, in which authorities are uncertain about their functions, roles, and resources. Local decision making and regional organizations working together on a common objective are new ways of working, and local governmental units are in the process of trying to establish their regional priorities from among a plethora of needs. The regional governments are working on their development plans and documents on regional health priorities. The Initiative and its partners should work to make improving child health and reducing diarrheal diseases prominent in these plans. At all levels, there are additional avenues for the expansion and sustainability of the project by linking it with current national political initiatives such as Reduction of Infant Malnutrition, Healthy Schools, and Water for Everyone, which do or could incorporate handwashing promotion. Despite this positive situation, converting political will into program actions remains a challenge because, as various persons interviewed noted, it is difficult to give special attention to one particular theme such as handwashing because there are so many other public sector priorities. Decrees published by government agencies at national, regional, and local levels are very important since they represent the main door leading to public funding of activities. They also define a period of time in which the strategy and activities will be implemented. So, as several respondents pointed out, although a decree does not guarantee further action (rules, regulations, and activities in work plans and in the field), without them there is no public spending. Following the MOH decree in 2004, the ministry financed a one-month handwashing campaign and direct consumer contact (local promotional events) in 24 regions in 2006. Partnerships • • • In general this has been a successful and innovative aspect of the program, in particular with private sector partners. Public and private organizations have generally worked well together, but not without some minor friction. Private partners sometimes become impatient because the public sector tends to be more formal and bureaucratic and to have more changes in personnel. Some local public officials consider private organizations to be too interested in receiving individual credit. Keeping key government ministries (particularly health, education, and housing) involved is essential, even though this can be difficult at times because of political changes and overburdened officials who are too busy to participate in meetings. 14 Global Scaling Up Handwashing Project • Different partners have played very different roles, from being fully engaged as a member of the national coordinating committee to providing short-term messages on handwashing and co-financing and/or managing local activities. This is fine as long as expectations are clear. The Initiative engaged with diverse organizations and persons, including regional and municipal governments, communication media, and health and education offices and organizations. Many partner organizations were able to insert handwashing promotion into existing strong and efficient networks. In general, the organizational partners were of three types: (1) WSP, donor organizations, and governmental organizations that managed the program (through the national committee); (2) national-level implementation partners—from various types of organizations (public and private), most of which collaborated on the basis of informal agreements and some on the basis of memoranda of understanding or contracts; and (3) regional and local implementing partners, also both public and private, and some with financial or material support from the Initiative. The different roles of partners at the national level that the team identified include: • • • • • • providing funding (for example, the Japan Social Development Fund) providing funding and participating in planning and management of the Initiative (for example, COSUDE, USAID) providing funding and participating in planning, management, and national implementation (for example, the MOH and the MOE, more recently) implementing communication activities directed to their personnel and customers (for example, Belcorp, CARE) carrying out M&E activities and playing a major role in preparing training and trainers (as, for example, PRISMA, which worked under contract) supporting a specific activity, such as dissemination or printing, based on its resources (for example, Banco de Crédito, Transportes Ormeño). At the regional level, the Initiative established strong relationships with various types of organizations, usually via the Regional Health Directorates (DIRESA), that made various contributions. Some examples are: • • • • providing funds and participating in the planning and management of the Initiative (for example, the Regional Government of Lambayeque) providing funds and participating in local planning, management, and implementation (for example, the DIRESA, Regional Education Directorate [DREA], or MOE’s Local Educational Management Unit [UGEL]) implementing communication activities directed to their staff and beneficiaries (for example, local NGO offices) getting involved in a specific activity (for example, dissemination or printing) appropriate to its resources (for example, Radio PROMUDEH in San Martín). Figures 1 and 2 show organizations that have done person-to-person promotion and mass media promotion. 15 Global Scaling Up Handwashing Project Figure 1. Partner Contributions to Interpersonal Communications PUERTA A PUERTA Socios Actividad / Impacto MINSA Promoción de la Salud PAC SEDAPAL Ampliación de cobertura AGAP Asociación de Agricultores Programa Mi Barrio CARE Desarrollo público local Belcorp Programa Promoción de la Salud Venta de cosméticos Peace Corps Voluntarios Prisma ONG Talleres Talleres itinerantes Talleres y réplicas Scouts Actividades de Scouts + + + + + + + + Source: Flórez P., Rocío. “Iniciativa de Lavado de Manos en el Perú.” 17 de Octubre, 2006 [PPT] 16 Global Scaling Up Handwashing Project Figure 2. Partner Contributions to Mass Media MEDIOS MASIVOS Socios RPP Actividad / Impacto Serie Radial, avisos Banco de Crédito Circuitos interno de TV220 agencias Luz del Sur Aviso en recibo de electricidad Avisos en periódicos de circulación nacional Expreso Extra Ormeño Circuito de TV en buses Interbank Circuito interno de TV, 40 agencias Terra Avisos en página Web Radios y TV Local 25 regiones SEDAPAL Aviso en recibo de agua Source: Flórez P., Rocío. “Iniciativa de Lavado de Manos en el Perú.” 17 de Octubre, 2006 [PPT]. The process of participating in such a public-private partnership has allowed government and company staff to learn about other ways of working together for public health, in a participatory way, with support that they could offer with their own resources. The public institutions, the companies, and the NGOs interviewed indicated their interest in continuing their involvement. In the case of NGOs, officials are pleased to collaborate to the extent that their goals and funding address reducing diarrhea and respiratory disease among children. At the central level, the Initiative worked to achieve financing from the Ministry of Women and Social Development (MIMDES) for disseminating broadcast materials in the Clean Hands, Healthy Kids campaign, 15 times a day, mostly in the preferred early morning hours. This dissemination included four regions where the project was active: Ayacucho, Cusco, Lambayeque, and San Martín. In Ayacucho, the Regional Health Council stimulated the formation of a regional Handwashing Initiative by establishing an implementation committee in which the MOH and DIRESA joined the regional government to prepare guidelines for health programs and projects. The objective of the committee is to safeguard the logic and consistency in the implementation of all health programs in the region. The local partners achieved the collaboration of the army for the temporary storage of training materials. In Cusco, the provincial municipality of Canchis participated in inter-institutional agreements with the UGELs of the Ministry of Education of Cusco and Canchis to train local trainers and health promoters. 17 Global Scaling Up Handwashing Project In Lambayeque, the regional government took the initiative to engage other partners, including the DIRESA. In San Martín, a partnership between communications media and the water company was established to support health communication. Many respondents praised the Initiative’s innovative and generally successful partnership of public and private organizations, particularly in regard to support from the private sector. Although all types of partners generally worked well together, some respondents did note that the public sector tended to be more formal and bureaucratic and to have frequent changes of personnel, which delayed approvals of actions and materials. In general, private sector partners are more flexible, comfortable with informal arrangements, and able to act more rapidly. Most private sector companies have had a more focused participation in specific promotional activities and have not been involved in overall planning or management. Private voluntary organizations, particularly at the local level, generally integrated handwashing promotion and/or activities and materials into their existing programs. Most private companies that collaborated in the first phase do not appear to have been motivated by a desire to expand their sales of soap (there was only one company that was a major soap vendor) or other handwashing products. Most collaborating companies have established units for supporting socially beneficial programs—no doubt motivated by both altruism and a desire to maintain a public image of social responsibility. Institutional Arrangements • • Many respondents felt that arrangements have been informal yet have worked well based on the basis of personal relations, particularly for NGOs and private organizations. Arrangements with governmental organizations were more formal: the MOH issued a ministerial decree in 2004, and some regional governments approved ordinances. Beginning in 2006, the Initiative made an effort to sign MOUs with national and local partners. The public sector has a strong need to formalize its relationships and commitments. The MOH did this by issuing a formal ministerial regulation that promoted the Initiative within the MOH and another decree that established an internal sectorial committee charged with coordinating implementation responsibility among the various offices and programs of the MOH. However, interviewees made two common points: (1) that with decentralization, national agreements would not necessarily translate to the regional level and below; and (2) that although formal agreements with government organizations were definitely desirable, they were also insufficient to ensure that the commitments would yield actions and funding in the field. The issuance of ministerial resolutions and directives contribute to the sustainability of handwashing-promotion activities by helping to orient work to a theme, but these resolutions and directives still need to be reflected in work plans, budgets, institutional directives, and actual activities. Initially, informal relations seemed to work quite well for private sector partners and some NGOs, but since 2006 the Initiative has negotiated and signed more formal agreements with public and private partners, a trend that most respondents feel is desirable. For example, there are letter agreements with such groups as Ecoclubes Perú, Asociación de Gremios Agroexportadores del Perú (AGAP), the regional government of Ica, Caritas Piura y Tumbes, Municipality of Surco, and Asociación Civil Pro Ica. More formal agreements are likely to facilitate the sustainability of organizational commitment, so it seems wise for the Initiative to try to make informal agreements more formal over time, appropriate to various organizations’ roles. 18 Global Scaling Up Handwashing Project At the regional level, governmental units, including municipal governments, require a formalized participation. Although NGOs and private organizations are willing to be flexible, a move toward more formality and the generation of agreements to govern joint work does facilitate program implementation as well as sustainability. Program Methodology • • • In general, opinions were positive; people felt that combining diverse partners’ strengths produced an effective approach. Some respondents mentioned the need to focus more on interpersonal communication, while media representatives felt that mass media could play a larger role. Many of the persons interviewed pointed out that it has been easier to generate enthusiasm and behavior change among children than among mothers, particularly in rural areas. The Peruvian program has followed the general PPPHW methodology. Findings from formative research formed the basis of a work plan for promoting behavior change. The Peruvian program relies strongly on a participatory training methodology that uses games and activities to build the capacity of change agents (teachers, health staff, and volunteers) and gives them motivations, resources, and information to influence mothers. Interpersonal communication is supported by print materials and complemented by mass media communication. The project managed the design, production, pretesting, and dissemination of all these communication materials. Opinions on the project methodology are quite positive. Most people appreciate the need for diverse communication channels to effectively carry information and motivations. A few interviewees believe that the Initiative has been implemented too much like a short-term campaign and had insufficient supervision and follow-up. The team’s impression is that this was certainly not the general situation, although it did happen in specific locations. Short campaigns, centered on brief public events, are indeed popular in Peru. The strength of supervision and follow-up seemed to depend very much on the normal working methods and resources of the local partner. In some cases this happened; in others it did not. Regarding work at the regional and district levels, various respondents emphasized the need for strong interpersonal communication in order to achieve behavior change. They view mass media as an important but supportive channel for sensitizing people and reinforcing information given person to person. Many respondents recommended that in the expanded program, the field staff of local partner organizations include interpersonal promotion of handwashing in the programs and plans; that is, that institutionalization goes beyond formal acknowledgment in program norms and general guidelines. This refers to the MOH at all levels, to the MOE, to the networks of women’s organizations, NGOs, and others. Some international public health specialists question the feasibility of interpersonal communication on a large scale, but in the opinion of the interviewees and the team, this component can be affordable and feasible as long as the Initiative: • • • stimulates the formation of strong local partnerships (of popularly respected organizations that manage cadres of change agents), provides strong training guidance and tools as well as job aids, contracts with implementing agencies for training teachers and health personnel and for post-training follow-up, and 19 Global Scaling Up Handwashing Project • encourages the MOH and the MOE to award certificates to change agents who satisfactorily complete training on handwashing promotion and who carry out actual counseling on HWWS in their communities and schools. Respondents judge the behavior-change methodology used to have been more effective with schoolchildren than with mothers. It would be interesting in the second phase to see if this impression is valid and, if so, why. (According to the monitoring study, 90 percent of school children talked with their families about handwashing after having sessions in school.) The November 2006 evaluation study found the impact of project activities on actual handwashing behavior to be inconsistent and fairly modest, so it would seem advisable for the Initiative to monitor behavior change periodically during the second phase to see if slow change is occurring or if the methodology needs strengthening in some respects in order to achieve the desired impact on practices. To effectively apply the methodology at the national and regional levels in the expansion phase, implementing agencies must master the methodology and have essential materials. Processes and products need to be standardized, but they also need to be adaptable. Possibly the Initiative can provide standard resources with instructions for adaptation when needed because of such local factors as climate, availability of water, ways of warming water in very cold zones, and cultural factors. For institutionalization of the at-scale program, it will be important that the methodology can serve as a resource that public sector institutions can use at the national and local levels, adopted formally in institutional strategies. The Initiative should meet with the persons responsible for related programs in the MOH, the MOE, and other partners to promote the use of each other’s communication materials where appropriate and possible. The global PPPHW methodology recommends that messages focus exclusively on HWWS. The team feels that such a focused approach could be quite effective in the short run, but it is not likely to be sustainable, because there are so many competing priorities, even within child health. On the other hand, the Initiative should work with the implementing partners to try to ensure that HWWS information is not given at the same time as messages on many other topics, because this is not likely to result in people being sufficiently informed and motivated to change their practices. The best strategy for sustainability is to integrate HWWS into many existing programs (advocate for ministerial decrees, regulations, budget allocations) but at the same time work with these programs to make handwashing promotion more effective and receive more attention. In general, there is NO guarantee of sustainability. However, the more that partners at all levels work well together and the more the public supports these activities, the better the chance of sustainability. Over a period of several years, HWWS at key times could become a social norm in Peru, passed on within families and communities with little or no need for programs to promote it. In the United States, this has begun to happen with such practices as using seat belts, using designated drivers, and smoking in public only in designated areas, but some promotion of the desired practices is still needed. Implementation Capacity • While the skills and systems needed to implement the program well certainly exist at the national level, a few of the persons interviewed at the national level expressed concern about capacity at the local level. 20 Global Scaling Up Handwashing Project A large-scale program requires that central planners in the public sector know enough about implementation conditions to be able to make good compromises between what they would like to do and what is feasible in the field. From the interviews and the team’s analysis, it appears that the national level has capabilities for program design, planning, preparation of norms and supervision of activities, but not perhaps for making needed adaptations at the local level because of varying local conditions. Availability of Products and Tools • • Most of the training and communication materials can be used with little or no change in the expanded program. There is little concern with the availability of soap, although access to water is difficult in some communities. The Initiative generated a variety of tools to support partner organizations in promoting handwashing among poor families. These included a methodology to motivate and teach handwashing through games and activities, modules to build capabilities of teachers and health/development personnel, and communication materials (posters; reminders; a radio soap opera, spots, and mentions; and television spots). These tools were developed on the basis of the baseline behavioral study, and then pretested with their target audiences. Unfortunately an administrative delay during the creative design process left little time for the complete intervention, with all of the communication channels working together. Disseminating all of these tools was a challenge that seems to have been met. Some of the tools were managed and used directly by the Initiative, while others were offered to partner organizations that intended to use them through their own channels. The program monitored the distribution of materials as well as the use of interpersonal materials used in educational sessions. The monitoring study provided useful feedback on the manuals and educational materials. In general these were considered well done and effective, although people did express the need to adapt materials to the zones of the country (coast, mountains, jungle). Problems in the availability of complementary materials were also noted, and the poster picture may need to be changed to focus more on hands. Persons interviewed expressed minimal concern about soap availability in the homes, since the baseline study (covering all regions of the country) found soap that could be used for handwashing available in 98 percent of homes (and usually in several places in the home). A few people in Arequipa, however, did mention that families in isolated mountain communities may have poor access to soap. Respondents considered the provision of plastic washing bowls and pitchers to have been useful in the first phase, and the team observed these being well used in schools. Financing • • • Many partners made financial and in-kind contributions during the first phase. The general opinion is that there is potentially sufficient funding in Peru for this activity, but that the partners need to work hard to obtain the funding to support HWWS. The team believes that some external funding is likely to be needed after 2009, mainly for covering the cost of implementing agencies to support new districts and, at a lower level, to support continued advocacy. However, partner contributions should increase during this phase, so the percentage of funding provided by external sources should decline. 