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The required communication strategic elements for effective health and development, derived from demonstrated long-term health and development progress.  

CAN TALK, THEREFORE …

There is a common impression in local, national and international Development that because people can talk, write, phone, type and “chat” … therefore everyone is a communicator. That is, of course, not the case. Communication to achieve Development goals requires very sophisticated skills and knowledge. Because we can all handle a knife does not mean that we are all surgeons. And, closer to our Development home, because we can all count does not mean that we are all epidemiologists. 

Sophisticated communication strategies have played a major role in the progress achieved across a range of local, national and global development issues, including health. Effective communication initiatives have been at the heart of some of the most substantial progress on health issues including family size, tobacco, Ebola, polio, HIV/AIDS and child health. Blame can be apportioned to either the absence of relevant and effective communication and/or poor communication choices for those stubborn issues on which it is proving difficult to “move the needle”.

How do we justify these statements? What have we learned about the required local, national and international policies and funding priorities for more effective development action? From these experiences, what core communication principles appear as essential for health policies from local wards and districts, through governments, to major international organizations?

The answers follow the analysis below. But as a forewarning, hopefully not a “spoiler”, the answers are not the normally understood and referred to communication strategies and actions. Messages, media channels, behavior change and supportive environments, for example, do not feature. There are different big communication dogs at play.

DRIVING FORCES FOR MAJOR HEALTH CHANGES
 
When we assess the major reasons why significant health improvements have taken place it is tempting to exclusively focus on health products with proven physical science attributes – condoms, vaccines, oral rehydration salts, clean water systems, food supplements, and many more.

But many of those “services” or “products” would not have been possible without a high degree of entanglement with a series of social changes. This is not supportive environment where the change is designed to simply support the availability and use of a product.

It is enmeshment, entwinement, entanglement of the health issue or problem with a series of social changes taking place that are equally as important for health progress as the physical products being developed and promoted.

Those social changes, some “natural”, others the result of initiatives designed to encourage and support that change, often a mix of the two, provide us with the strategic insights required for future, effective health communication policies, strategies, action and funding priorities.

Lets take a look at this dynamic specific to a few major health issues on which significant, positive change has been experienced over the past 20plus years.   

FAMILY SIZE – FERTILITY TRENDS

Family size is falling in most countries of the world. See for example the right column of the Word Bank table for country trends  and play with the decade data comparisons. There has been a very rapid decline in live births per 100,000 and fertility rates since the 1970s as highlighted in this chart - Birth rates (live births per 1,000 people per year) over the long run – Max Roser  

The International Conference on Population and Development (ICPD) in Cairo in 1990 identified why this trend was happening. It learned from the 1970s and 1980s and distilled the pathway for future progress. Though it is tempting, and normal, to credit vastly improved use of contraceptives as the core reason for family size decrease, some of those contraceptive products and services had been available for a long time with little impact prior to the 1970s. Others were of course new.

The ICPD identified that a key element for further progress on fertility rate and births per 100,000 was going to be (and turned out to be) the “recognition that reproductive health and rights, as well as women's empowerment and gender equality, are cornerstones of population and development programmes.” (from a recent UNFPA summary).

Rights, empowerment, equality and gender. There is no vaccine for these. Only communication strategies can move, and have moved, those issues in a positive direction.

Campaigns for the rights of women, initiatives that stressed male responsibility and involvement, the opening up of conversations across media and in other public spaces on often sensitive sexuality issues, support for conversations within households, the priority focus on girls going to and staying in school, and creating the positive social space for displaying and purchasing contraceptives, are just some of the communication processes that proved vitally important in helping to bring down fertility rate and births per 100,000 in so many countries. These processes were not simply oriented to support contraceptive use. Nor were they just a basic supporting environment for condom and birth control use. These social processes are enmeshed with, entangled with, intertwined with, those products. One cannot happen without the other.

TOBACCO

There has been a major social norm change related to tobacco and smoking in so many countries. Challenges remain of course. But over a 20year period, in many countries, smoking has gone from being the ultra-cool thing to do … to smokers being the new pariahs. As a result there has been a significant increase in the % of the global population over 15 years who are not “smokers” .  Progress has of course been uneven: spectacular in some countries; regressive in others. 

This change has been in the face of a product that is highly addictive with gazillions of dollars being spent by some of the largest and wealthiest companies in the world on their own highly expert, global scale, sophisticated, message driven communication campaigns to encourage and support people to start and continue a pack-a-day habit. For the first 25 (approximate) years after the initial United States Surgeon General’s report linking tobacco use to negative health results, including high incidences of lung cancer, much was tried but not much worked. From the patch to hypnosis, quit smoking campaigns based on individual responsibility to scare messages on the packaging, making progress was a real struggle. And then something happened.

A smoke-free social movement rapidly emerged. Tobacco became an issue for public debate in families, communities, local municipalities/councils, governments and gatherings of all stripes, colours and locales. Emerging from these conversations, by-laws, rules, regulations and customs were introduced; national and local governments banned smoking in their buildings; corporations banned smoking in places of work; taxes were raised to ensure a price barrier to purchase; sponsorship bans and restrictions quickly followed; parents paid much higher attention to discussing tobacco with their children and preventing them being around smokers; media campaigns highlighted what happens if you smoke; tobacco became a big news story; and people in their communities and countries started to organize - they raised their voices.

This was a social movement communication process. It was not narrowly focused on message delivery seeking to influence people to make individual behaviour changes. That would have been a losing proposition given the overwhelming power of tobacco messaging.

Like all social movements, stimulus points are vital. For tobacco this included the data on the negative health effects of second hand (or environmental) smoke, first in a secret Tobacco industry study in 1978 and later confirmed in a series of studies. Now, tobacco was everyone’s health business.

