Background - Word of Mouth: Learning from Polio Communication and Community Engagement Initiatives

Background

Challenges and Successes
Whether the benchmark is the Sustainable Development Goals, a national development plan, or an organizational mission, making progress on difficult development issues—such as education, health, poverty, gender, citizen engagement, the environment, HIV/AIDS, economic development, participative governance, infrastructure, and so much more—is anything but easy. These are steep hills to climb, not gentle inclines to stroll.

This reality underscores the importance of learning from experiences addressing issues on which there has been demonstrable progress. One such issue is polio eradication. In 1988, there were 365,000 cases¹ of the wild poliovirus in 2017, there were 22.² The journey toward polio eradication offers 30 years of accumulated learning. As with many other development challenges, progress was rapid in a number of countries but took longer in others, where environments were extremely complex and challenging. Some of the toughest and most important lessons learned from the polio program have come from these difficult contexts.

Success in these contexts required effective communication and community engagement strategies. Unless the polio program had a really solid communication and community engagement strategy as a central element of its work, it could not have effectively engaged families, accessed communities, overcome both valid and invalid perceptions and understandings, addressed relevant social norms, supported local leadership, and brokered important relationships. This strategy took time to develop. It was, in many ways, a rough journey—one that remains incomplete. The journey's struggles, however, only deepen the relevance and the value of the learning accumulated to date.

This document seeks to share insights and ideas gleaned from the polio program’s success that might inform accelerate action on other development issues.

Sharing the Learning
The learning outlined below is not presented as a directive on how to program communication and community engagement, based on what polio has learned in its journey. Rather this knowledge is shared in the spirit of supportive strategic insights and information—to be accessed and considered at the discretion of people engaged across the full range of development issues and concerns. The hope is that the reader will discover and take away what is relevant and useful in his or her own work.

This learning is derived from the work and analysis of a group of partners guided and supported financially by the United States Agency on International Development (USAID) to focus on communication and community engagement within the polio program. These partners include the: CORE Group Polio Project (CGPP); Maternal Child and Survival Program (MCSP); John Snow, Inc. (JSI); The Communication Initiative; and USAID.

In an effort to structure and organize their combined 100-plus years of actions aimed at eradicating polio, these organizations agreed on five major learning themes: social mobilization, norms and culture, community-based surveillance, use of data, and operational oversight. These themes were chosen because they evolved over time to become important aspects of their work in the most difficult situations.

In discussing the strategies used to make progress in these contexts, key questions posed by the partners included the following:

• How do we positively engage communities?
• What elements of the local culture and prevalent social norms are getting in the way, and how can we address them?
• How can we sharpen communication and community engagement with relevant data as a major contribution to strategic decisions?
• How can we ensure that this is not all a cozy and self-fulfilling process—that there is rigorous outside and inside oversight that helps to drive even better strategies and programs?

Although these questions emerged through partners’ discussion of the polio program specifically, there was a sense that they are relevant across many development issues. They are also at the heart of each of the themes presented in this document.

Shared Challenges and Issues
Actions involved in polio communication and community engagement focus on and respond to priority issues and challenges that the polio program has encountered at global, country, and local levels. These issues and challenges, which are common to many development areas, include:

• Reaching everyone (this means reaching every child in the case of polio);
• Tracking the key indicators (for polio, this includes knowing exactly how many under-5 children are in each household);
• Accessing real-time data (for polio, this includes parental responses in the polio context);
• Supporting and building local leadership (in the polio context, local/neighborhood leaders were very important);
• Strengthening the “ownership” and accountability of governments, implementing partners, and the people working on the development issue in question; and
• Timely detection of and response to new information and developments (for example, polio partners have had to respond to a number of outbreaks).

These and other challenges—such as, reducing fragmentation of efforts, increasing synergy across a strategy, and improving coordination—are central to the learning that follows.

Key Challenges
Those engaged in polio communication and community engagement have had to respond to some harsh conditions and challenges. In India, for example, there was a history of forced sterilization, while polio-specific immunization was boycotted in northern Nigeria in 2003. In Pakistan, over 100 polio workers and security guards were targeted and killed.³ Access to regions controlled by anti-government groups such as the Taliban, ISIS/DAISH, and Boko Haram had to be negotiated. In cases such as these, a way has to be found to engage in an atmosphere of lingering distrust and conflict. But from these experiences comes new knowledge and understanding. If the best steel comes from the hottest heat, then the following communication and community engagement learning themes have been strongly forged.^4–7

Funding
Some associate the strength of polio programming with the funding and political commitment levels that polio eradication has attracted, secured, and sustained. Polio efforts have been extremely well-resourced compared with almost every other development issue or program, despite missing many eradication deadlines.

The reasons for this support and funding are subject to discussion, which often points to a variety of possible contributing factors, such as the following:

• The inherent appeal of eradication and the success of smallpox eradication, which led to a single-health-issue focus and momentum;
• The clarity of the polio eradication strategy, its partnership base, and its demonstrated progress over time based on clear data points;
• A “too late to change our minds now—too much to lose as we are so close” pitch and mentality;
• Engagement by Rotary International, a major civil society organization, with deep roots in the relevant funding and programming countries;
• Political engagement of governments, both those experiencing polio and those supporting polio action;
• The involvement of the Gates Foundation; and
• The resourcefulness of the global polio leadership in Geneva, New York, and Washington.

Despite the major investments in the Global Polio Eradication Initiative (GPEI), only a small portion of those resources initially went toward communication and community engagement efforts. However, this investment grew over time, beginning as the polio program responded to resistance issues emerging in 2000–2003.⁸

The reasons behind the high overall level of financial and staff resourcing for polio eradication, and the often-critical analysis and response of other development communities to this high-level resourcing, are important. We, the USAID partners, have considered such cost issues and implications when outlining herein the lessons learned during our journey, as well as their potential applicability to other development initiatives. We also recognize that the opportunity for polio eradication to strengthen routine immunization has not been fully realized; however, the focus of this paper is not on missed opportunities, but rather on positive lessons that could be useful to other development initiatives. (Please note that the investment case for polio is discussed elsewhere.)⁹

The five major thematic areas of learning identified by the USAID-supported polio communication and community engagement partners, as further discussed below.

Editor's note: Above is an excerpt from the July 2018 paper "Word of Mouth: Learning from Polio Communication and Community Engagement Initiatives - Insights and Ideas to Accelerate Action on Other Development Issues", from the United States Agency for International Development (USAID)-supported Maternal and Child Survival Program (MCSP). Click here to go directly to the References page, where endnote information corresponding to the superscript numerals in the text above can be accessed.

Next section - Social Mobilization

Access the various parts of the document directly:

• Background
• Social Mobilization
• Norms and Culture
• Community-Based Surveillance
• Data-Driven Strategy
• Operational Oversight
• Conclusion
• References
• Acknowledgments

This paper is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

The Maternal and Child Survival Program (MCSP) is a global USAID initiative to introduce and support high-impact health interventions in 25 priority countries to help prevent child and maternal deaths. MCSP supports programming in maternal, newborn, and child health, immunization, family planning and reproductive health, nutrition, health systems strengthening, water/sanitation/hygiene, malaria, prevention of mother-to-child transmission of HIV, and pediatric HIV care and treatment. MCSP will tackle these issues through approaches that also focus on household and community mobilization, gender integration, and digital health, among others.