21 Global Scaling Up Handwashing Project As a result of awareness-raising and advocacy activities, various donors agencies such as USAID and COSUDE decided to provide funding to support the Handwashing Initiative. Also, the MOH showed its commitment by making funds available annually for local communication and mass media. In addition, the Initiative received many in-kind contributions from public, private, and civilsociety organizations, which facilitated the incorporation of handwashing messages in activities of their networks to reach the public. Some made financial contributions for message dissemination and/or implementation of extra workshops, in addition to those funded by the Japanese Development Fund, thus allowing the expansion of some handwashing promotion to 14 regions. These organizations included: Public Sector • • • • regional governments of Lambayeque and Ica municipalities: Santiago de Surco (Lima); Pucallpa (Ucayali); Piura, Castilla, and Catacaos (Piura); Trujillo (La Libertad); Santiago (Ica), among others MOH: Direcciones Regionales de Salud (Nivel Nacional); CLAS (Local Health Administration Committee) MOE: Dirección Nacional de Educación Comunitaria y Ambiental; Dirección Regional de Educación (Lima) Private Sector • • • • agricultural companies: Asociación de Gremios Agroexportadores del Perú (AGAP), Fundación ProIca; Gremio Pro-Citrus (Huaral), Sunshine Export (Piura) banks: Banco de Crédito, Interbank, Banco del Trabajo utilities: Sedapal, Luz del Sur cosmetics companies: Belcorp NGOs • • • • Healthy Cities (Ucayali, Ica, Piura) Caritas (Piura, Tumbes) CARE (Piura, Ayacucho, Huancavelica, Huánuco) Ecoclubes (Piura, Tacna) In general, there exists potential funding in-country, particularly with the decentralization process, since the regions are gaining autonomy in preparing and budgeting for their development plans. For the expanded handwashing program, it will be essential to identify regional priorities and then lobby (with regional presidents and others) to include handwashing in local plans and programs. In addition, each year the municipal governments allocate funds through a participatory budgeting process that includes discussions with organized citizen groups and local institutions. For sustainability, it would be highly desirable for the Initiative’s implementing agencies to participate in these deliberations, since they could lobby not only for activities to promote HWWS but also for the conditions that would support the sustainability of this and other desirable objectives. The team believes that if the handwashing promotion initiative is to continue to expand to new districts after this second phase, external funding is still likely to be needed after 2009, mainly to cover the cost of implementing agencies that will probably be needed to support new districts 22 Global Scaling Up Handwashing Project and also to support continued advocacy. However, the percentage of program costs contributed by national partners should continue to increase. Cost-Effective Implementation • • In the first phase, WSP and its partners collected extensive cost information and some impact information, but there was no attempt to calculate the cost-effectiveness of various activities or strategies. The capability for collection and analysis does exist in Peru, but technical support and training will be needed for particular partners and local areas. Analysis of cost-effectiveness probably cannot be done until the final year of the expansion phase, but clearly the methodology and data collection systems and procedures need to be designed sooner than that. The partners took full advantage of the materials that were developed. For example, the episodes of the radio soap opera comprise a series, but each can also be used independently to generate discussions in group education sessions. To maximize their use, the print materials were distributed to local radio stations, to some municipal radio stations, and to informal communication channels. Another cost-effective action was drawing on the regional training facilitators themselves to develop training materials for use with the local facilitators. Some local NGOs have the ability to collect and analyze information on cost and impact, but it is still necessary to strengthen existing capabilities and to monitor activities. Monitoring and Evaluation • • • The persons interviewed generally consider M&E to be very important for project success. Many of the persons interviewed were not very aware of the Initiative’s monitoring activities or results. On the electronic survey, respondents scored monitoring lower than any other dimension. With funding from the Japan Social Development Fund, the NGO PRISMA assumed M&E responsibilities. There were formal studies and routine monitoring, and the Initiative did disseminate the findings in annual reports and other summary documents. In the electronic survey, however, M&E scored lower than other dimensions, which seems to indicate that the M&E results were not widely or well disseminated; or it may simply be that most respondents to this survey collaborated at the local level and therefore were less likely to have been exposed to M&E findings. The persons interviewed indicated that M&E should be a key component in the expanded program and that the opportunity to show how well different interventions work in this type of project should not be lost. The team feels that it is going to be a challenge to allow the local implementation flexibility that many respondents recommend while at the same time keeping sufficient uniformity in the program districts to be able to generalize about them in relation to the control districts. In addition, the monitoring team will have to control carefully for the effects of the many existing programs and projects in both intervention and control districts. 23 Global Scaling Up Handwashing Project 4. RECOMMENDATIONS BY DIMENSION The team has a number of suggestions, many of which expand ideas suggested by persons interviewed. (In some cases, the team further developed some general suggestions from the interviewees). This section presents key recommendations by dimension. These are also described in table format in Appendix I. Policy, Strategy, and Direction Although the attitudes of public and private officials toward handwashing are generally very positive, many still lack knowledge of the multiple benefits of HWWS. Moreover, government officials in particular must try to address many different priorities simultaneously. Therefore, the Initiative should develop an advocacy strategy—with arguments and materials for different levels and types of decision makers—that describes the importance of HWWS for reducing diarrhea, respiratory disease, and infant mortality; for preventing malnutrition; and for improving school performance, mothers’ confidence and self-esteem, and the nation’s human capital. Advocacy activities should begin as soon as possible and continue throughout the project period. At the time of this assessment, even key partners lacked information and had differing expectations regarding the expanded handwashing program, although clearly steps were already planned to remedy this situation. Before the selection of implementation districts, the Initiative should hold individual and group meetings with the key partners to clarify their expectations and the project’s intentions and constraints (such meetings have already begun). The Initiative should prepare and disseminate a brief description of the new project that summarizes the proposed strategy and plans, making clear which features are required under the new project. Initial discussions of each partner’s role and responsibilities should also occur during these meetings, leading eventually to MOUs or other types of agreements. A similar process, managed by the implementing agencies, should be repeated at the regional, provincial, and district levels, once the intervention districts have been selected. The National Committee has played a key role in institutionalizing HWWS by making the major programmatic decisions and being viewed by others as the face of the Initiative. It is important in the expansion phase that it continues to play this role and that its decisions are well disseminated to give orientation to regional activities. The first phase of the Handwashing Initiative in Peru has achieved various degrees of integration with such programs as PRONASAR; PAC/SEDAPAL; the MOH’s Healthy Schools program; and, recently, the MOE’s Clean, Safe, and Healthy Schools program. The team (and many of the people interviewed) strongly support efforts to integrate with and strengthen promotion of HWWS in existing programs rather than implementing the handwashing promotion as a vertical program. This makes sense for several reasons: Many national and local programs, some with strong political support, already include hygiene improvement and/or handwashing, so they should be quite open to making this component more effective. For example, there is a strong link between handwashing and infant nutrition, which is a priority of the president, along with other programs such as Together and Water for Everyone that are being implemented by public and private organizations. This strategy of incorporating handwashing promotion into ongoing activities gives the best chance of institutionalization. In addition to existing programs, there is the potential of synergy of handwashing promotion with the rollout of rotavirus vaccine (since both interventions reduce diarrhea) and with planned sanitation marketing programs. 24 Global Scaling Up Handwashing Project Taking a more vertical, campaign-type approach can generate jealousy among other programs that eventually leads to the demise of the vertical program. In general, the team recommends a decentralized structure for this expansion phase. The national level should create supportive policies, standard tools and methods—including strong advocacy, program communication, and M&E activities—and work through the implementing agencies to establish strong coordination and clear responsibility at local levels. The national-level public sector institutions are in the process of taking on a normative role. More and more decisions on priorities and program activities will be taken at the regional level, which will also control the resources to implement them. Given the reality of decentralization, it is important that advocacy activities designed to build and maintain support for HWWS be directed to decision makers at the regional, provincial, and district levels as well as at the national level. In response to the past problem of frequent changes in public sector officials, it is important to promote the inclusion of HWWS in the annual work plans, guidelines, and budgets of the MOE and the MOH. Also, it is recommended to link with the National Health Council, a consultative group of the MOH that is charged with arriving at decisions via consensus and with coordinating the national Coordinated and Decentralized Health Systems. There are similar institutions at the regional level, with active civil society participation. These organizations work on health guidelines but also on implementing regulations and national plans. Partnerships The main recommendations at the national level are to proceed with making the MOE a full national and local partner (already in progress) and also to consider adding to the coordinating committee the Ministry of Housing, as well as at least one private sector partner such as CONFIEF, which represents an array of private companies. The Initiative should engage other old and new partners with national reach through the National (consultative) Committee. It should also assess the interest of potential new partners in joining the Initiative (for example, UNICEF, PAHO, Save the Children). The existence of a certain level of guaranteed funding (from the Gates Foundation), along with concrete products (training and communication materials, handwashing kits) should help build the confidence of old and potential partners. Although selling more soap has not been a strong motivator of private sector participation, the Initiative should meet with companies that produce soap, towels, and plastic containers to see if they would be willing to incorporate HWWS information in their advertising or packaging in the hope of expanding their markets. It can be argued that the Initiative is doing free market expansion, which they should be happy to encourage. To achieve impact and sustainability, the Initiative should focus on establishing and strengthening partnerships at the regional, provincial, and districts levels, where the implementing agencies need to identify existing public and private coordinating groups to take on explicitly the coordination of handwashing-promotion activities. The first choice for a coordinating group should be an existing structure such as the mesa de concertación or regional multisectoral committee. It is also important, at the local level, to identify one or more HWWS champion organization or person that can identify the groups best positioned to engage other partners. Partners at the district level should include the strongest programs and institutions in each district. A strong partner organization is one that has a good reach into communities, has built confidence among the population, and is committed to ongoing follow-up and supervision of promotion 25 Global Scaling Up Handwashing Project activities. Each partner should be asked to commit itself to strengthen or expand attention to handwashing in its objectives and work plans. Organizations to consider include those helping install or improve water and sanitation systems, Vaso de Leche, comedores populares, and NGOs with long histories and good reputations in an area. The WSP, the National Committee, and the implementing agencies should focus on providing guidelines, tools, and strategic technical assistance to local partnerships. To keep local partners motivated and informed, the team also recommends a strong project communication program with a newsletter, Web site, media coverage, and meetings and exchange visits that facilitate the dissemination of achievements and sharing of lessons learned (see Appendix L). As part of the process of consolidating the public-private alliance to promote HWWS, it is recommended that WSP and/or the National Committee lay out clear organizational responsibilities, including a checklist of requirements for implementing person-to-person promotional activities, assigning roles and functions to different actors at the regional level. At the national level, each partner should be invited to join one of the committees listed in Table 7, depending on each organization’s agreed-upon roles. 26 Global Scaling Up Handwashing Project Table 7. Committee Participants Type of Committee Participants National Committee One representative each from the MOH, the MOE, from each major donor organization, private-sector partners, and civil-society partners. • Those providing funding and participating in planning and management of the initiative (for example, COSUDE, USAID). • Those providing funding and participating in planning, management, and national implementation (for example, the MOE and the MOH) Collaborating organizations that have less overall involvement (in limited geographical or functional areas) • Those implementing communication activities directed to their personnel and customers (for example, Belcorp, CARE) • Those involved in a specific activity, such as dissemination or printing, based on their resources (for example, Banco de Crédito, Transportes Ormeño) Committee of Institutional Partners Type of Institutions Frequency Monthly meetings Meetings every three months to receive information and exchange experiences, plus information exchange via other communication channels In the first phase, there does not appear to have been a strong connection between the National Committee and the regional and local partnerships. The Initiative needs to clearly define and follow through on its relationship with the regional coordination committees. The project communication program (newsletter, Web site, and so on) should facilitate two-way communication. Institutional Arrangements Although MOUs and other formal agreements are no guarantee of follow-up, they are essential for working with government agencies since they are needed for budget allocations to occur, and they may limit disruptions caused by changes in personnel. Formal agreements are particularly important with the MOH, which maintains substantial control over its local offices. The Initiative should continue to pursue such formal agreements at the national level and instruct its implementing agencies to do so at local levels. Although it is fine initially to have less formal agreements with private and civil society partners, it the long run negotiating and signing more formal agreements is desirable because such agreements would clarify roles and expectations and support sustainability. All agreements should define roles, responsibilities, and expected contributions. Moreover, the fulfillment of all formal and informal agreements should be reviewed and documented every six months. The WSP and the MOH should be responsible for this monitoring at the national level, and the implementing agencies should have responsibility at other levels. More formal arrangements are also needed at the regional level, not only regarding implementation guidelines but also written commitments on responsibilities and in-kind and monetary contributions. The types of organizational involvement described in the section on major findings on partnerships provide a menu of possible relations with the Initiative. 27 Global Scaling Up Handwashing Project Program Methodology The study team feels that the expanded project can follow a very similar methodology that combines forming partnerships at every level, advocacy and institutionalization activities, and strategic communication activities that combine mass media and several channels for interpersonal communication. It should be possible to scale up interpersonal communication training and activities, since this will be done by implementing agencies, each of which will be responsible for three to five regions and selected districts within each region. A key to success will be the supervision and follow-up of the training by the local partners themselves. The team has made small suggestions for improving the methodology (for example, by suggesting handwashing-promotion activities that students and promoters can do in homes and communities, and preparing modified materials for each of the three zones in the country—see Appendixes J and K) but has not suggested major changes. Three general suggestions from various respondents were to: (1) focus on supporting the local levels, (2) allow local partners flexibility in implementing the general strategy, and (3) urge local partners to avoid a focus on short campaigns with no clear follow-up. Such campaigns seem to be very popular in Peru, but their impact is questionable. In the start-up period, the Initiative should develop a standard methodology and instruments for assessment visits at the provincial and district levels to identify existing activities in which handwashing promotion could be added or strengthened, and to identify the strongest partner organizations and potential HWWS champions. Most respondents recommended that implementation emphasize interpersonal communication, but all saw a continued role for mass media. The team favors a focus on local radio in local languages and interactive formats (call-in shows, radio listening groups, and so on). It is important to ensure better coordination between mass media promotion and on-the-ground activities, so they are mutually reinforcing. The team recommends encouraging and facilitating local partners to create opportunities for individual and group dialogue between change agents (teachers, students, health staff, health volunteers) and mothers, to give ample opportunity to explain and discuss the desired behavior changes and to jointly problem solve if there are barriers to action. Mass media should continue to support interpersonal communication by generating interest in and reminders of handwashing with soap. What is ideal, but only possible in one-on-one or group communication, is for the change agents to ask a few assessment questions to learn what the mother or group is currently doing regarding HWWS. So, for example, if the mother is already washing her hands at key times but not using soap, the focus of the conversation would be on the importance of using soap and how this can be done by this particular mother. If the mother is washing with soap but only before preparing food, then the importance of washing of other key times would be the focus. If feasible, it would be desirable to develop separate communication materials for the coast, mountains, and jungle areas of Peru. If this is not possible, the Initiative should encourage regions to modify materials to incorporate more appropriate images, language, and local conditions, such as limited water or cold temperatures, and counsel families on how to overcome them. For both effectiveness and sustainability, the Initiative should encourage strengthening of handwashing promotion within existing programs such as health promotion by the MOH, Escuelas Saludables, Viviendas Saludables, Municipios Saludables, PRONASAR (new water 28 Global Scaling Up Handwashing Project and sanitation systems), PRONOEI (preschool program), initiatives directed at malnutrition, JAAS (water and sanitation boards), NGOs doing health promotion, and so on. Although moving away from a single focus on handwashing contradicts the general PPPHW strategy, the team feels that this is the most appropriate approach for Peru as well as the one mostly likely to be sustainable. On the other hand, any particular educational opportunity should have a specific focus (on handwashing or some other topic) and be as interactive as possible, so as not to overwhelm people with too many messages and too much information all at once. To try to build and maintain a positive program image, to motivate partners and supporters, and to share useful technical and strategic information, the Initiative needs a strong project communication program directed at both collaborating organizations and the outside world (political leaders, donors, the public). At a minimum there should be an electronic newsletter, a section on the WSP/Peru and MOH Web sites (with links to partners’ sites), and specific efforts to obtain radio and press coverage of accomplishments and activities. These communication spaces should include basic information on the program, descriptions of particularly effective/innovative strategies or activities; updates on achievements and impact; and exchanges on lessons learned. (This recommendation combines respondent and team ideas.) The “implementing organizations” that the Initiative intends to contract to manage the program in several regions should collaborate in preparing an operational guide for the district level. The guide should propose implementation steps in a way that encourages each district to select those that are likely to be most feasible and effective. The program should take advantage of children’s enthusiasm by suggesting activities for students to promote HWWS at home and in their communities. The Initiative should work with students, health promoters, and local organizations (soliciting and testing their ideas) to develop new activities and materials. In addition, the workshop methodology and supplementary materials should add coverage of how change agents can work with individual mothers on solving problems, such as (perceptions of) limited water, soap, or time. Lack of compensation for transportation and food costs are said to be barriers to promoters making more home visits. Where other partners are willing to share the cost, the Initiative should contribute to the costs of such compensation at the local level. Finally, the key partners should develop an exit strategy that addresses both sustainability and expansion issues. This might include steps to institutionalize support (funding and commitment) for HWWS in government and partner organizations, plans to expand the program into some control districts as soon as the final measurements have been completed, intensified efforts to get handwashing benefits and promotion in curricula and pre-service training, and local and national presentations on the project’s lessons learned and impact on health and malnutrition. Implementation Capacity Considering implementation capabilities of national public sector organizations, and looking at the institutionalization of the process and human capabilities, the team recommends that the Initiative link not only