A C S M F R A M E W O R K F O R A C T I O N 2 0 0 6 - 2 0 ...

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ADVOCACY, COMMUNICATION AND SOCIAL MOBILIZATION TO FIGHT TB

A C S M F R A M E W O R K F O R A C T I O N 2 0 0 6 - 2 0 1 5

A 10 YEAR FRAMEWORK FOR ACTION

ACSMSUB GROUP AT COUNTRY LEVEL

© World Health Organization 2006

All rights reserved.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

The named authors alone are responsible for the views expressed in this publication.

Disclaimer

Acknowledgements 3Preface 4Executivesummary 5Introduction 7

PARTONE:THECALLFORACTION 8

1 Communication can make a contribution to TB control 8 1.1 Improvingcasedetectionandadherence 10 1.2 Combatingstigmaanddiscrimination 11 1.3 EmpoweringpeopleandcommunitiesaffectedbyTB 12 1.4 PoliticalcommitmentandsecuringresourcesforTBcontrol 122 Defining terms: advocacy, communication, social mobilization, capacity building 13 2.1 Communicationasanoverarchingtheme 13 2.2 Programmecommunicationtoinformandempower 13 2.3 Advocacytochangepoliticalagendas 13 2.4 Socialmobilizationtobuildpartnerships 14 2.5 Capacitybuildingtosustainandmultiplyhealthgains 153 Evidence and lessons learnt 16 3.1 WhatisthecurrentevidenceforACSMcontributiontoTBcontrol? 16 3.2 Whatlessonshavebeenlearntsofar? 164 Clear principles underpinning this work 19 4.1 Knowledgeiscritical 19 4.2 Knowledgeisnotenough 20 4.3 ACSMmustbeintegraltoNTPs 21 4.4 ACSMshouldbenondiscriminatoryandrights-based 21 4.5 ACSMrequiresacountry-ledapproach,andinvestmentinnationalandsubnationalcapacity 21

PARTTWO:THEFRAMEWORKFORACTION 24

5 Framework for action 266 Strategic vision and goals 27 6.1 Vision 27 6.2 Goals 27 6.3 Strategicobjectivesandtargets 277 A five-point framework 28 7.1 BuildingnationalandsubnationalACSMcapacity 28 7.2 Fosteringinclusionofpatientsandaffectedcommunities 32 7.3 Ensuringpoliticalcommitmentandaccountability 33 7.4 Fosteringcountry-levelACSMpartnershipswithinthecontextofNTPs 33 7.5 Learning,adaptingandbuildingongoodACSMpracticesandknowledgeexchange 348 Monitoring and evaluation 359 Links to other development processes 36 9.1 TheGlobalFundtoFightAIDS,TuberculosisandMalaria 36 9.2 Otherfundingsources 36 9.3 Nationalpolicyprocesses 37 9.4 HIV/AIDS 3710 The role of the country-level ACSM subgroup 3811 The budget and its justification 40

Contents

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A C S M F R A M E W O R K F O R A C T I O N 2 0 0 6 – 2 0 1 5

PARTTHREE:ANNEXES 42

1 Planning models and approaches 44 Diagnostic and planning tools 482 Communication materials and resources 53 StopTBPartnershipSecretariatlistofACSMdocuments,productsandtools 54 Initialplanningresources 55 Resourcesforinitialorganization 56 Resourcesonmapping 58 Resourcesforparticipatoryplanningandconceptualization 59 Resourcesonhowtoinvolvepartners 60 Resourcesforselectingobjectives 62 Resourcesfordevelopingacommunicationstrategy 64 Resourcesfordevelopingaworkplan 66 Resourcesforconsultingaworkplan 67 Resourcesfordevelopingcampaigns 68 Resourcesformonitoringandevaluation 703 Monitoring and evaluating ACSM for TB control 71 Assessingsocialmobilizationandcommunicationcapacity/Inputs 72 AssessingdeliveryofACSMactivities/Outputs 744 ACSM budget analysis and justification 825 Notes 85 Endnotes 86

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ThisstrategicframeworkwascompiledbyJamesDeaneandWillParks. Itbuildson theworkandcontributionsofmanypeopleand is inpart acollation frommanyexisting strate-gic documents and workplans. These have been creditedwhereverpossible.Particularthanksareduetothefollowingindividuals:ThadPennasoftheStopTBSecretariat,whohascollatedandsupportedthisprocesswithgreatefficiencyaswellasproducingoreditingmanydocumentsfromwhichthisworkisbased;MichaelLuhanandthemanyothercolleaguesfromotherworkinggroupsoftheStopTBPartnership,whogave their time and insights into this exercise; and SilvioWaisbord, who has provided an exceptional amount ofanalysisunderpinningtheworkplan.Ithasbenefitedsubstan-tially from the reviewand inputof theStopTBPartnershipAdvocacy,CommunicationandSocialMobilizationSubgroupatCountryLevel,andwasapprovedatameetingofthatgroupinMexicoCityinSeptember2005.

Advocacy, Communication and Social Mobilization Subgroup at Country Level (asofSeptember2005)

RobertoTapia-Conyer,Vice-ChairThaddeusPennas,Secretary

YoanaAnandita,SamAjibola,SoniaAmuyAtapoma,AyodeleAwe,SusanBacheller,CarmeliaBasri,EmilyBell,JeremiahChakaya James Deane, Carole Francis, Giuliano Gargioni,Case Gordon, Khandaker Ezazul Haque, Mischa Heeger,EveroldHosein,SamarIbrahim,AkramulIslam,NettyKamp,BertrandKampoer,JosephKawuma,PetraHeitkamp,JaimeLagahid, Michael Luhan, Benjamin Lozare, Fran du Melle,WillParks,ElilRenganathan,MáximoDaríoAbarcaRunruil,Satyajit Sarkars, Tom Scalaway, Marta Schaaf, YoussefTawfik, Ted Torfoss, Melanie Vant, Silvio Waisbord, WandaWalton,RisardsZaleskis

Administrative supportHananTwal

Special thanks to: MarcosEspinal,ExecutiveSecretary,StopTBPartnershipJoanneCarter,Chair,Advocacy,CommunicationandSocialMoblizationWorkingSubgroup(2005-2006)ThierryCailler,GraphicDesigner,issues.ch

Acknowledgements

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Thevalueofadvocacy,communicationandsocialmobiliza-tion (ACSM) isbecoming increasingly valued inTBcontrolstrategies.ItistothecreditoftheStopTBPartnershipthatanewACSMworkinggroupwassetupin2005toinjectgreaterstrategiccoherenceandurgencytothiswork.Iamhonouredtobeelectedasboththevice-chairofthisgroupandthefirstVice-ChairoftheACSMSubgroupatCountryLevel.

There is an increasing wealth of experience and evidence,includingfrommycountryMexico,demonstratingthevalueofACSMinmobilizingpoliticalsupportandleadershipforTBcontrolstrategiesatalllevels;inempoweringpeopleaffectedbyTB; in improvingcasedetectionandboosting treatmentadherence;andintacklingstigma.

This document sets out a 10-year strategic framework forACSMactivitiesandisakeysupportingdocumenttotheStopTB Partnership’s Global Plan to Stop TB 2006–2015. Thisplandemonstratesastepchangeinbothambitionandinno-vationintacklingTB,andIbelievethattheACSMstrategiessetoutinthisframeworkwillplayacriticalroleinsupportingtheachievementoftheStopTBPartnershipobjectives.

Dr Roberto Tapia-ConyerVice-Minister of Health MexicoVice-Chair of the Advocacy, Communication and Social Mobilization Subgroup at Country Level

Preface

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Asignificantscalingupofadvocacy,communicationandso-cialmobilization(ACSM)willbeneededtoachievetheglobaltargetsfortuberculosiscontrolasdetailedintheGlobalPlantoStopTB2006–2015. In2005, theACSMWorkingGroup(ACSMWG)wasestablishedastheseventhworkinggroupoftheStopTBPartnershiptomobilizepolitical,socialandfinan-cialresources;tosustainandexpandtheglobalmovementtoeliminateTB;andtofosterthedevelopmentofmoreeffectiveACSMprogrammingatcountrylevelinsupportofTBcontrol.ItsucceededanearlierPartnershipTaskForceonAdvocacyandCommunications.

ThisworkplanfocusesonthoseareaswhereACSMhasmosttoofferandwhereACSMstrategiescanbemosteffectivelyconcentratedtohelpaddressfourkeychallengestoTBcon-trolat country level:• Improvingcasedetectionandtreatmentadherence• Combatingstigmaanddiscrimination• EmpoweringpeopleaffectedbyTB• MobilizingpoliticalcommitmentandresourcesforTB.

