Presentation of ACS Country Level Workplan, st Meeting of Advocacy, Communication and Social Mobilisation sub group: September 2005, Mexico City James Deane Communication for Social Change Consortium

What is the country level workplan and why has it been produced?  Fulfil the request of the Geneva country level workshop, February 2005  To support the TB 2 summary submission with a more detailed workplan in line with other working groups  Request from those tasked by the country level subgroup with following up the Geneva meeting  To synthesise discussions and conclusions of TB ACS debates over the last 4 years  To provide a framework for country level action on advocacy, communication and social mobilisation

The process of producing this workplan Process strengths  Detailed review of many hundred documents, discussions and presentations over last four years;  Analysis rooted in needs assessments from within countries.  Call for contributions from the whole working group  For the first time a detailed synthesis of the analysis, methodologies and tools available for country level action on ACS  Mexico meeting an opportunity for detailed discussion Process weaknesses  A deadline determined by the TB2 schedule  Inadequate time for sufficient consultation and discussion  Lack of clarity of over where country level advocacy (as opposed to communication and social mobilisation) sits  A desk study

Some Assumptions  This is not a roadmap – more accurately a framework for action and implementation;  Tools and methodologies rooted as much as possible in demand and needs assessments as expressed by country level TB programmes and actors;  Central assumption that strategies will be country driven;

The problem that ACS needs to help address  Improving case detection and treatment compliance  Combating stigma and discrimination  Empowering people affected by TB  Political commitment and resources for TB.

What our response consists of  Advocacy  Programme communication  Social Mobilisation  Capacity Building in each of these  INTEGRATED STRATEGIC COMMUNICATIONS

An evidence base, a foundation of good practice  Successful country based ACS programmes leading to impact on TB (Mexico, Peru, Vietnam et al)  Extensive experience from other health communication initiatives, much (not all) of which is relevant to TB  An expectation of 5-10% increase in desired changes based on experience with other health challenges  Several years of debate, analysis and research, and substantial needs analysis, of the necessity for a greater requirement of ACS in TB control.  Substantial experience, practice and knowledge exists to achieve real impact.  Workplan includes detailed list of resource materials illustrating wealth of communication practice

Clear principles underpinning this strategy  Knowledge is critical: a huge effort is required to use communication to educate people  TB symptoms;  How TB is transmitted;  That TB is curable;  That TB treatment is free;  That TB cases should seek care;  That active TB cases should comply to TB treatment  Lack of knowledge prevents people from seeking treatment or takes them to other health providers;  Knowledge is not enough: many people who know that they should seek treatment are unable to do so:  Stigma and marginalisation  Gender  Distance  Time  Poverty  Generate demand only for services that exist;  Country driven ACS strategies are those that work  Principle of subsidiarity  Capacity building central to this strategy

Goals of this process  to provide guidance for GP2 goals and targets as these translate to national ACS initiatives;  to foster participatory ACS planning, management and evaluation capacity at regional, national and sub-national levels; and  to support and develop strategies to achieve key behavioural and social changes, depending on local context, that will contribute to sustainable increases in TB case detection and cure rates.

Objectives  By the end of 2008:  At least 15 priority high burden countries will have both high level capacity and be implementing ACS initiatives and generating qualitative and quantitative data on the ACS contribution to TB control;  And will have developed comprehensive communication and social mobilization strategies in support of the national TB control plan;  Have senior level communication managers coordinating these plans  By the end of 2012:  All high burden countries will have reached this stage;  All priority countries will be implementing multi-sectoral, participatory-based ACS initiatives and generating qualitative and quantitative evidence of ACS contribution to TB control;  These plans should contribute to setting and affecting the political, institutional and societal agenda and behavior against TB.  By the end of 2010 (NB change from submission to GP2 which state 2015)  Multi-sectoral, participatory-based ACS methodology will be a fully developed component of the internationally recommended strategy for controlling TB

Process Targets  By the beginning of 2006  a process will have started to form strategic agreements with international technical support organizations able to offer technical support to countries.  By the middle of 2006:  A detailed ACS capacity building implementation plan will have been developed aimed at ensuring the appointment/recruitment of senior level communication strategists in all high burden countries.  Such a plan will draw heavily on the experience, expertise and insight of national TB programmes and partners.  At least 5 technical support agreements will have been agreed and implementation will have begun.  By the end of 2006  a strategy will have been developed with medium burden countries detailing the communication support necessary (including technical advice, resource materials and other mechanisms) to meet TB targets in those countries (Particular discussion needed).