with the directorate level of each ministry but also with higher levels such as ministers and vice ministers, who can instruct the ministry’s various directorates and programs to be involved. The Initiative is already working on such contacts. All needed capacities exist in Peru, so the challenge in the expanded program is to build capacity at decentralized levels. Although regional and district levels have resources of institutions such as NGOs and some public sector units, it is evident that the large-scale program, mainly through the implementing agencies, must work intensively to strengthen local capabilities both before 29 Global Scaling Up Handwashing Project and during implementation. Although training is the main approach, provision of materials (manuals, a district implementation guide, a newsletter, and so on), technical assistance by implementing agencies, mentoring, and exchange visits are also important. More intense support should be given to regions, provinces, districts, and municipalities where the local assessments show particular weaknesses. WSP and other National Committee members should train key staff in the implementing agencies, who in turn should train and support persons and organizations in the regions. Training should be participatory and capacity-based and should include as much practice of skills and exercises to draw out attitudes as possible. WSP should ensure that the MOH, the MOE, and implementing organizations receive information on the most outstanding people who were trained in the first phase, since they are an excellent resource to support implementation in the regions. The local partners should be responsible for monitoring the implementation of training skills a few months after training and then every six months after that. They should also monitor if significant numbers trained teachers or promoters have left their positions, so additional training sessions may be planned and implemented. After their assessment of each region, province, and district where this phase will be active, the implementing agencies need to identify key leaders or “champions” who can serve as spokespersons, as well as persons who are already trained and informed about the Initiative and who can support expansion. For example, these could include the group of regional facilitators who trained many others to give training in the first phase. Most of them are regional health or education staff who have leadership capabilities. The Initiative should encourage and facilitate the existing trend for regional partner organizations to integrate HWWS into preservice training curricula and, in addition, explore at the national level adding or strengthening coverage of the benefits of HWWS and promotion of handwashing in professional training institutions. Availability of Products and Tools It is important that the products and tools are appropriate to the local reality at the regional and district levels—for example, illustrations should reflect coast, mountains, or jungle. If it is not possible to prepare completely different sets of materials for each geographical zone, the Initiative should support regional efforts to devise their own appropriate activities and local materials. Except in isolated rural communities, soap availability is not a problem, but change agents in those particular communities should be trained to offer alternatives to soap, such as ash, sand, or quinoa oil (their acceptability and feasibility should be investigated first; as well as the efficacy of quinoa oil). Difficult access to water is a problem in some communities, schools, and homes. Three potential solutions are to: (1) link handwashing promotion to existing initiatives that install or improve water systems; (2) train change agents to promote water-saving technologies such as Tippy Taps, and (3) delay working in schools and communities with poor access to water. Some persons interviewed suggested that the Initiative support encourage municipal governments to support infrastructure such as construction of water faucets near kitchens and latrines and simple systems for disposal of used water. This seems like a logical idea, as many interviewees’ suggested that handwashing stations near the kitchen and bathroom would facilitate consistent handwashing at key times. 30 Global Scaling Up Handwashing Project Materials to support training and communication on HWWS (for the hygiene corners in schools and the training modules) should be given out in the training workshops for local facilitators and promoters, as was done in most workshops in Phase I, so that they can have the needed tools to effectively carry out their tasks related to HWWS. Although the team favors the continued provision of plastic bowls and pitchers, with an eye to sustainability, this should be made a district responsibility rather than a national one. District partners could devise a plan to have these materials donated to schools and to some or all families. The Initiative can continue to use the existing behavior-change materials, which were prepared and approved with great effort. However, as mentioned, the team has recommended a few supplementary materials, and the widespread call for more locally appropriate versions needs to be addressed. The Initiative or its local partners should consider producing reminder materials that families can place at handwashing stations. It is important to identify and measure the storage capacity in each intervention area because of the considerable volume of materials. Because of the ongoing changes related to decentralization, this issue needs to be followed carefully. Financing Aiming toward sustainability, the Initiative should continue to focus during this phase on getting national and local partners to finance increasing portions of handwashing-promotion costs. To the extent possible, commitments should be included in signed MOUs whose implementation should be monitored. In order to expand into new districts at the end of this phase, it is likely that some funding from external donors will still be needed—mainly to support advocacy, program communication, implementing partners, and M&E—but the percentage of external funds should be significantly less than for the current phase. The team recommends preparation and implementation of an exit strategy so that ideally there can be a smooth transition to the following phase of handwashing promotion in Peru. Other, specific ideas include: • • • • Continue to explore a co-financing agreement by the Fund of the Americas (FONDAM), which has expressed interest in supporting HWWS in Peru. Obtain information on USAID’s small grants program and then decide if it wants to share this with local partners. Lobby at all levels of government for budgetary funds directed toward handwashing or hygiene education. Continue to seek donated air time and publicly acknowledge the donation of free air time by private media companies. Cost-Effective Implementation In the first phase in Peru, the Initiative collected extensive cost information. This should continue. The second phase will focus on M&E, so the Initiative should be able to combine findings on costs and on effectiveness to help formulate recommendations on adding, dropping, or changing certain program inputs. Although calculating the cost-effectiveness of certain inputs or strategies requires both art and science, making programmatic decisions on the basis of cost-effectiveness should also factor in sustainability and non-monetary costs, such as WSP time to coordinate. In the interest of holding down costs, the use of national radio and television should be modest and directed more toward decision makers (advocacy). Local radio should be used to reinforce interpersonal activities at the local level. As much as possible, the local partners should try to 31 Global Scaling Up Handwashing Project negotiate the inclusion of information, discussions, or contests on HWWS in existing programs, at little or no cost to the Initiative. The Initiative’s materials appear to have been used effectively and efficiently. For example, chapters of the radio soap opera could be used independently and as a stimulus to discussions in group educational sessions. Other audiovisual materials were given to local radio stations, some municipal radios, and informal communication channels. For sustainability and replicability, the Initiative should continue to look for and utilize such opportunities to maximize human and material resources. Monitoring and Evaluation A key to maintaining partner and public motivation is the timely dissemination of achievements and results. There was quite thorough project monitoring, but it came at the end of the first implementation phase and the findings apparently were not well disseminated—many of the persons interviewed felt that monitoring was one of the weaker aspects of the program. For the expanded program, interviewees suggested better communication of achievements, a suggestion that the team expanded into a recommendation for a strong communication program that updates partners at regular intervals on major activities, resources, innovations, and achievements, as well as on the dimensions of scalability and sustainability that this study has used. There will be a thorough M&E program in this phase, standardized across the four countries. The team recommends that M&E be managed by a person or group connected to but separate from those managing implementation, and that findings be used to modify to program. No information should be collected unless it potentially can be used to modify the program in an important way. In general the focus should be on changes in practice and their determinants, not on changes in knowledge. Findings from M&E should be appropriately packaged and well disseminated to partners, decision makers, and the public. 32 Global Scaling Up Handwashing Project 5. NEXT STEPS Steps recommended by the study team to support program expansion and sustainability are found in Appendix L. In some cases additional detail may be found in Appendix I. Among the principal recommendations are: • • • • • • Plan and implement a dynamic advocacy strategy that begins immediately and that continues throughout implementation. Plan and implement a strong project communication strategy directed primarily to partners but also to decision makers at various levels and to the public. Materials, formats, and activities should be directly related to reaching one of the strategy’s objectives (for example, partner motivation, sharing good ideas) and audiences, which should be clearly defined. Develop and implement an exit strategy that includes steps for dissemination and sustainability of program activities and achievements. Continue to negotiate and sign more formal agreements on partners’ roles and responsibilities and develop systematic mechanisms to monitor the implementation of the agreements. Have the key national-level partners, including the implementing organizations; dedicate themselves to establishing the conditions and providing the tools and support for successful local implementation. In this decentralized vision, the team expects that key factors for program success will be strong and dedicated partnerships at local levels, with effective tools and methodologies and support from the national level. Great attention should be given to carrying out thorough regional, provincial, and district assessments of organizations, potential champions, resources, programs, and conditions and to establishing and supporting strong local partnerships. Although Appendix L contains some elements of a work plan, these ideas should be considered to be no more than recommendations to the Peru country coordinator, for her to consider in consultation with in-country partners and WSP staff in Peru and Washington. 33 Global Scaling Up Handwashing Project APPENDIX A: SELECTED DOCUMENTS AB PRISMA. 2004. Estudio de comportamiento de lavador de manos con jabón en zonas periféricas del Perú. Preparado como línea de base para la Iniciativa de Lavado de Manos en el Perú, liderado por PAS-Banco Mundial. June, Cogswell, Lynne. 2007. “Revised PROTOCOL. Enabling Environment Assessment of HW and TSSM Programs.” World Bank (Water and Sanitation Program). April 19. COSUDE. Brochure institucional. Cuerpo de Paz. Brochure institucional. Flórez P., Rocío. 2007. Informe de Implementación 2006-2007. May. Flórez P., Rocío. 2006. “Iniciativa de Lavado de Manos en el Perú.” October 17 (PPT). Flórez P., Rocío. 2006. “Sistematización. Período 2003-2005.” February. Iniciativa de Lavado de Manos. 2006. Proyecto de fortalecimiento de capacidades para el cambio de comportamiento: reducción de diarrea en niños de escasos. Informe de monitoreo. November. Iniciativa de Lavado de Manos. 2006. Proyecto de Fortalecimiento de capacidades para el cambio de comportamiento: reducción de diarrea en niños de escasos. Informe de Evaluación de Efecto. November. Iniciativa de Lavado de Manos. No date. Módulo para facilitadotes – promotores de salud y desarrollo. Iniciativa de Lavado de Manos. No date. Módulo para docentes del nivel inicial y primaria. Jensen, Lene. 2007. “Quick Backgrounder on the PPPHW Approach to Handwashing Promotion.” Water and Sanitation Program/Handwashing Secretariat. April 12. Ministerio de Vivienda, Construcción y Saneamiento, PRONASAR. 2006. Proyecto Piloto de Agua y Saneamiento en Pequeñas Ciudades. “Cuidar el Agua: La escuela en acción.” July. Ministerio de Educación, Viceministerio de Gestión Pedagógica, Programa de Educación Ambiental. Brochure Educación Ambiental. Ministerio de Educación, Viceministerio de Gestión Pedagógica, Programa de Educación Ambiental. “Guía instructiva de la Campaña nacional Escuelas Limpias y Saludables 2005 al 2014.” Programa Nacional de Agua y Saneamiento Rural (PRONASAR). 2007. “Documento de Sistematización del Proyecto Piloto de Agua y Saneamiento en Pequeñas Ciudades.” January. SEDAPAL. 2005. “Guía metodológica para la intervención técnico social en la elaboración y ejecución de proyectos condominiales de agua potable y alcantarillado.” November. 34 Global Scaling Up Handwashing Project Sub Región de Salud Luciano Castillo Colona, Sullana. 2007. Informe de Lavado de Manos. World Bank (Water and Sanitation Program). 2006. Grant Proposal: Scaling Up Handwashing Behavior Change. September 25. World Bank (Water and Sanitation Program). 2007. “Terms of Reference. Enabling Environment Assessment and Baseline to Scale up, Sustain and Replicate Handwashing with Soap Behavior Change Programs.” March 9. World Bank, BNWP, WSP Water and Sanitation Program. 2005. The Handwashing Handbook: A guide for developing a hygiene promotion program to increase handwashing with soap. 35 Global Scaling Up Handwashing Project APPENDIX B: LISTA DE ENTREVISTADOS LISTA DE ENTREVISTADOS NACIONAL INSTITUCION PERSONA CARGO Ministerio de Salud Beatriz Ugás Coordinadora Comisión Nac Armando Barrantes Director Nacional Dirección Nacional de Educación Sanitaria y Ambiental Jorge Chumpitaz Ministerio de Educación Ministerio de Educación Ministerio de Vivienda/PRON ASAR Ministerio de Vivienda/PRON ASAR Rosa Meza TELEFONO FECHA HORA 3156600 Jueves 31 3 p.m. Van de Velde 160, San Borja Pabellón A, Tercer Piso, Of. 305 2155800 2155830 (1139) Martes 22 9 a.m. Consultor Dirección Nacional Educaciòn Sanitaria y Ambiental Van de Velde 160, San Borja Pabellón A, Tercer Piso, Of. 305 2155800 2155830 (1139) Jueves 24 11 a.m. Especialista técnico UGP Paseo de la República 3361, San Isidro 4226608 99271760 Jueves 31 9:30 a.m. Paseo de la República 3361, San Isidro 4226608 4226585 Viernes 01 9:30 a.m. Gabriela Flores DIRECCION 36 Global Scaling Up Handwashing Project REGIONAL INSTITUCION PERSONA CARGO DIRECCION TELEFONO FECHA HORA Municipalidad Piura Giovanna Bisso Gerente Educación, Cultura Biblioteca Municipal de Piura 073-302525 9687691 Jueves 17 8 a.m. Omar Palacios Jefe de Oficina de Población, Salud e Higiene Municipalidad de Piura 073-307775 / 0739961239 Viernes 18 11 a.m. Municipalidad Catacaos Deisy Chero Presidente de la Comision de Salud, Salubridad y Saneamiento Municipalidad de Catacaos 073-370239 Viernes 18 3 p.m. DIRESA Piura Dr. Carlos Bayona Sub director DIRESA Piura 073-342424 341563 Jueves 17 12 m. Red de salud Sullana Jenny Portocarrero Relaciones Públicas Red de Salud Sullana Viernes 18 9 a.m. Germán Robles Especialista Gestión Educativa y Ambiental Ronda Recoleta s/n 054-270975 054-252391 Lunes 28 9 a.m. Sonia Sánchez Gerente Gestión Social Calle Alvarez Tomas 304, Altos (Altos Biblioteca Municipal Arequipa) 054-229240 9862105 Lunes 28 8 a.m. Gobierno Regional Arequipa Dr. Aníbal Díaz Autoridad Regional de Medio Ambiente Calle Unión 100, Urb. Cèsar Vallejo, Dist. Paucarpata 054-463165 054461319 Martes 29 8 a.m. DIRESA Arequipa Haydé Rodas / Mariela Díaz Promoción de la Salud Av. Alcides Carrión - Hospital General Honorio Delgado 235155 Martes 29 11 a.m. Dirección Regional Educación Arequipa Municipalidad de Arequipa 37 Global Scaling Up Handwashing Project LISTA DE ENTREVISTADOS Bilateral Projects INSTITUCION USAID/Comuni dades Saludables PAC SEDAPAL PERSONA CARGO DIRECCION TELEFONO FECHA HORA Edgar Medina Director MSH Gonzales Prada 350 Miraflores (frente teatro Marsano) 2429800 Miércoles 16 3 p.m. Eliana López Comunicación MSH Miércoles 16 4 p.m. Miércoles 23 10 a.m. Javier Acosta Sotomayor Especialista social Av. Nicolás Ayllón 2309, Piso 4, Ate. (Por la Clínica San Juan de Dios). 3261182 99176790 LISTA DE ENTREVISTADOS Media INSTITUCION RPP PERUTV PERSONA CARGO DIRECCION TELEFONO FECHA HORA Directora Paseo de la República 3866, San Isidro (altura Paseo de la República y Aramburú) 215-0200 Martes 22 11:45 a.m. Oswaldo Vizcarra Director de Prensa Centro Comercial Cayma Of. R2 054-252525 Martes 29 2:00 p.m. César Portillo Gerente de Producción Frida Delgado 38 Global Scaling Up Handwashing Project LISTA DE ENTREVISTADOS INSTITUCION PRISMA Ciudad Saludable ONG Labor Local NGOs CARGO DIRECCION TELEFONO FECHA HORA Delia Haustein Directora Ejecutiva Carlos Gonzales 251, San Miguel 6165500 Viernes 11 11 a.m. Ruth Pérez Especialista en comunicación Viernes 11 12 m Lunes 28 3:30 p.m. 5 p.m. PERSONA Albina Ruiz Directora Av. Jorge Basadre 255 Of. 401 S.I. Jorge Béjar Coordinador Arequipa Calle Paz Soldán 307, Yanahuara 421-5163 92759213 054-272883 256740 992 2496 997 8788 ONG DESCO Arequipa Oscar Toro Coordinador Calle Málaga Grenet 678, Umacollo 054-257043 Lunes 28 LISTA DE ENTREVISTADOS Private Sector INSTITUCION Belcorp PERSONA CARGO DIRECCION TELEFONO FECHA HORA Daniela Barbieri Gerente corporativo responsabilidad social Av. Canaval y Moreyra 480 San Isidro 2113300 (1466) Martes 15 11 a.m. Gerente Av. Camino Real 456, Torre Real Piso 11 98382401 Lunes 21 11:30 a.m. Gerente Calle Quezada 104, Yanahuara 054-253920 254188 Lunes 28 8 a.m. PROICA María Sonia Arenas Cámara de Comercio e Industria de Arequipa Martín Cotrina 39 Global Scaling Up Handwashing Project LISTA DE ENTREVISTADOS International Agencies INSTITUCION PERSONA CARGO DIRECCION TELEFONO FECHA HORA COSUDE Cesarina Quintana OFICIAL DE PROGRAMA Av. Salaverry 3242, S.I. 2645001 Miércole s 23 3 p.m. Directora de Programas Calle Vía Láctea 132, Urb. Los Granados, Surco. 617-2200 / 617-2210 Martes 15 PAS 9 a.m. Voluntaria Plaza de Armas de Catacaos (073) 9628939 Jueves 17 10 a.m. Oficina de Salud Av. La Encalada cdra. 17 Monterrico Viernes 11 9 a.m. Mabe Arce Especialista en comunicaciones Av. La Encalada cdra. 17 Monterrico 6181225 6181350 Lunes 14 4:30 p.m. PAS Rocío Flórez Coordinadora Iniciativa LM Alvarez Calderón 185, Piso 9 615-0685 Lunes 14 mayo 10 a.m. WSP/PPL Iris Marmanillo Coordinadora Perú PAS/BM Alvarez Calderón 185, Piso 9 615-0685 Martes 15 mayo 4 p.m. Mercedes Zevallos Especialista comunicación PPL Alvarez Calderón 185, Piso 9 615-0685 Lunes 14 mayo 3 p.m. Cuerpo de Paz Cuerpos de Paz (Catacaos) USAID Emilia Villanueva Ana Turves Jaime Chang 40 Global Scaling Up Handwashing Project International NGOs PERSONA CARGO DIRECCION TELEFONO FECHA HORA CARE Perú Lourdes Mindreau ESPECIALIST A EN CAPACITACI ÒN Gral Santa Cruz 659 Jesús María 4317430 Lunes 21 4 p.m. CARE Piura Carolina Aguilar CAPACITADO RA Urb. 4 de Enero Mz E Lote 3 073-304675 Jueves 17 5:00 p.m. ASESOR Av. Javier Prado Este 5318 La Molina (alt. cruce Los Frutales) 4372727 Martes 22 3 p.m. INSTITUCION FONDAM Cáritas Piura Cáritas Arequipa Alvaro de la Romaña Juan Manuel Cendra Pablo Manrique Secretario General Calle Cusco 179 Piura 073-311203 Viernes 18 9:00 a.m. Secretario General Federico Barreto 146, Frente mercado Palomar 054-608800 Martes 29 9 a.m. 41 Global Scaling Up Handwashing Project ►(USAID) Se ha tomado la decisión de apoyar anualmente con ►Existe una marcada voluntad política de la agencia. La iniciativa tiene una buena identidad que se traduce en la existencia de un logo. Se identifica que la Iniciativa no es percibida como exclusivamente de una organización, sino de socios igualitarios. ►Es interesante ver cómo las empresas privadas han estado participando en temas de salud. ►La nueva gestión del MINSA tiene un marcado interés en seguir participando en la Iniciativa. ►Existe voluntad política de trabajar lavado de manos desde Ministerio de Vivienda (PRONASAR). Global Scaling Up Handwashing Project Agencia internacional ►Desde la Dirección Nacional de Educación Comunitaria y Ambiental (DINECA) existe una voluntad política de participar y de vincularse a otras iniciativas. Gobierno ►Las ordenanzas que se emitieron desde el nivel central generó un interés de salud en el nivel local. Fortalezas Tipo de institución Política, estrategia y dirección 42 ►La voluntad política ha sido variable dentro del MINSA porque todavía no se ►Falta presentar lo que se está avanzando. Es posible que la actuación del MINSA no esté tan bien descrita. ►Faltó involucrar mayor participación de otras instituciones como UNICEF, OPS, las que podrían constituir alianza de soporte y no nuclear. Debilidades ►Se debe hacer más diseminación de los avances y actividades ►Esta segunda etapa no debiera constituirse en un modelo de intervención rígido. Se requiere uniformidad, pero debe ser flexible como para permitir seguir involucrando otros socios y otros aportes. ►El nivel central tiene que cumplir su labor de facilitador con herramientas o guías específicas para una ejecución más eficiente. ►La Iniciativa coincide con la priorización de los cuatro temas de esta nueva gestión MINSA: descentralización, seguridad ciudadana, nutrición y maternidad saludable. ►El MINSA considera necesario trabajar un proceso muy participativo en el diseño de la segunda fase. ►Considerar las zonas que se están identificando para el concurso del próximo año en PRONASAR, componente 1 (rural con 2,000 habitantes a menos) y 2 (pequeñas ciudades 2,001 a 30,000 habitantes). ►Chequear disponibilidad de agua primero para que el tema tenga más impacto. (Gerencia medio ambiente, Arequipa). ►Revisar la decisión política en los Planes Regionales Concertados de Salud (DIRESA Piura). ►Para la sostenibilidad de la intervención, sería necesario que se haga una sensibilización inicial a las autoridades que harían seguimiento al programa (Municipalidad Piura). ►Promover la voluntad desde las Regiones vinculando a la Dirección Regional de Educación, Área gestión pedagógica. Recomendaciones APPENDIX C: RESUMEN DE PUNTOS IMPORTANTES DE LAS ENTREVISTAS ►La visión ha sido desarrollado en una manera muy participativa. ►Los alcaldes han mostrado mucho interés por la relación de lavado de manos con desnutrición y la falta de capacidad humana. ►Se identificó una fuerte voluntad política en Lambayeque. ►La estrategia funcionó muy bien con el sector privado. ►Se ha logrado una visión compartida, de tal manera que se privilegia la Iniciativa más allá de la presencia institucional. ►Forma parte de un componente de los programas con la comunidad, que ellos financian. Existe un marcado de interés de verlos como procesos: como mecanismo de Iniciativa y como alianza público privada. 