TheworkplansupportstheACSMcontributiontotheGlobalPlantoStopTB2006–2015andsetsouta10-yearstrategicframeworkforcountry-levelACSMprogrammingthatcomple-mentsstrategicworkattheglobaladvocacyleveldesignedto exert pressure on governments and other authorities toprioritizeTBcontrol.

Theworkplanisdividedintotwoparts:

Part 1 – the call for action• describesthekeychallengestobeaddressed;• defines important terms – programme communication,

advocacy,socialmobilizationandcapacitybuilding;• summarizesthecurrentevidenceofACSMcontribution

andlessonslearnt;• setsoutthekeyprinciplesunderpinningtheworkplan.

Part 2 – the framework for action• explains the vision, goals, objectives and targetsof the

country-levelACSMstrategicframework;• outlinestheframework’sbasiccomponents;• examineshowprogresscouldbemonitoredandevaluated;• exploreskeypartnershipsandroles;• presentsandjustifiesthebudget.

ThevisionofthisworkplanisonewhereallcommunitiesatalllevelsareempoweredtoremovethethreatofTBtohumanhealth. By applying ACSM strategies from health-care set-tingstohouseholds,TBpatientsaresupportedandtreatedeffectivelywithdignityandrespect.Furthermore,thosemostaffectedbyTBwillbeinvolvedinshapingtheresponse.

Overthenext10years,thisframeworkaimstoestablishanddevelop country-level ACSM as a core component of TBpreventionandtreatmentefforts.Theframeworkhasthefol-lowinggoals:• Toprovideguidance forGlobalPlan toStopTB2006–

2015 goals and targets as these translate into nationalACSMinitiatives.

• TofosterparticipatoryACSMplanning,managementandevaluationcapacityatregional,nationalandsubnationallevels.

• To support and develop strategies to achieve keybehavioural and social changes, depending on localcontext, that will contribute to sustainable increases inTBcasedetectionandcurerates.

Thefollowingstrategicobjectiveshavebeenidentified:• By2008,at least10endemiccountrieswillhavedevel-

opedandwillbeimplementingmultisectoral,participatoryACSMinitiativesandgeneratingqualitativeandquantita-tivedataonACSM'scontributiontoTBcontrol.

• By2010,atleast20prioritycountrieswillbeimplement-ing multisectoral, participatory-based ACSM initiatives,andmonitoringandevaluatingtheiroutcomes.

• By 2015, multisectoral, participatory ACSM methodolo-gieswillbeafullydevelopedcomponentoftheStopTBStrategy.

• By2015,allprioritycountrieswillbeimplementingeffec-tiveandparticipatoryACSMinitiatives.

Theseobjectiveswillbeachieved throughamixoffivekeystrategiccomponents:1. BuildingnationalandsubnationalACSMcapacity2. Buildinginclusionofpatientsandaffectedcommunities3. Ensuringpoliticalcommitmentandaccountability4. Buildingcountry-levelACSMpartnerships5. Learning, adapting and building on good ACSM

practice.

Executive summary

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The framework for action proposes a dual strategy of in-tensivelysupportingACSMactivities infivehigh-TBburdencountriesperyearoverthenextfiveyears,andthensustain-ingthatsupportthroughoutthe10-yearperiodoftheGlobalPlantoStopTB2006–2015.Theframeworkisdesignedtoimplement intensive, sustainable and detailed communica-tionstrategiesinallhigh-burdencountries,aswellassupportstrategiesinmedium-burdencountries.

Theframeworkdoesnotattempttoprovidearigidblueprintforcountriestofollowinimplementingcommunicationactivi-tiesinsupportofTBcontrol,sincedecisionsonthemostap-propriateACSMstrategiesneedtobetakenaccordingtothespecific situations and demands of TB-affected countries.Instead, the framework offers a series of interrelated com-ponents,approachesandtoolsfromwhichcountrypartnerscanselect.The frameworkdrawsupon the latest research,recentagreementsintheTBcontrolcommunityandexistingdocumentationonhowACSMprogrammingcancontributetoTBpreventionandcontrol.

The total estimated budget for global advocacy, country-level communication and mobilization, capacity building,monitoringandevaluation,researchandACSMWGrequire-mentsisestimatedtobeUS$3.2billionforthe10-yearpe-riod.Supportforglobaladvocacyequatesto6%ofthetotalbudget.Supportforcountry-levelcommunicationandsocialmobilizationrepresents90%ofthetotalbudget.Technicalas-sistanceconstitutes1%ofthebudget,operationsresearch,monitoringandevaluationaround2%,andWorkingGroupadministrativeandnetworkingrequirementsabout0.6%.

Itisassumedthatfundingforthecoordinationofglobalandre-gionalstrategicplanning,technicalassistanceandevaluationwillcomefromgrantstotheStopTBPartnershipSecretariatfrom bilateral donors. The bulk of funding for country-levelACSMactivitieswillcomefromtheGlobalFundtoFightAIDS,Tuberculosis and Malaria (GFATM) and bilateral sources intheshortterm,andincreasinglyfromnationalgovernmental-locationsinthelongerterm.Partnersatcountrylevelshouldalso contribute by committing realistic proportions of theirbudgetstoACSMactivities.

Monitoringandevaluationof this frameworkwill takeplaceat several levels. At global level, annual technical reviewswill be commissioned to analyse the progress being madein national ACSM capacity building and the contributionandcost-effectivenessofACSM toGlobalPlan toStopTB2006–2015 goals and targets. ACSM WG and subgroupmeetingreportswillalsobeusedtotrackthisplan’sprogress.Frequentinternational,regionalandnationalmeetingswillbeheld todocumentanddisseminateevidence todate,goodpractices and lessons learnt. Regular technical advisorymissions provided under technical service contracts withhighlyexperiencedcommunicationpartnerswilloffermanyopportunities for national TB control programmes (NTPs)to monitor and supervise national and subnational ACSMactivities. Country-level ACSM initiatives will develop theirown participatory monitoring and evaluation processes, in-cludingappropriateindicatorsandreportingsystems.Finally,existinginformationsystems,methods,indicatorbanks,andtechniquesusedwithinandbeyondNTPswillbeusedandadaptedwherenecessarytostrengthenthemonitoringandevaluationof thisworkplan.Rigorouslyderivedevidenceofcountry-levelACSMcontributiontoTBcontrolshouldbegintoaccumulatebytheendof2007.

ACSMstrategiestomakeasubstantialcontributiontotack-lingTBexist.Intermsofincreasingcasedetection,improvingtreatment adherence, tackling stigma, empowering peopleaffected by the disease and raising political commitment.Suchstrategieshave,however,notbeenprioritizedbyNTPsor internationally,either intermsofstrategicemphasisor inbuildingcapacitytoimplementeffectiveACSMprogrammes.Thisdocumentlaysouta10-yearworkplantorectifythissitu-ationinordertocontributetoglobalTBcontrol.

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ThisworkplanfocusesonhowACSMcansupportNTPsandinitiatives at a country level. It has been produced to sup-portthecontributionofACSMtotheGlobalPlantoStopTB2006–2015 and sets out a 10-year strategic framework forACSM programming. The workplan complements strategicwork at the global advocacy level designed to exert pres-sure on governments and other authorities to prioritize TBcontrol.

Thisworkplandoesnotattempt toprovidearigidblueprintforcountriestofollowinimplementingcommunicationactivi-tiesinsupportofTBcontrol,sincedecisionsonthemostap-propriateACSMstrategiesneedtobetakenaccordingtothespecificsituationsanddemandsofTB-affectedcountries.Itdoes,however,seektoprovideaframeworkforactionfromwhichcountriescanmapoutthemosteffectivestrategiestosuittheirowncircumstancesoverthenext10years.

While the precise combination of approaches needs to bedeterminedatacountry level, thisworkplanhasoneprimemessage–NTP’sneedtoprioritizeACSMifTBcontroltar-getsaretobeachieved.

Thisworkplanisdividedintotwoparts:

Part 1 – the call for action • describesthekeychallengestobeaddressed;• defines important terms – programme communication,

advocacy,socialmobilizationandcapacitybuilding;• summarizesthecurrentevidenceofACSMcontribution

andlessonslearnt;• setsoutthekeyprinciplesunderpinningtheworkplan.

Part 2 – the framework for action• explains the vision, goals, objectives and targetsof the

country-levelACSMstrategicframework;• outlinestheframework’sbasiccomponents;• examines how progress could be monitored and

evaluated;• exploreskeypartnershipsandroles;• presentsandjustifiesthebudget.

