Local solutions solve local problems best'

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Local solutions solve local problems best.
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Somewhere in the future

• Masri and Fitri represent the resourceful couple.
  He is a driver she is a street vendor. Health is
  a priority in their lives and like their friends,
  they invest time and money to ensure that they
  remain healthy.

3
Somewhere in the future

• Masri and Fitri have only two children because
  they wanted to provide them with love and care
  and ensure their health, education and welfare.
  They saved enough money before they had their
  first child. They sought information on pregnancy
  and child birth and learned the danger signs of
  pregnancy. It did not matter to them whether
  their child was a boy or girl.

4
Somewhere in the future

• When Masri developed fever and severe coughing
  that lasted for two weeks, FItri was extremely
  worried not just for Masri but for their children
  as well.
• Masri and Fitri understand the risks of
  tuberculosis so they went to a health clinic
  where Masri had a sputum smear microscopy.

5
Somewhere in the future

• The result was positive and Masri was placed in a
  standardized short-course chemotherapy for 6-8
  months. Fitri and Masri were so impressed with
  the courtesy and professionalism of the
  providers.
• When they asked providers why they were committed
  to providing excellent treatment, the providers
  replied that thanks to the NTP, STOP TB and WHO
  and other cooperating institutions, they receive
  adequate resources and high quality training on a
  continuing basis.

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Somewhere in the future

• Even the private sector contribute to the
  program. Policy makers and local leaders are all
  knowledgeable about TB and have made elimination
  of TB high priority.
• Their neighbors and friends were supportive and
  encouraged Masri to follow the treatment protocol
  strictly.
• Masri recovered completely and resumed his normal
  activities and zest for life!

7
Somewhere in the future

• Masri and Fitri were so grateful at his complete
  recovery that they organized a Health and TB
  prevention support group among their friends and
  neighbors. They shared their positive experience
  with the DOTS approach and encouraged their
  support group members to see their providers if
  they experience TB symptoms.

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Somewhere in the future

• Knowing that TB is contagious, Masri made sure
  that he got better and that he wont infect his
  children.
• Both Masri and Fitri are deeply concerned about
  the political and economic future of their
  country. They vote intelligently and always
  encourage their friends to do the same.

9
Somewhere now

• Parman and Wulan are living together. Parman is a
  mechanic who works when he wants to. Wulan would
  like to earn some money but Parman refuses to let
  her work. They do not know much about health and
  have not been to a health clinic in five years.
  They believe that people get sick because of the
  evil eye or because they committed a sin.

10
Somewhere in now

• They have six children, all unplanned. Four are
  seriously malnourished. Because Parman income is
  meager and irregular, their children often go
  hungry. When there is food, the boys get the
  largest portions and eat first.

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Somewhere now

• Parman and Wulan do not talk about their
  condition or the future. Parman has a bad temper
  and often beats Wulan when he is in a bad mood.
  He was surprised one time when Walan fought
  back. This made him so furious that he beat her
  severely.

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Somewhere now

• Wulan ended up in the hospital. The police jailed
  Parman briefly but he did not have any remorse
  when released.
• Recently, Wulan started having fever and severe
  cough but Parman refused Wulans request to go to
  a clinic.

13
Somewhere now

• Wulan did not know that she had developed active
  tuberculosis. Her neighbors and friends shunned
  away when they suspected that she has TB. She was
  treated rudely by the providers in a clinic. The
  clinic staff did not know about sputum smear
  microscopy as they do not have sufficient
  training. They wanted her to have an x-ray but
  for a fee, money she did not have. She ended in a
  hospital but never recovered.

14
Somewhere now

• Wulans death went unnoticed by local leaders who
  did not feel that the TB program is their
  concern. Her death was just a number added to
  statistics which most policymakers, program
  managers hardly read or understand.
• There were many more Wulans the day she died.
  There were also several workshops that opened to
  talk about lack of coordination, poor planning,
  lack of accurate data as often done every year.

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Why is there a difference?

• Our challenge is to think deeply and then act.

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Shared vision for TB By 2015,

• Households, communities and government are
  working together so that no person dies from TB
  in community X, Y, or Z.
• There is universal knowledge about TB symptoms,
  the treatment process, and its availability.
  Those with disease symptoms seek care immediately
  and conform rigorously to treatment regimen.
• There is strong family and community support to
  have any case of TB to be treated and stigma
  regarding the disease is absent. DOTS is
  implemented from a multidisciplinary and
  multi-sectoral perspective.

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Example -Current Situation

• At present, the government works alone in
  implementing a DOTS strategy without ACS
• Because there is no enabling environment to
  support DOTS, knowledge about TB symptoms, the
  treatment process, and its availability is low
• Those with disease symptoms do not seek care
  immediately
• Those diagnosed with TB do not conform rigorously
  to treatment regimen.
• There is little family and community support to
  treat TB cases and TB stigma is prevalent. People
  engage in medical shopping, try self-treatment
  and rely on traditional healers before seeking
  professional help.
• Government implements DOTS from a single
  discipline perspective (bio-medical) without
  engagement of other sectors.

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• The DOTS program suffers from
• Lack of material and non-material resources and
  resourcefulness.
• Slow and cumbersome process in flow of funds.
• Lack of district planning.
• Weak coordination
• Lack of accurate reporting data.

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Why is there a difference?

• Our challenge is to think deeply and then act.

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Where do leaders operate?
Beyond Imagination
Thats Impossible
Looks Difficult

Easy to do
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1. How do we usually define health problems?

