Polio Communication in Nigeria: Interruption and Beyond

1. Polio Communicationin Nigeria: Interruption and Beyond Final TAG Recommendations 29 June 2007

2. 2007 TAG Context A real opportunity… • Evidence suggests an epidemiological and operational opportunity in 2007-08 for interruption; • Case trends show significant reduction over 2006; • The media environment is vibrant; • There is significant investment and commitment from Federal and State Government and International Agencies; • There is a clear recognition of, and desire for, increased local [State and LGA] ownership to improve effectiveness.

3. 2007 TAG Context con’t But gains need to be consolidated by… • Making maximum use of communication; • Rationalising social mobilisation and communication activities by focusing on high impact strategies; • Preparing a solid and thorough multi-year Communication Strategy; • Improving the effectiveness of vaccinator teams and supervisors through training, supervision and monitoring; • Developing resource mobilisation plans at Federal and State levels; • Keeping in mind that the situation is still fragile and Nigeria and other countries have been at this point before only to see cases increase.

4. TAG Review - Intention • To support improvements and consolidate gains made towards Polio eradication in Nigeria over the past two years. • To introduce communication related recommendations to accelerate and strengthen short term polio action while supporting the continued development of sustained communication action on polio, routine immunization and other primary health care needs. • To make strategic recommendations backed-up wherever possible with specific examples. • To make each recommendation as specific and clear as possible while recognizing that decisions on whether and how to operationalise recommendations rests with the government, partners and donors responsible for implementing the polio programme in Nigeria.

5. TAG Review - Scope What follows is not a comprehensive review nor a fully fledged plan… It is a set of recommendations designed to: • Support effective social mobilization and communication action; • Set a wider dynamic in play through these actions; • And help inform and support Nigerian decisions and planning related to Polio eradication.

6. Critical Polio Issues The specific strategies and ideas that follow are intended to address a cluster of critical issues identified by the Technical Advisory Group that may, if left unaddressed, undermine or reverse progress: • Missed Children/Non-Compliant Households • Improving the accuracy of estimates for the total population of under-fives at State, LGA and Ward levels. • Establishing better understanding of the reasons behind, and the numbers of, missed and zero dose children and non-compliance. 2. Vaccinators, Supervisors and Monitors • Improving the motivation and skill levels of vaccination teams. • Strengthening the capacity of supervisors and monitors to support the teams and ensure quality control.

7. Critical Polio Issuescon’t 3. Ownership at State and LGA and Community Levels. • States have taken an increasingly active and lead role in IPDs which should be further expanded and supported through enhancing their capacities in areas such as analyzing data, producing IEC materials and conducting localized media outreach in line with the strategic communication plan. 4. Coordination and Supervision Amongst all Main Parties • Coordination needs to be strengthened between and among government and partners especially though not exclusively at the state and LGA levels. 5. Data Quality and Utilisation for Communication • The quality of communication related data collection and analysis is a major concern and needs to be addressed across a number of fronts including training and motivation for vaccinator teams, improved monitoring for quality control, independent spot monitoring and linking data needs more closely to the strategic communication plan.

8. Critical Polio Issuescon’t 6. The Implications of a Broader IPD and PHC Focus • IPDs, RI and PHC need to be more strongly linked and integrated in order to be able to sustain the gains made during the rounds and maintain high enough levels of immunity to move from interruption to eradication. 7. Systemic and Sustainable Capacity Building • Many of the critical issues mentioned above depend on capacity building from State and LGA staff to vaccinator teams, supervisors and monitors. Taken together the recommendations are designed to positively address these issues.

9. Recommendations

10. Communication Strategy:A Multi-Year/Multi-Stakeholder Approach Recommendation 1: That a multi-year/multi-stakeholder communication strategy aimed at disrupting polio transmission, sustaining polio-free status through certification and strengthening routine immunisation in Nigeria in the context of primary health care be prepared.

11. Communication Strategy:A Multi-Year/Multi-Stakeholder Approach Rationale There is a well developed communication strategy ‘Engaging Communities’ which provides an excellent basis for the elaboration of a multi-year strategy. However, current SM/C activities appear to be year to year, periodic and operationalised mainly around campaigns. At minimum eradication will take another 5 years which will require a 6-12 month plan, within a 2-year plan, within a 5-year plan A more sustained month-by-month approach is needed that engages on a permanent basis with communities (perhaps primarily via the development of the community dialogue model). This planning process will need to happen without interrupting or drawing resources away from ongoing programme effectiveness.

12. Communication Strategy:A Multi-Year/Multi-Stakeholder Approach A multi-year/multi-stakeholder communication strategy will: • Be able to look to communication needs over the coming year as well as post-interruption needs. • Provide clearer communication as to the relationship between IPDs, routine and other immunisation programmes within the Primary Health Care system and how these strands fit together over time. • Coordinate longer needs such as providing training and consistency to front line communication and the development of skills at State and LGA levels. • Establish a year round set of communication activities linking IPDs to other health communication needs related to strengthening Routine Immunisation. • Better match the communication plan to the technical plan.