Introduction

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THECALLFOR ACTION

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T H E C A L L F O R A C T I O N

THECALLFOR ACTION

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1.1Improving case detection and adherence

TheUnitedNationsMillenniumDevelopmentGoalscommitthe international community to have halted and begun toreverse the incidence of TB by 2015 and to have reducedTBprevalenceratesby50%comparedwiththeyear1990.Thesegoalsbuildonandcomplementearliertargets,ratifiedby the World Health Assembly in 1991, aimed at detecting70%ofnewinfectiousTBcasesandsuccessfullycuring85%of these cases. Currently, around 50% of the estimated ofnewcaseseachyeararereached,detectedandtreated.

These targets – which are considered too conservative bymanygroups–canonlybemetiftheresponsefromtheTBcommunityshiftsmoredecisivelyfrompassivecase-findingtoactivecasedetection.

Social,cultural,behavioural,epidemiological,economic,andpoliticalfactorsaffectnotonlyprovisionofservicesforTBdi-agnosisandtreatment(1-2).Criticalfactorsaffectingdemandand use of services include: HIV/AIDS, multidrug-resistantTB(MDR-TB),stigmaanddiscrimination,gender inequality,publicservicereforms,populationdisplacementandmobility,andchangingcommunicationenvironments.

Strategic and intensive deployment of communication andsocial mobilization strategies is increasingly acknowledgedasnecessary toencourageandsupportat-riskpopulationswhohaveacoughformorethanthreeweekstoseektreat-ment;andtoadoptotherhealth-seekingbehavioursrelatedtoTB(3).

The link between a lack of communication and poor casedetection has been repeatedly demonstrated. Studies, in-cluding from Ethiopia, India, Mexico, Nigeria, Pakistan andThailand, have shown that patients with low knowledge

It is important at the outset to be explicit about why ACSM strategies are becoming vital in controlling TB, and the

specific problems this workplan seeks to address. There are many challenges to be confronted in reaching global TB

targets, but this workplan is focused on those areas where ACSM has most to offer and where ACSM strategies can be

most effectively concentrated. This workplan brings together the latest research, recent agreements in the TB control

community and existing documentation into a coherent framework designed to use ACSM to help address four key

challenges:

• Improving case detection and treatment adherence

• Combating stigma and discrimination

• Empowering people affected by TB

• Mobilizing political commitment and resources for TB.

These challenges will not be met without far greater prioritization and improvement in TB-related communication

activities. In addressing each of these issues, there are strong organizational synergies with efforts to combat HIV/AIDS.

Communication can make a contribution to TB control

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aboutthesymptomsofTBaremorelikelytopostponeseek-ingcareandgetting tested.Studies in theUnitedRepublicof Tanzania found that in some communities, patients withlowknowledgearemorelikelytovisittraditionalhealersandpharmacists thanDOTSproviders.NTPshavebeenshowntodoabetterjobatholding,ratherthanfinding,casesandinincreasingcasedetection(4).

Communication is also seen as having an important rolein improving treatment adherence. Progress towards thetarget of 85% treatment success has been much moremarkedthanthatagainstcasedetection,althougheveryef-fortmustbemadetomaintaincureratesinmanycountries.Communicationandsocialmobilizationprogrammesensur-ing patient education, combined with broader communitysupport and empowerment initiatives, are essential if cureratesaretoimproveandbesustained.

1.2Combating stigma and discrimination

StigmaanddiscriminationassociatedwithTBareamongthegreatest barriers to preventing further infections, providingadequatecare,support,andtreatment (5).TB-relatedstigmaanddiscriminationareuniversal*.Stigmaisharmful,bothinitself,sinceitcanleadtofeelingsofshame,guiltandisolationofpeoplelivingwithTB,andalsobecausenegativethoughtsoften lead individuals to do things, or omit to do things,thatharmothersordenythemservicesorentitlements(i.e.discrimination).

Forexample,healthworkersareoftenakeysourceofstigma-tizingbehaviour through their treatmentofpeoplewithTB;hospitalorprisonstaffmaydenyhealthservicestoapersonwithTB.Oremployersmayterminateaworker’semploymentonthegroundsofhisorheractualorpresumedTB-positivestatus. Families and communities may reject and ostracizethoseliving,orbelievedtobeliving,withTB.Suchactscon-stitutediscriminationbasedonpresumedoractualTB-posi-tivestatus.

Studies repeatedly demonstrate that stigma deters peoplefromseekingcareanddiagnosisand thatwomenbear thehighest burden of stigmatizing behaviours (6). Stigma anddiscriminationaretriggeredbymanyforces,includinglackofunderstandingofthedisease,mythsabouthowTBistrans-mitted,prejudice,lackofaccesstodiagnosisandtreatment,irresponsible media reporting, the link between HIV/AIDSandTB,andfearsrelatingtoillnessanddeath.

LackofaccesstoTBdiagnosisandtreatmentisakeyissuethatenhancesoradvancesTB-relatedstigmaanddiscrimina-tion inmanycountries.Theperceived“untreatability”ofTBisakey factorcontributing to thestigmatizationofmanyofthoseaffected.

Thechallengeofreducingstigmaanddiscriminationneedstobeaddressedwithinpublicandprivatehealthsectorsandamonghealthworkersontheground.Fear,lackofknowledge,andmisconceptionsaredeep-rooted.ThewaysoflookingatpatientsingeneralandpatientswithinfectiousdiseaseslikeTBneed tobe radically changed.Servicesneed tohaveamorepatient-orientedapproach.

Stigmaresultsinpartfrommisinformationoralackofinfor-mation.MisinformationaboutwhatcausesTB,howitistrans-mittedandwhetheritcanbecuredislinkedtothestigmatiza-tionofTBandofpeoplewithTB.VariousculturesassociateTBwithsociallyandmorallyunacceptablebehaviour.TB isalso widely believed to be inherited, and people who haveTB are sometimes considered unmarriageable. Such be-liefs,generatedbymisinformation,haveledtopeoplebeingphysicallyisolated,discriminatedagainstanddismissedfromwork.Publiceducationandawareness-raisingprogrammesdesigned to counteract myths and to encourage greaterinclusionofpeoplewithTBareanessentialelementofanyefforttocombatstigmaassociatedwithTB.

Stigmahasitsrootsnotonly in lackof informationbutalsoin deep-seated social mores and structures. Stigma par-ticularlyaffectswomenbecausesocialpressuresandstatusoften make them especially vulnerable to marginalization


*Stigma has been defined as “an attribute that is significantly discrediting” and “an attribute used to set the affected person or groups apart from the

normalized social order, and this separation implies a devaluation”. Stigmatization therefore describes the process of devaluation within a particular

culture or setting, where certain attributes are seized upon and defined as discreditable or not worthy.

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and discrimination with the consequences of contractingTBsometimes leadingtodivorce,desertionandseparationfrom their children (7). Stigma as a “disease of the poor”,well documented historically, persists and has been com-poundedmorerecentlybythelinkwithHIV/AIDS.HIV/AIDSstigmathataffectsTBpatientshasbeenshowninhigh-HIVprevalent communities, including Ethiopia, Pakistan andThailand, demonstrating that TB patients with HIV suffer adoublestigma.

AnyACSMstrategydesignedtoconfronttheseissueshastofocusonsocialaswellasindividualbehaviouralchallenges.ACSM programmes are essential in empowering peoplewithoraffectedbyTBtotakecommunityactiontoconfrontstigma, and to educate broader communities to reducestigma.AnycommunicationstrategydesignedtocombatTBneedstosupportbothaprocessofsocialchangeinsocietytotacklestigmaandmarginalizationofpeoplewithTB,andaprocessofbehaviouralchangedesignedtopersuadepeopletoseektreatment.

1.3Empowering people and communities affected by TB

A thirdmajorchallenge forACSMprogrammes is tocombatinsufficientinclusionofpeoplemostaffectedbyTBandrelateddiseases in the design, planning and implementation of TBcontrolstrategies.Animportantlessonfromotherhealthcrises,particularlyHIV/AIDS,isthatthegreatertheinclusionofthosemostaffectedintheresponsetothesecrises,thegreatertheimpactsuchresponsesarelikelytoachieveandsustain(8).

Communication strategies have much to offer in this regard,both in termsofadvocacy interventionsand inhowdifferentcommunicationactions/programmescanenablepeoplewithand affected by TB to have their voices heard in the publicdomain.

Contemporaryhealthcommunicationstrategiesareincreas-inglypreoccupiedwithprovidingspacesandchannels,par-ticularlythroughthemedia,wherepeopleaffectedbyhealthissuescanmaketheirvoicesheard,engageindialogueanddebateandachievegreatervisibilityandprofileaspeoplewith

importantperspectivesthatdeserveattention.Animportantcomponentofthisworkplanreflectsthispriority.

