We have identified water, sanitation and hygiene – or WASH for short – as one of the areas where we believe we can make a sizeable and scalable difference if we focus our efforts and partner closely with others.
We have set ourselves a bold goal to help more than a billion people take action to improve their health and hygiene.
We are already changing hygiene behaviour at scale. Since 2010 we have reached 303 million people - 183 million† of these with Lifebuoy’s 21-day handwashing programmes, which are now in eight of the ten countries with the highest levels of child mortality.
Pureit is now providing safe drinking water to 55 million† people in 12 countries and Domestos is working with UNICEF and the Unilever Foundation to scale up UNICEF’s Community Approaches to Total Sanitation (CATS) programme. Through CATS, 760,000 people have been reached with sanitation behaviour change interventions; this will result in these individuals living in open defecation-free communities.1
While we are doing a lot, there is much more we would like to do. But scaling-up presents challenges.
We make Lifebuoy as low cost as we can to make it as affordable as possible. That means we are constrained by how much we can spend on behaviour change programmes.
Pureit is broadening its appeal to more people and encouraging regular usage by highlighting not just its safety benefits but its better taste and convenience compared with boiled water. However, the strong distribution and after-sales channels Pureit requires to get established, and the micro-finance partnerships needed to make Pureit affordable to people on low incomes, takes time to get established.
But if there’s one thing our business is good at, it’s achieving cost efficiencies, so we have applied our skills to achieving the most effective hygiene behaviour change programmes at the lowest cost per contact.
There is only so much we can do on our own, which is why we work with others to drive much greater scale. We are tackling this in four ways:
Advocacy to get WASH higher up the policy agenda, such as through the UN post-2015 High Level Panel on the Post 2015 Development Agenda, Global Handwashing Day and World Toilet Day.
Multi-brand, multi-behaviour approaches which reduce costs and reach more people. Water, sanitation and hygiene are clearly interrelated, so if we can address all three at the same time, it means better health outcomes and lower costs.
Partnering with more organisations to pool resources and complement capabilities, such as Unilever Foundation Partners, UNICEF and PSI, WSUP and Millennium Villages and with governments in India, Indonesia and Vietnam.
Innovative products and approaches, such as Lifebuoy’s colour changing handwash and Pureit’s new models that remove excess salt from water, as well as harmful bacteria, viruses and parasites.
Three years into our Unilever Sustainable Living Plan, we have learnt that it is possible to reach people at scale with hygiene messages and safe drinking water. But the challenge to reach more than a billion people remains daunting.
This is particularly true for Lifebuoy. We have accelerated and scaled up our Lifebuoy programmes, reaching more people in more countries every year, but nevertheless we need to reach more than 800 million people by Lifebuoy’s own target date of 2015.
We remain committed to Lifebuoy’s target but it is clear it will take us beyond 2015 to achieve.
A major barrier is cost: we make Lifebuoy as low cost as we can to make it as affordable as possible. This means we are constrained by how much we can spend on behaviour change programmes. We need to develop even lower cost, mass-scale, behaviour change approaches and take our partnerships and co-investment models to even greater scale than we have in place today.
We are looking at innovative approaches such as a 21-day digital handwashing behaviour change programme for children and their parents which will be trialled in India in 2014. We will also extend our existing partnerships, seek new ones and co-invest with organisations who share our goal of reducing diarrhoea and pneumonia to help more children reach the age of five.
The challenges we face on Lifebuoy, as well as on Pureit and Domestos, have led us to investigate whether an integrated approach could lead to more rapid scale up. Water, sanitation and hygiene are clearly interrelated, so if we can address all three at the same time, in theory it means better health outcomes and lower costs. In practice, multi-behaviour change programmes are very difficult to make work. We have been trialling different approaches in different countries with varied success. Our plan is to develop a workable, integrated, behaviour change programme that is both repeatable and scalable. Partnerships will be critical to success, particularly to address areas which fall outside our core capabilities such as infrastructure development.
