Imprints of effective communication: Looking back at the PAIMAN project after more than a decade

Author: Zaeem Haq, May 31 2022 - It was amazing to see a recent tweet by a Pakistani journalist in which he used a punchline of the movie Bol to comment on the current political situation in the country. Bol (meaning "speak up" in English) was a depiction of social problems that arise from lack of birth spacing and was produced by Pakistan Initiative for Mothers and Newborns (PAIMAN), a United States Agency for International Development (USAID)-funded, John Snow Inc. (JSI)-led project implemented in 23 districts of Pakistan and completed more than a decade ago. Johns Hopkins Center for Communication Programs designed PAIMAN's communication strategy with several innovative interventions - Bol being the most colorful feather in this cap.

The line in Urdu Khila nahi saktay to paida kyoon kartay ho? (If you can't feed, then why did you give birth to us?), delivered by a powerful female character in the movie, addressed the irony of a poor household where the wife endured repeated childbirths because her husband wanted a male heir. My amazement at the stickiness of this message led to the question, "What else still exists as the legacy of this health project completed over a decade ago?" A quick review of online documents and some discussions revealed interesting insights.

PAIMAN's strategy had two main pillars: generate evidence for strategic advocacy, and use the power of communication. In its formative phase during 2004-2005, the household-level data unravelled the preference for a male child as a major reason for repeated pregnancies, putting mothers' health and survival at risk and causing high mortality, later documented at 276 maternal deaths [PDF] out of each 100,000 live births. Emerging from the same research, the lack of a Skilled Birth Attendant (SBA) was a system-related anomaly, forcing women in rural areas to seek pregnancy and delivery care at the hands of informally trained Traditional Birth Attendants (TBAs). In addition to the high maternal deaths, this unskilled care also contributed to high newborn mortality [PDF], 54 deaths out of every 1000 live births.

PAIMAN's philosophy was to set the right direction of Mother, Child Health (MCH) care through powerful structural interventions and creative communication. To fulfill this aim, the project worked on improving the continuum of care for mother and child by improving household and community behaviours and enhancing capacities at the health facility. Bol and several accompanying communications targeted health behaviours, while the introduction of a Community Midwife (CMW) in rural areas set a new direction in the county's healthcare system. Notably, both strategies faced resistance. After several decades of conservative, Islamist governments in the country, taking up a bold topic like birth spacing was not easy for mass communication. On the system side, many health experts still believed that improving the capacity of TBAs was a more viable strategy than introducing a brand-new cadre of CMWs. However, PAIMAN continued its advocacy by generating new evidence and delivering it through strategic communication.

Today, the number of CMWs that started from zero in 2005 has grown to 8,000 CMWs trained and deployed by the public sector in all provinces. The "sticky" health messages like the one mentioned in the tweet triggered similar health content for the next generation of health communication programs. Improvement in several behavioural and outcome indicators can be observed by comparing the status of indicators between 2005 [PDF] and 2020 [PDF]. The use of SBAs has increased from 61% to 86%, delivery at health facilities has increased from 34% to 66%, maternal deaths per 100,000 live births have decreased from 276 to 186, and the rate of newborn deaths has decreased 54 to 42 per 1000 live births.

PAIMAN is a case study of how effective projects can set the future trajectory of healthcare through the power of evidence and strategic communication. Introducing a trained midwife working at the community level established the significance of SBAs. It linked the community to a facility for essential obstetric care that paved the way for saving lives. In strategic communication, it adopted a disruptive approach to the existing risk-free yet lusterless communications. It developed message content that stood apart and was memorable. This memorability or stickiness of a message, as described by Malcolm Gladwell, is the fundamental requirement for generating interpersonal discussions [PDF] that facilitate decisions and the ultimate adoption of positive behaviour.

In terms of evaluation, this retrospective view highlights that effectiveness is not time-bound. Development projects and their funders need to watch even beyond the culmination of a project. The existing evaluation guidance suggests that communication is a cycle. However, the same direction suggests that evaluating the impact of health programs and their communication component is linear. As a result, all projects monitor their implementation, carry out some outcome assessment at the end of the project, and leave it there. It is important to remember that robust interventions may have results that sustain over time, and projects can do good to themselves and society by also considering their long-term effects.

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