Communityempowermenthasalsobeenshowntobecriti-caltosuccessfulimplementationofDOTSprogrammes,andsomeofthemostsuccessfulexamplesofTBprogramminghavebeenrootedinstrategieswithastrongcommunityem-powermentcomponent(seeSection7.1).

1.4Political commitment and securing resources for TB control

Politicalcommitmenthasbeenrecognizedasacrucialele-mentofDOTS.LackofpoliticalwillhashamperedboththedevelopmentofappropriateTBcontrolpoliciesandthesuc-cessful implementation of thosepoliciesat thecentral,dis-trict,andlocallevels.EvenwhengoodTBpoliciesexist,thereisoftenagapbetweenthepoliciesandtheprogrammesontheground.ExperiencesuggeststhatTBcontrolservicesarenegativelyaffectedwithoutstrongcommitmentfromdifferentsectorsofsociety,particularlydecision-makersand influen-tialpoliticalandcommunityleaders.Challengesinrelationtoinsufficientpoliticalcommitmentcaninclude:• Insufficientresources—bothhumanandfinancial• Lackoflocalownershipandbuy-inofNTPs• WeakleadershipintheNTPand/oralossofcoherence• WeakcapacityoftheNTPtoprovideguidancetodistrict-

and local-level programmes (both public and privateproviders)

• Lackofaccountability for resultsamong theministryofhealth(MoH),NTP,andhealthproviders

• Lowlevelsofknowledgeamongpolicy-makersandotherstakeholdersaboutTB

• LackofintegrationofNTPswithotherMoHprogrammes• Lack of clear and relevant ACSM guidance available

locally and weak capacity to develop effective ACSMprogrammes

• WeakadvocacyandcommunicationcapacitytoadvocateupwardsforTBprogrammeprioritization,particularlywithministersofhealthandfinance.

Advocacyneeds tobean inherentpartofacountry-basedACSMstrategy.

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2.1Communication as an overarching theme

The term “communication” is an overarching one meaningtheprocesspeopleuse toexchange informationaboutTB.Allcommunicationactivitiesmakeuseofsomeformofmediaor channel of communication (e.g. mass media, commu-nitymedia,interpersonalcommunication).WhilemuchofthecommunicationeffortonTB isconcernedwith transmittinga series of messages to people affected by TB, nearly allcommunicationpractitionersstressthattobeeffective,com-municationshouldbeunderstoodasatwo-wayprocess,with“participation”and“dialogue”askeyelements.

Withinthisoverarchingterm,therearethreelinked,overlap-ping and complementary communication strands – pro-grammecommunication,advocacy,andsocialmobilization.The degree of overlap between these terms (particularlybetweensocialmobilizationandadvocacy)hascausedcon-fusion in the past, and these definitions are the subject ofcontinuousdebate in thepublichealthandcommunicationcommunities.Thisworkplanisconcernedwithbuildinganin-tegratedresponse,applyingallcommunicationapproachesandmethodologiesas theyare relevant to tackling the fourkeychallengesoutlinedinSection1.Inthisworkplan,“com-munication”isusedinterchangeablywith“ACSM”.

2.2Programme communication to inform and empower

Withincountries,andinthecontextofTBcontrol,programmecommunication is concerned with informing and creatingawareness among the general public or specific popula-tionsaboutTB,andempoweringpeopletotakeaction.Itisoftenprincipallyconcernedwithcommunicatingaseriesofmessagesabout thedisease (e.g. “if youhaveacough formorethantwoweeks,seektreatment”,or“TBiscurable”),orinformingthepublicaboutwhatservicesexist(fordiagnosisandtreatment).

Programmecommunicationalsoworkstocreateanenviron-mentthroughwhichcommunities,particularlyaffectedcom-munities, can discuss, debate, organize, and communicatetheirownperspectivesonTB.Itisaimedatchangingbehav-iours (such as persuading people with symptoms to seektreatment) but can also be used to catalyse social change(suchassupportingcommunityorothercommunication-for-social-change processes that can spark debate, and otherprocesses to shift social mores and barriers to behaviourchange).

2.3Advocacy to change political agendas

Advocacy denotes activities designed to place TB controlhighon thepoliticalanddevelopmentagenda, fosterpoliti-calwill,increasefinancialandotherresourcesonasustain-


Defining key terms: advocacy, communication, social mobilizationcapacity buildingIt is important to be clear about the definitions of communication that are used in this workplan, particularly the

terms “communication”, “advocacy” and “social mobilization”. “Capacity building” is another process of particular

importance to this workplan and a definition is provided below.

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ablebasis,andholdauthoritiesaccountable toensure thatpledgesarefulfilledandresultsachieved.

Policy advocacy includesdataandapproachestoadvocateto senior politicians and administrators about the impactof the issue at the national level, and the need for action.Programme advocacy isusedat the local,community leveltoconvinceopinionleadersabouttheneedforlocalaction.Relatedformsofadvocacyincludemedia advocacytogener-atesupport fromgovernmentsanddonors,validate therel-evanceofasubject,putissuesontothepublicagenda,andencourage the media to cover TB-related issues regularlyandinaresponsiblemanner(9).

Intheglobalcontext,advocacyforTBcontrolistobeunder-stood as a broad set of coordinated interventions directedatplacingTBcontrolhighonthepoliticalanddevelopmentagenda,forsecuringinternationalandnationalcommitment,andmobilizingnecessaryresources.

In country contexts, advocacy efforts broadly seek to en-sure that national governments remain strongly committedto implementing national TB control/elimination policies.Advocacyatcountryleveloftenfocusesonadministrativeandcorporate mobilization through parliamentary debates andotherpoliticalevents;pressconferences;newscoverage;TVand radio talk shows; soap operas; summits, conferencesand symposia; celebrity spokespeople; meetings betweenvariouscategoriesofgovernmentandcivilsocietyorganiza-tions, patients organizations, service providers, and privatephysicians;officialmemoranda;andpartnershipmeetings.

2.4Social mobilization to build partnerships

Social mobilization is the process of bringing together allfeasibleandpractical intersectoralalliestoraiseawarenessofanddemand foraparticularprogramme, toassist in thedelivery of resources and services and to strengthen com-munity participation for sustainability and self-reliance (10). “Allies”includedecision-andpolicy-makers,opinionlead-ers,nongovernmentalorganizations(NGOs)suchasprofes-sional and religious groups, the media, the private sector,communitiesand individuals.Socialmobilizationgenerates

dialogue, negotiation and consensus, engaging a range ofplayers in interrelated and complementary efforts, takingintoaccount theneedsofpeople.Socialmobilization, inte-grated with other communication approaches, has been akey feature in numerous communication efforts worldwide.Someprominentexamplesinclude:(a)Soul City’scampaignagainstdomesticviolenceinSouthAfrica,(b)thepolioeradi-cationcampaign inUttarPradesh, (c)HIV/AIDSpreventionin Uganda and Thailand, and (d) eliminating the vitamin AdeficiencydisorderinNepal.

Socialmobilizationrecognizesthatsustainablesocialandbe-haviouralchangerequiresmanylevelsofinvolvement—fromindividual to community to policy and legislative action.Isolated efforts cannot have the same impact as collectiveones. Advocacy to mobilize resources and effect policychange,media andspecial events toraisepublicawareness,partnership building and networking, and community par-ticipation are all key strategies of social mobilization (11).Specific activities include group and community meetings,partnershipsessions,schoolactivities,traditionalmedia,mu-sic,songanddance,roadshows,communitydrama,leaflets,posters,pamphlets,videos,andhomevisits.

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2.5Capacity building to sustain and multiply health gains

Capacity building can be defined as the process of devel-opingcompetenciesandcapabilities in individuals,groups,organizations,sectorsorcountriesthatwillleadtosustainedand self-generating performance improvement. ACSM ca-pacitybuildingoftenconsistsofatleastthreecoreactivities:(1)building infrastructuretodeliverACSMprogrammes, (2)building partnerships and organizational environments tosustainACSMprogrammes–andhealthgains;and(3)build-ingproblem-solvingcapability.

Thislastelementisparticularlycrucial.Asonecapacitybuild-ingexpertputsit,“Thereislittlevalueinbuildingasystemthatcementsintoday’ssolutionstotoday’sproblems.Weneedtocreateamore innovativecapabilityso that in the future thesystemorcommunityweareworkingwithcanrespondap-propriatelytonewproblemsinunfamiliarcontexts”(12).