Lack of safe drinking water, poor sanitation and poor hygiene are the cause of millions of preventable deaths, particularly amongst children. Whilst great progress has been made, the gap to achieving the Millennium Development Goal of reducing the mortality of children under five by two thirds by 2015 is still considerable. Pneumonia and diarrhoea remain the leading causes of deaths in children under five, with 6,000 children dying every day.2 Some 2.5 billion people still lack access to improved sanitation and 768 million people do not yet have access to an improved drinking water source.3 Around 3 billion people do not have access to a piped water supply at home.4
These issues are closely interconnected. Their impact is felt most by low income groups in Sub-Saharan Africa and Asia, with 10 countries accounting for two thirds of all neonatal deaths.5 On the other hand, evidence is compelling for the positive impact of improved access to hygiene, safe drinking water and good sanitation. The World Health Organization estimates that water, sanitation and hygiene have the potential to prevent at least 9.1% of the global disease burden and 6.3% of all deaths.6
Evidence shows that individuals will be healthier and communities more productive if they have access to clean water and better sanitation and if they adopt improved hygiene practices. Good hygiene habits can help to stop the spread of infectious diseases and can pre-empt preventable diseases, such as tooth decay, which can lead to more serious health conditions and affect people’s self-esteem, confidence and even employment prospects.
Overall, individuals will be healthier and happier, and communities more productive, if they have access to clean water and better sanitation, and if they adopt improved hygiene practices.
Why does behaviour change matter?
Giving people access to good-quality, affordable products such as soap and toothpaste represents a crucial starting point in encouraging behaviour change. Our Lifebuoy soap is on sale in over 50 countries across Asia, Africa and Latin America. In these countries, many people live on less than US $1 a day and basic hygiene is vital to good health.
Yet products alone are not enough if people do not use them in the right way and at the right time. Studies show that people often know they should brush their teeth twice a day, and wash their hands with soap after going to the toilet and before eating, yet they often don’t.
What is our role?
As one of the world’s leading companies producing consumer goods that people use every day, we understand the triggers, barriers and motivators that generate sustained behaviour shifts.
Underpinning our approach is our model of behaviour change, Unilever’s Five Levers for Change – a set of principles which, if applied consistently, increases the likelihood of creating a lasting impact. See Handwashing Behaviour Change for more.
We use this knowledge, coupled with our expertise in marketing and in delivering campaigns at mass scale, to reach large, diverse populations and to achieve a lasting impact on everyday behaviours.
However, bringing about widespread, sustainable behaviour change is not something we can do alone. We therefore work closely with governments, NGOs, academia and funding partners to increase our reach and impact.
Addressing social challenges makes business sense
When the society we serve enjoys better health, hygiene and well-being, our business also benefits. Many of our programmes drive growth directly - our oral care and handwashing programmes are good examples. When more people brush their teeth or use soap regularly, toothpaste and soap consumption increases – improving health and growing our business. Lifebuoy, for example, is one of Unilever’s fastest-growing brands, achieving three years of sequential double-digit growth to become the world’s number one anti-bacterial brand.
Addressing social challenges is good for society - and good for business.
Water, sanitation and hygiene issues (known collectively as WASH) are closely interconnected. We are exploring how we can increase our impact and unlock efficiencies by combining our individual programmes into integrated WASH interventions.
We have piloted programmes which improve access to WASH infrastructure and services. An example is the SmartLife concept in Kenya. In 2013, GAIN, Water and Sanitation for the Urban Poor (WSUP), Ideo and Unilever, with sponsorship from Aqua for All, established a pilot business called SmartLife in Kenya. SmartLife is a service to deliver safe, affordable drinking water alongside hygiene and nutrition products to low income families. Kenya was selected as the pilot location due to the urban water challenges faced by residents – with piped water only available two or three days a week and many families relying on buying expensive water supplies from supermarkets and independent retailers. Two SmartLife shops and a network of sales agents have been established, providing safe drinking water to 2,000 families. The service has now expanded to selling nutrition products including Blue Band margarine (which is fortified with vitamins), vitamin powders that can be sprinkled on food and in water (from DSM) and a fortified porridge. Our next steps are to to prove the business model and scale up potential and to extend the portfolio of hygiene and nutrition products being offered.
