Sindh Polio Communication Review Recommendations: Building on Progress/Addressing Challenges

This 12-page report details recommendations presented at the conclusion of the Sindh Polio Communication Review meeting, held in Karachi, Pakistan, from September 15-18 2008. The recommendations for the Sindh review were generated by a panel of 4 national and international communication experts. The review panel undertook an assessment of the current polio eradication initiative (PEI) communication programme in Sindh, using a combination of: field visits; presentations from 5 high-risk town/districts; presentations on innovative communication programmes seeking to reach high-risk groups, reluctant communities, and political leaders; meetings with senior government and programme officials; and plenary session briefings and discussions from provincial- and district-level teams.

Specific recommendations are provided here, in combination with contextual analysis of key communication programme issues. They are presented with the goal of supporting and accelerating polio eradication efforts in Sindh specifically and Pakistan more generally, and form a resource to be used by Sindh's polio communication teams in accordance with their own judgments and experience.

First, background is provided. An international review of the communication component of the PEI in Pakistan was held in September 2007. This review made a number of recommendations, which focused on: sustaining achievements of the programme; intensifying communication focused on sub-district strategic approaches that link data with social mapping/communication (SM/C) activities, develop and monitor indicators, and refine and modify approaches accordingly; using data more effectively in training, combined with strengthening interpersonal communication (IPC) quality and the use of social mapping; increasing communication capacity and leadership at both the provincial and district levels; and ensuring adequate follow-up through regular meetings and reporting involving the Technical Advisory Group (TAG).

Gauged against these indicators, the panel considers progress in the intervening years (a chart on page 3 outlines specifics). In outlining this progress, the panel emphasises the ongoing support from senior Provincial Ministry of Health (MoH) officials as crucial in strengthening PEI in Sindh and keeping it a top priority in the provincial health agenda. Notably, this support has been maintained in spite of a period characterised by both intense political change and increasing population movement within Sindh, between provinces, and into and out of Afghanistan. In the midst of such change, the programme has implemented campaigns on an almost monthly basis - doing so while implementing the recommendations from 2007 and adding "innovative and adaptable local strategies to its programming", especially in Karachi. In particular, the panel highlights coordination efforts at the provincial level through the steering and coordination committees, and the development and implementation of the political ownership indicator form. (This form encourages consideration of indicators such as whether the Nazim (town coordinator) conducted a field visit during the last campaign, attended an evening meeting, and/or participated in a polio walk, media event, or public event regarding polio).

One of the achievements described here is an improvement in the use of data, especially for SM/C activities. For instance, in one case baseline data were used to identify the total number of missed children in a district across 3 rounds. By looking at the numbers, PEI personnel determined that a focus on the refusal schools could provide them with access to nearly 50% of the missed children in their district. This recognition stimulated the development of a communication strategy to reach out to these schools to make them partners in polio immunisation. This is illustrative of the "good efforts...being made towards engaging other key partners, such as the police, private sector, different political parties, and leaders from different minority and mobile populations." In essence, the panel concluded that increased attention and focus is being given to communication components of the programme at all levels, as seen in joint workshops, as well as national TAG and global meetings. "It is an important step forward to be able to say that communication is a much higher priority for the entire programme at all levels than it was even one year ago."

There are, however, remaining challenges. For instance, communication plans are being prepared but they do not systematically review appropriate/updated data to identify and track priority issues over time. Furthermore, these plans do not always include objectives; nor do they always prioritise activities according to issues. Despite improvements, plans are often missing the data underpinning issues, as well as evaluation, process indicators, and surveillance data components. In short, the panel found that many communication initiatives are being planned and implemented without baseline evidence as to their strategic value to the programme or their impact on overall immunisation coverage.

Other challenges relate to the need for improved team coordination, as well as more robust human resources (HR): stronger communication capacity, and more consistent participation by lady health workers (LHWs) in social mobilisation and in supplementary immunisation activities (SIAs). The panel also urged stronger reporting mechanisms. While there is a flow of information from district to province, technical feedback is lacking related to communication plans and monthly reports, communication meetings are not being held regularly, and there is no quarterly provincial communication work plan.

The panel focused especially on the use of data, explaining that - despite some progress at the district level, while multiple data sources are available they are often not being utilised. Crucially, too, attention given to the main reasons for missed children seems unbalanced. For instance, although looking at data for children who were missed, the PEI focused its efforts mostly on refusals (rather than on weightier reasons such as "No Team" and "[Child] Not Available", or NA: "The big block of NA is something that needs to be disaggregated to get a better understanding of the reasons for this constant level and what kind of interventions (communication or other) are required to reduce it)....Even with this disproportionate focus on Refusals it was also of concern that reasons for refusals were not always detailed and there was limited mention of initiatives to reach inaccessible populations." The panel has also been concerned by the insufficient collection and use of finger marking.

In addition, the panel notes that strong communication efforts have been made towards tracking and mapping of nomadic communities, mobile populations, camps, and seasonal migrants in Karachi, but this has not been done to the same extent in the rest of Sindh. Furthermore, while there has been cross-border coordination of campaigns, there is a lack of joint cross-border communication planning with neighbouring provinces Punjab and Baluchistan.

The concluding pages of the document present a series of specific recommendations. The need for particular types of planning and reporting mechanisms is described. The panel highlights the importance of documenting technical feedback on all communication plans and reports, for instance. Strategies for improved team coordination (e.g., regular communication reviews and field support visits) are outlined. HR-related recommendations include appointing a communication focal person in the MOH to lead the provincial communication committee and prioritising districts requiring extra communication support and providing this creatively. Various ideas for better using data are presented, and include the need to define quantifiable objectives, monitor outcomes, evaluate impact, and sustain and improve quality of communication with inaccessible areas/populations (for instance, by selecting and training a mobile communication officer for interior Sindh to cover nomadic groups). A provincial follow-up communication review should be completed by mid-2009.

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