Capacityisbuiltforthefollowingreasons:• toimprovethemanagerialskillsofindividualsandinways

thattheycanleadparticularprogrammesandrespondtoparticularissues;

• todevelop independent capabilitiesover time, so as tomakeprogrammaticresponsessustainable.

TherationaleforbuildingACSMcapacitywithingovernmentand nongovernmental agencies working on TB control atcountrylevelisclear:bybuildingACSMcapacity,TBpartnerscansustainandincreasehealthgainsmanytimesover.


Disease and transmission

TB is a contagious disease that spreads through the air.

Only people with pulmonary TB are infectious.

Each person with infectious TB will infect on average

between 10 and 15 people every year.

Someone in the world is newly infected every second.

Overall, one-third of the world’s population is currently infected.

People infected with TB will not necessarily get sick. The immune system ‘walls off’ the TB germs, which can lie dormant for years.

5-10% of people who are infected with TB become sick at some time during their life.

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3.1What is the current evidence for ACSM contribution to TB control?

Evaluationsofpublichealthprogrammes, includingpromo-tionofnewbehavioursandnewmedicalproducts(suchascontraceptives, drugs and vaccines), have shown repeat-edly that ACSM plays a powerful role (13-16). Studies inAfrica have demonstrated continuing correlations betweenexposure to mass media, exposure to specific health mes-sages,anddesiredbehaviouralchange(17-18). UnobtrusivemeasuressuchasincreasedsalesofcondomsinGhanaandNicaragua testify to the effectiveness of these promotions(19, 20).Intheglobalpolioeliminationprogramme,theTaylorCommission(1995)reported:“Socialmobilizationasutilizedby the [polio programme] has relied on massively utilizingIEC[information-communication-education],includingmassmedia, strengtheningexistingcommunityorganization,andinvolvingpoliticalandcommunityleaders…Thethreecom-ponents were identified as having strong positive effects.”Thereportalsodeclaressocialmobilizationas“thevariablewiththemostpositiveeffectsinallcountries”(21).Majordo-norsandinternationalorganizationssuchasUSAID,UNICEF,DFID,andtheWorldBankarenowactivelypromotingtheuseofACSM(22-25).AlthoughthereislittledocumentedevidenceofthescaleofACSMcontributiontoTBcontrol,thisworkplandrawsuponrecentevaluationmeta-analysesinotherpublichealthcom-municationfields topropose that,ataminimum,ACSMforTBcontrol shouldhelp tomaintain current casedetectionandcasecure rates inmostcountries(26-28). Insituationswhere DOTS services are assured, well-planned and fully-resourcedACSMcouldincreasetheseratesbyasmuchas5–10%,althoughaccountingforallconfoundingvariablesinthefinalanalysiswillbeproblematicandmaketheimpactofACSMdifficulttoquantify.

TheReport of the Meeting of the Second Ad hoc Committee of the TB EpidemicexaminedtheconstraintsandsolutionstoTBcontrol/eliminationthroughacomprehensiveconsultativeprocess.ThereportidentifiedACSMasastrategicmeansto

enableachievementofthegoalsoftheStopTBmovement.ThereportstronglyrecommendedtherapidstrengtheningofACSMatbothglobalandnationallevels(29).

In July 2003, a declaration from an expert consultation oncommunicationandsocialmobilizationstatedthat:

...Intermsofavailabletreatmentsandanexistinghealthinfra-structure,morehadbeenachievedtotackleTBthanalmostanyothercurrenthealth issue.However, for these interven-tionstoachievetheirfullpotential inTBcasedetectionandtreatmentcompliance,thecentralstrategicchallengeisnowoneofadvocacy,communicationandempowerment” (30).

AclearconclusionfromtheACSMWGisthatcommunicationstrategies tomakeasubstantialcontribution to tacklingTBexistintermsofincreasingcasedetection,improvingadher-ence, tackling stigma, empowering people affected by thedisease, and raising political commitment. Such strategieshave,however,notbeenprioritizedbyNTPsorinternationally,eitherintermsofstrategicemphasisorinbuildingcapacitytoimplementeffectiveACSMprogrammes.Finally,whilemanyeffectiveandprovenACSMstrategiesexist,theyareneitheramagicbulletforTBcontrolnorasimpletemplatethatcanbeapplieduniversally.WhilePart2ofthisworkplanoutlinesand recommendsa seriesofmethodologies for scalingupcommunicationprogramming,ACSMstrategieswillneedtobedevelopedfromwithincountriesaccordingtothespecificrealitiesofeachcountry.

3.2What lessons have been learnt so far?There isa substantialbodyofgoodpractice todrawuponindesigningeffectiveTBcommunicationprogramming.Themost important lesson learnt is that ACSM strategies aremosteffectivewhentheirdesignisledbyandappropriatetospecificcountryprocessesandexperiences.Inotherwords,theyareeffectivewhenACSMprogrammingfullyandbroadlyengages governments, NGOs, patients and their families,

Evidence and lessons learnt

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communities, and other sectors of society such as privateenterprisesandthemedia.

Two of the most successful and best documented uses ofcommunicationintacklingTBarederivedfromtheexperienc-esofMexicoandPeru.Bothexperienceshavedemonstratedsomeclearprinciplesofanycommunicationstrategy.

InPeru,therewasaclearconclusionthat,“inthefightagainstTBitiscrucialtounderstandthattheproblemofTBoriginatesinpoverty,andthatanystrategywhichdoesnottakethisac-countwillsurelyfail.ThereforetheproblemofTBshouldbeapproachedinacomprehensivemannerwheretheconstantdialoguewith thepatientsandtheirorganizationswillshowustheothersideofthecoin”.

InsimilarveininMexico,“Today,itisunthinkableanymoretodefendtheideathatpublichealthproblemssuchasTB,canbesolvedwithoutregardtotheeconomic,socialandculturalcontextwherethediseaseoriginatesanddevelops”.

Inbothcases,thecentralityofunderstandingthecontextofTB,particularlythatofpoverty,isemphaticallyarticulated;andtheprocessofbringingaboutchangeisbasedonempower-ing communities to play a lead role in that process. Theseexperienceshavebeenechoedrepeatedlyandconsistentlyin discussions on effective programme communication. In

Bangladesh,increasingprioritizationofACSMisrootedcare-fullyinasocialempowermentframework(seeAnnex1).

The Mexican model, which has the commitment of theMinistryofHealth,isstronglyrootedintheprocess-orientedtradition of participatory approaches, and is based on fivestrategicelements:(1)community-joineddiagnosisofhealthissues; (2)community-joinedreviewandassessmentof theoperationsofhealthprogrammes;(3)continuouscommuni-cationbetweengovernmentandcommunitiesonthestatusofhealthandwelfare;(4)articulationofallsocialactorsinthefield–government,privatesectorandsocialorganizations;(5)jointevaluationofprogressandoutcomesbetweenhealthpromotersandcommunities.

IntheprojectareasofMexico,communicationmechanismshavebeen implementedat thecommunity level in the formofnetworksofcommunityfacilitators,healthpromotersandlocalauthorities, thataresupportedbytheuseofappropri-atecommunityandlocalmassmedia.Communities,healthpromotersandhealthexpertsjointlyanalyseandcreatecol-lective knowledge about the population’s health situation,assesscommunityknowledgeaboutavailableservicesandtheir quality, maintain continuous communication betweenthe government and the community, share informationand experiences, and finally evaluate progress jointly. Theoverarching themeof theentireprocess is that information


“We have a unique historic opportunity to stop tuberculosis, but we must act now.” The challenge is for people to work together in putting the plan into action, in order to stop one of the oldest and most lethal diseases known to humanity. This plan tells the world exactly what we need to do in order to defeat this global killer.”

Dr Marcos Espinal, Executive Secretary of the Stop TB Partnership at the launch of the Global Plan to Stop TB 2006–2015, Davos, Switzerland, 27 January 2006

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must be translated into knowledge, and knowledge into apermanent change in behaviour. While ACSM was one ofseveralcontributions, it is important tonote thatMexicore-centlyachievedandsurpassedinternationalcasedetectionandcasecuretargetsforTBcontrol.

InPeru, thepatient-centredmobilization revealed the inher-entlyunequalpowerrelationsbetweenhealthpersonnelandpatients.However,theprocessoforganizingthepatientsintogroups/networkswasinitselftransformativeatmanylevels.Asidefromcreatingspacesforpatientstoexchangeinforma-tionandshareconcerns,theprocessalsohelpedinresolvingtheirsenseofisolationandexclusion.Besidestreatmentandcure, the process empowered poor and marginalized sec-tions of society to demand their rights. The growing voiceandpublicpresenceoftheTBpatientsinthewidersocietyhelpedcreatecitizenshipawarenessaboutthecomplexityofTB,andbroughtinthecommitmentofnewactorsinthefightagainstTB (31).