43 ►Las responsabilidades del nivel central y regional están en un claro proceso de descentralización, lo que crea confusión. ►Para revisar la visión y estrategia los líderes gubernamentales tienen poco tiempo para participar, pero las agencias cooperadoras pueden ayudar desarrollar estrategias y métodos a usar en todos niveles. ►Sería muy importante ganar el apoyo del Presidente de la República, relacionándolo con la contribución a alcanzar los objetivos del Milenio. ►Es muy importante afinar los roles y involucrar otros socios que trabajan con agua y saneamiento y/o salud infantil. Se podría hacer un matriz con todos los roles y responsabilidades de salud, educación y vivienda a cada nivel. ►Asegurar el vínculo con programas como Agua para Todos (programa paraguas de PRONASAR). ►A nivel nacional falta una estrategia intersectorial que pone LM dentro de muchos programas e iniciativas grandes del gobierno (salud, educación, vivienda). ►El LM ha sido una excelente actividad inicial para ayudar a nuevos Voluntarios del Cuerpo de Paz integrarse en sus comunidades y ganar la confianza del pueblo. ►Muchas áreas del MINSA participaron en las discusiones de estrategia. ►Su ejecución ha sido muy importante para el auto-estima de mujeres rurales. Se puede usar estas resultados positivos para motivar a otros a unirse al programa. ►Teniendo en cuenta el momento político, la Iniciativa debiera unirse a la Alianza contra la desnutrición crónica. El gobierno está muy comprometido a reducir en un 5% la desnutrición antes de 2011. ►La estrategia no funcionó tan bien con el sector público – es más difícil por los cambios frecuentes en personal y la abundancia de prioridades para ellos. ►Muchos políticos han cambiado con las elecciones recientes, lo que genera una necesidad de orientación sobre LM. ►La Iniciativa debiera estar integrada a programas de agua y saneamiento para que pueda asegurar su sostenibilidad. ►Es muy importante institucionalizar lavado de manos en el MINSA, debido a que lo tiene más explícito en el plan sectorial. También es muy importante tener una relación más formal entre MINSA y MINED. ►Se requeriría trabajar un plan de abogacía para involucrar otros actores. ►Un obstáculo es que el personal de MINSA tiene demasiadas prioridades y en ese sentido tienen que estar bien convencidos sobre el valor de LM antes hacer algo. ►La voluntad política ha variado mucho con los cambios de líderes en el MINSA. ►La Iniciativa podría ser más fuerte con el sector público. ►Se debiera tender a que los instrumentos se conviertan en parte de las propias instituciones. de reconocimiento sociales al sector público y privado. ha consolidado una institucionalización de LM. Esto depende completamente de los líderes actuales y su opinión. fondos exclusivamente para lavado de manos. ►Ha tenido un estilo de trabajo informal y abierto a las instituciones. Recomendaciones Debilidades Fortalezas Global Scaling Up Handwashing Project Tipo de institución ►Existe voluntad política e interés por parte de CARE, sobre todo si se vincula al actual proyecto que maneja con PRONASAR. ONG ►En PAC SEDAPAL existe la voluntad política de trabajar el Global Scaling Up Handwashing Project Proyecto ►Fuertes compromisos de líderes en Ica. Una muestra es que el nuevo presidente regional envió una carta a la Iniciativa confirmando su compromiso. ►La video conferencia en que participó algunos actores del sector privado ayudó a explicar la visión y estrategia común. 44 ►La falta de lavado de manos es un problema de desarrollo y ►Prestar atención a los planes políticos, aunque la implementación sea lo prioritario. ►Tener reuniones para asegurar que los socios principales entiendan y apoyen la misma visión. ►El apoyo del Presidente Regional es esencial, pues tiene redes para llegar a los líderes comunitarios. ►Se evidencia una voluntad política muy fuerte dentro de la compañía. Hay el sentido que mucha gente está unida en la Iniciativa. Sector privado (incluye medios) ►Consolidar la voluntad política en instrumentos operativos, como mejora en la currícula escolar local. ►Teniendo en cuenta que las municipalidades muchas veces no cuentan con personal capacitado, se debiera realizar sesiones de capacitación, por ejemplo al responsable de la Comisión de Salud, a los equipos que trabajan saneamiento y al equipo de promoción comunitaria. ►Se requiere mantener informadas a las autoridades locales para mantener la voluntad política. ►Es bueno aprovechar el contexto que es totalmente favorable: hay inversión de infraestructura, hay indicadores en lavado de manos en proyectos como PRONASAR, vinculado a un cambio de comportamiento. ►Sería bueno que el programa de lavado de manos se desarrolle junto con otro como es ahorro de agua para asegurar su buen uso. ►Sería útil revisar los planes de transferencia de los programas a nivel regional y local. Recomendaciones ►En el nivel operativo se ha visto que el compromiso y la voluntad son muy importantes (PRISMA). ►Falta un soporte comunicacional que permita que la Iniciativa sea identificada por todos. ►Se siente el impacto de la Iniciativa Lavado de Manos en el nivel central, aunque todavía no es suficientemente fuerte (CARE). Debilidades ONG local internacional Fortalezas Tipo de institución tema, que se traduce en la existencia de este tema en la línea de base. bilateral ►Existía alguna confusión en las relaciones de agencias públicas y privadas. El sector público está ►La generación de alianzas se ha dado de manera intuitiva, lográndose el involucramiento de actores. Global Scaling Up Handwashing Project Agencia internacional ►El programa Escuelas Saludables se plantea contar con 12,000 escuelas en 2007, por lo que se identifica muchas posibilidades de colaboración. Gobierno ►La participación de las empresas privadas ha sido muy importante, porque están asumiendo un nuevo rol en la salud de la población. Fortalezas Tipo de institución Alianzas Fortalezas Tipo de institución 45 ►Los frecuentes cambios de personal en el sector público generan retrasos en la marcha del proceso o hace que sea más lenta. ►Todavía se depende demasiado del equipo nacional. Debilidades Debilidades ►Desarrollar guías con los pasos para trabajar la iniciativa a ►La Iniciativa debe identificar un actor comprometido que asuma la formación de la iniciativa regional, o en todo caso una institución local que lo asuma. Alguien debe apoyar, teniendo en cuenta que usualmente las personas ya están trabajando a tiempo completo. ►Para fortalecer las alianzas se debiera presentar lo que se ha venido trabajando, como experiencia previa y las lecciones aprendidas para tener una retroalimentación de los socios. ►Promover alianzas estratégicas con especialistas de PRONASAR para incluir metodología lavado de manos como condición a sus operadores. ►Es importante trabajar con “champions” al nivel técnico porque el nivel político siempre cambia. ►Generar el compromiso de MINSA es esencial para aspectos técnicos y normativos. ►Colaborar con el programa de Vivienda Saludable, un ataque integral a agua e higiene, incluyendo cocinas mejoradas. Recomendaciones ►Usar las Juntas Vecinales Comunales, ahora formalizadas en la ley de descentralización, como la unidad de implementación local. ►Se debe trabajar mirando a las Regiones, pero enfocando en los distritos y comunidades. ►La Iniciativa puede tener más éxito y sostenibilidad si está implementada como un programa de desarrollo local, enfocando en un estilo de vida saludable; no como un programa sectorial de salud. debe ser atacado desde ese enfoque. Recomendaciones Global Scaling Up Handwashing Project ►En el MINSA se identificó mucho entusiasmo; ha tomado algún liderazgo pero aún no es suficiente. ►La iniciativa es ”un éxito” que muestra un esfuerzo unificado para el desarrollo. ►Es una excelente modelo, muy flexible. acostumbrado a tomar dirección, pero son los otros socios que tienen los fondos. 46 ►La Iniciativa no ha involucrado los ministerios de Educación y Vivienda suficientemente. ►La comunicación con algunos socios ha sido difícil. As veces la Iniciativa tenía que continuar llamando a MINSA para recibir una respuesta. ►El MINSA no se siente cómodo con las relaciones informales. ►Es importante notar qua hay varios tipos de socios que juegan varios roles. Algunos solamente hacen su contribución puntual en coordinación con la Alianza. ►El problema era que muchas de las contribuciones han sido muy puntuales, solamente para una campaña corta, y muchas organizaciones no mantuvieron su participación activa. ►Es necesario vincular el tema con salud, nutrición, capital ►Usar una figura famosa como portavoz en radio y televisión. ►Es importante vincularlo con programas que mejoran acceso a agua. ►Para mantener las alianzas hay que monitorear y evaluar mejor. También los socios tienen que entender que el cambio de comportamiento lleva tiempo y tiene que ser mantenido. ►Los líderes al nivel nacional y regional estarían interesados en saber como lavado de manos contribuye a las metas de Desarrollo del Milenio. ►Las Juntas Administradoras de Agua y Saneamiento (JAAS) seria una buena estructura a involucrar. ►Se debería involucrar a los líderes comunitarios, quienes tienen “total credibilidad.” ►Trabajar con Escuelas Saludables. ►Teniendo en cuenta el marco de la descentralización, es muy importante involucrar los gobiernos regionales – promover LM en sus planes de desarrollo, de salud, de educación. Así se puede ganar más aporte de los medios. ►Existe más potencial en socios del sector privado que les interesan en contribuciones sociales, por ejemplo compañías mineras. ►Muchísimas organizaciones puede compartir la meta de niños sanos y hacer varios tipos de contribuciones. ►El paso mas importante es demostrar el impacto de la Iniciativa en diarrea y desnutrición; los socios necesitan esto para mantenerse motivados. ►Para la segunda fase la exploración de los actores para la alianza podría ser algo planificada. ►Se debe ordenar el uso de herramientas para formar alianzas de este tipo. ►Para el nuevo programa se debiera pensar en alianzas como en federaciones en que la nacional involucra a las regionales, pero éstas también son autónomas. nivel regional, como alianza público privada. ►Ha sido una experiencia muy ►PROICA ya es una alianza de 4 empresas y trabaja en alianza con varios gobiernos locales. ►Las alianzas son difíciles pero son importantes para la sostenibilidad. ►El rol y responsabilidad de los miembros de la Iniciativa es muy clara. Global Scaling Up Handwashing Project Sector privado ONG local internacional ONG 47 ►La alianza en ICA no incluye a ONGs, pero PROICA misma se convierte en ONG. Quieren hacer alianzas con medios masivos locales. ►Se puso de relieve el asocio, pero todavía es muy nuevo para las Regiones. ►No se identificó al Ministerio de la Mujer y el Desarrollo Social (MIMDES), con el Programa Juntos, que tiene una intervención en 210 distritos, cuyo objetivo es disminuir la desnutrición crónica, siendo lavado de manos un componente. ►Hacer más alianzas con compañías privadas y ONGs. ►Hacer contacto con las muchas organizaciones que ya tienen programas dirigidos a niños, diarrea, desnutrición. ►Identificar una estrategia que oriente la decisión de trabajar en alianzas hacia algo más corporativo que de personas. ►Sería importante trabajar con el MIMDES [otras personas dicen que no, porque ha sido demasiado politizado]. ►La Mesa de Concertación de Lucha contra la Pobreza puede ser en algunos lugares una plataforma para la construcción de la Iniciativa de Lavado de Manos. ►La búsqueda de alianzas debiera ser un poco más sistemática. ►Todas las organizaciones tienen que sentir que la Iniciativa es de ellas. ►Los ministerios tienen que tener voluntad de compartir el crédito. ►Colaborar estrechamente con Agua Para Todos, que ya tiene buenos indicadores, incluyendo la práctica de LM, que la Iniciativa puede compartir. ►Además de tener un impacto en diarrea e infecciones respiratorias, considerar que tiene un impacto en desnutrición crónica. Eso puede implicar mirar otros aliados. ►La Iniciativa tiene que comunicarse mejor con sus miembros, tanto como con el público, por ejemplo una página Web interactiva, estado de ejecución, indicadores de progreso, historias de éxito, lecciones aprendidas, entre otras. ►Es necesario identificar socios regionales y locales que ya tengan sus programas que llegan directamente al público. ►La Iniciativa debe dejar que espacio para que cada región desarrolle sus propios métodos. ►Al nivel regional, es esencial identificar “champions”, pues crear propiedad es crítico para firmar compromisos; planear juntos y capacitar. humano, infecciones respiratorias. ►La Dirección Nacional de Educación Comunitaria y Ambiental está abierta a realizar una directiva que describe su colaboración con la Iniciativa. ►Se ha manejado bien. No ha sido tan formal y ha permitido que Gobierno Agencia internacional Global Scaling Up Handwashing Project Fortalezas Tipo de institución Acuerdos institucionales Proyecto bilateral ►PERUTV ha estado acostumbrado a apoyar y participar en alianzas con otras instituciones. interesante pues ha permitido la participación del sector público y privado desde su propio aporte, sin condicionar la participación. 48 ►Con excepción del sector público, los socios trajeron sus propios recursos. ►No se ha informado a las instituciones de lo logrado, para lograr reiterar los acuerdos. ►A partir de los lineamientos de Promoción de Salud se utilizan las láminas de salud e higiene, que responde también a la incidencia de la Iniciativa, pero lo utilizan sin criterio de uso (lo usan también en escuelas que no cuentan con servicio de agua y desagüe). Debilidades ►Podría trabajarse un mapa de relaciones más visual que establezca dónde está ubicado cada actor en el sistema y qué ►En el Comité Nacional también debiera participar el sector privado. ►El MINSA está pensando en comités descentralizados por Regiones o Macro Regiones, que tengan autonomía y legitimidad. ►Evaluar si el Comité Regional Multisectorial podría ser la instancia de apoyo a la Iniciativa en la Región Arequipa. ►Trabajar acuerdos con municipalidades para que prioricen agua y saneamiento en escuelas (PROMSA Arequipa). ►Establecer acuerdos formales con Ministerio de Vivienda y los programas de agua y saneamiento, vinculándolo a la Iniciativa de Lavado de Manos. ►Los acuerdos locales deben partir del análisis de los Planes Regionales de Salud o de las prioridades identificadas por el Consejo Regional de Salud (municipalidad Piura). Recomendaciones ►La generación de alianzas locales se hace más fuerte cuando existe una obra de infraestructura y una distribución de roles muy clara (PAC). ►Así también se podría buscar a la empresa privada agrupada, con el Grupo Empresarios por la Educación que CONFIEP está fomentando y mapeando. ►Existe un espacio que la Iniciativa debiera buscar vinculado a los espacios regionales, como la Coordinadora de Presidentes Regionales (RPP). ►Ganar el apoyo del MINSA es esencial, aunque las autoridades cambian frecuentemente. ►Fortalecer los equipos de trabajo en Ica (PROICA y otros socios) para hacer mejor seguimiento; formar una comisión sobre Lavado de manos. Global Scaling Up Handwashing Project ONG Local internacional ONG ►El MINSA ha tenido una participación adecuada. ►Más socios tienen interés en mejorar la calidad de vida de familias pobres, algunas específicamente en reducir la diarrea. ►La nueva administración gubernamental ha aceptado la Iniciativa, y hay un interés mucho más fuerte del MINEDU. ►Ha sido un enfoque desde el inicio. Por eso la Iniciativa no es percibida como programa del BM sino como una iniciativa del Perú. ►Al nivel local, fueron acuerdos tácitos y funcionaron bien sin muy ayuda de fuera. ►Hay capacidad de adaptación a las necesidades de cada institución. Si se necesita más formalidad (DISAS, municipalidades) se ha trabajado en ese sentido. los procesos sean más fluidos. 49 ►Los acuerdos institucionales podrían ser más claros. Por ejemplo cuando las campañas de comunicación comenzaron, varias organizaciones se sintieron celosas que no eran parte. ►Faltaría involucrar educación y vivienda al nivel nacional. ►En muchos casos la participación activa de una institución no es tanto por las metas de la institución, sino por el interés fuerte de una o dos personas de influencia (factor clave es mas personalista). ►Aunque muchos gobiernos regionales tienen fondos, no saben bien como gastarlos eficientemente (el gobierno ha gastado 12% de sus asignaciones este año). ►Existió confusión durante el proceso porque el MINSA insistió en acuerdos más formales. ►Se recomienda que los acuerdos con las municipalidades sean independientes, de manera que le dé valoración al acuerdo. ►Tener cuidado con algunas instituciones u ONGs locales que participen, porque pueden estar en conflicto con el sector ►Para la siguiente fase promover acuerdos con una serie de instancias como Consejo Nacional de Salud, FOROSALUD, donde se identifiquen a colectivos que trabajan por salud. ►Aprovechar el potencial que tienen los convenios saludeducación regional. ►Se necesitan procedimientos claros, un paso por paso. ►Los acuerdos nacionales no son importantes si las alianzas no funcionan al nivel local. ►Construir una plataforma de discusión para compartir lecciones aprendidas sobre agua y saneamiento, así como promoción de higiene. ►Hay campo para más involucramiento de empresas privadas en las regiones y de ONGs. ►Establecer comités regionales que pueden coordinar lavado de manos en su región y también dirigirse a otras iniciativas a largo plazo. ►Es importante tener un compromiso institucional escrito, especialmente para socios donde el personal cambia frecuentemente. ►Para mantener el entusiasmo hay que medir y divulgar los resultados, de modo que la gente puedan tener confianza que sus esfuerzos hacen una diferencia. ►Con el Cuerpo de Paz se llegó a acuerdo y ahora debería firmarse. produce cada alianza. ►Las organizaciones no gubernamentales hacen lo que prometen. Proyecto bilateral ►El MINSA considera que los productos de la Iniciativa fueron buenos, pero siempre considerando el aspecto de distribución. Gobierno Global Scaling Up Handwashing Project Fortalezas Tipo de Respond. Metodología del programa ►En Ica han trabajado bien informalmente. Sector Privado 50 ►Se sintió que algunas actividades se trabajaron en función a la demanda. Debilidades ►Todavía las autoridades regionales faltan un buen entendimiento de la importancia de lavado de manos. ►Las alianzas son necesarias e importantes pero los socios tienen que contribuir más que palabras lindas. ►Evaluar la experiencia PRONASAR en el área rural: es más fácil promover la práctica en la costa que en zonas más arriba de ►Incentivar a la gente con visitas o viajes de intercambio de experiencias. ►Se debiera contar con un ejército de supervisores que aseguren que las actividades se realicen para que salud y educación lo hagan. Es al principio, luego ya se convierte en una práctica. ►No es recomendable promover lavado de manos donde mucha gente no tiene buen acceso a agua. El impacto será limitado en estas áreas. ►Sugiere que se realicen diagnósticos participativos locales, vinculando a desarrollo humano, calidad de vida. Poner en evidencia que esta Iniciativa contribuye a la nutrición infantil, a la descentralización y a tener familias saludables. ►Es importante trabajar el nivel regional desde un principio, desde la sensibilización, para que en las regiones se sientan “parte de”. Recomendaciones ►Participar en un gran esfuerzo nacional de mejorar el estilo de vida de familias. ►Hacer todo lo posible para que los Presidentes Regionales asuman su responsabilidad hacia lavado de manos y otros aspectos de una vida saludable. ►Formar alianzas más amplias en el nivel nacional, regional y distrital. Cada socio nacional puede involucrar sus redes locales. ►Sería útil orientar a los funcionarios claves sobre sus roles y funciones en relación a lavado de manos. ►En Ica cree importante para sostenibilidad formalizar los compromisos de varias unidades gubernamentales. privado. ►Aborda bien los aspectos básicos y tiene una manera simple ►La metodología ha funcionado bien. ►En general los comités funcionaron muy bien; ganaron varios tipos de pericia y muchos contactos de valor. Los miembros aprendieron uno del otro. ►Funcionó bien, aunque un poco lento. Global Scaling Up Handwashing Project ONG Agencia internacional 51 ►Faltó articulación entre la difusión masiva y el enganche con las acciones interpersonales. ►Se necesita ajustar las expectativas para áreas con diferencias en ►Las actividades han sido muy puntuales. Se necesita una revisión estratégica de la Iniciativa para pensar más al largo plazo y en términos de institucionalización. ►Todos los socios principales tienen que tener la oportunidad de entender, hacer sugerencias y aceptar la metodología para la nueva fase. ►Se debiera dar más énfasis en comunicación interpersonal; diseñar otras actividades para fortalecer actividades interpersonales. ►Los fondos de Gates deben ir a los operadores las agencias ejecutoras, incluyendo la encargada de monitoreo y evaluación, no al MINSA y los socios. ►Se necesita una fase de sensibilización en todas las regiones nuevas. Hay que sentarse con los directores de salud y mostrar cifras sobre como pueden reducir la diarrea. Posiblemente preparar un video o documento con testimonios de líderes de las regiones ya trabajadas. ►Una estrategia importante es capacitación de líderes locales como alcaldes porque la población sigue sus consejos. Los niños también pueden ser agentes de cambio efectivos. ►La comunicación interpersonal debiera estar unida a iniciativas y herramientas existentes, por ejemplo, Municipios Saludables, Escuelas Saludables. ►Medios masivos pueden ser más agresivos en ofrecer tiempo en radio y televisión. ►Se requiere considerar equipos de trabajo descentralizados para el programa. ►Estandarizar más la metodología con procesos y productos más estandarizados. Que exista un menú de posibles actividades que facilite la decisión de los nuevos aliados y su inclusión en una matriz de monitoreo. ►Sugiere trabajar con los actores locales claves y público objetivo, más que a los socios. los 3,500 msnm, debido al clima. Hay que pensar en tecnologías alternativas que faciliten subir la temperatura del agua. ►Muy buena relaciones informales. ►El éxito de la Iniciativa es que ha logrado cosas concretas: investigaciones, manuales, actividades en manuales, material audiovisual. ►Muy participativa y motivadora. Apropiada para la cultura, pues fue muy visual y verbal. de hacer entender los mensajes, lo que lo hace muy replicable. Global Scaling Up Handwashing Project Proyecto bilateral Sector privado ONG Local internacional 52 ►En Ayacucho hubo avances en conocimiento y actitudes pero poco en prácticas. ►Los líderes regionales dan apoyo verbal pero no lo sigue con acción. ►Cada región debe elaborar su propio plan de comunicación y materiales. ►Trabajar mucho más por comunicación interpersonal, especialmente el tipo que estimula a la comunidad a reflejar sobre sus problemas y proponer e implementar soluciones. No depende en medios masivos. ►Para sensibilización se puede abordar desde programas TV como espacio “cabildo abierto” que población puede hacer reclamos y preguntas y el fin de semana va el alcalde a dar respuesta a inquietudes. ►También se propone trabajar lo masivo con un mensaje simple y la profundización de contenidos se trabaje