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

Operational Oversight


No matter the job being undertaken across any development issue and in any situation, if one gets too close to the trees, it is difficult to see the entire forest. Seeing and understanding the forest is crucial for effective and sustainable long-term development progress. The folks working day-to-day on the ground are invaluable. And their value can be enhanced through regular, consistent review by informed and knowledgeable people who are not consumed by that day-to-day work (i.e., those who can still see the forest).

Oversight Infrastructure
Over time, to ensure operational oversight, the global polio program built an oversight infrastructure that was crucial for improving program effectiveness. At the global and country levels, this infrastructure includes the Independent Monitoring Board (IMB), country Technical Advisory Groups (TAGs), a series of external country reviews, and, in some countries, Emergency Operation Centers (EOCs). Through the use of data dashboards, this infrastructure brings together government and all polio partner staff in a single work team that develops and shares a single strategy, plans and monitors together, and tracks data through sophisticated collection and analysis tools. On the ground, there are day-to-day data reviews, evening meetings, post-campaign monitoring, and review of the LQAS data. While all of this activity provides insight and guidance from the general direction offered by groups like the IMB (global) and TAGs (national and sub-national), as well as local program monitoring and assessment, deeper external assessment is often missing from key elements of the program oversight processes.

Oversight Experience
Oversight of elements of the polio program’s communication and community engagement at the country level attempted to follow the model described above. Although making a significant contribution, this process was a little more ad hoc than it could have been. Had communication reviews, for example, been conducted on the same basis and with the same regularity as the surveillance reviews in high-risk countries, progress towards eradication would likely have accelerated. This lack of equivalent attention to surveillance and communication indicates reliance on a medicalized approach to health and disease, a bias that has had a negative impact on overall polio program performance.

Many countries that stopped polio transmission without significant communication efforts benefited from trust between communities and government programs, as well as from a favorable view of immunization. In such settings, public service announcements together with well-run campaigns sufficed. However, other countries struggled to end transmission of wild poliovirus cases. During the campaigns, international observers came to realize that there were many reasons for vaccination refusals. They saw that frontline workers could not answer common questions, encountered confusing information, or faced deliberate misinformation. It became clear that the medicalized model and messages originally used by the GPEI were not resonating with some communities and families. Assumptions about government trust, trust in medicines, trust in health workers, cultural and gender influences, and household decision-making were leading to ineffective programming.

Some partner organizations were too closely wed to their plans to be able to see the issue objectively or were unable or unwilling to challenge the dominant medicalized approach that was used during the early stages of the program. In this context, independent campaign observers, third party monitoring, and external reviews became invaluable components of eradication approaches adopted by the WHO and the Centers for Disease Control and Prevention (CDC). The communication component of eradication slowly became part of the data and planning reviewed by the country-specific TAGs, the IMB, and independent communication reviews that were modeled on surveillance reviews.

External Reviews
External communication reviews²⁴ provided an opportunity to assess the appropriateness and quality of all communication elements, including mass media, interpersonal communication, and information education and communication. Communication and community engagement strategies were critiqued and recommendations were shared with implementing partners. It was vitally important that external and independent review, which was intended to sharpen communication and engagement strategies, complemented the normal planning, review, and line management processes of the implementing partners.

This external review process was a key tool for program and organizational accountability. It also provided cross-country sharing of best practices and drew on a larger knowledge base than was resident in the country program. It took a long time for an external review process to be fully accepted; however, in the end, it was seen as invaluable. Future programs should include an external oversight and review process.

Regular Reviews
These reviews are most effective when they are repeated over time. One-off events have limited impact with no momentum and accountability. Having a mix of communication disciplines from inside and outside the country as part of the review process has improved country programs and built capacity.²⁵

Know the Culture
Communication efforts benefited from review by experts who know the culture intimately, including health epidemiologists, social scientists, data analysts, anthropologists, and development practitioners—in addition to pure communication or behavior change experts. Tapping into a more extensive network of senior experts provided fresh perspectives and ideas.

Current Status and Accountability
The review teams were able to describe the present polio situation in a country/state/province/district/town and propose recommendations for improved action. The teams reaffirmed positive approaches and proposed solutions to challenges and obstacles. Donors encouraged the external review process and requested updates on the progress of implementing recommendations. Donor interest also helped with accountability. It is vitally important that the major implementing agencies own the results of the review, thus committing them to give real and serious consideration to the analysis and recommendations from the independent review process.

For many years, the global polio program was setting policy, implementing activities, and engaging in self-monitoring and self-evaluation—in short, it had limited external oversight, which led to groupthink and a fear of exposing program weaknesses. This insular dynamic had a negative impact on the program and stifled innovation. Increasing independent review, minimizing conflicts of interest, listening to low-level/bottom-up concerns, and encouraging problem solving are now considered best practices.

Avoiding Groupthink
Avoiding groupthink was a major preoccupation for the communication reviews that were undertaken. People with an outsider’s perspective were invited into the process to contribute their analysis and ideas. It was important to challenge the internal, often orthodox, view of the present state-of-play with polio in a country and the effectiveness of the response, especially at the community level. Debate and conversation were supported and facilitated, not shut down. The presence of some devil’s advocates to challenge any groupthink has been found to be very helpful.