Experiences inMexicoandPerustronglydemonstrate thattheprocessofsocialmobilizationtofightTBcantransformandbringaboutchangesthatassistthewiderprojectofsocialdevelopment. It is important tonotethat in theseandothercountrieswhere intensiveandeffectivecommunicationhasbeencriticaltoboostingcasedetectionandreducingstigma(suchasVietNam), therewasnoseparatecommunicationstrategy(32). Rather, thecommunicationactivitieswereinte-grated into the national TB control/DOTS strategy. In bothcountries,activitieswere intensiveandsustainedover time.These includedadvocacyactivities,massand localmedia,interpersonalcommunicationandcounselling,andcommu-nitymobilization.Politicalwillwashigh,andTBwashighonthepoliticalagenda. It is important tonote that inall thesecountries,ittookmanyyearsofworkbeforeresultsbecameapparent.InVietNam,forexample,ittookaboutfiveyearstoattain100%DOTScoverage,withadequateclinicalservicesandhumanresources.Whencasedetectionwaspassive,theratewassteady.Whencommunicationwasadded,thecasedetectionrateincreasedrapidly.

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Tuberculosis

TB kills 2 million people per year.

The breakdown in health services, the spread of HIV/AIDS and the emergence of multidrug-resistant TB (MDR-TB) are contributing to the worsening impact of the disease.

It is estimated that between 2000 and 2020, nearly one billion people will be newly infected. 200 million people will get sick. 35 million people will die from TB if control is not further strengthened.

Global Plan to Stop TB 2006–2015

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4.1Knowledge is critical

TB is transmitted by proximity, but also by ignorance. Thelack of knowledge that having a cough for more than twoweeksisapossiblesymptomofafatalbutcurablediseasepreventsmillionsofpeoplefromseekingtreatment.Studiesrepeatedlyshowthatifpeoplehavethatknowledgetheyarefarmorelikelytoseektreatment.Withoutit,theygenerallywillnot. In this sense,noactivecasedetectionandadherencestrategycanhopetosucceedwithoutamajorcommunica-tioncomponent.

Intermsoftraditionalcommunication,educatingpeoplewiththeknowledgeandpersuadingpeopletoseektreatmentforTBhaschallengesbut isconsideredbymanycommunica-tionorganizationstobearelativelystraightforwardprocess.Othercommunicationissues,suchaspersuadingpeopletoaltertheirsexualbehaviourtopreventtransmissionofHIV,orreducethenumberofchildrentheyhave,arefarmorechal-lengingandcomplex.TherearemanyexamplesofsuccessinTBcommunicationprogramming,andawealthofexperiencedrawnfromotherfields(bothinhealthandinotherssuchasagriculture) thatdemonstrate the impactof communicationprogrammesingeneratingknowledge.

Athemerunningthroughoutthisworkplanisaninsistencethatstrategiesneedtobedeterminedatalocallevel,butintermsofthecoreknowledgethatpeopleneedtohavetochangetheirbehaviour,thefollowingareessential(butnotsufficient):• KnowledgeofTBsymptoms• KnowledgeofhowTBistransmitted• KnowledgethatTBiscurable• KnowledgethatTBtreatmentisfree-of-charge• Knowledge that potential TB cases should rigorously

seekprofessionalcare• Knowledge that active TB cases should adhere to a

treatmentregimen.

This knowledge cannot simply be targeted at individuals.Householdsaretheprimaryproducersofhealthandconsti-tutetheprimaryactorsofthehealthsystem,whichincludescommunitiesandhealthinstitutions,bothpublicandprivate.Primary “diagnosis and treatment” are often made at thehousehold level,aswellas thedecision toseek (or refuse)professional health care(33). In many ways, mothers serveas “first responders” to illness, followed by their spouses,parents, in-lawsandother relatives. Inmanycountries,pro-fessionalhealthprovidersaresoughtonlywhenhouseholdand traditional healers have failed. Any behaviour changecampaignneedstounderstandtheroleofmenandwomenindecision-makingindifferentculturalsettings.


The central strategic challenge in applying good practice to future communication programming is matching the

technical methodologies designed to achieve behavioural change with the social processes required to ensure strong

political and community ownership. The technical methodologies that can be drawn upon are outlined in Part 2, but

at least six fundamental principles for action can be learnt from the most successful experiences of the past:

• Knowledge is critical

• Knowledge is not enough

• ACSM should be integral and proportionate to NTPs

• ACSM should be nondiscriminatory and rights-based

• ACSM requires country-led approach, and investment in national and subnational capacity.

Clear principles underpinning this work

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4.2Knowledge is not enough

“Tuberculosisisnot(only)ahealthproblem.Itisasocial,eco-nomicandpoliticaldisease.Itmanifestsitselfwhereverthereisneglect,exploitation,illiteracyandwidespreadviolationofhumanrights”,arguedKundaDixit,formerdirectorofPanosSouthAsia(34).

Whilestudiesconsistentlydemonstratethatincreasedknowl-edge is critical to increasing the chances that people willseek treatmentorcomplywith treatment regimens,educat-ingpeoplewithaseriesof factsaboutTB is insufficient toinducewidespreadbehaviouralchange.Fewstudiessuggestthat transmitting a series of messages to targeted popula-tionstopersuadethemtoseektreatmentinthemselveshasa sufficient effect in changing behaviour. The vast majorityof people affected by TB face substantial problems in ac-cessingtreatmentevenwhentreatmentfacilitiesexist.Theseinclude:• Stigma and marginalization. As outlined earlier, stigma,

marginalization, discrimination, and poverty are majorfactorsinpreventingsickpeoplefromseekingtreatment.Stigma,lowriskperceptioncombinedwitheconomicandphysicaldifficultiesmaycontinue todelaycareseekingandcausedefault.

• Gender. Worldwide, TB is the greatest single infectiouscause of death in young women. While fewer womenthan men are diagnosed with TB, a greater percentageofwomendie from thedisease.Thestigmaattached tohavingTBfallsfarmoreheavilyonwomen.ConveyingthemessagetowomenthattheyshouldseektreatmentforthesymptomsofTBwillnotalwaysinducetreatment-seekingbehaviour unless it is accompanied by programmesthat confront the obstacles women face in seekingbehaviour.Suchprogrammeswilloftenbebroadersocialprogrammes aimed at empowering women, but manyopportunitiesexistforweavinginempoweringmeasuresintoTBcommunicationprogrammes.

• Distance.PeoplemostaffectedbyTBareoftenthosewithleastproximitytohealthservices.Insuchcircumstances,encouragingpeopletoseektreatmentforwhattheymayconsider to be a non life-threatening illness is a majorbehaviouralchallenge.

• Time and effort. In comparison with other diseases,particularly HIV, the detection and treatment of TB isconsidered “simple”. Three sputum examinations arenecessary for all infectious cases; X-rays are requiredfor some specific cases. Case treatment depends ona “straightforward” proven regimen: standardized foreachcase type;directlyobservedbyasuitable trainedpersonwithpatientcounselling;drugsmaybetakendailyor three times a week (for at least six months); healthworkerscanadministertreatmentonceaweek,atrainedvolunteeronotherdays;treatmentcanbeadministeredatahealthfacility,patient’shomeorcommunitycentre;treatmentfollow-upissystematicincontentatfixedtimesand based on inexpensive sputum smear microscopy.ForpeoplewithTB,however,thisisnotasimpleprocess.Mostwouldhave to take twodaysofoutof their life togettoahealthfacilityfortheTBtest,coughandspitforsputumonceatthefacility,thentakeaplasticcuphomeandcough-and-spitthenextmorning,comebacktothefacility that second day, cough-and-spit once more forsputumatthefacility,andwaitthereforthetestresult.IftheresultisTBpositive,then(underthecurrenttreatmentregimen) they will need to come back to the facility orsomeotherspot(hopefullynearertheirhomes)everydayfortwomonthsandtakeasetofpillsunderthewatchfuleyes of a health worker (or some other designatedresponsibleperson),doanothercough-and-spitsputumtest,andthencontinuetakingasetofpillseveryotherdayforanothersixmonths(35).

• Lack of health efficacy. Populations that are mostvulnerabletoTBoftenhavehighratesof illiteracy,poorhealthknowledge,andfeelingsofpowerlessnesswhenconfrontingthehealthsystem.

