The politics of soap

Fit For School (FFS) is a programme that ensures that children in government-run elementary schools wash their hands with soap every day, brush their teeth with fluoride toothpaste and are de-wormed every six months. To implement the programme, the education and health sectors of the Philippines are pooling efforts.

Fit For School is also the name of the Philippine NGO that supervises the programme. Its work is supported financially and with human resources by InWent, GTZ, CIM and the pharmaceutical giant GlaxoSmithKline. Because it is simple, effective and in line with global and national health policies, FFS is successful. Its acceptance was boosted considerably by a campaign run by various UN organisations and multinational soap manufacturers to mark Global Handwashing Day (see also Monse et al, E + Z/D+C, November 2008, S. 434f.).
The programme fits neatly into the structures of the centralised education sector and is thus easy to implement. The schools cooperate. What is more difficult is the funding and procurement of the materials by the local governments. Local education authorities (Schools Divisions) report to central government. They are responsible for implementation. The health sector, on the other hand, is decentralised, so soap, toothbrushes, toothpaste and de-worming tablets are financed and procured by provincial authorities.

Tasks for provincial government

The programme costs less than half a euro a year per child and is thus affordable even for provincial governments that are strapped for cash. However, the support of provincial governors is crucial, according to Alex Villano of the League of the Provinces, an umbrella organisation: “Once staff realise that their governor is interested in the project they will hold the line.” From then on, it is all plain sailing. For the same reason, PhilHealth, the national health insurance agency, also focuses on governors, as a staff member explains: “We talk only to one person and that is the provincial governor. If you get his commitment, then the job is almost done.”

To identify “champions” – relevant agents of change, that is – it is crucial to know who the prime movers are. Local policymakers need to be competent and interested. Technical cooperation can support such champions – and sensitise them – through capacity building. In the Philippine health sector GTZ and InWent financed courses called SHIAC (Social Health Insurance for Advocates and Champions) for the governors as the re­presentatives of their provinces. They – and not the relevant civil servants – decide whether new programmes are introduced.

Governors also have an impact on local education authorities. According to a senior school nurse, one reason for teachers and Schools Division health officials cooperating on successful FFS introduction in her province was funding from the provincial government: “We are really committed because we don't want to fail the governor after he invested a lot of money.”

Improving re-election prospects

It takes more than an affordable concept to win the backing of a governor. Support from other partners is helpful. Two such actors are PhilHealth and the League of the Provinces. Both have good connections with provincial governments.

Governors want to make political capital out of projects. In the case of FFS, provincial governments can proclaim its ownership in every classroom of every village by having toothpaste containers designed according to their wishes. Typically, the labels display an image of the local governor and a slogan of his or her government. FFS can thus become a vehicle for reaching out to potential voters. Parents and teachers like the programme, which is another incentive for politicians to get involved. Popularity, of course, also serves the sustainability of the programme. Parents, after all, are voters and would be unhappy if a programme that matters to their children’s health was discontinued.

The project office of the Fit for School NGO makes sure the media take note. Governors reap accolades for introducing a meaningful health programme – which, in turn, encourages their counterparts in other provinces to follow suit. Leonila Cajarte of the Philippine development authority NEDA believes that FFS thus contributes to the success of political decentralisation: “It's a matter of really making these governors realise their very crucial role in the delivery of the basic health services.”

Any programme meant to be implemented in all provinces has to be designed flexibly enough to fit local circumstances. While the same laws apply to budget management and procurement in every province, the application of those laws depends on the respective governor’s leadership. Any programme with too strict procedural and operational specifications would indirectly question governors’ executive authority by restricting their discretion.

FFS, moreover, is financed from different resources in different provinces. Procurement processes also vary, depending on the governor. This has pros and cons. One result is that provinces are moving ahead at different speeds. Technical cooperation needs to help the authorities implement individual solutions that suit the style of the governor in question. Moreover, technical cooperation can provide forums for provincial governments to exchange experiences and learn from one another.

Tricky balance

Local embedding means devolving responsibility to local institutions. That, in turn, means that donor agencies have little control. Before a programme is started, the governance issues that need to be considered include whether the local institutions concerned deserve support in the first place in general and whether they show a real potential for capacity development. Existing power structures and the local decision-making logic also must be taken into account. These are sensitive matters, especially in the Philippines, where corruption is quite common.

FFS has been tailored to local conditions, particularly to the position of the governor within provincial government. Procurement is not subject to external monitoring; nor can it be. The provincial governments spend the money. Responsibility resides entirely with them and their supervisory bodies. The FFS project office checks the quality of materials and negotiates terms with a number of manu­facturers, helping to identify the best and most economical. Ultimately, however, it is up to the provincial government to decide what products are bought at what price.

The high cost-benefit efficiency of FFS is a cogent argument in favour of the programme. This factor has often been crucial in negotiations. That low-cost procurement is facilitated for provincial governments helps to prevent corruption.

A total of 22 (of 80) provinces are implementing FFS so far. In some provinces, all public elementary schools are covered, in others only pilot schools are. Currently, 630,000 primary students – five percent of 13 million primary school children in the Philippines – have daily access to preventive health measures at school. Their share is set to rise.

The conventional wisdom of many Filipinos is that politicians invest mainly in programmes that provide them with some kind of irregular income. FFS, by contrast, makes it worthwhile for politicians to support sensible measures of community relevance. The governors receive no foreign funds. Instead, they are given the opportunity to improve the health of local school children for relatively little money and, in doing so, boost their own popularity. The fact that more and more politicians are backing FFS is not only encouraging in terms of preventive health care. It also shows that incentive-based programmes can be effective.