Despite being vastly (really vastly!) out-muscled and out-spent, and facing an addictive “agent”, the anti-tobacco forces have scored some considerable victories with their social communication processes. Momentum remains on their side.

EBOLA

When people in West Africa saw their just-died loved ones spirited away from their homes by “foreigners” they did not know, completely anonymous in their full (and scary) Hazard Material (HazMat) suits that looked like something from outer space, who whisked in and out of their homes rapidly, and disposed quickly of the bodies of those loved ones, they read the communication signals inherent in those actions and they responded. What the HazMat people were doing may have been the required technical prescription to reduce transmission. But it back-fired really badly.

Epidemiology and medical expertise came up against something much stronger - hundreds of years of cultural and family practice around dying and death. Wanting to give their loved ones the proper way (from their own frame of cultural and family reference) to die and be cared for after death, and definitely not wanting the snatch and grab raids in their homes, people hid their dying and dead. Then they cared for them – washed them, kissed them and dressed them, for example. It was an almost perfect recipe for accelerated transmission of Ebola. And that is what happened.

The fault here does not lie with the people in Guinea, Liberia and other countries. The fault lies with the communication signals and messages transmitted by the actions of the international development community.

It was only when some real communicators became involved that the tide began to turn. Now there were initiatives that gave locals in Liberia, Guinea and elsewhere a voice; facilitated public and private spaces for conversation about Ebola; shared important knowledge in ways that resonated with local cultural touchstones; in thought and deed were highly respectful of local, cultural and family tradition and practices, even as they sought to facilitate adapting those ways of life to ones that advance safer health; and that was openly led with a much better balance between local people and international “experts”.

The tide turned in the Ebola struggle.

POLIO

In 2001 and 2002, people and communities in some of the economically poorest parts of the world essentially defeated a billion dollar a year health programme that had been seeking their “cooperation” to eradicate a major health issue. Those people and communities had only one strategy available - communication. They organized their own “anti-vaccination” movement. It was remarkably successful from their frame of reference. And it was terrible for health. Polio incidence rates began to rise after years of falling. Sometimes there were dramatic increases. Local people in Northern Nigeria and Northern India had provided a huge headache (tsunami sized headache) for some of the world’s most powerful health agencies, such as UNICEF and WHO, and for their own governments.

The polio folks had to rethink their overall strategy including the communication elements that were in place. They had to learn from what had happened to them. And they did.

The new approach to polio communication that emerged can be characterized as “closer to people”. In general: out went the rather detached and remote, simple messaging; out went the use of public service announcements; out went Bollywood and Lagos film and TV stars “pushing” polio vaccinations; out went a mass media focus; and, out went a mainly medical perspective.

The most dramatic new development exemplifying the “closer to people” approach was the Social Mobilization Network jointly developed by CORE (a USAID supported programme) and UNICEF, in Northern India. The emphasis was on local people; organized at community block level; with tasks that required local engagement (for example mapping of families and the house markings); a focus on working with local political representatives, religious figures and administrators; with localised data sets (for example missing children); and, spaces for local debates (for example in mosques) on the issues involved in polio eradication.

As we well know now this local communication approach had a very significant and positive effect in advancing the polio eradication effort. It was a model that came to be adopted in other (then) endemic countries such as Pakistan and Nigeria. Progress continues. 

Major success followed.

HIV/AIDS

Did the global international development organizations - bilateral governments, UN agencies, the big NGOs - fail to learn from the early, successful struggles to confront HIV/AIDS? As a result, did their actions, including their communication and media strategies, help contribute to the 15 years of HIV/AIDS hell that enveloped so many countries between 1990 and 2005? And that continue to this day for so many people, communities and countries. The data – for example compiled by Moser  shows the HIV/AIDS trend with which we are all too familiar.

The initial response to HIV/AIDS was driven by civil society actors - a combination of local community groups and people living with HIV/AIDS individuals and networks in the South, and predominantly Gay Rights networks in the Northern countries. They put the issue on the agenda, had real “ownership” of HIV/AIDS as a major concern, facilitated and undertook high levels of action. This dynamic was captured by The Panos Institute in its policy paper: “Critical Challenges in HIV/AIDS Communication”. 

That perspective was backed up by the data. For example, Uganda was doing so much better than other countries when HIV/AIDS incidence data was compared. Rates were lower than other countries. Everyone wanted to know why.

In 2004 Population Health Evaluation Unit at Cambridge University in the United Kingdom, through CADRE, undertook a substantive research project examining the Ugandan approach to HIV/AIDS  . That research resulted in this conclusion:

“Casual sex and HIV prevalence had dramatically declined in Uganda between the late-1980s and mid-1990s, a trend that was not observed in Uganda's neighbouring countries suffering from high HIV incidence. The authors hypothesised that horizontally communicating HIV-related matters through social networks would have positive impacts on population behaviour and HIV prevalence. Comparisons were made between Uganda and its neighbouring countries (Kenya, Malawi, South Africa, Tanzania, Zambia, and Zimbabwe) to discern the impacts of HIV-related communication patterns” .

A strong civil society process had begun in Uganda. The Cambridge research results linked the comparatively lower HIV inflection rates in Uganda to the essence of the Ugandan strategy: strong local and national civil society action; embedded in and led by local people; raising and discussing the very sensitive issues that surround sex; in established local community, district and national “spaces” (from family to parliament); with programmes that emerged from that consideration and the analysis, had a positive effect in responding to HIV/AIDS – all through local social networking (pre-digital social networking!). 

This was known at the time. Many people, in the early 1990s, from their social communication perspectives, reflecting on the lessons learned from Gay Movements and Uganda, were almost literally yelling at policy makers and funders to please pay attention to this dynamic and to please support these localized communication actions