All of these factors are exacerbated by and are particularobstaclestothoselivinginpoverty.Theseissuesarewellrec-ognizedinTBcontrolstrategiesandneedtobeaddressedin any effective communication strategy. The frameworkoutlined in thisdocumentproposesacombinationofcom-munication methodologies aimed at achieving behaviouralchangebutalsoatcatalysingaprocessthatcanshiftsocialmores,whichoftenprevent individuals fromchanging theirbehaviour.

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4.3ACSM must be integral to NTPs

Communicationpractitionershaveadualrole:advocacyandsocialmobilizationseektoincreaseresources,commitmentandprioritygiventoTBatalllevelstherebyincreasingserv-icesforTB.Inthisrespect,increasingcommunicationcreatespressuretocreateservices.Atthesametime,aprincipaltaskofcommunicationandsocialmobilizationistostimulatede-mandamongpublicsforTBservices.Itiscriticalthat,whileadvocacyeffortsputpressureonauthoritiestoincreaseserv-ices,communicationandsocialmobilizationeffortsgeneratedemandonlyforservicesthatareavailable.Muchharmcanbeinflictedinpersuadingpeopletoseekservicesthatdonotexist.Inotherwords,anycommunicationandsocialmobiliza-tionstrategyneedstobecarefullyintegratedintoannationalTBcontrolplan,generatingdemandandsupportingeffortsthatareavailable.

4.4ACSM should be nondiscriminatory and rights-based

Theprincipleofnondiscrimination is fundamental topublichealthandhumanrights’, thinkingandpractice,andunder-pins this workplan. Freedom from discrimination is a keyprinciple in international human rights’, law and has beeninterpreted, in regard to the right to health, as prohibiting“anydiscrimination inaccesstohealthcareandunderlyingdeterminantsofhealth,aswellastomeansandentitlementsfor their procurement, on the grounds of race, colour, sex,language,religion,politicalorotheropinion,nationalorsocialorigin, property, birth, physical or mental disability, healthstatus (including HIV/AIDS), sexual orientation, civil, politi-cal,socialorotherstatus,whichhastheintentionoreffectofnullifyingorimpairingtheequalenjoymentorexerciseoftherighttohealth”(36).

Article19oftheUniversal declaration of human rightsstatesthat everyone “shall have the right to … seek, receive andimpart information and ideas of all kinds …”. The provisionofandaccesstohealth-relatedinformationisconsideredan“underlyingdeterminantofhealth”andanintegralpartoftherealizationoftherighttohealth (37).

Neglectoftherighttoinformationcanhavesubstantialhealthimpacts,andnohealthprogrammecanbesuccessfulifthosewhocouldpotentiallybenefitfromitlacktheinformationtheyneed.Educationand informationcanpromoteunderstand-ing,respect,tolerance,andnondiscriminationforpeoplewithTB.

Thisworkplanalsoassumesthatitisdesirablethat,whereverpossible,ahigher institution (e.g. international institutionorgovernment) should give over authority to the communitywhat thecommunitycanaccomplishby itsownenterprise,sometimesknownas theprincipleofsubsidiarity (38).Thisrequiresdiscussionandacceptanceby thepartiesofcleartermsofreference.Itiscombinedwithprinciplesofsolidarity(theexpressionbycitizensoftheneedtobeunited,tosharetheneedsandproblemsofothers,andtorecognizeandde-fendthedignityofeachindividual)andofresponsibility(whichreferstotheneedforindividualcitizensandsocialgroupsinexercisingtheirrightstohaveregardfortherightsofothers,dotheirowndutiestoothersandseekthecommongoodofall).Theprincipleofsubsidiarityisaimedatempoweringlocalcommunities, but it requires a responsibility at thenationallevelforfunding,andshouldnotbeanexcusetoderogateoravoid responsibility fornational-levelprioritizationandplan-ningforTBcontrolinitiatives.

4.5ACSM requires a country-led approach, and investment in national and subnational capacity

This workplan demonstrates that there is a wealth of infor-mation,experienceandexpertiseavailabletoTBmanagerson TB communication programming in all its forms. Thisexperience and expertise reside both within countries andinternationally,butakeyprincipleunderpinningthisworkplanisthatACSMstrategiesarelikelytobemosteffectivewhentheyareledbyandframedwithinspecificcountries,societiesandcommunitiesinthecontextofNTPs.

Country programmes have identified a series of ACSM ca-pacityweaknessesrequiringurgentstrengthening:• Technicalcapacitytoensurehigh-qualityACSMaction• ProgrammecapacitytoactivelyempowerandinvolveTB

patientgroups.


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In 2002, an in-depth assessment of ACSM capacities andactivitieswasconductedwith10NTPs–Cambodia,China,India,Indonesia,Kenya,Myanmar,Philippines,SouthAfrica,Uganda,and theUnitedRepublicofTanzania(39).Theas-sessmentrevealedthefollowing:• Of the 10 NTPs, 6 had established reasonably strong

national advocacy mechanisms, but subnationaladvocacymechanismswereweak.All10NTPsrequestedassistance in strengthening advocacy activities atnational levelbutespeciallyatdistrict levelwhere,asaconsequence of health reforms, many budgetary andhumanresourcedecisionsarenowmade.

• Social mobilization and communication activities in all10NTPsvariedintermsofintensityandreach.NoNTPshaddocumentedACSMimpact.All10NTPsrequestedtechnicalsupporttoimprovetheplanning,managementandevaluationofsocialmobilizationandcommunicationactivities.

• Having designated managerial staff with appropriatequalifications and experience has been shown to bevitalincoordinatingandimplementingACSM(40).Only3 of the 10 NTPs reported having a designated ACSMmanager.

• Havingawell-researched,detailed implementationplandesigned on the basis of widespread consultation hasproved vital for ACSM programmes (41). Only 1 of the10NTPsreportedhavingdevelopedadefinitiveplantomanage,monitorandevaluateACSM.

• Access to appropriate agencies from which technicaladvicecanberegularlysoughtandtowhichspecializedwork can subcontracted is crucial for building andsustaining ACSM capacity (42). All 10 NTPs hadaccess toMinistry of HealthandUnitedNations publicrelations/communicationofficers.Nevertheless,allNTPrepresentatives (government and nongovernmental)statedtheywouldwelcomelonger-termpartnershipswithspecializedACSMtrainingagencies.

These results indicate that all NTPs wish to build and sus-tain national and subnational ACSM capacity. In the era ofdecentralization,ACSMplanningandmanagement isoftenrequired at district and community level. Evidence and ex-periencetodatestronglysuggestthatthescarcityofskillsatthedistrictlevelcontributessubstantiallytomostprogrammeimplementationfailures.Inaddition,staffatpublicandprivatehealth institutions, NGOs and community-based organiza-tions(CBOs)needtechnicalsupportinplanning,implement-ing,monitoringandevaluatingACSM.There isalsoaclearneedforcountry-levelACSMtobeinformedandsupportedby participatory research and evaluation, and it is equallyclear thathuman resourcesmustbestrengthened in thesefields,especiallyatsubnationallevel.

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The2002reportconcludedasfollow:• NTPsshouldensure that thecomplex,multi-levelACSM

activitiesrequiredtosupportDOTSexpansionandotherTBprogrammeelementsaremanagedbyadesignated,full-time,well-qualifiedstaffmemberorteam.

• Comprehensive training programmes to build capacityin ACSM planning, implementation, monitoring andevaluation are urgently required. Capacity buildingprogrammes could include: short courses, in-servicedistance education, and on-the-job technical assistancetofieldstaff.Centralizedorregionaltrainingteamscouldbe established so that one or more teams of “mastertrainers” travel tovarious locations todeliverhigh-qualitytraining. This strategy offers the advantage of providingparticipantswithamorestandardizedpackageof skills-buildingactivities.

• NTPsshouldactivelyseeksupportfrommultinationalandnational commercial corporations, not just in finding orotherresources,butintermsofskills.Theselinkagesmayresult in substantial benefits to NTPs as well as servingasausefulpublic relationsexercise for thecorporationsconcerned. Resource groups that are available withincountrytohelpplan,developandimplementACSMneedtobeidentified.Thesewouldincludemediaprofessionals,production agencies, patient organizations, NGOsand professional bodies that could operate as key NTPpartners.

Thereisnoevidencetosuggestthatthefindingsofthe2002report are any less relevant today. Given that little has oc-curredtoaddresstheseconcerns,thereismuchtosuggestthattheyareasrelevantnowastheyhaveeverbeen.

ThesecondcapacityconstraintcentresofthedifficultypeoplemostaffectedbyTB(alsooftenaffectedbyHIV)toinfluenceandshapeTBcontrolprogrammes.Thereisanurgentneedforprocesses thatwill facilitateandempowercommunitiesmostaffectedbyTBtoparticipatein,takeownershipofanddrivetheagendafortheeliminationofTB.