Building Capacity is central  More dedicated, trained and senior level communication staff at country level;  Technical support contracts aimed at:  Improving country partner access to timely and quality assured technical assiatance in agreed priority areas;  Encourage a collaborative approach to the delivery of technical assistance in support of country partner-owned and partner-led ACS plans;  Assist in the professional development of national institutions as well as national and regional ACS consultants  Through:  Training  Development and dissemination of support materials  Networking  Mentoring  Strategic addition of personnel, equipment and supplies  Distance consultation and support

Building Inclusion  More practical guidelines and mechanisms needed to build inclusion  Ideas suggested include:  Positively Empowered Partnerships (tbtv.org)  Community/patient/affected representatives appointed at national level to provide strategic guidance and support to national ACS TB programmes  Empowerment and participation hard wired in to strategic planning

Knowledge Exchange  Much good practice, in fragmented community and local experiences:  No such thing as best practices  A wealth of good practice  Knowledge exchange programme on ACS strategies  e.g. Communication Initiative

Communication Approaches  Communication for Behaviour Change  Many models and tools available to country programmes  COMBI Process already developed and tested for TB (assessment in progress)  Communication for Social Change  Individual change difficult to sustain without broader social and community changes  CFSC a dialogue process adapted to modern communication environments and adapted to different cultural contexts  PIM Process (Participation, Interaction, Mobilisation) in Bangladesh one example of many community based approaches

Key tools available  Handbook for communication programming (AED/PATH and COMBI processes)  Needs assessment tool developed by the Stop TB Partnership  JHU Outcome map  AED Cough to Cure Pathway

Monitoring and Evaluation Indicators proposed for:  Assessing social mobilisation communication capacity  Assessing delivery of ACS activities  Assessing sputum test outcomes (communication related behavioural impact only)  Assessing treatment outcomes (communication related behavioural impact only)  Assessing stigma and discrimination outcomes  Measuring most significant change  Detailed analysis and list of indicators in workplan

Role of the working group  Providing strategic guidance and frameworks for national and regional ACS strategies, and oversight of:  international technical agreements;  progress of key elements of recommendations made in this workplan;  the production of key documents (such as an ACS country level handbook);  other elements of strategic support;  Helping to ensure that sufficient, and sufficiently senior, human resources are available at all levels (international and national)  Providing an ongoing forum for discussion and lesson learning on the most effective and appropriate communication strategies and methodologies in supporting TB control efforts;  Commissioning regular technical reviews of ACS contribution, to GP2 goals and targets based on country-level data and reports, including cost-effectiveness research and tool development.

Role of the working group  Making recommendations to the Stop TB Partnership’s Coordinating Board and to STAG on the strategic direction and resourcing of ACS activities.  Acting as a reference point for the whole TB community on ACS strategies and initiatives;  Holding regular meetings to monitor progress and ensure targets are met and ACS is demonstrating its value to meeting the goals and targets set out in Global Plan 2.  Engaging, in combination with the secretariat, to monitor and understand broader communication and media processes and trends to ensure that ACS strategies keep pace with rapidly changing media and communication environments.

Some outstanding issues  Pinning down a country level advocacy strategy and where responsibility rests for this;  TB prevention (TB aware communities)?: communication is traditionally focused on prevention – is there no role for this in relation to TB?  Structured relationships/joined up strategies with other working groups – what are the mechanisms which can guarantee this?

Some outstanding issues  Implementation/strategic engagement mechanisms at country level - workplan weak on:  what are the precise mechanisms/loci of responsibility at country level to take forward ACS programming?;  Staffing and human resources: how can country level ACS staff be better qualified, more senior and more influential in design and implementation of national TB strategies?;  Can we ensure that ACS is a comprehensive strategy doing what is easy (posters, TB events) rather than what is necessary?  A patient/affected inclusion/empowerment strategy: further development of practical steps/mechanisms needed;  Good practice and knowledge exchange: how important? what mechanism?

Conclusion  Near universal agreement throughout the TB community that increased emphasis on ACS needs to be urgent and substantial at the country level – substantial expectations of the work of this group;  Universal agreement from throughout the communication community that many of the methodologies, tools and learnings exist to make a substantial impact on TB;  The challenge is one of organisation and resources.