Pakistan PEI/EPI Communication Review

This report details a July 2001 review of communication support to the Polio Eradication Initiative (PEI) in Pakistan, designed to help shape the autumn 2001 National Immunisation Day (NID) campaign in Pakistan. The 3-member review team - comprising communication experts from the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the United States Agency for International Development (USAID)'s CHANGE Project - sought to: examine the communication, social mobilisation and training strategies and activities in the framework of the recently adopted house-to-house approach; identify strengths and weaknesses; and propose improvements, emphasising practical approaches both for immediate adoption in the fall 2001 round as well as for subsequent NIDs and routine immunisation.

The team reports, first, on the situation of polio in Pakistan at the time of the review, noting that interruption of polio virus transmission in Pakistan is critical to the success of global eradication. Yet "Polio virus transmission within Pakistan and across open borders within Afghanistan continues to be a source of virus importation into neighbouring Iran and other polio-free countries within the Middle East." To that end, at the time of the review 7 rounds of NIDs had been held in Pakistan since 1994. During each NID, 200,000 centres were set up to vaccinate 25 million children under 5 years of age, with more than 600,000 volunteers working at the centres on polio days. Evaluations of the strategy established that awareness amongst parents reached 98% and that on average almost 90% of children were covered during each round. Nonetheless, "the continued transmission of the virus after so many rounds suggested that the quality of NIDs was neither uniform nor sufficient."

As explained here, in 1999, the vaccine-delivery strategy was changed from a fixed site to a house-to-house approach in an effort to reach every child. The change in strategy has had the effect of diminishing the importance of parents' demand for polio immunisation (they were now asked merely to await the arrival of the teams; in the event that a team did not arrive, parents were requested to call a universal access number and/or to take eligible children to a limited number of fixed sites). This shift entailed preparation of micro-plans and maps, formation of 70,000 vaccination teams, payment of a small stipend (Rs. 80 per day) to each team member, appointment of paid district and zonal coordinators and union/council/ward/area in-charges, establishment of training programmes, and development and implementation of new strategies for communication and social mobilisation. These activities included television and radio spots and programmes, mosque and mobile loud speaker announcements, launch ceremonies, press releases and conferences, banners and posters, and team visits to homes, during which print materials were sometimes given to families.

The review team points out here that cultural norms make it necessary for a woman to be present on each team, "a requirement that is difficult to meet, particularly in rural and tribal areas. It is also unacceptable in some areas to have a two-woman team or a male-female team if the members are not related."

An additional 2-round campaign was introduced in the spring of 2000. Intensified efforts were continued in 2001 with a 3-round spring campaign, to be followed by sub-NIDs in high-risk districts and then a 2-round fall campaign. The number of wild polio virus cases had decreased from 324 cases in 1999 to approximately 25 cases in the first half of 2001.

Main findings of the review, and recommendations (based on interviews with a cross-section of respondents and observations from brief visits to a few sites):

Planning

• Incomplete and/or last-minute planning is a problem that seems to pervade all levels.
• Social mobilisation committees at the federal, provincial, and district levels are generally not coordinating and implementing communication and social mobilisation activities as intended, "with adverse effects on decision making and advocacy".
• As additional programme activities such as MNT (maternal and neonatal tetanus elimination) and Hep-B vaccine are introduced without a commensurate increase in human resources, they increasingly have adverse effects on planning and management.
• Co-ordination among partners, disparities in their allocations of human and financial resources to the programme, and differences of opinion and expectations concerning programme strategy and implementation hamper planning.
• How to improve planning: Develop integrated social mobilisation/communication plans for 2002-2003 at all levels; adopt a "bottom-up" approach to planning of social mobilisation; devolve more responsibility and resources for social mobilisation to provinces and districts for facilitation of local strategies; and hold more frequent meetings among partners.
  

Management

• Provinces and districts are almost totally dependent on the national level for strategies, plans, messages, materials, and funding. As a consequence, sub-national staff have little sense of control over the programme.
• The team observed a sense of powerlessness among local managers and functionaries that appeared to hamper ownership, commitment, and the development of a culture of proactive and innovative problem solving.
• Team members observed: a lack of communication materials and messages specifically appropriate to local needs (e.g., addressed to local cultural or service-delivery challenges and available in regional and sub-regional languages); the funds allocated to the districts for social mobilisation are inadequate for adapting existing materials or producing local materials; and in North-West Frontier Province (NWFP) and Sindh the package of communication and training materials was not received at all for the 2001 rounds.
• Weak/slow decision-making was observed at provincial and district levels, in part due to a shortage of managerial and supervisory personnel.
• The full potential of partners such as Rotary International, schools, community-based organisations, and private-sector entities has not been adequately tapped.
• How to improve management: Appoint communication/social mobilisation officers at the national and provincial levels; reactivate social mobilisation committees with regular meetings; improve co-ordination between partners and resolve outstanding differences; strengthen advocacy at national and sub-national levels; strengthen community partnerships, particularly in the private sector; and consider innovative service delivery options, such as including weekend campaign days or utilising popular restaurants and supermarkets as fixed sites.
  

Communication strategy

• Materials for the campaign, including the television spots, were competently produced and had achieved success in raising awareness. However, the team felt that many materials lack some of the additional attributes that might make them motivational by being engaging, entertaining, and memorable.
• Parents (especially mothers) appeared to be knowledgeable about the polio campaign. However, they lack a clear understanding of what they should do if the teams don't visit or if a child is missed. Parents are also uncertain about the reasons for multiple visits to their homes and so many repeat doses. Many are not clear about the exact locations of the fixed sites. The need to immunise every child during every NID is also not fully appreciated.
• Studies carried out in the provinces show that the mass media played a significant role in informing urban parents about the campaigns.
• There is scope for better use of other electronic media such as cable television. Team members noticed the popularity of foreign TV channels which have the potential to effectively complement national programmes.
• Mosque announcements and mobile public address before and during the rounds are important, particularly in the smaller towns visited.
• The strong communication focus on polio eradication has diluted or confused messages on routine immunisation. (This reinforces the need for integrated polio/immunisation/child health communication plans.)
• How to improve the communication strategy:
  • Focus messages on reaching every child every round, e.g. search for the missed children beginning the evening of last day of each round. Involve school children.
  • Extend mass media broadcasting before and after rounds; work more creatively with Pakistan TV (PTV) and build their capacity to plan and produce effective spots; improve the use of BBC, VOA, and other international networks; place spots on cable TV channels; and explore synergies with neighbouring country mass media channels.
  • Develop other channels for reaching hard-to-reach groups: Place the "every child, every time" message on balloons, matchboxes, posters, vehicles, product labels, etc. Distribute calling cards to closed homes. Involve pre-schools.

Training and motivation
• The success of the house-to-house strategy depends largely on team members having effective interpersonal communication skills.
• Polio eradication activities are regarded as routine, mundane, and not necessarily important.
• Many team members do not feel sufficiently motivated by such a small payment.
• How to improve training and motivation: Promote the concept of "National Polio Heroes"; use national media to motivate health workers and supervisors by emphasising the national importance of their roles; involve local communities more actively in recruitment for campaigns; employ innovative approaches to training (e.g. comedian role-play training video and games); ensure timely remuneration; award certificates and other tokens of appreciation to team members; involve local media in documenting human interest stories; and offer training in effective use of communication materials.

A behaviour change strategy geared toward key audiences is found in ANNEX B.