Effect of Consistent Review
In the course of the polio communication and community engagement journey, there have been numerous examples of the impact of these ongoing, consistent review processes, such as the gatherings of annual or biannual communication TAGs in priority countries and regions. Additional examples of the impact of these review processes include:

• Priorities were set with timelines, and the operational agencies were held accountable in future review meetings.
• The use of GPS to monitor vaccinator teams in Nigeria made them much more accountable for actually going to and vaccinating in their assigned communities and for validating campaign coverage.
• The move from booths to house-to-house polio immunization expanded and deepened coverage, particularly among those who are hardest to reach.
• Evening meetings, timed to enable more community members to attend, were introduced during campaigns to improve accountability, local decision-making, and coordination.
• Accountability frameworks were developed and implemented in polio-endemic countries.
• External, independent review processes for surveillance and communication put a significant check on the earlier problem of falsifying data, instituting a zero-tolerance policy and response. This development held vaccinators, mobilizers, and monitors accountable for their performance in, for example, India, Pakistan, and Afghanistan.
• The India Social Mobilisation Working Group met after every campaign to identify and analyze issues, followed by the development of appropriate responses.
• The Horn of Africa TAG worked to ensure that community-based surveillance data were included in all epidemiological reports.
• Micro-planning was recommended and introduced in many countries. This allowed monitoring and tracking at the grassroots level instead of relying on overall, aggregated data at the national or state/province level.

In addition, The CORE Group organized its work in Nigeria with clear operational oversight as a central principle. As part of this effort, polio focal points from communities and villages in project areas have between five and 50 families to follow. They track information about individuals in the family during and in between campaigns. One of the things that makes this approach effective is that the responsible people at the community level receive regular supervision. There is clear and accountable oversight of the work at the micro-action level.

Also in Nigeria, but across the partnership, the use of GPS as an oversight and accountability mechanism identified a major gap in the missed children strategy, as was reported:

“During this period, >2500 settlements that were initially missed during the 4-day campaigns were identified by the VTS [vaccination tracking system] and targeted for mop-up. This uses GPS and GIS to create a VTS.”^26,*

The previous coverage reports stated that the Nigeria polio program was reaching a high percentage of the population during its campaigns, but it was a high percentage of only half of the population.

Evening meetings during the campaigns created a sense of control over what was happening in the campaigns, facilitating community ownership and problem solving, which is another vitally important principle for effective and relevant oversight. The evening meetings were led by local government officials with participation of polio focal points from implementing partners, government supervisors, and third party monitors. Each supervisor reported on the progress of the teams, any challenges, and any need for mid-course correction due to issues such as poor team performance or an uptick in refusals. This approach led to on-the-spot decisions and improvements. Immediate problem solving increased government ownership and accelerated program improvement with measurable results (more children immunized per round).

Core Question
The key question for all operational oversight processes is, “Why?” Why are there missed children? Why didn’t the vaccinators visit this house? Why didn’t people hear about the campaigns in advance? Why were children in transit hard to find? Why are children listed as receiving “zero dose” or never receiving a routine immunization dose? Unearthing the underlying issue and continuously asking, “Why does this issue exist?” has meant the difference in improving from good performance to excellent performance. Answering the “Why?” question has driven the strategy to reach every eligible child. By stratifying the reasons and populations for missed children, the program could develop a specific response to each concern or problem. Strategies evolved to improve vaccination for the children of the underserved, mobile/migrant, nomads, brick kiln and construction workers, those living in urban high rises, members of minority ethnic or tribal groups, and refugees and internally displaced persons.

Oversight can also come through interagency programming partnerships. The “secretariat” model developed by the CORE Group and USAID consists of national program and communication advisors who are independent of any organization and supported by the CORE Group. Working together, these advisors created a secretariat that prepares joint proposals for funding and that implements solutions to solve a health problem.²⁷ It has proved to be an important component of the operational oversight process in the polio eradication effort. When a number of organizations come together to form an autonomous expert group, a platform is created for: a singular focus on the issue at hand (in this case, polio); a process for harnessing the capacities of the partners in a coordinated manner; and the basis for serving as intermediaries between the government and communities. The secretariat model also serves as a useful mechanism for mobilization and cooperation of networks of international and national civil society organizations.

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^*Another paper on the use of GIS from 2013 to 2015 says: “There was a reduction in the number of settlements missed during polio campaigns in Kano, Kebbi, and Sokoto states. However, an increase in the number of missed settlements was recorded in Bauchi and Zamfara states during the same period. Jigawa and Katsina states also had a slight increase in the number missed. Also, in Table 2, the number of chronically missed settlements (i.e., settlements that had been consistently missed in the last 3 polio campaigns) decreased significantly for all states except Zamfara, which had a slight reduction between 2014 and 2015. In Kano state, the number of chronically missed settlements decreased from 1,298 in 2014 to 165 in 2015, showing a huge drop in missed settlements.” Source: Touray K, Mkanda P, Tegegn SG et al. 2016. Tracking vaccination teams during polio campaigns in northern Nigeria by use of geographic information system technology: 2013–2015. Journal of Infectious Diseases. 213(Suppl 3): S67–S72. Accessed at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4818548/

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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).

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Next section - Conclusion

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.