desde programas como consultorios diferentes a diferentes públicos, urbano marginal, otro rural en que se podría poner a hablar a los promotores. ►Usar RPP para alcanzar todas partes del programa; es un fuente muy confiable y salud y nutrición son de mucha interés popular. ►Se debe dar más apoyo en monitoreo. ►En las comunidades identificar al líder, que muchas veces es el médico, para que ejecute la práctica con las mismas personas. La práctica misma con ellos les genera una sensación de autoestima. (Labor de Arequipa). ►Los incentivos que podrían apoyar la implementación del programa son: costo reuniones de sensibilización, certificación oficial para operadores coordinando con educación y salud, logos institucionales en los materiales y premiación a los actores que han logrado mejores resultados. ►En zonas donde no hay facilitad de contar con agua, se puede trabajar adicionalmente el uso que se puede dar al agua jabonosa después de lavarse las manos, como echarla al suelo para que no levante polvo. ►Para obtener apoyo y participación gratuita de otras instituciones, es necesario identificar sus prioridades y engancharlas a lavado de manos. Por ejemplo Cáritas Piura lo enganchó con su eje ahorro del agua. ►Se necesita hacer más visible el tema con espacios en televisión. altura, temperatura, cultura. Global Scaling Up Handwashing Project Agencia internacional ►El Ministerio de Vivienda a través de sus programas PRONASAR en zonas rurales y pequeñas ciudades tiene asegurado fondos hasta el 2008 y se está planificando la convocatoria para el siguiente año. Gobierno ►Desde el MINSA se identifica que hubo capacidad de ejecutar las acciones de la Iniciativa, lográndose elaborar materiales y productos comunicacionales, talleres realizados y personal capacitado. Fortalezas Tipo de Respond. Capacidad de ejecución ►Considerar a los operadores de PRONASAR como posibles aliados en los comités regionales o distritales. ►Hubiera sido necesario más acciones de supervisión y monitoreo. ►La estrategia es identificar y contratar varias organizaciones que pueden, cada una, manejar la implementación en 3 a 5 regiones. ►El aspecto clave es mantener el entusiasmo de los socios; con eso van a proveer los fondos y otros recursos como el tiempo de ►Falta confirmar que todos los actores estén integrando sus actividades. ►Todavía no se ha logrado que los gobiernos regionales publiquen las 53 ►Es necesario trabajar en el nivel local, pero tiene una tremenda necesidad de fortalecer sus capacidades y por ellos quizás sea necesario empezar por ahí. ►El MINSA es muy jerárquico, pues el personal necesita órdenes de arriba antes de actuar. ►Es bueno que para esta segunda fase se contemple medición de impacto, además de resultados. Recomendaciones Debilidades ►Trabajar con los niños, que tienen entusiasmo y que son más abiertos a cambiar. Usar música, drama, y otras tradiciones para crear interés. ►El público tiene más confianza en las organizaciones que dan promoción porque ya han ayudado con infraestructura. ►Combinar la promoción de lavado de manos con programas que mejoran la infraestructura de agua y saneamiento. ►Dar más responsabilidad de planificar e implementar a las organizaciones y estructuras locales. Trabajar mucho más con los gobiernos distritales, que tienen mayor contacto con familias. ►Más allá de los convenios, se necesita buena voluntad. ►Existió capacidad de la institución para diseñar las estrategias, metodologías y aplicarlas. Global Scaling Up Handwashing Project Proyecto bilateral Sector privado ONG local internacional ONG 54 ►La vinculación de quienes operan con las alianzas regionales fue muy básica. ►Las capacidades existen pero la Iniciativa no ha aprovechado de muchos oportunidades de involucrar lavado de manos en los planes de trabajo de varios programas. No ganara mucha atención en agencias gubernamentales como una cosa extra. ordenanzas sobre lavado de manos. Esto es un decreto sobre la Iniciativa que se necesita para tener fondos dirigidos a lavado manos en el presupuesto regional. ►Si el programa se ejecuta en Lima, se puede trabajar en colaboración con los consorcios ya formados por PAC Sedapal. ►La vinculación del MINSA debe estar comprometido más allá de Promoción de la Salud, para lograr como las campañas de vacunación en que se dedican a eso por uno o dos meses. ►Además de la alianza público privada que orienta este trabajo, se deberían identificar grupos de soporte o especializados que apoyen las actividades y le den sostenibilidad (PRISMA). ►Enfatizar el programa en el nivel regional y local, más que en el nacional. Este último puede estar vinculado o muy cercano al aspecto político. ►Es interesante evaluar la capacidad de convocatoria que puede tener una institución, más allá de la firma de un contrato. Algunas, tal como Cáritas, pueden movilizar líderes catequistas. ►Es posible que tiene que adecuarse al ritmo del sector público (más lento). sus profesionales. Global Scaling Up Handwashing Project Proyecto bilateral local ►No debe ser una barrera si la gente usa su creatividad; como vincular lavado de manos con temas como agua segura y abastecimiento de agua. ►Se necesita adaptar los materiales para la región (idioma e imágenes). ►Se necesita agregar nuevas mensajes e información para mantener el cambio de comportamiento y facilitarlo donde existan barreras. Por ejemplo, estrategias cuando falta agua. ►Usar más radio y menos material impreso. ►Se requiere elementos de monitoreo que facilite a las instituciones que apoyan cómo medir las capacitaciones efectuadas y su calidad (Cáritas Piura). ►Desarrollar estrategias distintas para costa, sierra, selva, así como manuales sobre lavado de manos para profesionales de salud. ►Se puede promover que las familias con difícil acceso preparen y usen Tippy Taps para poder lavar las manos con poca agua. ►Se puede solicitar donaciones de jabón de los hoteles en las ciudades más grandes para ser donados a las familias más pobres. Sector privado 55 ►Alrededor de 1/3 de familias no tiene fácil acceso al agua. ►En proyectos que consideren infraestructura, acercar la zona de lavado y no sólo el jabón a la letrina y otro a la cocina para facilitar la adopción de la práctica. ►Promover la participación de promotores de salud con la entrega de incentivos como chalecos, materiales y gorros. Recomendaciones ►Para el nuevo programa se debiera asegurar la entrega de materiales con la ejecución de las actividades de comunicación y fortalecimiento de capacidades. ►Pfizer ha donado jabón a los Voluntarios de Cuerpos de Paz. ►Mas de 90% de las familias se disponen de jabón que puede ser usado para lavado de manos. ►La disponibilidad de zonas de lavado y de agua sí puede constituir un problema para la promoción de la práctica. ►Los promotores muchas veces se cansan de apoyar porque no reciben incentivos. (PROMSA Arequipa) Debilidades ONG internacional ONG Agencia internacional ►Se está evaluando la propuesta técnica de acercar una zona de lavado a las letrinas que PRONASAR promovería. Gobierno ►El jabón no constituye un problema ni en las zonas rurales, pues siempre existe. Fortalezas Tipo de Respond. Disponibilidad de productos y herramientas ►FONDAM tiene 4 tipos de financiamiento para programas como lavado de manos: concursos, co-financiamiento, proyectos especiales (chicos), y proyectos de desarrollo innovadores. Tienen sus prioridades geográficas y técnicas. Gobierno Global Scaling Up Handwashing Project Proyecto Sector privado ONG local internacional ONG Agencia internacional Fortalezas Tipo de Respond. Financiamiento 56 ►Aún cuando tiene los fondos las entidades gubernamentales tienen que pasar por procesos burocráticos pesados para gastarlos. Debilidades ►Cuando el proyecto se presente a la Región se debe solicitar que sea un proyecto especial y que tenga autonomía en el manejo presupuestal, organizacional e institucional. ►Para que haya decisión de apoyar inclusive financieramente se requiere entrar por la nueva Gerencia Regional de Educación, que está muy cercana a orientar la voluntad política del gobierno regional. (Labor) ►Debe existir suficientes fondos en los gobiernos regionales donde reciben canon del las empresas mineras. Para las otras regiones seria bueno hacer abogacía con el Presidente Regional para disponer de algunos recursos. ►USAID tiene un programa de donaciones pequeñas (small grants) que puede apoyar proyectos comunitarios con hasta $2,000. ►Más fondos deben estar disponibles del sector privado y de agencias internacionales como UNICEF y SAVE que trabajan a favor de los niños. ►Identificar el financiamiento de proyectos de agua y saneamiento para poder vincularlos. ►Explorar mayor financiamiento para este programa. ►El MINSA considera que la fuerza está en los gobiernos regionales, con el proceso de descentralización, pues ahora disponen de fondos y debieran priorizar este tema. Recomendaciones ►Escuelas Saludables ha desarrollado una tabla de indicadores que está en el proceso de aprobación final. Gobierno Global Scaling Up Handwashing Project Fortalezas ►El proceso ha sido bien documentado en términos de costos e impacto; pero no específicamente en términos de costo-efectividad de varias actividades, materiales, etc. Fortalezas Tipo de Respond. Monitoreo Proyecto bilateral Sector privado ONG Local internacional ONG Agencia internacional Gobierno Tipo de Respond. Costo eficiencia de la ejecución bilateral Debilidades Debilidades 57 ►Es importante que esté desarrollada desde el diseño del proyecto, con instrumentos precisos y presentados a los socios. Recomendaciones ►Es la responsabilidad del equipo de monitoreo y evaluación. Recomendaciones ►No se ha realizado monitoreo de las actividades de Belcorp. ►PRISMA realizo informes periódicos; los socios monitorean sus actividades; las instituciones que replican talleres envían informes (RPP, CARE, etc.) ►La línea de base y su repetición fueron bien hechos, lo que constituye un aspecto sobresaliente del programa. Global Scaling Up Handwashing Project Proyecto bilateral Sector privado ONG local internacional ONG Agencia internacional 58 ►Ha sido un poco ausente pero ha mejorado recientemente. ►Muchas actividades no han sido evaluadas. ►Los resultados del monitoreo y evaluación deben ser trabajados y compartidos con todos los socios de la Iniciativa. ►El proceso de revisión de indicadores de monitoreo y evaluación podría ser elaborado y/o revisado conjuntamente (RPP). ►Debiera promoverse la participación de la población a través de un monitoreo participativo muy visual que permita medir las condiciones generales y las críticas. La escuela debiera ser un espacio de medición necesario. ►Se necesita mayor monitoreo y medición de resultados. ►Hay que preparar un plan de monitoreo que explique bien su relación con la evaluación de impacto. Hay que incluir requerimientos de informes en los contratos con agencias implementadotes. ►Publicar la evaluación. ►Usar indicadores más sensibles, simplificar los instrumentos, no recoger tantos datos y hacer más observaciones. ►Promover el monitoreo y la evaluación de las actividades, capacitando a los socios en este aspecto y dotando de herramientas simples de monitoreo. Global Scaling Up Handwashing Project Tener flexibilidad ajustar el programa a las realidades en el campo y no tener que seguir la metodología global cuando no funciona bien aquí; no 59 Hacer buenos asesoramientos regionales para identificar los socios, programas y estructuras mejores. Identificar 3 a 5 organizaciones que puedan manejar la implementación en las regiones. Se necesita una buena comunicación entre los muchos socios, con un comité nacional que trabaja bien y puede resolver problemas. Se necesita un buen diseño para una ejecución realista. Incluir el mensaje de poner jabón en todos lugares donde se lavan las manos; usar la repetición de mensajes persona a persona. Realizar un buen esfuerza de crear voluntad política; difusión de resultados; usar muchas canales con los mismos mensajes. Monitoreo y evaluación es sumamente importante. La Alianza debe apoyar los socios en esto, dando herramientas y ayuda técnica. Por ello se necesita coordinar mejor la hora de las acciones de muchos socios para que se apoyen mejor una a otra. Hacer alianzas a partir de iniciativas existentes; uniéndolo con el interés en disminuir la desnutrición. No se crea hábitos nuevos solamente con campañas—necesita una intervención sostenida. No tener una intervención aislada—hacer como parte de un paquete de intervenciones para disminuir la diarrea. Institucionalizar la promoción de lavado de manos. Planificación participativa en todos niveles. Mejor definición de una estrategia que coloca lavado de manos dentro de muchas otras iniciativas relacionado con agua y saneamiento y salud infantil a todos niveles. AGENCIA INTERNACIONAL Emitir en horas para el lugar (5/6 a.m. en el campo) con productos adecuados a los padrones culturales de cada región. Ajustar los productos o servicios para responder; usar radio local, teatro popular, títeres para los niños, no TV. Antes de implementar, dar la oportunidad para los beneficiaros explicar sus vidas, esperanzas, deseos. Focalizar; asegurar que las áreas del programa tiene acceso a agua. PROGRAMA INTER-GUBERNAMENTAL Tener en evaluación que cuando existe caño facilita más la práctica, que entregando lavatorios y jarras. Revisar las condiciones de lavado en zonas de altura, mayor a 3,500 msnm Asegurar que las zonas de lavado como infraestructura existan o se promueva su construcción para facilitar la práctica. La construcción conjunta de la propuesta facilitaría que los actores nacionales y regionales se apropien de la propuesta, poniendo en evidencia que son parte del problema y de la respuesta. GOBIERNO Factores más importantes para las condiciones de éxito Global Scaling Up Handwashing Project Source: Summary of the team’s interviews in Peru. 60 Juntar promoción de lavado de manos con programas de infraestructura de agua y saneamiento puede ser muy efectivo porque los mejoramientos físicos crean confianza de la población a la organización ejecutora. Tiene que ajustar la promoción dependiendo en el acceso a agua que las familias tienen. La Iniciativa tiene que hacer muchos esfuerzos a crear compromisos y colaboración al nivel regional y distrital por muchos socios de varios sectores. PROYECTO BILATERAL Ayudar a todos con monitoreo. Hacer una línea de base. Trabajar más con comunicación alternativa como pasacalle, teatro, títeres. Proveer evidencia que los cambios de comportamiento están aconteciendo. SECTOR PRIVADO Tener un enfoque más amplio hacia desnutrición y pobreza. Explorar las mesas de concertación como alianzas locales que ya existan. Trabajar lo más posible al nivel local. La alianza público/privada es esencial porque el sector público solo no puede tener los resultados. ONG LOCAL Buscar la relación con las16 mineras que están orientando sus acciones de responsabilidad social, a través de la creación de Fundaciones. La Iniciativa tiene que general opinión publica favorable. Se necesita buenas alianzas, financiamiento, recursos humanos, un símbolo unificador. Pensar no en una campaña sino en actividades continuas. Simplicidad; claridad de roles; mecanismos de reconocimiento; retroalimentación oportuna. ONG INTERNACIONAL dejar los requerimientos de monitoreo y evaluación condicionen la ejecución. Fecha Tiene una meta y objetivos claros y entendibles en todos La iniciativa de lavado de manos, incluyendo el programa: POLÍTICA, ESTRATEGIA, Y DIRECCIÓN Maque con "X" el numero que mejor refleja su respuesta a cada pregunta o frase. Instrucciones: 0 1 1 6 61 2 área en esta mejorar mucho Excelente Se necesita __1_ nacional __3_regional ___3_ provincial __6__ distrital __4_ local _____1________ otro A qué nivel se ha vinculado con el programa? __5_ tomador de decisiones ___3_ejecutor __3__supervisor/gerente ____3_________ otro Global Scaling Up Handwashing Project 1 I. __2__ entre 1 y 2 años Cuál es su papel en su organización? __2__Entre 6 meses y un año ___5__ Más de 1 año Hace cuánto tiempo está involucrado en este programa? Nombre de la organización: APPENDIX D: ENCUESTA SOBRE LAS CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN: 10 RESPUESTAS 0 0 0 0 0 Tiene un plan completo formulado Tiene miembros que entienden su estrategia de larzo plazo Tiene un plan formulado para guiar sus esfuerzos. Tiene políticas y procedimientos que hace posible cambiar la manera cómo se hacían las cosas Tiene una visión que es comprendida en todos los niveles Se destacan los esfuerzos exitosos que pueden ayudar a reforzar la visión Tiene líneas de autoridad claras Puede implementar su visión de manera efectiva Puede llevar su visión a sus miembros y sus comunidades ALIANZAS 5 6 7 8 9 10 11 12 13 II. 0 Tiene la capacidad de ofrecer el apoyo requerido por sus miembros para implementar el programa? 62 Insatisfecho 0 0 0 0 Está satisfecho con que el programa, porque … Global Scaling Up Handwashing Project 1 0 Ha trabajado en pro de establecer políticas favorables 4 0 Establece hitos y alianzas que apoyan sus objetivos 3 0 Ha establecido un visión y estrategia compartidas 2 los niveles 1 Algo insatisfecho 0 0 1 1 0 1 0 1 0 1 1 0 1 Neutral 2 3 1 2 4 2 3 0 3 2 1 3 5 Satisfecho 6 4 6 5 5 4 5 7 5 5 4 7 3 satisfecho Muy 2 3 2 2 1 3 2 2 2 2 4 0 1 0 0 0 Totalmente en desacuerdo 0 0 0 Busca activamente conseguir nuevos contactos en el transcurso del tiempo? Utiliza sus contactos y relaciones? Actúa en una manera abierta e inclusiva? Es eficiente y productivo, enfocado en resultados? Se asegura que se disponga de suficientes recursos para que los miembros alcancen sus objetivos? Brinda suficiente orientación a sus miembros? En este programa, La colaboración y el sentido de equipo juegan un papel important en el desarrollo del programa. Los miembros están involucrados en encontrar soluciones a los desafios del programa. El aprendizaje es parte del trabajo y luego se convierten en tareas de rutina 7 8 9 10 11 12 13 14 15 Global Scaling Up Handwashing Project En 0 Tiene varios contactos fuertes en el sector gubernamental? 6 0 63 1 1 Tiene varios contactos fuertes con ONGs, grupos sociales? 5 1 0 Tiene varios contactos fuertes en la empresa privada? 4 0 0 0 desacuerdo 1 1 1 0 0 1 1 3 2 0 Tiene amplios contactos que puede motivar a ayudar la iniciativa, p.e. adogados, banqueros, etc.? 3 1 0 Cuenta con la cooperación y apoyo de sus miembros? 2 3 3 1 Neutral 2 1 2 2 3 3 3 1 2 5 1 4 4 4 De acuerdo 5 5 5 5 3 4 2 3 2 0 6 3 3 5 de acuerdo Fuertemente 2 3 2 2 3 2 4 4 3 3 2 0 Los miembros están involucrados en encontrar soluciones a los desafios del programa. Se comparte el crédito del éxito Los socios se benefican con la colaboración. ACUERDOS INSTITUCIONALES 17 18 19 III. 0 0 0 0 0 Fomenta que todos los miembros propongan soluciones a problemas. tiene disponible información presupuestario actual para avaluar gastos del proyecto. Tiene la costumbre de proveer las herramientas/recusos necesarios para apoyar iniciativas. Tiene la costumbre de comunicarse con todos los niveles. tiene una historica de identificar y resolver problemas. Sigue un proceso claro de toma de decisiones para nuevas iniciativas. 3 4 5 6 7 8 Global Scaling Up Handwashing Project 0 Continuamente busca entender las necesidades de sus miembros con encuestas y entrevistas. 2 64 0 Incluye la retroalimentación de los clientes en la generación de nuevas ideas 1 0 desacuerdo El programa: Totalmente en 0 0 0 Se fomenta equipos con representación de varios sectores. 16 1 1 2 0 1 0 1 1 desacuerdo En 0 0 0 0 2 4 2 2 4 3 2 2 Neutral 1 2 2 1 6 5 3 5 2 6 5 5 De acuerdo 5 3 5 6 1 0 3 3 3 1 2 2 de acuerdo Fuertemente 4 5 2 3 0 0 0 mejorar mucho El programa: Usa technología para mejorar la eficiencia de sus actividades Cuenta con un conjunto de tecnología informática para sus necesidades, ej. Base de datos, programas, etc. Entiende la importancia de la tecnología informática como una herramiento estrategica y para mejorar el programa Capacitación El programa: 1 2 3 B. mucho 0 El programa: Realiza una evaluación de destrezas como parte del proceso de planificación. Global Scaling Up Handwashing Project 6 mejorar Destrezas/Capacidades C. 65 Se necesita 0 Brinda oportunidades a asistir capacitaciones. 5 0 Apoya la capacitación de sus miembros. 4 Se necesita Mejorar mucho Tecnología A. 1 0 0 0 1 1 Se necesita CAPACIDAD DE IMPLEMENTACIÓN IV. 0 Tiene las personas apropiadas a cada cargo y tarea. 9 0 5 3 0 4 4 3 3 4 3 6 3 3 4 6 0 área en esta Excelente 4 4 área en esta Excelente 3 2 2 en esta área Excelente 1 MONITOREO V. Determina lo que cada unidad operativa contribuye al valor del programa 6 Global Scaling Up Handwashing Project Hace seguimiento de los resultados 5 0 0 3 Tiene actividades que estado conectadas a los esfuerzos por capturar lecciones. Tiene un plan y método para recoger lecciones claves y divulgarlas 2 4 0 Ha desarrollado métodos para recoger y usar retroalimentación sobre las actividades del programa. 1 0 0 Se esfuerza continuamente a avaluar las necesidades de los beneficiarios a través de encuestas cortas y entrevistas. a sus miembros y otras personas interesadas de manera continua mucho Este programa: 66 2 2 1 1 1 0 1 3 4 3 4 2 2 3 3 3 5 4 6 5 4 1 1 2 1 3 0 1 0 0 área en esta 0 Provee a los miembros con habilidades y recursos para que logren sus resultados 10 1 1 5 mejorar 0 Es capaz de desarrollar las destrezas necesarias en sus miembros actuales. 9 3 2 Ya excelente 0 Puede contratar a pesonas con las destrezas que se necesitan. 8 2 Se necesita 0 Tiene suficientes recursos dedicados a proveer oportunidades regulares para desarrollar destrezas. 7 1 0 0 1 2 1 1 1 Utliza las redes de las empresas para informar y divulgar los resultados logrados Revista sus metas cada año y espera ver mejoras cada año Tiene un sistema de información que está alimentado por los resulados en los beneficiarios Mide la satisfacción de los beneficiarios al menos trimestralmente Adapta los servicios y actividades a la retroalimentación de los beneficiarios Ha establecido indicadores para medir la satisfacción de los beneficiarios Vincula sus procesos internos al impacto programático Desarrolla métodos simples de recolección de información para uso de los beneficiarios Tiene un plan comprensible de monitoreo y evaluación 7 8 9 10 11 12 13 14 15 1 0 Tiene escritas las medidas e indicadores de desempeño del programa. Sí No 4 Mide el impacto de sus servicios y actividades en sus beneficiarios. Sí No 2 16 17 Global Scaling Up Handwashing Project mucho Para lo siguiente, favor indicar si lo tiene. En caso sea positivo, evaluarlo. 67 0 0 0 0 5 3 1 0 0 1 0 0 2 1 1 0 0 0 área en esta 3 5 4 3 5 4 2 4 2 5 mejorar 3 2 3 3 1 3 3 3 3 2 Ya excelente 1 1 1 1 1 1 2 1 2 1 Se necesita 1 1 y lo comunica a los miembros. 