Sindh Polio Communication Review Recommendations

UNICEF (Abdelwahab); The Communication Initiative (Morry); Pakistan Ministry of Health Education Cell (Natta, Nisar)
This 17-page document provides background and further detail on recommendations presented at the conclusion of the Sindh Polio Communication Review meeting in Karachi, Pakistan, from November 23-25 2009. The objectives of the report, which was prepared by a panel of 2 national and 3 international communication experts, were to: follow up on the status of recommendations made during 2008; review communication challenges (focusing on activities in areas identified as being at high risk of ongoing virus transmission); and provide guidance on improving specific areas of the overall communication strategy, including some aspects of Expanded Programme on Immunization (EPI) communication. The review's methodology combined: field visits to Gadap and Gulshan-e-Iqbal; presentations from high-risk town/districts; presentations on communication programmes geared toward high-risk groups, reluctant communities, and political ownership; and discussions between panel members and presenters, combined with some review of data.
As reported here, at the time of the review, Pakistan had a total of 80 Wild Polio Virus (WPV) cases in 30 infected districts. The outbreak experienced in Punjab in 2008 is under control, but over the past 3 years 3 areas have continually reported cases: Quetta block, central North-West Frontier Province (NWPF)/Federally Administered Tribal Areas (FATA), and the Karachi area of Sindh. The primary challenge for Sindh has been the lack of consistent high-quality vaccination activities, especially at the sub-district levels, despite no significant access issues. High population movement, especially from insecure areas of Pakistan and Afghanistan, further complicates matters.
In summary, the review team found the following progress and remaining challenges in implementing the 2008 Sindh recommendations:
- Planning and Reporting Mechanisms: The review team notes that planning matrices are being used more consistently. For example, a combined Polio Eradication Initiative (PEI) and EPI initiative to increase immunisation rates among brick kiln workers made use of the planning matrix to: build the project based on data that showed low routine coverage rates, inform the decision of which group to be worked with, conduct baseline surveys and structure meetings with key partners, develop a SMART (Specific, Measurable, Achievable, Relevant, and Time-framed) objective, and measure outcomes. Despite such positive examples, the review team finds that the processes for analysing data, reviewing activities, and providing ongoing feedback and monitoring of communication plans still need more attention.
- Team Coordination at Provincial and Federal Levels: Despite considerable improvement in the way teams are working together, a 6-month vacancy in the provincial-level communication officer post has slowed progress.
- Human Resources: Provincial-level commitment remains high, but ensuring engagement at the district level requires more work and focus. The Ministry of Health (MoH) has yet to appoint a communication focal person, yet it was positively noted that there are plans to do so. There has been some provision of extra communication support in the form of social mobilisers, and the review found increased female participation in teams within conservative communities in districts such as Gadap and Gulshan. However, more attention needs to be dedicated to strengthening such efforts.
- Use of Data: Improvements were evident, especially in some of the planning matrices, the use of baseline data, and the development of SMART objectives. Progress was made in use of social maps, as demonstrated by 2 maps (one from 2008; one more recent) of Sukkur that are included in the text. (The more recent map has had further information added to it as the programme has learned more and changed its focus.) However, many presentations studied as part of the review did not use independent monitoring or disaggregated reasons for missed children ("No Team" (NT), "Not Available" (NA), etc.) data as thoroughly as is needed for planning and linking it with the activity to assess/correlate any impact. Fingermarking is being used across the programme. For instance, the team in Gadap cited above has also linked progress in increasing women's participation with the fingermarking monitoring data for the same period, showing an increase in coverage from 84 to 92%. However, the review team stresses, the methodologies for independent monitoring are still being finalised, resulting in campaign-to-campaign variations which remain open to interpretation. One solution proposed is sentinel site surveys, especially for developing and evaluating localised communication initiatives.
- Cross-Border Communication: Provincial cross-border meetings do not seem to be happening in a regular fashion.
- Mobile Communities: While mobile populations in Karachi are a significant and growing issue for the programme, maintaining coverage levels among nomads and reaching other clusters of mobile populations in Sindh needs to be given more attention.
This report reveals that continued and visible commitment from the Provincial MoH, supported at the Federal level, continues to be an important achievement. The review team positively highlights coordination efforts in 2008 at the provincial level and the development and implementation of a "political ownership indicator form".
Furthermore, there was evidence of use of approaches such as street theatre, circuses, and poetry readings to reach out to different groups in different ways. These positive developments, some of which are a reflection of partnerships built with new sectors and non-governmental organisations (NGOs), are understood to reflect the continued energy and creativity in the programme.
However, consistent sub-optimal coverage continues to be a major challenge for Sindh. Overall coverage has fallen over the past 4 years there. The key challenge to the polio communication programme is how to better address low coverage and the high numbers of children who are missed due primarily to NT or NA. There is a need to keep the focus on disaggregating the overall breakdown of missed children to be able to prioritise areas of work and develop plans accordingly - especially to address NT and NA. Other challenges include:
- Managerial and accountability issues continue to be a major challenge for the programme. Progress on these issues in Sindh is essential to reaching necessary coverage levels and remains uneven, especially at the District and Town level.
- The programme seems to be relying more on planning matrices, which are an excellent tool, but are not a replacement for a good and regularly reviewed communication strategy. This applies to both the provincial and district/town level.
- This and other issues have been exacerbated by the Communication Officer post being vacant for the more than 6 months, but the hiring process is underway.
- While there has been some communication training, it has not been enough; nor is there an overall training plan that provides regular and progressive training related to a communication strategy.
- Communication is not regularly reviewed as part of provincial campaign review meetings.
- Independent monitoring continues to be underutilised, at least in the presentations given during the review and the linking of activities with outcomes and achievements is not done consistently.
- The T/DHCO (Town and District Communication Officer) and social mobilisers exist in limited numbers and, despite valiant efforts, must confront sub-optimal performance related to communication.
- There is a lack of focus on media, media engagement, and local media strategies within the programme.
- The review team had 3 days in total, including the time required to reflect on findings and prepare and present recommendations. It would enhance the quality of future reviews if the review panel were able to observe between-round programme communication and social mobilisation activities.
Detailed recommendations with timelines (see pages 10-12) are provided. The review team then offers concluding remarks: while "[t]here are a number of significant innovations and new initiatives and good progress on critical challenges...the programme needs a standardized process for developing evidence based communication strategies, objectives and monitoring mechanisms which can be applied flexibly across different districts and towns. And finally, while some progress was evident further strengthening the integration of EPI/PEI in communication and social mobilization activities remains a major challenge."
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Email from Chris Morry to The Communication Initiative on December 10 2009. Image credit: Dawn.com
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