13. Communication Indicators: Coherent and Impact Related • Recommendation 2: • That the impact of SM/C activities be measured in terms of their own outcomes, and correlated with operational (coverage) and epidemiological (circulating virus) data using central indicators such as: • 75% recall of major messages of key knowledge shared through communication action. • 50% of people have discussed polio/routine with a friend/family member in the past week. • 80% of respondents got 3 of 5 major polio/routine facts correct. • 70% of household respondents stated that the vaccinators both [a] took the time and [b] were courteous and polite in discussing any concerns that they may have had about vaccinating their child. • Associate these measures with operational and epidemiological performance data at relevant level (village, ward or LGA). • The above should be collected andreviewed between every round at agreed time interval and correlated with overall programme outcomes.

14. Communication Indicators: Coherent and Impact Related (con’t) Rationale • Common impact indicators drive focus and coherence – what you count…is what you do. • All of above indicators are justifiable from literature as having significant role in impact though Nigeria will need to review and develop indicators specifically related to its own communication strategy and associated appropriate impact measurement requirements.

15. Communication-Related Data Recommendation 3: That significant improvements be made to the quantity and quality of communication-related data including: • Better estimates of the overall population of under-fives in each state, LGA and ward as well as the numbers of missed and zero dose children and those in non-compliant households. • Preparing reporting data using both percentages and absolute numbers for coverage to aid in the identification of actual numbers of missed and zero dose children and non compliant households to better plan well-targeted SM/C activities. • Gathering more in depth qualitative knowledge related to “non-compliance” – with the support of independent agencies that have the required skills and with results fed back into round planning.

16. Communication-Related Data cont’d Rationale: • Absolute numbers will give LGAs and States a clearer idea of targets and gains and help clarify the actual numbers of people being immunised. • Understanding the numbers of children to be immunised, whether they are zero dose, missed or in non-compliant households is essential to the communication strategy for any round in every state. • Improving the depth of qualitative knowledge will provide a better ‘feel’ for people related issues and opportunities and provide a necessary compliment to quantitative data. • Existing forms for capturing qualitative data especially, though not exclusively, in the community dialogues tend to miss important information regarding communication issues effecting community ownership of the polio programme. • Present tools do not allow States and LGAs to collate the qualitative results to what's happening in the communities they work in.

17. Independent Monitors Recommendation 4: Strengthen existing monitoring systems and capacities with further training, earlier deployment and the addition of one or more fully independent agencies to conduct in and end process monitoring and provide periodic reports to the partners in Abuja. Rationale: • Quality control remains a very large issue for household level data collection, accurately transferring data from one level to another and ensuring maximum coverage during IPDs. • Numbers of monitors have been increased significantly over recent rounds but their training and skills are not consistent. • Independent (e.g. outside the polio programme partners) and fully trained monitors doing proper in and end process monitoring would help identify gaps and problems and allow specific training and other needs to be identified and targeted.

18. Community Dialogues • Recommendation 5: • That Community Dialogues (CDs) be improved and strengthened through • greater methodological coherence and focus on local community • leadership, agenda setting and facilitation. Specifically this will include: • Reviewing and consolidating the approach, purpose and practice of CDs. • Conducting CD’s year round focused on community determined PHC issues but used to spot emerging issues pre-round and evaluation post-round. • Identification of appropriate local facilitators. • Training facilitators directly. This has resource implications as cascade training will not be adequate. • Moving government and technical agency staff to support roles and negotiating a larger role for Ward Development Committees. • Continued support and expansion of ‘peer’ CDs for women, religious leaders and other segments of the community. • Following Katsina’s lead – integrating community dialogues with local radio.

19. Community Dialogues con’t • Rationale: • Polio, RI and PHC programmes are considerably strengthened by local ownership. • CD’s can be an important tool to link and embed programmes in local systems and cultures helping to support long term healthy behaviour change. • CD’s are significant but under-utilised sources of pre and post round information and evaluation.

20. Social Mapping Recommendation 6: That more extensive use be made of social mapping strategies. Specifically this should include: • Engaging all actors in a community [local community members to international agency personnel] in jointly building over time a social map of their community – incorporating key social themes, data, resources, problems and issues along with polio, routine and other primary health care knowledge. • Building on the route/social maps now used and already being adapted to include some social information. • A strong relationship with the community dialogue process.