0 0 0 0 0 Ha establecido medidas e indicadores de resultados. Sí No 3 Ha probado y adaptado herramientas para medir ressultados. Sí No 3 Ha probado y adaptado herramientas para medir el desempeño del programa. Sí No 4 Ha probado y adaptado herramientas para medir procesos de implementación. Sí No 3 Ha probado y adaptado herramientas para medir el impacto del programa. Sí No 5 19 20 21 22 23 Global Scaling Up Handwashing Project 0 Ha establecido un medidas e indicadores de procesos. Sí No 3 18 68 0 0 0 0 0 0 1 1 1 1 1 1 1 2 1 2 2 4 1 1 1 1 2 0 APPENDIX E: LAS CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN. GUÍA DE ENTREVISTA Fecha de la entrevista ____________________________________________________ Nombre del entrevistador _________________________________________________ Nombre del entrevistado __________________________________________________ Cargo __________________________________________________________________ Rol del entrevistado (tomador de decisión, ejecutor, supervisor) ________________________________________________________________________ Tipo de organización (sector público, privado, ONG) __________________________ Alcance de la organización (nacional, varias regiones, regional, distrital, comunal) ________________________________________________________________________ Introducción (5 minutos) Introducción Agradecimiento por el tiempo otorgado Propósito de la entrevista Explicación de la confidencialidad de la entrevista, no se usará el nombre u otro dato de identificación Información de la existencia de preguntas. Apertura (10 minutos) Solicitar información acerca de la importancia de lavado de manos Solicitar información acerca de la institución a la que pertenece, lo que hace en relación a lavado de manos y los planes que tienen respecto a este tema. 69 Global Scaling Up Handwashing Project Nota importante: Aclare si la pregunta se refiere al nivel nacional, regional, o local o a varios niveles. Política, estrategia y dirección (Gobierno, Agencia Int., ONG Int., ONG Local, Sec. Privado, Proj. Bilat.) ►Qué tan sólida ha sido la voluntad política (nacional, regional, local) para promover el lavado de manos? ► Qué sugerencias tendría para mejorarla en un programa a escala ampliada? ►¿En su opinión cuánto ha dispuesto la Iniciativa de una visión y estrategia compartida que asegure la voluntad política? Explique. ►¿Tiene Ud. sugerencias sobre cómo este aspecto podría ser fortalecido en el programa expandido? ►Esta visión y estrategia fue desarrollado de una manera participativa? ►¿Tiene Ud. sugerencias sobre como este aspecto puede ser fortalecido en el programa expandido? Alianzas (Gobierno, Agencia Int., ONG Int., ONG Local, Sec. Privado, CBOs, Media, Proj. Bilat.) ►¿Cuán efectivas han sido las alianzas público privadas al nivel nacional y regional? ►¿Cree Ud. que los miembros de la alianza han tenido metas complementarias y cómo han funcionado? ►¿Cree Ud. que los miembros han compartido los riesgos, el poder, así como los resultados o procesos? 70 Global Scaling Up Handwashing Project ►¿Las alianzas han sido construidas en todos los niveles entre los sectores público, privado y ONGs? ►¿Tiene Ud. sugerencias sobre como estas alianzas pueden ser fortalecido en el programa expandido? 3. Acuerdos institucionales (Gobierno, Agencia Int., ONG Int., ONG Local, CBOs, Media, Proj. Bilat.) ►¿Cree que las instituciones que participan en la Iniciativa de Lavado de Manos en todos los niveles claramente entienden sus roles, responsabilidades y autoridad? ►¿Cree que los socios contaron con los recursos para llevar a cabo sus roles? ►Cree que los socios para un programa a escala ampliada podrían contar con los recursos necesarios? ►¿Tiene Ud. sugerencias sobre cómo se puede disponer de mas recursos para complementar el financiamiento de Gates en el programa a escala ampliada? ►¿Cuán adecuados han sido los acuerdos institucionales en definir los mecanismos o procedimientos para los actores coordinar sus actividades? ►¿Tiene Ud. sugerencias sobre cómo este aspecto puede ser fortalecido en el programa a escala ampliada? Metodología del programa (Gobierno, Agencia Int., ONG Int., ONG Local, CBOs, Media) La metodología del programa consiste en las reglas del programa, actividades específicas y su secuencia y cronograma. 71 Global Scaling Up Handwashing Project ► ¿Qué opina sobre la metodología de trabajo de la Iniciativa? ►¿Tiene Ud. sugerencias sobre cómo mejorar la metodología en el programa a escala ampliada? ►¿Cree Ud. que la metodología ha sido clara y acordada por los socios? ►¿Tiene Ud. sugerencias sobre como tener certeza que la metodología es clara y acordada por los socios en el programa a escala ampliada? Capacidad de ejecución (Gobierno, ONG Int., ONG Local, Sec. Privado, CBOs) En la capacidad institucional se considera aspectos como recursos humanos con las capacidades y habilidades requeridas para ejecutar sus funciones, una estructura organizacional dentro de la institución, un manejo de la metodología acordada, sistemas y procedimientos requeridos para su implementación y la habilidad para monitorear el programa y hacer los ajustes oportunos. ►¿Cree Ud. que al nivel nacional los socios de la Iniciativa han tenido la capacidad institucional para llevar a cabo sus roles y responsabilidades? ►¿Cree Ud. que al nivel regional los socios de la Iniciativa han tenido la capacidad institucional para llevar a cabo sus roles y responsabilidades? ►¿En el programa a escala ampliada, cree Ud. que hay uno o más aspectos de capacidad institucional que se necesita fortalecer en cualquier nivel? ►[Si sí] ¿qué sugerencias tendría al respeto? 6. Disponibilidad de productos y herramientas (ONG Int., ONG Local, Sec. Privado, CBOs) ►¿Cree Ud. que la Iniciativa ha provisto de los productos y herramientas que respondan a las preferencias del público objetivo y su decisión y habilidad para pagar por ellos? 72 Global Scaling Up Handwashing Project ►¿En el programa a escala ampliada, cree Ud. que hay uno o más aspectos de productos apropiados que se necesitará fortalecer en cualquier nivel? ►[Si sí] ¿qué sugerencias tendría al respeto? Financiamiento (Gobierno, ONG Int., CBOs) ►¿Han sido suficientes los acuerdos para el financiamiento de los costos del programa? ►¿Tiene Ud. sugerencias sobre como se puede disponer de mas recursos para complementar el financiamiento de Gates en el programa expandido? Costo eficiencia de la ejecución (Gobierno, ONG Int.) ►¿Los socios han tenido los sistemas y procedimientos para recoger y analizar la información requerida para un análisis de costo eficiencia? ►¿Tiene Ud. sugerencias sobre cómo se puede fortalecer esta capacidad en el programa a escala ampliada? Monitoreo (Gobierno, ONG Int., Sec. Privado, CBOs) Un monitoreo eficiente permite identificar las fortalezas y debilidades en la metodología del programa, su ejecución y costo-eficiencia. ►¿Cómo ha sido el proceso de monitoreo en la Iniciativa? ►¿La responsabilidad ha sido clara? ►¿Tiene Ud. sugerencias sobre cómo se puede fortalecer esta capacidad en el programa a escala ampliada? 73 Global Scaling Up Handwashing Project ►¿Tiene Ud. sugerencias sobre como se puede tener suficiente capacidad de recoger información recogida en el nivel comunitario o distrital? Cierre (5 minutos) ¿Cuál sería el factor más importante que permitiría que el proyecto logre sus objetivos? ¿Cuál sería el aspecto clave que debiera realizarse con el fin de generar las condiciones para que el proyecto tenga éxito y se pueda trabajar a escala ampliada? ¿Hay una o dos otras personas en [la organización] que pudieran responder a unas preguntas sobre el tema por correo electrónico? Ellos pueden hacerlo en 10 a 15 minutos. Podría darme sus direcciones de correo electrónico? Nombre Cargo Correo electrónico Gracias por su tiempo. 74 Global Scaling Up Handwashing Project APPENDIX F: ESTUDIO DE CONDICIONES PARA LA EXPANSIÓN DEL LAVADO DE MANOS CON JABÓN (GUÍA DE ENTREVISTA PARA SOCIOS POTENCIALES) Primera versión en español Este cuestionario ha sido creado para ser usado por el equipo del estudio de condiciones para la expansión de lavado de manos con jabón. Fecha de la entrevista ____________________________________________________ Nombre del entrevistador _____________________________________________________ Nombre del entrevistado _____________________________________________________ Cargo ______________________________________________________ Rol del entrevistado (tomador de decisión, ejecutor, supervisor) ______________________________________________________ Tipo de organización (sector público, privado, ONG) ______________________________________________________ Alcance de la organización (nacional, varias regiones, regional, distrital, comunal) ______________________________________________________ Introducción (5 minutos) Introducción Agradecimiento por el tiempo otorgado 75 Global Scaling Up Handwashing Project Propósito de la entrevista Explicación de la confidencialidad de la entrevista, no se usará el nombre u otro dato de identificación Información de la existencia de preguntas. Apertura (10 minutos) Solicitar información acerca de la importancia de lavado de manos Solicitar información acerca de la institución a la que pertenece, lo que hace en relación a lavado de manos y los planes que tienen respecto a este tema. Dimensiones de la entrevista (50 – 60 minutos) Usar el cuestionario anexo. Encuestas (10 -15 minutes) Usar en la medida de las posibilidades de los actores. Política, estrategia y dirección (Gobierno, Agencia Int., ONG Int., ONG Local, Sec. Privado, Proj. Bilat.) ¿Qué tan conscientes están los tomadores de decisión sobre la importancia del lavado de manos con jabón en reducir la diarrea y las infecciones respiratorias agudas? ¿Sabe qué dicen los resultados de los estudios de lavado de manos con jabón? En caso sea así, qué recuerda? (Si no sabe, explíqueselo). ¿En qué medida existe una voluntad política para promover el lavado de manos con jabón (en el nivel apropiado al entrevistado)? ¿Conoce usted algún decreto o política o norma que el gobierno o las organizaciones privadas hayan efectuado para promover lavado de manos en esta región. Si no es así, piensa que estas políticas serían posibles de efectuarse? ¿Su organización ha participado en programas de salud infantil en esta Región? 76 Global Scaling Up Handwashing Project ¿Su organización ha participado en la promoción de lavado de manos en esta región? Si es así, por favor descríbalo y explique qué tan exitoso ha sido. ¿Qué tan importante es la promoción de lavado de manos en su organización, comparado con otras iniciativas de salud? Si varias organizaciones se reunirían en una iniciativa de promoción de lavado de manos, ¿quiénes serían los decidores y de quién se requeriría apoyo? Agradeceríamos nos indique qué organizaciones, individuos o agencias podrían actuar como catalizadores o líderes de la promoción de lavado de manos en la región. Voy a mencionar varios tipos de organizaciones. Para cada tipo, mencione cuáles piensa podrían ser las más interesadas y con recursos para contribuir a la promoción de lavado de manos. Actividades o contribución financiera actual a lavado de manos Sector público ONGs Sector privado 77 Global Scaling Up Handwashing Project Tipo de recurso que podría dar en apoyo a la iniciativa Actividades o contribución financiera actual a lavado de manos Tipo de recurso que podría dar en apoyo a la iniciativa Medios de comunicación Otros proyectos de agua y salud Organizaciones de base Alianzas (Gobierno, Agencia Int., ONG Int., ONG local, Sector privado, medios de comunicación, proyectos bilaterales). ¿Existen diferentes tipos de organización en la Región que estén interesados y tengan las capacidades para trabajar como socios en programas que beneficien a las madres y los niños? Dé ejemplos. 78 Global Scaling Up Handwashing Project ¿Cómo describiría la calidad de las alianzas entre los gobiernos locales y las ONGs? ¿Cómo podría mejorarse? ¿En qué medida los roles, responsabilidades y expectativas están claras y acordadas en estas alianzas? ¿Cómo describiría las relaciones que se establecen entre las ONGs y las comunidades en que trabajan? ¿Cómo podrían mejorarse? ¿Qué alianzas en esta Región supo utilizar el potencial de las alianzas estratégicas entre el sector público, privado, las ONGs y las organizaciones en el nivel local y nacional? Si es así, ¿cómo se llegó a realizar? ¿Qué necesitaría ser explorado? Acuerdos institucionales (Gobierno, Agencia internacional, ONG internacional, ONG local, organizaciones de base, medios de comunicación, proyectos bilaterales) ¿Hay ejemplos de alianzas establecidas con objetivos en salud? Si es así, ¿qué tan bien los diferentes grupos trabajaron en…. Planificación Ejecución Capacitación Monitoreo y evaluación? ¿En qué medida los acuerdos estuvieron claramente definidos? ¿Tiene mecanismos establecidos para coordinación entre los socios más importantes? Si es así, ¿cómo están trabajando estos mecanismos? ¿Cómo podrían mejorarse? ¿Tiene idea en cómo establecer o mejorar los mecanismos de coordinación entre las diferentes organizaciones y niveles de ejecución para un programa de lavado de manos a escala ampliada? 79 Global Scaling Up Handwashing Project Capacidad de ejecución (Gobierno, ONG internacional, ONG local, sector privado, organizaciones de base) ¿Qué habilidades, métodos, herramientas y recursos humanos piensa que podría requerirse para ejecutar un programa de lavado de manos en esta Región? ¿Qué recursos ya existen localmente, de manera que pueda apoyar la capacidad requerida? Qué está faltando? Financiero Bienes Humanos Capacitación Tecnología Otro ¿En qué medida existe una adecuada capacidad para planificar y ejecutar promoción de la higiene el sector público? ¿Y entre las ONGs? ¿Entre otros grupos o socios? Por favor describa un programa de promoción de higiene o salud en esta Región que considere exitoso? ¿Qué lo hizo exitoso? ¿Cómo se involucró al sector privado (agencias de publicidad, etc.) en el programa de salud o higiene? 80 Global Scaling Up Handwashing Project Para usar SOLO en caso que se necesite continuar con la entrevista: ¿Hay capacidad desarrollada en el nivel local para abordar la ejecución del programa y monitorear los cambios a nivel de los hogares y comunidad? Si es así, describa. ¿En qué medida existe una adecuada capacidad en el sector privado para otorgar bienes y servicios y responder a las preferencias de los consumidores? ¿Será el sector privado capaz de responder a la demanda creciente en tanto el programa de lavado de manos se desarrolle en gran escala? Disponibilidad de productos y herramientas (ONG internacionales, ONG locales, sector privado, organizaciones de base) ¿En qué medida las siguientes dimensiones de mercadeo de lavado de manos necesitarían ser fortalecidas? Producto: ¿Qué productos que lavado de manos con jabón están disponibles, dónde y cómo? Se consideran productos al jabón, recipientes para almacenar agua, elementos para tener agua segura. ¿En qué medida siente que esos productos ofrecidos responden a la demanda del consumidor? Precio: ¿En qué medida la gente de menores recursos tiene dinero para comprar productos para lavarse las manos con jabón? ¿El costo de los productos corresponden a la capacidad y deseo de pago del público? Ubicación: ¿Qué tan disponibles están los elementos esenciales cerca de las comunidades pobres? ¿Qué cadenas de producción han sido establecidas para responder a la demanda de los hogares? ¿Existen planes en la actualidad que puedan fortalecer las dimensiones de producto, precio y ubicación? 81 Global Scaling Up Handwashing Project ¿En qué medida es común la preparación de jabón en algunas áreas? ¿Existen programas que promuevan el uso de este tipo de jabón para lavado de manos? Financiamiento (Gobierno, ONG internacionales, organizaciones de base) ¿Qué organizaciones posiblemente podrían contribuir al financiamiento de los costos programáticos de implementar un programa de lavado de manos a escala ampliada? (Costos como salario de personal, capacitación, transporte, etc.) ¿En qué medida las actividades de promoción ya están incluidas en los presupuestos regionales, provinciales y distritales? ¿Cómo han contribuido los socios del sector privado a las campañas públicas de salud?, ¿con dinero en efectivo o en servicios? Monitoreo (Gobierno, ONG internacional, sector privado, organizaciones de base) ¿Existen en la actualidad programas en esta región que tengan un buen proceso de monitoreo para medir la efectividad de los programas y sus resultados? Si es así, ¿cómo lo hacen? ¿Qué instituciones del sector público, privado y las ONGs están presentes para conducir varios tipos de estudios (cualitativo, cuantitativo, etc.), y cuál es su capacidad (en términos de habilidades técnicas que podrían están disponibles para lavado de manos con jabón? ¿Qué mejoras técnicas, administrativas o financieras son necesarias para asegurar que los actuales sistemas de monitoreo son adecuados para apoyar un programa a gran escala? ¿Cuáles serían los costos de estas mejoras? ¿Qué incentivos se requieren para lograr el enganche y la diseminación de los resultados de las actividades de monitoreo? ¿Qué podría fortalecer la valoración del monitoreo? 82 Global Scaling Up Handwashing Project APPENDIX G: INFORME DE VIAJE A PIURA Fecha 17 y 18 de mayo del 2007 Realizado por Mike Favin Consultor internacional Doris Alfaro Consultora local Instituciones entrevistadas Giovanna Bisso Gerente de Educación y Cultura Municipalidad de Piura Teodora Miranda Coordinadora de PRONOEI Ana Turves Participante Cuerpos de Paz en Catacaos Omar Palacios Jefe de la Oficina de Población, Salud e Higiene Municipalidad de Piura Dr. Carlos Bayona Sub Director DIRESA Piura Carolina Aguilar Encargada área social CARE Piura Juan Manuel Cendra 83 Global Scaling Up Handwashing Project Secretario General Cáritas Piura Deysi Cheros Presidente Comisión salud, salubridad y saneamiento Municipalidad distrital de Catacaos Eleuteria Cruz Jefa Asuntos comunales y sociales Municipalidad distrital de Catacaos Jenny Portocarrero Relaciones Públicas Sub Región Salud Sullana Principales hallazgos por tipo de institución Sector salud Existe un marcado interés por participar en acciones vinculadas a la Iniciativa de Lavado de Manos. No ha sido evidente un involucramiento directo de la DIRESA con la Iniciativa, aunque sí conoce de la realización de actividades que sí se han realizado en la Región. Existe un nicho interesante a partir de Escuelas Saludables y dentro de las campañas de promoción de la salud en las escuelas. Se puso en evidencia la necesidad de dar incentivos (como capacitación, certificados o movilidad) a los promotores de salud para asegurar la llegada continua a la población. No es difícil asegurar la voluntad política para lavado de manos. El Presidente Regional apoya muchas iniciativas de salud y existen ordenanzas relacionadas a disminuir la desnutrición crónica o a mejorar la gestión del Vaso de Leche. Las autoridades recuerdan mucho la importancia del lavado de manos durante la epidemia del cólera. 84 Global Scaling Up Handwashing Project Sería importante buscar involucramiento con MINED y con el Programa Juntos que trabaja en regiones de extrema pobreza y está apoyando en solventar un profesional en cada establecimiento de salud (54 profesionales), con fondos de la Presidencia de Consejo de Ministros. La elaboración y aprobación del Plan Regional Concertado de Salud constituye una oportunidad para que el tema sea asumido por todas las instituciones de la Región. Están empezando a trabajar este proceso. Gobierno municipal provincial Existe una marcada diferencia entre el involucramiento de la Municipalidad de Piura de la Oficina de Salud, Población y Ambiente, frente a la Gerente de Educación y Cultura. En el primer caso se realizó una capacitación al personal de la municipalidad, pero no se realizó seguimiento posterior. Se señaló que no existiría ningún problema en involucrar al alcalde. Les pareció muy adecuada la dinámica y el enfoque participativo del taller. Se sugirió trabajar una coordinación posterior a través del programa de Municipios Saludables. En el segundo caso, ha sido muy interesante el trabajo en capacitación con los PRONOEI, llegando a 1,273 niños menores 5 años. La metodología fue muy aceptada por las promotoras de los PRONOEI y han trabajado las seis sesiones, aunque señalan que requerirían un refuerzo. Los salones de los PRONOEI tienen sus rincones de aseo instalados. Sugieren que al inicio se considere siempre una sensibilización a las personas que serían las encargadas de realizar el seguimiento. Sugieren que se trabajen campañas agresivas, en que el mensaje llegue por todos lados y de manera muy lúdica, como canciones. Gobierno municipal distrital Trabajó de manera consensuada con las líderes del Vaso de Leche (cada uno entre 30 – 50 miembros), a quienes se les encargó la capacitación, así como el monitoreo en cada grupo y comedor popular. Acostumbran trabajar en alianzas con el sector público y privado en el distrito. 85 Global Scaling Up Handwashing Project Refuerzan la práctica con el lavado de manos antes de comer en los comedores y antes de recibir los alimentos en las reuniones del Vaso de Leche. Han trabajado con incentivos como entrega de ropa a madres. Sugieren que se establezcan fichas y guías para saber cómo hacer un monitoreo más cercano y eficiente. Encuentran que puede ser más interesante trabajar con niños, quienes pueden asumir muchos comportamientos. Agencia internacional A partir de una capacitación de pocas horas se abocó a trabajar con las familias de una comunidad en Catacaos. Funcionó lavado de manos cuando lo vinculó a un proyecto concreto, como de cocinas mejoradas. Para recibir la cocina la familia debía saber los momentos críticos de lavado de manos. Encontró más entusiasmo y posibilidad de trabajar este tema con los niños y las profesoras. Sugeriría capacitar a los que trabajan con población qué aspectos o respuestas dar para motivar más. ONG Internacional La supervisión del proyecto que realizan con PRONASAR muestra que alrededor del 30% de las familias saben los 5 momentos críticos, frente a un 0% inicial, y el 35% aplica la técnica correcta de lavado de manos, a través de la observación (agua a chorro, lavado con jabón, secado con toalla). Se ha podido definir roles y planes de trabajo con los establecimientos de salud y escuelas. Un aspecto a considerar que han sabido mantener a las municipalidades totalmente informadas de los avances. Contar con un equipo de capacitadores pagados por el proyecto facilita la promoción de la práctica en las familias (1 x 300 familias). Se consideró necesario incluir el secado con toalla como un tema adicional (por la existencia de mucho polvo en la zona). Sugieren que los videos sean más cercanos a la realidad socio cultural de las zonas. Indican que debiera trabajarse un material que quede en las familias. 86 Global Scaling Up Handwashing Project Recomienda que primero se fortalezcan las capacidades de las personas que trabajarán lavado de manos con la población. 