We have developed schools-based behaviour-change programmes which address a number of health behaviours in Indonesia, Nigeria and Vietnam. In Indonesia and Vietnam, our programmes span handwashing, sanitation, safe drinking water and nutrition, with different combinations deployed according to need and capacity.
In Nigeria, we have brought together behaviour change for handwashing, toothbrushing and nutrition, and have partnered with an external company – Dlite – to promote solar lighting which helps children do homework after dark.
Challenges of multi-behaviour programmes
Published studies of work to integrate WASH programmes show mixed results. The main challenges to overcome are that water, sanitation and hygiene require distinct approaches and capabilities. The speed and ease of adoption of each approach differs.
There is also a question around the extent to which it is possible to change multiple behaviours through a combined behaviour-change intervention. Behaviour change theory and approaches typically focus on changing one specific target behaviour at a time. We will pilot and further evaluate multi-behaviour integrated WASH programmes and, where proven, take successful approaches to scale.
Our partnerships help us to deliver a bigger impact. We work with partners in a number of ways.
With experts and academics: to access the latest and best thinking on how to drive behaviour change at scale and how to measure the impact and effectiveness of our programmes.
With NGOs: to develop, pilot and improve programmes, to achieve greater scale by leveraging existing on-ground networks, to run joint advocacy programmes to raise the profile and resources given to our WASH programme, to make joint funding proposals, to run cause-related marketing campaigns and to work together on long-term sustainability, particularly with governments and policy makers. For example, working together to encourage hygiene education to be built into schools’ curricula, or securing investment to improve infrastructure for clean water, good sanitation and improved hygiene in schools and communities.
Through the Unilever Foundation, launched in 2012, we are partnering with five leading global organisations – Oxfam, PSI, Save the Children, UNICEF and the World Food Programme – several of which we are working with to help improve the health and hygiene of communities and individuals in need.
Examples of partnerships in action
In 2013, we delivered a joint Lifebuoy handwashing programme with Population Services International (PSI) in schools in Kenya, Zimbabwe and Vietnam. With PSI we are working to make a tangible contribution to improving the health of children and families, by delivering behaviour-change interventions that focus on handwashing and clean drinking water. In India, as part of our goal to make safe drinking water available and affordable, the Unilever Foundation and PSI launched WaterworksTM in Bhopal. WaterworksTM trains women to teach families how to use our Pureit water purifiers. 75 women from the communities have been trained as Waterworkers, helping to improve their livelihoods and provide 15,000 low income households with free Pureit home water purifiers.
With UNICEF, Domestos and the Unilever Foundation are improving access to sanitation in developing countries through UNICEF’s Community Approaches to Total Sanitation (CATS) initiative. This aims to eliminate open defecation by changing people’s behaviour and promoting demand for sanitation at the community level. Through CATS, 760,000 people have been reached with sanitation behaviour change interventions; this will result in these individuals living in open defecation-free communities1. A proportion of the profits from sales of Domestos in developed countries is given to UNICEF to increase the reach of CATS. We also partner with UNICEF to deliver school handwashing programmes in South Africa and India.
By supporting Save the Children’s EVERY ONE campaign we are improving access to health workers and life-saving interventions, and ensuring children and mothers in need are reached with high-impact health and nutrition programmes. Our partnership will improve the lives of 2 million children and their mothers by 2016. We are also supporting advocacy work to strengthen national health systems in key countries.
We are using our communications expertise and convening power to get WASH on people’s radar and higher up the policy agenda to accelerate progress against the more difficult to reach external goals (such as the Millennium Development Goals on sanitation). We are doing what we can to make sure WASH remains a priority in the remaining months of the Millennium Development Goals and on the post-2015 Development Agenda.
