Conflict & Its Impact on Polio Eradication South Khyber Pakhtunkhwa: Innovative Social & Behavior Change Strategies & Models [Presentation from the Sharing Learning from Polio SBC Side Event at the 2022 SBCC Summit]

"...still the biggest problem is basically the mistrust or the distress..."

Following the United States (US) invasion of Afghanistan in 2001, Pakistan and the merged Tribal Districts, particularly the North Waziristan Tribal District (NWTD), experienced increasing violent conflict that has further challenged the attempt to eradicate polio in this region. Ejaz Ur Rehman explores conflict and its impact on polio eradication in South Khyber Pakhtunkhwa (SKP), Pakistan, in this talk at the Sharing Learning from Polio SBC: Misinformation, Social Data and Conflict side event at the 2022 International SBCC Summit.

Ur Rehman begins by presenting some context for the conflict and discussing the nature of challenges for polio eradication, especially fear and mistrust among communities. In this setting, social and behaviour change (SBC) has an evolving role, including within known chronic refusal clusters/large-scale demand-based refusals, as well as in response to fake finger marking and other hidden refusals. Designed to match the operational and security context, social interventions are:

• Overlaid with different data sources: security data, anthropology and local/epidemiological data to identify the challenges in each union council (UC)/area;
• Informed by the available data, which is superimposed on refusals and challenge mapping on the security map to identify appropriate community engagement approaches; and
• Developed in part by a local-based consultant from KP (Dawar tribe), who conducted low-profile focus group discussions (FGDs) and interviews to identify drivers and relevant approaches for community engagement. Areas for the FGDs are guided by security mapping, communication challenges, and cluster refusals.

Four key SBC areas of work in SKP include:

1. System strengthening, ensuring participation [social profiling, challenge mapping, mapping of influencers, single-knock strategy, gender-appropriate activities]
2. Social listening, shifting social norms [backdoor meetings with boycott initiators, Jirgas (traditional platforms for conflict resolution and consensus building), social norms]
3. Accounting for multiple deprivations [polio fatigue, plus polio, integrated service delivery, or ISD]
4. Building new partnerships and maintaining neutrality [moving beyond traditional partners to include non-governmental organisations (NGOs)/community-based organisations (CBOs), traditional birth attendants (TBAs), and others to manage misinformation and build trust]

Ur Rehman discusses UNICEF Pakistan's community-owned approach to centring polio at the local level by addressing mistrust and multiple deprivations through engagement of sub-tribe leaders, or "mashers". The process begins with mapping of these village-level influencers, who tend to be more trusted than high-level leadership, who people in SKP may suspect of being motivated by their own interests and/or infiltrated by agencies. The mapping involves blockwise identification of mashers to take the lead in granular-level Polio Eradication Initiative (PEI) work, which UNICEF's Communication Network (COMNet) orients/trains them to do. This work may involve facilitating Jirgas and/or Marakas (a form of Jirgas) to build trust around the polio vaccine, coordination of vaccination, and micro-plan validation.

Initial results of this work have included: a reduction in fake finger marking; 97% resolution of all boycotts; 100,000 additional children vaccinated with support of pluses; detailed mapping of sub-tribe level influencer mapping and engagement; and implementation of community-owned health camps.

During the discussion session with audience members, Ur Rehman details the work of the religious support persons (RSP) network, which was formed in 2014. UNICEF Pakistan has hired more than a thousand religious scholars across the country (except Punjab, because in Punjab isn't plagued by that kind of an issue), but in Baluchistan in Kabir predominantly. There is so much misunderstanding around polio in many areas of Pakistan that it has even tarnished the image of the religious scholars in these areas. A couple of national religious scholars that UNICEF Pakistan asked to initiate or even inaugurate a polio campaign for them were then trolled on social media and particularly in the newspapers and within the community. They were accused of having sold out their religion and of being in it for the money (considering the dollars connected to the polio programme). These kinds of communication challenges pose a real problem for UNICEF Pakistan in places such as South Waziristan, which is not only conservative but is extremely religious in nature. In response, UNICEF Pakistan has expanded its approach so as to emphasise the value of immunisation beyond just polio.

In sum, the SBC focus in SKP is on: (i) engaging the sub-tribe level local influencer network and leveraging the expanded package of services and commodities being delivered through health camps and pluses, and (ii) investing in social listening and holding tribal elders and other leaders accountable for prevention of boycotts, fake finger marking, and hidden refusals. Fatwas have been negotiated by top religious leadership in this regard.

Click here, and then click on the Part 2 video recording, to locate and watch Ur Rehman's presentation (beginning at approx. 1 hour and 37 minutes into that Part 2 recording).