87 Global Scaling Up Handwashing Project APPENDIX H: CONDICIONES PARA LA PROMOCIÓN DE LAVADO DE MANOS Informe de viaje a Arequipa Fecha 28 y 29 de Mayo del 2007 Realizado por Mike Favin Consultor internacional Doris Alfaro Consultora local Instituciones entrevistadas Germán Robles Especialista Gestión Educativa y Ambiental Dirección Regional Educación Arequipa Sonia Sánchez Gerente Gestión Social Municipalidad de Arequipa Aníbal Díaz Autoridad Regional de Medio Ambiente Gobierno Regional de Arequipa Haydee Rodas Mariela Díaz Lourdes Benavides Zula Carpio Mary Ann Zeballón Promoción de la Salud DIRESA Arequipa Oswaldo Vizcarra Director de Prensa 88 Global Scaling Up Handwashing Project César Portillo Gerente de Producción Jorge Béjar Coordinador Arequipa ONG Labor Oscar Toro Coordinador Arequipa ONG DESCO Martín Cotrina Gerente Cámara de Comercio e Industria de Arequipa Pablo Manrique Secretario General Cáritas Arequipa Resumen El viaje se realizó en un momento clave de la reorganización del gobierno regional y por ende de las instituciones de salud y educación. En el marco de la descentralización, Arequipa es la primera Región que ha decidido eliminar la gerencia de desarrollo social para convertir la DIRESA en Gerencia de Salud y la DREA en Gerencia de Educación. La intención es evitar duplicidades de funciones y áreas y tener más posibilidad de implementar programas, con menos carga burocrática. Un aspecto a considerar es que el 80% de la población de la Región se encuentra en Arequipa, con facilidades de accesibilidad y el 20% restante está en las otras 7 provincias, siendo algunas muy lejanas. Sin embargo, existen comunidades andinas distantes que requieren con urgencia programas de desarrollo social y económico. La recomendación sería que la Iniciativa trabaje en ambos tipos de áreas. En las rurales sería interesante que se enganche a programas u ONG existentes. Respecto al interés por participar en la Iniciativa Lavado de Manos, es muy positiva la reacción de los representantes de las instituciones aunque el conocimiento sobre los beneficios sea todavía 89 Global Scaling Up Handwashing Project muy limitado. Todos creen que la Iniciativa podría ser incluida en actividades existentes como proceso, sin pensar en campaña, lo cual es alentador. Ninguno de los entrevistados pudo brindar un ejemplo de un programa efectivo de cambio de comportamiento en la Región. Un tema de discusión con varios de los entrevistas fue respecto a la existencia de un grupo de coordinación interinstitucional que pudiera asumir la coordinación de lavado de manos. El CIIMSA (Comité inter institucional de mejoramiento de la salud ambiental) es una posibilidad, aunque el liderazgo y la promoción está a cargo de una ONG. Es posible que sea mejor trabajar con un comité liderado por el Gobierno Regional, sobre todo vinculado a las gerencias de salud o educación. Nos indicaron que por norma existen comités multisectoriales regionales, provinciales y distritales, aunque sus intereses son muy generales. Los programas de Cáritas y la actitud empresarial de su director regional causaron buena impresión. En todo caso, se recomienda que la Iniciativa evalúe su participación en esta Región y posiblemente en otras donde tenga programas fuertes. La empresa de televisión regional que está llegando a todo el país vía satélite es Perú TV, quienes señalaron su voluntad de colaborar con un presupuesto razonable. La programación podría estar dirigida a tomadores de decisión, además de involucrar lavado de manos en sus programas existentes. Si bien no se pudo conseguir una entrevista con funcionarios de la minera Cerro Verde, ellos han establecido un contacto vía correo electrónico y se les ha pedido una cita cuando vengan a Lima. Principales hallazgos por tipo de institución Salud Lavado de manos es uno de los temas que forma parte del programa de salud e higiene en Escuelas Saludables, trabajando con 322 en Arequipa. Cuentan con un convenio entre DIRESA y la DREA. Utilizan el juego de láminas que ha elaborado Promoción de Salud desde el nivel central (10 láminas sobre cada uno de los 6 temas), siendo uno de los temas higiene y ambiente, entregándose un juego para cada una de las escuelas. Señalan que el problema es que muchas de las escuelas no cuentan con agua o servicios higiénicos porque dependen de las municipalidades para dotarlos de servicios (este hecho pone en evidencia la necesidad de vincularse con socios que faciliten estos servicios). Cuentan con un Comité Multisectorial Regional (salud, educación, agricultura, vivienda, policía), en que cada institución señala lo que puede trabajar en función a un tema específico, pero no hay cultura de trabajo estableciendo sinergias en las mismas actividades. En las provincias y distritos debieran tener comités similares. 90 Global Scaling Up Handwashing Project En todo Arequipa cuentan con 2,800 promotores, los que necesitan incentivos y materiales para seguir trabajando y evitar la deserción. Los materiales tendrían que servir para su identificación como chaleco, sombrero, material educativo. Sugieren que se trabajen materiales como rotafolio, que se enseñe por televisión y que se promueva el intercambio de experiencias. Educación Abordan las áreas de prevención como violencia, drogas, prácticas de salud incluyendo lavado de manos. Algunas aulas cuentan con rincón de aseo, pero no son muchas. Su programa tiene una hora de tutoría semanal en cada aula y cuenta con un documento oficial que define su trabajo, incluyendo salud corporal y mental. Las asociaciones de padres de familia (APAFA) funcionan bien en algunas escuelas, pero en otras han generado conflicto con las administraciones. Las APAFA funcionan mejor en escuelas privadas. Colaboran bien con la DIRESA en el marco del Programa Escuelas Saludables. Gobierno municipal La Gerencia de Gestión Social se orienta a trabajar con las poblaciones más pobres, especialmente las de zonas urbano marginales y rurales, en áreas como alimentación, capacitación, organización de asociaciones culturales y recreativas. Cuentan con un centro de atención médica en el mercado, pero no desarrolla actividades específicas de promoción de la salud. Identifica que los mejores espacios para hacer acciones de lavado de manos podrían ser los 309 comedores populares que benefician a más de 15,400 beneficiarios. Autoridad Regional de Medio ambiente Consideran que la falta de servicios de agua puede ser una barrera para lavado de manos en áreas rurales y es por ello podría ser que el Programa de Escuelas Saludables se circunscriba a la provincia de Arequipa, donde se ubica al 80% de 1´170,000 personas, de la cual el 50% es urbano marginal. Su oficina podría promover lavado de manos en restaurantes y en la industria alimentaria. Señaló la existencia de un Comité Regional de Salud en que se invitan a instituciones relacionadas, como educación, municipalidades, instituciones de enseñanza médica, Cruz Roja, entre otros. Asimismo, existe un comité equivalente para educación. Sugiere que con el personal de salud se realicen charlas en las salas de espera de los hospitales y se aproveche la movilización de vacunación en su llegada casa a casa para promover lavado de manos. 91 Global Scaling Up Handwashing Project Puso de relieve la necesidad de que se cuenten con fondos para contratar un contingente de supervisores que aseguren que las personas que sean capacitadas cumplan con sus tareas en los hogares. ONGs Las ONG tienen vinculación con los sectores, en función del objetivo del proyecto, aunque no es siempre fácil por la burocracia existente, perdiendo muchas veces su sentido técnico por el político. Se recalcó la necesidad de promover una voluntad política manifiesta desde el gobierno regional, debido a los índices de diarrea en la Región y los gastos que se generan para su tratamiento. Sugirieron orientar el programa hacia las escuelas y los clubes de madres, pues algunos de estos últimos son fuertes. Estiman importante conversar con las empresas mineras, teniendo en cuenta la tendencia a la formación de Fundaciones para derivar fondos para desarrollo social. Medio de comunicación Buscan ser una propuesta alternativa al enfoque nacional de los medios que se emiten desde Lima, priorizando un enfoque regional. Trabajan noticieros, programas de análisis político, de entretenimiento, magazines incluyendo consultorio médicos y de concurso con feedback masivo a través de cartas o teléfono. Cuenta con un programa interesante (Cabildo Abierto) que promueve la participación de la población durante una semana y el fin de semana las autoridades municipales van al programa y responden a las preguntas planteadas por la población. 92 Global Scaling Up Handwashing Project APPENDIX I: SUMMARY OF MAJOR FINDINGS AND RECOMMENDATIONS BY DIMENSION The following table summarizes major findings and recommendations. Readers interested in more detail should also consult Appendix C, which contains all of the recommendations (in Spanish) made by persons interviewed. Although the team agrees with the most of those recommendations, for this document it selected the ones it considered the most important. While virtually all of the recommendations listed in this document were made by the persons interviewed, those ideas that the study team developed further are marked with an asterisk. Dimensions Major Findings Major Recommendations Policy, Strategy, and Direction ►There is generally strong, positive political will toward handwashing promotion and child health among organizations and government officials, although some government officials find it hard to give it much attention because of so many other priorities. ►Although the attitudes of public and private officials towa very positive, many still lack knowledge of the multiple ben government officials in particular must try to simultaneousl priorities. Therefore, the Initiative should develop an advoc and materials for different levels of decision makers, that de HWWS for reducing diarrhea, respiratory disease, and infan malnutrition; and for improving school performance, mothe and the nation’s human capital. Advocacy activities should and continue throughout the project period. ►The new national administration has accepted the Initiative and seems well disposed to collaborate. ►Key partners feel that they understand the approach used in the first phase and feel ownership, but they do not yet have a good understanding of the expanded project (which is still being designed). ►There are several politically prominent national initiatives (re: malnutrition, healthy schools, water and sanitation) that offer natural links with handwashing. ►Although the MOH signed a ministerial decree in support of the Handwashing Initiative, its enthusiasm has waxed and waned with frequent changes of officials; current officials appear to be quite supportive. ►At the beginning of the Initiative, national MOE involvement was minimal, but now the MOE is actively engaged. ►In addition, it appears that even key partners lack informa expectations regarding the expanded handwashing program that, before the selection of districts and implementation, th group meetings with the key partners to clarify their expecta intentions and constraints. In preparation for these meetings and disseminate a brief description on the new project that s strategy and plans, making clear which features are required discussions of each partner’s role and responsibilities shoul meetings, leading eventually to MOUs or similar agreement ►A similar process, managed by the implementing agencie regional, provincial, and district levels once the intervention ►Many officials remember the role of handwashing during the cholera epidemic and are therefore well disposed to support the Initiative. Partnerships ►In general this has been a successful and innovative aspect of the program, in particular with private sector partners. ►The process of public and private organizations working together has not always gone smoothly. The public sector tends to be more formal and bureaucratic and to have more changes in personnel. ►Different partners play very different roles, from being fully engaged as a member of the coordinating committee 93 Global Scaling Up Handwashing Project ►Consideration should be given to inviting the MOE's env the MOH’s PRONASAR (small water systems) program to Committee. (The MOE already has been invited.) It would a private sector partner such as the CONFIEF, an association ►Assess the interest of potential new partners in joining th UNICEF, PAHO, Save the Children, and so on). ► WSP, the National Committee, and the implementing ag providing guidelines, tools, and strategic technical assistanc ►To achieve impact and sustainability, work hard to establ to providing short-term messages on handwashing and co-financing or managing local activities. This is fine as long as expectations are clear. ►Keeping key government ministries (particularly health, education, and housing) involved is essential, even though this can be difficult at times because of political changes and overburdened officials who are too busy to participate in meetings. district level. ►Partners at the district level should include the strongest p district. A strong partner organization is one that has good r built confidence among the population, and is committed to supervision of promotion activities. Each partner should be strengthen/expand attention to handwashing in its objective to consider include those helping install or improve water an Leche, comedores populares, and NGOs with long histories area. ►The Initiative and implementing agencies should work at district levels to have an existing public-private coordinatio the handwashing activities, such as the mesa de concertació committee. Institutional Arrange-ments ►Many respondents felt that arrangements have been informal yet have worked well based on personal relations, particularly for NGOs and private organizations. ►Arrangements with governmental organizations were more formal: the MOH issued a ministerial decree in 2004, and some regional governments approved ordinances. Beginning in 2006, the Initiative made an effort to sign MOUs with key national and local partners. ►Although MOUs and other formal agreements are no gua essential for working with government agencies, since they allocations to occur, and they may limit disruptions caused Formal agreements are particularly important with the MOH control over its local offices. The Initiative should continue agreements at the national level and require its implementin levels.* ►Although it is fine initially to work less formally with pri it the long run negotiating and signing more formal agreeme agreements would clarify roles and expectations and suppor ► WSP and the implementing agencies should periodically these agreements.* Program Methodology ► In general, opinions were positive; people felt that combining diverse partners’ strengths produced an effective approach. ►Some mentioned that the Initiative took too much of a campaign approach, without follow-up in some places, and with insufficient concern for institutionalization. ►Some respondents mentioned the need to focus more on interpersonal communication, while media representatives felt that mass media could play a larger role. ►Several of the persons interviewed pointed out that it has been much easier to generate enthusiasm and behavior change among children than among mothers, particularly in rural areas. ►Three general suggestions from various respondents were local levels, (2) to allow local partners flexibility in implem (3) to urge local partners to avoid a focus on short campaign campaigns seem to be very popular in Peru, but their impac ►Develop a standard methodology and instruments for ass and district levels to identify existing activities in which han added or strengthened and to identify the strongest partner o HWWS champions.* ►Most respondents recommended that implementation emp communication. Use mass media when possible, emphasizin and interactive formats* (call-in shows, radio listening grou possible to ensure that there is good coordination between m the-field activities so they are mutually reinforcing. ►If possible, develop separate communication materials fo jungle areas of Peru. Encourage regions to modify materials appropriate images, language, and so on. Recognize local b cold temperatures, and counsel families* on how to overcom ►For both effectiveness and sustainability, the Initiative sh of handwashing promotion within existing programs such a MOH, Escuelas Saludables, Viviendas Saludables, Municip (new water and sanitation systems), PRONOEI (preschool), malnutrition, JAAS (water and sanitation boards), NGOs do on. Although moving away from a single focus on handwas PPPHW strategy, the team feels that this is the most approp as the one mostly likely to be sustainable. On the other hand 94 Global Scaling Up Handwashing Project opportunity should be as focused and interactive as possible ►To try to build and maintain a positive program image, to supporters, and to share useful technical and strategic inform strong project communication program directed at both coll outside world (political leaders, donors, and the public). At electronic newsletter, a section on the WSP/Peru and MOH partners’ sites), and specific efforts to obtain radio and pres and activities. These communication spaces should include program, descriptions of particularly effective or innovative on achievements and impact; and exchanges on lessons lear combines respondent and team opinions.) ►The Initiative intends to contract several “implementing o the program in several regions. These organizations should operational guide for the district level. The guide should pro way that encourages each district to select those that are like effective. ►The program should take advantage of children’s enthusi students to promote HWWS at home and in their communit develop such materials with suggestions for students and he partners to invent additional ideas. In addition, the worksho supplementary materials should put a greater emphasis on h with individual mothers on solving problems, such as (perce or time.* ►Lack of compensation for transportation and food costs a promoters making more home visits. Where other partners a Initiative should contribute to the costs of such compensatio ►The key partners should develop an exit strategy that add expansion issues. This might include steps to institutionaliz commitment) for HWWS in government and partner organi program into some control districts as soon as the final mea completed, and local and national presentations on the proje on health and malnutrition. Implementation Capacity Availability of Products and Tools ►Although the skills and systems needed to implement the program well certainly exist at the national level, there was some concern about capacity at the local level. ►Develop implementation guidelines and tools to support i and district levels. ►There is little concern with the availability of soap, although access to water is difficult in some communities. ►Ideas mentioned were to collect soap bars from hotels in the poorest communities; promote Tippy Taps and similar w needed; promote hand-drying on clean cloths or towels in d would not be recommended); and promote use of ash, sand, available. ►Respondents considered the provision of plastic washing bowls and pitchers to have been useful in the first phase. ►Where the local assessments show particular weaknesses agency should provide training, mentoring and exchange vi technical assistance. ►Local change agents should be prepared to counsel famili and, where needed, local partners should address shortages. ►Partners at the district level should consider purchasing a and even soap to the poorest families. The national level mi these items in order to obtain lower prices.* Financing ►Many partners made financial and in-kind contributions during the first phase. 95 Global Scaling Up Handwashing Project ►Continue to explore a co-financing agreement by the Fun which has expressed interest in supporting HWWS in Peru. ►The general opinion is that there is potentially sufficient funding in Peru for this activity but that the partners need to work hard to actually obtain the funding to support HWWS. ►The team believes that external funding is likely to still be needed at the end of this phase, mainly for covering the cost of implementing agencies supporting new districts and, at a much lower level, to support continued advocacy. However, partner contributions should increase in this phase, so the percentage of funding provided by external sources should decline.* Cost-Effective Implementation ►The first phase collected extensive cost information and some impact information, but there was no attempt to calculate the cost-effectiveness of various activities or strategies. ►Obtain information on USAID’s small grants program an partners. ►Lobby national and regional government officials for bud handwashing or hygiene education. ►Continue to seek donated air time and publicly acknowle by private media companies. ►The Initiative needs to identify its needs and contract indi meet them.* ►The capability for collection and analysis does exist in Peru, but technical support and training will be needed for particular partners and local areas. Monitoring and Evaluation ►Persons interviewed generally consider M&E to be very important; many are not very aware of monitoring activities or results. ►The M&E functions are very important in this program, b the responsibility of persons outside of the central managem interfere with their ability to manage implementation.* ►On the electronic survey, respondents scored monitoring lower than any other dimension. ►A key to maintaining partner and public motivation is the achievements and results (see suggestions for project comm ►It is going to be a challenge to allow the local implementation flexibility that many respondents recommend while at the same time keeping sufficient uniformity in the program districts to be able to generalize about them in relation to the control districts. The monitoring team will have to carefully control for the effects of the many existing programs and projects in both intervention and control districts.* 96 Global Scaling Up Handwashing Project APPENDIX J: MENÚ DE ACTIVIDADES PARA ALUMNOS (IDEAS PRELIMINARES) En casa: 1) Aplique una encuesta en casa sobre las condiciones para LM con jabón en momentos críticos: Hay jabón para lavar? Hay agua para lavar? Hay toallas o trapos para secar las manos? Hay lugares con agua, jabón, toalla o trapo limpio cerca de donde ir al baño y donde prepara la comida? Producto: Las preguntas y respuestas. Note: Si falta buenas condiciones se debe repetir la encuesta una semana después. 2) Dé una clase a su familia sobre como lavar las manos bien (con agua corriente o echado; jabón, cenizas, o óleo de quinua; frotando los dedos muy bien; secando en una toalla o trapo limpio (o no aire libre se es una zona de poco polvo). El día después, dar un “examen” a su madre y hermanos de 5 a 9 años para ver si saben lavar correctamente. Si no, explique como puede mejorar. Producto: Un pequeño informe sobre la experiencia. 3) Dé una clase a su madre sobre los momentos críticos para lavar: después de ir al baño, después de cambiar el pañal o tener cualquier contacto con heces; antes de preparar la comida. El día después de la “clase” dar un examen a su madre para ver cuantos momentos críticos ella recuerda. Si ella no sabe todos, explique lo que falta. Producto: Un pequeño informe sobre la experiencia. 4) Construye un aparato simple que se deja lavar las manos sin gastar mucha agua. Puede usar su propio diseño o uno de los siguientes diseños (véa los dibujos abajo): Tome una lata o recipiente de plástico con forma similar a una lata. Hace un hueco pequeño al fundo del lado de la lata. Ligar una cuerda al parte superior de la lata para poder colgarla en un lugar apropiado para lavar manos. Para usar el aparato, hay solo que echar un poco de agua en la lata, y puede usar el agua que sale por el hueco para lavar las manos con jabón. Un otro diseño usa una calabaza o botella plástico con pico. Ligar una cuerda para poder colgar la vasija de un árbol o la casa. Llénela con agua, y cuando quiere lavar las manos simplemente derríbela una vez para lavar y una segunda vez para echar los burbujas y sucio. 97 Global Scaling Up Handwashing Project Producto: El aparto pronto para ligar y usar. Source: Salubritas 9: 4 (December 1986) (left); M. Ponga for SANRU (middle and right). En la comunidad: La próxima vez que haya alguna fiesta o evento publico en su comunidad, 5 a 10 estudiantes pueden organizar una esquina educativa sobre lavado de manos con jabón. Pueden cantar las canciones que aprendieron en clase. Pueden demostrar la técnica correcta de lavar. Un estudiante puede explicar los beneficios para la salud (proteger contra diarrea, infecciones respiratorias, y desnutrición). Otro puede explicar los momentos críticos. Si quiere, pueden preparar afiches u otros materiales. Producto: Un pequeño informe sobre la experiencia, incluyendo el número de personas que asistieron, lo que los estudiantes hicieron, y la respuesta de la comunidad. 98 Global Scaling Up Handwashing Project APPENDIX K: MENÚ DE ACTIVIDADES PARA PROMOTORES DE SALUD (IDEAS PRELIMINARES) Estas ideas son para un promotor en su comunidad o para un grupo de promotores en una comunidad. Puede combinar varias ideas si quiere, por ejemplo, 2 y 3, o 2, 3, y 4. 