21. Social Mapping con’t Rationale: • Social Mapping places the specific issues – eg polio – in the context of overall community, LGA, State and other resources and opportunities. • Mapping out the full depth of social resources will help identify and track important local partners for the IPDs over time. • Data presently shows that the involvement of some CBOs and NGOs is irregular and there is evidence to show that in some communities they may be getting fatigued. • Reviewing and updating these on a regular basis will enable tracking over time and support communication strategies to strengthen and build on these relationships and respond to changes between rounds. • Social maps will provide a coherent relatively simple platform built on already existing tools for accumulating knowledge and taking advantage of relationships • These maps will be an important post polio PHC support and tool.

22. Vaccinators and Supervisors: Front Line for Communication • Recommendation 7: • That vaccinators and supervisors be formally recognised as the front line communicators for polio, routine and other primary health care initiatives and be supported to be more effective communicators through: • An improved selection process that stresses experience; skills; the ability to understand and relate to household dynamics; and personal commitment to child health. • More extensive inter-personal communication skills training. • A support ‘package’ that increases retention and motivation possibilities – allowance, transport, equipment. • Tracking of retention rates and identification of reasons for low retention. Rationale As the public interface between the delivery system and the households the quality of the communication by vaccinators is vital for success – this aspect of their work has been overlooked.

23. Data Collection and Analysis • Recommendation 8: • That data collection be improved so that it is accurately captured, organised, analysed and submitted upwards or re-submitted downwards in a timely fashion. • In the short term this should include: • Training to vaccinators, supervisors and monitors on accurate data collection and proper use of forms. • Training for supervisors and monitors on assessing data quality and implementing simple quality control measures. • Data sampling to determine areas of weakness for targeting in successive rounds. For the longer term Nigeria should: Explore more advanced technologies for collecting, analysing and sharing data - for example: • Widening access to computers and internet (to LGAs for instance) would enable faster and more open distribution of data and reduce the points at which data is transferred from one form to another by hand. • Other technologies for collecting data such as mobile phone or personal digital assistants (PDAs) could also be explored.

24. Data Collection and Analysis con’t • Rationale • A long term goal for immunisation and the wider health system is the advancement of health information systems. Improving how data is gathered from the local level to a central organising point and then back to the local level for planning is vital. • Data collection and accuracy has been identified as a major problem within Nigeria’s polio programme starting from the house to house collection during rounds and then moving up through the collection and anlaysis system. • Without dependable data shared in a timely fashion it will be very difficult to know how successful the programme is or how to strategically focus communication.

25. Strengthening Knowledge Sharing • Recommendation 9: • Establish a platform for sharing and critically reviewing the very significant knowledge being generated at LGA, State and Federal levels and throughout the full range of partners – so for example what is learned in Katsina can be easily accessed by Jigawa • Key actions to include: • A monthly update – email/print – on [a] key developments in past week [b] major learnings [c] main issues and [d] new communication programme developments [Federal level to facilitate]. • A text message network – so people from an agreed communication support network can both [a] share key developments quickly and [b] seek guidance on particular issues. • An online knowledge base. • Financial data sharing.

26. Strengthening Knowledge Sharing con’t • Rationale • Vitally important knowledge is generated at LGA and State level but is not consistently shared. • Such knowledge could become an essential tool resonating with, and therefore significantly helpful to, those involved in the “on-the-ground” action.

27. Mass Media and Communication Support Unit Recommendation 10: That suitably qualified Nigerian entities – agency/university/company – be contracted (possibly by the Social Mobilisation Working Group) to provide national mass media and communication support and to generate knowledge for use by all partners and states that includes: • A regularly updated comprehensive map of the Nigerian media landscape with state specific breakdowns. • A listing of the most popular programmes and their audiences. • Continuous monitoring of the impact of mass media polio communication programmes at national and state level • Regular communication and information and support to partners and government placing content in mass media. • Support and development of suitable partnerships with media. • Rapid assessments, surveys and research as needed. Rationale: Mass media plans and the monitoring of campaigns will be considerably strengthened by this resource.

28. IEC State Hubs Recommendation 11: That the capacity of states to produce IEC materials specific to their needs and based on their communication strategies be increased. Specifically this means: • Updating existing (such as HECTIC) and/or establishing new IEC production centres in the high risk states. Rationale: • IEC production technologies are now quite cheap and easy to use. • States presently spend a lot of time producing things like hand painted banners and other IEC materials for IPDs. This cost in time and resources could be reduced by introducing relatively inexpensive new technologies. • As states continue to take on greater leadership roles they will need to produce more IEC materials tailored to their specific needs.

29. Engaging Key Community Groups Recommendation 12: Consolidate, institutionalise and further strengthen partnerships with traditional, religious, women and youth groups in their role in PEI, RI and other PHC initiatives. Rationale: • Considerable progress in reaching many more under-five children has been made through building partnerships such as those with Qur’anic Schools, Ulamas, CAN, Traditional Birth Attendants, FOMWAN, the Miyetti Allah Association and the Christian Association of Nigeria.

30. Thank you – over to you