• 1. Deviation from norm or indicator
  chasing 2. Existing solutions in tool box
• - Ideology
• - Training
• 3. Knee-jerk lack of resources

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Deviation from the norm

• 1. Who determines the norm?
• 2. What if norm is the source of the
  problem?
• 3. Restoration of norm is system maintenance
  not improvement

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Use existing solutions - When we have a hammer,
everything looks like a nail!

• 1. Trainer - everything is a training problem.
• 2. Manager - everything is a management problem.
• 3. Community mobilizer - everything is a
  community mobilization problem.
• 4. Medical doctor -everything is a medical
  problem.

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Lack of resources

• 1. Resources are universal constraints - when
  will we ever have enough?
• 2. Are we using existing resources effectively
  and efficiently?
• 3. How resourceful are we?

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Relationship between income and malnutrition
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The disconnect between income and malnutrition
Alternatively, Malnutrition falls independent
of rises in income (among the lowest income
countries)
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Examples Deviation from norm

• Overall strategic objectives
• Detect at least 70 of active TB cases
• Successfully treat at least 85 of TB cases
  detected

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Analysis

• What are the factors that lead to case detection
  and successful treatment?
• Which factors account for the gaps in
• A. Case detection
• B. Successful treatment

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Analysis Existing tools in our tool box

• Communication Which communication factors
  impact on case detection and successful
  treatment?
• Which communication factors are weakest in the
  current situation? KAP?

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Analysis Lack of resources

• Which communication activity impacts the most on
  case detection and successful treatment?
• How much do we allocate for these activities?

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2. What is an alternative way to defining
problems?

• Define problems in terms of why there is a
  difference between what we want (shared vision)
  and what is happening (current situation) and how
  to bridge this difference.

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Approach requires two things

• 1. We need to know clearly what we want.
• 2. We need to know clearly what is happening now.

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Work backwards and ask why there is a difference.
Determine what need to happen to realize the
shared vision
Universal access to SSM
No one dies from TB
Universal effective DOTS treatment
Political will at all levels
High TB mortality
Marginal improvements
Lack of Political will
Poor access and diagnosis

Poor adherence to treatment
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Which approach is best for your country to STOP
TB?

• 1) Change conditions one at a time.
• 2) Achieve doses of improvement in
  several conditions over time.
• 3) Conduct local experiments and
  scale up
• 4) Devolve or decentralize

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Change one condition at a time
No one dies from TB
Universal Effective DOTS treatment
Universal access to SSM
Political will at all levels
High TB mortality
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Little changes in all conditions over time
Vietnam and Peru
Less deaths from TB
Improvements in access to SSM
Improvements in effectiveness of DOTS treatment
Improvements in political will at all levels
High TB mortality
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We improve through local experiments and scaling
up
No deaths from TB
National scaling up
Learning communities
Local experiments
High TB mortality
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Devolve or decentralize
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Who should be our audience in tuberculosis
control and prevention campaigns?

• 1. Audiences on the program side
• 2. Audiences on the client side

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Audiences on the program side

• Policy makers
• Influentials
• Program managers
• Health workers
• Donor agencies

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Audiences on the client side

• 1. Everyone
• 2. High risk groups
• Those in areas with high
• incidence and
• prevalence of active TB
• 3. Low risk groups
• Those in areas with low
• incidence and prevalence of active TB

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Audiences on the client side High prevalence
areas

• Those with low levels of education and access to
  mass media
• Connectors
• Mavens
• Salesmen
• Very young
• Very old
• Immunosuppressed

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What is audience segmentation?

• Audience segmentation categorizes audiences into
  logical groups to enhance a better fit among
• Audiences
• Messages
• Media
• Service or products

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Audience Profile - Naila

• Naila has been married for 12 years and has given
  birth seven times. One child died within 30 days
  of giving birth. She lives in a small village
  outside Lahore where she washes clothes for other
  families. She is illiterate. She does not want
  more children but she is afraid to talk to her
  husband, Azmat, a farmer. She is fearful of a
  severe cough and blood in her sputum.

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Audience Profile - Deneb

• Deneb is a health worker. She lives in Rawalpindi
  with her husband, Akhtar, a business executive in
  a computer firm. Deneb is so tired from doing
  housework and a fulltime job at the same time.
  She does not have state of the art knowledge
  about TB and thinks unkindly of patients who come
  for treatment. She is rude to them most of the
  time. She is afraid that she will also get TB
  from her patients and keeps her distance.

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Audience profile - Ahmed

• Ahmed is a camel driver in a caravan. He lives in
  Sindh. He has been married for seven years and
  has four daughters. He wants to have a son but he
  knows that his wifes health has been poor. Her
  wife has been losing weight and appetite, has
  chills and fever and nighttime sweating. He is
  kind and does not want his wife to die.

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Audience profile The modern couple

• Amir and Sadia are a modern couple. In a recent
  seminar in his work, Amir learned about TB
  symptoms and shared them with Sadia. Sadia became
  alarmed because she noted that their maid seems
  to have symptoms of TB. They are even more
  concerned because they have a newly born child.

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Possible questions

• What are your strategic communication objectives?
• What is the overall communication strategy that
  matches the situation in the community
  /governorate/country

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• 3. Who should be your intended audiences?
• Program side? Program managers, policymakers,
  health workers, media, donors
• Client side? People with are about to marry,
  ante-natal, child-birth, post partum, child care.
  
• Both phased or simultaneous?

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• What are the key messages of each intended
  audience?
• What is the best way to present these messages?