1) Aplique una encuesta en las casas sobre las condiciones para LM con jabón en momentos críticos: Hay jabón para lavar? Hay agua para lavar? Hay toallas o trapos para secar las manos? Hay lugares con agua, jabón, toalla o trapo limpio cerca de donde ir al baño y donde prepara la comida? Primero, haga una pregunta. Entonces, pregunte si puede mirar (el jabón etc.). Después de hacer las preguntas, explique sobre los beneficios de lavado de manos (proteger contra diarrea, infecciones respiratorias, y desnutrición). Al terminar todas las familias, haga un análisis si puede. Cuántas familias hay y cuántas tienen jabón, etc. Aplique la encuesta de nuevo un mes o mas después y comparar los resultados. 2) Enseñe a una familia o a un grupo de madres y otros familiares sobre como lavar las manos correctamente (con agua corriente o echado; jabón, cenizas, o óleo de quinua; frotando los dedos muy bien; secando en una toalla o trapo limpio (o no aire libre se es una zona de poco polvo). Después de explicar y demostrar la técnica correcta, pida a cada participante mostrar la técnica correcta. Después de cada vez, pregunte al grupo para sugerencias sobre como la persona puede mejor su técnica. 3) Enseñe a una familia o a un grupo de madres y otros familiares sobre los momentos críticos para lavar: después de ir al baño, después de cambiar el pañal o tener cualquier contacto con heces; antes de preparar la comida. Pida el grupo que repita los momentos, y después pida cada individuo. 4) Ayude a las familias que carecen de agua construir un aparato simple que se deja lavar las manos sin gastar mucha agua. Puede usar su propio diseño o uno de los siguientes diseños (véa los dibujos abajo): Tome una lata o recipiente de plástico con forma similar a una lata. Hace un hueco pequeño al fundo del lado de la lata. Ligar una cuerda al parte superior de la lata para poder colgarla en un 99 Global Scaling Up Handwashing Project lugar apropiado para lavar manos. Para usar el aparato, hay solo que echar un poco de agua en la lata, y puede usar el agua que sale por el hueco para lavar las manos con jabón. Un otro diseño usa una calabaza o botella plástico con pico. Ligar una cuerda para poder colgar la vasija de un árbol o la casa. Llénela con agua, y cuando quiere lavar las manos simplemente derríbela una vez para lavar y una segunda vez para echar los burbujas y sucio. Source: Salubritas 9: 4 (December 1986) (left); M. Ponga for SANRU (middle and right). 5) La próxima vez que haya alguna fiesta o evento publico en su comunidad, organice una esquina educativa sobre lavado de manos con jabón. Puede demostrar la técnica correcta de lavar; explicar los beneficios para la salud (proteger contra diarrea, infecciones respiratorias, y desnutrición); y explicar los momentos críticos. Si quiere, pueden preparar afiches u otros materiales. 100 Global Scaling Up Handwashing Project Global Scaling Up Handwashing Project ►including HWWS activities in work plans. ►devoting time to handwashing plans and programs, ►committing to handwashing promotion in official documents, ►allocating funds, Prepare and implement an advocacy strategy directed to officials at the national, regional, provincial, and district levels. The strategy should disseminate arguments and materials for different levels of decision makers that show the importance of HWWS for reducing diarrhea, respiratory disease, and infant mortality; preventing malnutrition; and improving school performance, mothers’ confidence and self-esteem, and the nation’s human capital. Materials and interpersonal communication should show how HWWS can easily fit into existing objectives and plans. Try to obtain free donated mass media coverage. Meet with Build decision makers’ support for HWWS as a long-term priority as shown by their: Political support The attitudes of public and private officials toward handwashing are generally very positive (many recall how important handwashing was in the control of cholera), but many still lack knowledge of the multiple benefits of HWWS. Moreover, government officials in particular are under pressure to address numerous priorities. The current Strategy Objective Current Situation 101 ►Less intense implementation (including keeping alert for ►Intense implementation (including trying to add HWWS to broader advocacy events). Give special focus to regional presidents (early Phase II). ►Monitor to ensure that the national and regional coordination committees are giving attention to advocacy (Phases II and III). ►Draft, pretest, and finalize materials; make printing, broadcasting, disseminating arrangements; identify advocacy champions during regional/ provincial/district assessments (Phase I/early Phase II). ►Send draft to partners for comments; meet with national partners to discuss (Phase I). ►Draft an advocacy strategy (Phase I). Phase III: 9–12/08 Phase I: 12/06–8/07, Phase II: 9/07– 8/08, Recommended Steps and Timing Two main challenges are to (1) develop and implement a strategy that appropriately addresses the diversity of leaders of different types of organizations working at different levels, and (2) to convince leaders to give sufficient support to HWWS at the same time that they are being pressured to attend to many other development priorities. Expected Implementation Challenges ►Ability to develop and manage a complex, multilevel advocacy activity. ►Ability to periodically insert fresh ideas, materials, and activities over time; this is an ongoing activity, not just a shortterm campaign. ►Ability to negotiate and manage mass media contributions. ►Ability to periodically monitor and make appropriate adjustments. Skills and Expertise APPENDIX L: ACTION PLAN TO IMPROVE THE ENVIRONMENT FOR AN EXPANDED HANDWASHING PROJECT IN PERU Provide opportunities for partners to have input into the project strategy and plans; and for them to understand the methodology, plans, and their roles. Circulate draft documents and hold meetings to obtain partner suggestions and clarify roles and expectations. the leading political candidates during electoral campaigns to ask them to make a public commitment to improving child health and nutrition and to HWWS specifically. The implementing agencies (contracted by WSP) would have major implementation responsibility at the regional, provincial, and district levels. Global Scaling Up Handwashing Project Although many people praise the open and collaborative management in the project, it appears that even some key partners lack a good understanding of the expanded project. Understanding and expectations government’s focus on health and education is a positive factor. 102 ►Prepare and disseminate a brief description on the new project that summarizes the proposed strategy and plans, making clear which features are required under the Gates grant (Phase I) ►Hold individual and group meetings with the key partners to clarify their expectations and the project’s intentions and constraints. Initial discussions of each partner’s roles and responsibilities should also occur during these meetings, leading eventually to MOUs or similar agreements (Phase I). (This process has begun with the MOE.) ►In abbreviated form, repeat this process at the regional, provincial, and district levels, once the intervention districts have been selected (Phase I and early Phase II). ►Meet to review implementation progress and results (every 6 months, Phases II and III). opportunities to add HWWS to broader advocacy events) (Phases II and III). ►The main challenge is simply for WSP staff to find the time during this busy period to have adequate two-way communication with key partners. ►Another challenge is to be able to repeat similar processes at the regional level and below. This responsibility may be shared between WSP and the implementing agencies that it contracts. Decentralization in the public sector creates the need for intense work at the regional level and below. ►A final challenge will be to negotiate clear roles and responsibilities at the subnational level with organizations that already have active programs and WSP has the project management experience and negotiation and other expertise required. ►Keep partners motivated and engaged throughout the project period. ►Recognize their organizational contributions. ►Collect and share tools and lessons learned that can improve the effectiveness of Stronger alliances are needed, particularly with partners that can make strategic contributions. Develop and maintain a strong project communication program directed at both collaborating organizations and the outside world (political leaders, donors, the public) in order to maintain a positive program image, motivate partners and supporters, and share useful technical and strategic information. Strengthen alliances at all levels with partners that have both the resources and desire to contribute. Give particular attention to district-level partnerships that include organizations that enjoy popular confidence and that are committed to ongoing follow-up and supervision of HWWS promotion activities. Global Scaling Up Handwashing Project Some partners note the lack of regular communication from the Initiative about its activities, progress and impact. Partnerships In general, publicprivate alliances have been a successful and innovative aspect of the program. Adding a few new national partners might strengthen the program. There has been minor, temporary tension between public and private organizations, because the public sector tends to be more formal. Strong partnerships 103 ►Invite the MOE (environmental health division), and the MOH (PRONASAR), and possibly a representative of CONFIEP to join the coordinating committee (Phase I). ►Add HWWS to the agenda of an existing coordinating group in each participating region, province, and district (early Phase II). ►Seek inclusion of the strongest programs/institutions in each district. A strong partner organization is one that has good reach into communities, that has built confidence among the population, and that is committed to ongoing follow-up and supervision of promotion activities. Particular targets of opportunity are those organizations that support water and sanitation infrastructure improvements in the project districts (early Phase II). ►Develop, pretest, and finalize guidelines and tools for local partnerships (early Phase II) ►Draft a project communication strategy. At a minimum there should be an electronic newsletter (featuring a partner or district of the month or quarter), a section on WSP &/or MOH Web sites (with links to partners’ sites), and radio and press coverage of accomplishments and activities. These communication spaces should include basic information on the program, descriptions of particularly effective or innovative strategies or activities; exchanges (meetings, visits) on lessons learned, M&E, and cost-effectiveness ►Keep these activities strategically focused, that is, directed toward clearly defined audiences and objectives. ►Provide information in appropriate detail and formats. ►Collect good information from people in the field who are too busy with implementation to sit back and reflect and document activities. ►Find channels to reach many priorities. Challenges include: ►inviting the right partners and individuals to play key roles ►adding HWWS coordination to already full agendas of coordinating groups ►identifying the strongest partners in each district ►developing guidelines and tools that are easy to use and adapt in a variety of settings and conditions ►getting sufficient attention and participation of key government officials, many of whom are overwhelmed with competing priorities. ►Capability to design and implement strategic communication activities, not merely activities that make a lot of noise but with no clear purpose. ►Ability to monitor activities and impact and to make needed adjustments. ►Responsibility ►Excellent analytical and communication skills, as well as a thorough understanding of the Initiative and its methodology. ►Ability to identify and accurately assess potential partners, their resources, and their true interest in collaborating. ►Achieve clearer definition and commitment to roles and responsibilities of partners at all levels. ►Facilitate sustainability of organizational commitments to HWWS. Although MOUs and other formal agreements are no guarantee of follow-up, they are very important, particularly for working with government agencies. They should also facilitate longer-term commitments from NGOs and other private partners. Therefore, the Initiative should actively pursue at least semi-formal agreements at all levels. Global Scaling Up Handwashing Project Most arrangements have been informal, yet they have worked well based on personal relations, particularly for NGOs and private organizations. Nonetheless, many partners feel that more formal relations would help with clearer understandings of the program and roles and responsibilities in the expanded Institutional arrangements activities. ►Send draft strategy to partners for comments; solicit their comments and suggestions (Phase I). ►Share the project communication strategy with the implementing agencies and include in their terms of reference their tasks in implementing the strategy at the local level in support of national activities (early Phase II). ►Implement the strategy (Phases II and III). ►Review implementation progress and results (every 6 months during Phases II and III). ►Meet with partners and reach agreements on their expected roles and responsibilities at the national level. For government agencies and other partners that so desire, prepare and sign MOUs describing the agreements. For other partners, the WSP can simply prepare a letter to the organization describing expected roles and responsibilities (Phase I, early Phase II). ►Engage with partners with informal agreements to try to move them to make formal commitments (Phase II). ►At the regional, provincial, and district levels, the coordinating groups should prepare a brief document on HWWS activities that describes the expected role of major partners. The members should approve this document (early Phase II). (This document should be considered the conceptual framework for development of the HWWS work plans at the local levels.) 104 information (Phase I). should be shared by WSP, the national communication subcommittee, and possibly contracted individuals or groups. Negotiation and interpersonal skills are needed, as well as the ability to craft agreements that are at the right level of specificity. WSP possesses such skills. people and organizations at the local level, in more isolated districts that lack access to the Internet. ►Negotiating and getting MOUs signed is likely to be more difficult the more bureaucratic the organization is. There could easily be setbacks if key personnel change. ►The periodic reviews of MOUs could cause ill feelings unless done in a spirit of working together to achieve the most possible in the existing circumstances. The general objective is to achieve good impact on the practice of HWWS at critical times in the short run, by using an approach that can be sustained and institutionalized. The basic strategy is a decentralized one in which the national level prepares useful tools and guidelines and aims to stimulate strong local partnerships, and then provides strategic support as needed to local levels. Build strong alliances first, at all levels, beginning with the implementation of the advocacy strategy and of a thorough assessment process at regional, provincial, and district levels. A major project objective should be to build promotion of HWWS into ongoing, permanent activities of agencies and programs, as indicated by official directives, work plans, and budget allocations. Focus on interpersonal communication local radio (interactive formats) and group activities. Global Scaling Up Handwashing Project Although respondents feel that most aspects of the pilot methodology worked well, some felt there was too much reliance on mass media and a campaign approach with uncertain followup. Program methodology program. 105 ►Coordinating groups should review MOUs and committee documents every 6 months to assess to degree to which they are being implemented, barriers to implementation and how these may be resolved, and any needed revisions in roles and responsibilities (Phases II and III). ►Develop methodology and instruments for assessment visits at the provincial and district levels that will support identification of existing activities in which handwashing promotion could be added or strengthened and the strongest and most collaborative partner organizations and HWWS champions (Phase I). ►At the national level, develop, pretest, and finalize communication and training materials for the coast, mountains, and jungle areas of Peru (early Phase II). ►Develop an operational guide for the district level (early Phase II). ►Make a few small additions to the workshop methodology and supplementary materials: (1) put greater emphasis on how persons promoting HWWS can work with individual mothers on solving problems … such as (perceptions of) limited water, soap, or time; and (2) incorporate ideas for what students and health promoters can do in homes and communities to motivate, teach, and facilitate HWWS (early Phase II). ►To manage and support program activities in so many diverse districts, with different challenges and resources, scattered all over the country. This requires excellent communication and a national program capable of supporting but not trying to control district activities. ►In some districts, poverty, isolation, climatic and geographical conditions, lack of access to water and to mass media, and so on will make implementation more difficult. ►Local effectiveness will be very dependent on the strength of local partners, their reputations and abilities to reach and influence families in the communities where they work. Designing and implementing the program methodology will require a range of communication, managerial, and political skills. Although these certainly exist within the WSP and its partners, this is a complex project to manage since—given the multiplicity of partners and variety of local settings—it must be done in a decentralized manner. A final challenge is to avoid devoting time and effort to communication activities that remind people about HWWS temporarily but that have no Improve the implementation capacity in regions, provinces, and districts that have weak capacity. ►Explore possibilities for national and local financing, and publicly acknowledge contributions. ►Lobby for budgetary commitments beyond this phase. Improved local implementation capacity. Secure additional financial and inkind resources at the national and local levels for this phase and beyond. Global Scaling Up Handwashing Project There are many potential sources of funding and inkind contributions, although accessing them will require effort. Some government programs have limited implementation funding. Financing While the skills and systems needed to implement the program well certainly exist at the national level, there is some concern about capacity at the local level. Implementation capacity ►Continue to explore a co-financing agreement by the Fund of the Americas (FONDAM), which has expressed interest in supporting HWWS in Peru (Phase I). ►Obtain information on USAID’s small grants program and then decide whether to share this with local partners (Phase I, early Phase II). ►As part of advocacy activities, lobby at all levels of government for budgetary funds directed toward handwashing or hygiene. ►Monitor the extent to which the partner organizations have included funds for the promotion of HWWS or provision of water in their annual budgets. ►Give public recognition for free air time and other contributions from private companies, on Web page, in 106 ►As parts of regional, provincial, and district assessments, assess local implementation capacity (early Phase II). ►Where the local assessments show particular weaknesses, provide training and mentoring and exchange visits with pilot districts with effective programs (Phase II). ►Develop implementation guidelines and tools to support implementation at the provincial and district levels (early Phase II). ►It is difficult to predict what challenges may arise, but in general funding agencies and programs have their own unique requirements, which may or may not fit well with the planned activities and time line of the Handwashing Initiative. ►In-kind contributions from the private sector are relatively easy to obtain; focus on those that are most likely to effectively support HWWS. ►Government agencies may be reluctant to commit funds to such a narrow objective. ►To establish and implement mechanisms that will detect and feedback local needs for capacity support. ►To provide appropriate and effective support in a timely manner. The WSP and its main partners, including the implementing agencies, should share this responsibility. The skills needed are those required to establish a monitoring and feedback system, as well as a variety of capacity building skills, ranging from conducting good needs assessments to making good choices on modes of capacity building and implementing those actions. The skills needed are basically diplomatic and interpersonal, as well as the ability to write appropriate proposals. WSP and its partners possess these skills. What may be lacking is sufficient time. follow-up. Defining data collection and analysis procedures should be the task of the M&E group. Defining data collection and analysis procedures should be the task of the M&E group. Without overburdening partners, collect and use cost and effective-ness information to improve this and future projects. Measure impact on behavior and, to the extent possible, the strategies and inputs most closely associated with impact; use this information to improve this and future projects. Global Scaling Up Handwashing Project Persons interviewed generally consider monitoring and evaluation to be very important and to have received insufficient attention in the pilot phase. The real problem may have been insufficient dissemination. ►The pilot project collected extensive cost information and some impact information, but there was no attempt to calculate the costeffectiveness of various activities or strategies. ►The capability for collection and analysis does exist in Peru. M&E Cost-effective implementation 107 Steps should be defined by WSP with the executive committee. newsletter, and so on (Phases II and III). Steps should be defined by the WSP with the executive committee. The main challenge is to collect, analyze, and use essential information, without overburdening persons in the field who need to focus on implementation. The main challenge is to collect, analyze, and use essential information, without overburdening persons in the field who need to focus on implementation. Skills needed are the ability to conceptualize essential needs and decide how to collect needed information in a manner that least burdens field people; as also needed are analytical skills, and the ability to share, discuss, and use the results both to improve the Peru program and similar programs. Skills needed are the ability to conceptualize essential needs and decide how to collect needed information in a manner that least burdens field people; also needed are analytical skills and the ability to share, discuss, and use the results both to improve the Peru program and similar programs. Global Scaling Up Handwashing Project 108