We work closely with our partners to increase the impact of our advocacy efforts. We join forces around events such as the UN General Assembly; regional water, sanitation and hygiene summits such as the South Asian Conference on Sanitation; and high profile days such as Global Handwashing Day, World Toilet Day, International Women’s Day and Day of the Girl.
We also look to draw on our strategic engagement with global non-governmental and inter-governmental organisations. One example is the United Nations Secretary-General’s campaign ‘Every Woman, Every Child’, which focuses on child and maternal health. Our participation allows us to position our own work on water, sanitation, hygiene and self-esteem within a context that external key opinion formers find highly relevant and credible.
While we are making progress, we realise that our ambitions will only be met if we draw on the capabilities, expertise and experiences of others. In this respect, partnerships – with civil society, peer companies and governments – are critical to the successful implementation of lasting solutions.
Innovative products and approaches
We aim to reach more people by trying out new approaches. For example, we have developed a 21-day digital handwashing programme aimed primarily at children and parents at home. This is being piloted in India and, if successful, we will introduce it to other countries.
Innovation is also key.
Lifebuoy’s colour changing handwash makes handwashing great fun for kids so they want to wash their hands properly - and do not need to be pestered to do so.
Our ten-second handwash makes it easy to wash hands well – delivering effective germ kill in just ten seconds versus the recommended 25 seconds which most people don’t actually practise.
Pureit has extended its appeal by communicating on great taste as well as safety and offering new models which tackle growing problems such as removing excess salt from brackish water.
Domestos has launched new, low cost packaging formats to make toilet cleaner accessible to low income families.
How do we measure success?
We have defined a metric to measure progress against our Unilever Sustainable Living Plan commitment to help more than a billion people to improve their health and hygiene. This is the number of people reached on a cumulative basis by an intervention which, based on past studies, can be expected to result in sustained, positive behaviour change.
We aim to provide as accurate a picture of our programme impacts as possible. To do this we conduct detailed evaluation studies and independent evaluations of our programmes’ and products’ effectiveness.
Measuring behaviour change is challenging, particularly for health behaviours where people tend to overclaim good behaviour such as handwashing or toothbrushing.
To help overcome the risk of positive bias, we have pioneered the use of two methodologies which aim to counter the bias in reporting which is often seen with self-reporting.
One effective way of doing this is through quantitative diary studies where mothers and children track everyday behaviours over a period of time. By masking the target behaviour we are seeking to measure among a number of daily habits, we limit the risk of bias as respondents do not know which behaviour we are evaluating. This methodology has been used to measure toothbrushing and handwashing behaviour.
See Handwashing Behaviour Change for more.
We also draw on advanced technologies to assist us in our impact evaluation. For example, we use smart sensors inside soap bars, toothbrushes or other products. This enables researchers to gather data unobtrusively during behaviour-change trials in people’s homes. From this data, we can monitor the extent to which different types of interventions lead to meaningful behavioural change.
In addition, we monitor the business results of our health and hygiene interventions through market data such as World Panel usage data and Neilsen sales data. This provides insight into the short and long-term impacts of our programmes. For example, in France, market data shows that the oral care market has grown by 5% over 2009-2012, where Signal’s Brush Day and Night programme is increasing brushing frequency.
Logger technology can provide data and insight into both hygiene behaviour and business impact. For example, initial results from a logger study to assess the impact of our joint handwashing programme with Millennium Villages in Ghana showed a significant increase in both the frequency and quality of handwashing with soap. Schoolchildren washed their hands more thoroughly and used more soap per handwash. These behavioural changes create a win-win, improving hygiene through handwashing and increasing soap consumption.
In many cases we partner with external experts to to evaluate the impact of our initiatives. Pureit has partnered with a number of leading institutions including the Indian National Institute for Epidemiology to evaluate the impact of its in-home water purifier on the incidence of diarrhoea. The study showed a 50% reduction in diarrhoea incidence.