Bearingthesekeychallenges,definitions,lessonslearntandprinciplesinmind,Part2presentsthe10-yearstrategicframe-workforACSMactionthatwillcontributetoTBcontrol.


The number of patients treated in DOTS programmes in the 22 high-burden countries (i.e. the top 22 ranked by number of incident TB cases) more than doubled over five years, from two million in 2000 to a projected figure of over four million in 2005. Total spending on TB control in the 22 high-burden countries increased from US$ 800 million in 2000 to a projected figure of US$ 1.2 billion in 2005.

Global Plan to Stop TB 2006–2015

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THEFRAMEWORKFOR ACTION

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T H E F R A M E W O R K F O R A C T I O N 2

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This framework for action proposes that while the greatestACSM efforts need to be targeted at where the greatestburdenexists,thisshouldnotbetotheexclusionofeffectiveACSMeffortsinmedium-burdencountries.

Not all high-burden countries have similar case detectionratesand,takingotherfactorsintoaccount,priorityforACSMactivities shouldgenerallybegiven to thosecountrieswiththeweakestcasedetectionrates(casedetectionratesvaryfrombetween9%and100%inhigh-burdencountries).

The framework foractionproposesadualstrategyof inten-sively supporting ACSM activities in five high-burden coun-triesperyearoverthenextfiveyears,andthensustainingthatsupportthroughoutthe10-yearperiodoftheGlobalPlantoStopTB2006–2015.

This10-year framework for action isbasedon thepremisethat ACSM represents an important means of engagingpolicy-makers,localgovernmentofficials,publicandprivatehealth professionals, traditional and religious leaders, com-munityleaders,patientsandtheirfamiliesinbringingaboutsustainablebehaviouralandsocialchangesthatwill inturncontribute toareduction inTBburden.ACSMalsoplaysacrucialroleinexpandingthenumberandrangeofservicesforbothTBandHIV/AIDS.

This framework draws on and brings together more thanfouryearsofdiscussionsonhowACSMprogrammingcancontributetoTBpreventionandcontrol.Whilethereremainimportantareasrequiringfurtherdevelopment,andcommu-nicationprogramminghas toconstantlyadapt tochangingenvironmentsandneeds,substantialagreementexistsonaTBACSMstrategywithinaffectedcountries.

This framework is not a predetermined roadmap thatTB-affectedcountriesshouldfollowinimplementingcommu-nicationactivities. Instead, the frameworkoffersaseriesofinterrelatedcomponents,approachesandtoolsfromwhichcountrypartnerscanselect.

Framework for actionAlmost 80% of the global TB burden is carried by 22 high-burden countries, principally in Asia and Sub-Sahara

Africa. Five of these countries – Bangladesh, China, India, Indonesia and Nigeria – account for 50% of the global

burden. Most TB control efforts are focused on these 22 high-burden countries.

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Strategic vision and goals6.1Vision

Our vision is one where all communities at all levels areempoweredtoremovethethreatofTBtohumanhealth.ByapplyingACSMstrategiesfromhealth-caresettingstohouse-holds,TBpatientsaresupportedandtreatedeffectivelywithdignityandrespect.Furthermore,thosemostaffectedbyTBwillbeinvolvedinshapingtheresponse.

6.2Goals

Overthenext10years,thisframeworkaimstoestablishanddevelop country-level ACSM as a core component of TBpreventionandtreatmentefforts.Theframeworkhasthefol-lowinggoals:• to provide guidance for Global Plan to Stop TB 2006–

2015 goals and targets as these translate into nationalACSMinitiatives;

• tofosterparticipatoryACSMplanning,managementandevaluationcapacityatregional,nationalandsubnationallevels;

• to support and develop strategies to achieve keybehavioural and social changes, depending on localcontext, that will contribute to sustainable increases inTBcasedetectionandcurerates.

InSection7.1,differentACSMapproachesaresummarizedandrecommendedforuseinTBcontrol,buttheseareout-linednotastemplatesforadoptionbutasoptionsavailableforin-countryprogramming.Theheartofthisstrategicframe-workisitsfocusonbuildingupcountry-levelASCMcapacityso that appropriate, effective, country-led communicationstrategies can be developed, prioritized and implemented.Thebottomline,however,isthatmanyofthetoolsandmeth-odologiesforactionexist;theresourcesnowneedtofollow.

6.3Strategic objectives and targets

Thisframeworkisdesignedtoimplementintensive,sustainableanddetailedcommunicationstrategiesinallhigh-burdencoun-tries,aswellassupportstrategiesinmedium-burdencountriesover the next 10 years. Such work will be phased to ensuremaximumstrategicintensity.Inthefirstfiveyearsofthiswork-plan, an intensive process of capacity building and strategicplanningwilltakeplaceinallhigh-burdencountries.Thiswillbeaphasedprocess,focusedonfivecountriesperyear.

Thefollowingstrategicobjectiveshavebeenidentified:• By2008,atleast10endemiccountrieswillhavedeveloped

andwillbeimplementingmultisectoral,participatoryACSMinitiativesandgeneratingqualitativeandquantitativedataonACSM'scontributiontoTBcontrol.

• By2010,atleast20prioritycountrieswillbeimplementingmultisectoral, participatory-based ACSM initiatives, andmonitoringandevaluatingtheiroutcomes.

• By2015,multisectoral,participatoryACSMmethodologieswill be a fully developed component of the Stop TBStrategy.

• By 2015, all priority countries will be implementingeffectiveandparticipatoryACSMinitiatives.

Inaddition,aseriesofprocesstargetshavebeenidentified:• Bythemiddleof2006,adetailedACSMcapacitybuilding

implementation plan will have been developed aimed atensuringtheappointment/recruitmentofsenior-levelcom-municationstrategistsfocusedexplicitlyontacklingTBinallhigh-burdencountries.Suchaplanwilldrawheavilyontheexperience,expertiseandinsightofNTPsandpartners.

• Bytheendof2006,astrategywillhavebeendevelopedwithmedium-burdencountriesdetailing thecommunication sup-portnecessary(includingtechnicaladvice,resourcematerialsandothermechanisms)tomeetTBtargetsinthosecountries.

• Bythebeginningof2006,aprocesswillhavestartedtoform strategic agreements with international technicalsupport organizations able to offer technical support tocountries.Bythemiddleof2006atleastfiveofthesewillhavebeenagreedandimplementationbegun.

Theseobjectivesandtargetswillbeachievedthroughamixoffivekeystrategiccomponents.

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7.1Building national and subnational ACSM capacity

Intheareaofprogrammeplanning,mostcountrieshaveawell-establishedorimprovingplanforDOTSexpansion,butonlyrarelyisthiscomplementedbyawell-developed,technicallysoundandwrittenplanforcommunicationactivities.Thereisahighdemandfromwithincountriesfortechnicalassistanceindevelopingappropriatecommunicationtools,training,pro-posalwriting,planningandmaterial’sdevelopment.Thereiswidespreadagreementthatasubstantialincreaseincountry-levelcapacityisrequiredifNTPsaretodesign,developandimplementeffectiveACSMprogramming.

Tocombatcapacity shortagesatnational level,morededi-catedandspecifically trainedcommunication staff need toberecruitedtoNTPsandalliedprogrammeswhoarequali-fied to plan, implement and evaluate complex large-scalecommunication interventions; resources need to be madeavailableforthis.Thisframeworkrecommendsthat:

• allhigh-andmedium-burdencountriesappointanationalACSMcoordinatorandthatthisperson:o hasastrongunderstandingofallaspectsofACSM;o hasstrongmanagementskillsrelevanttoACSM;o is capable of engaging, working and reaching

populationsoutsidethecapital;o isnormallyemployedinadedicatedpostbutinsome

casescouldholdajointHIVACSMfunctioninsomecountries.

• all endemic countries carry out an ACSM needsassessmentfromwhicha10-yearACSMstrategycanbedevelopedinpartnershipwithotherstakeholders.

• each country needs to have an agreed, prioritized,budgeted ACSM workplan and that budgets arespecificallyallocatedforthisworkandexplicitlybuiltintoGFATMproposals.

• regular,structuredmeetings(atleasteverytwomonths)needtohappenwithinfected/affectedcommunitiesandNTPprogramme.

This 10-year workplan addresses four key challenges to TB control:

• Improving case detection and treatment adherence

• Combating stigma and discrimination

• Empowering people affected by TB

• Mobilizing political commitment and resources for TB control.

It does so by presenting a framework for action consisting of five components and the methodologies and resources

available to implement these components:

1. Building national and subnational ACSM capacity

2. Fostering inclusion of patients and affected communities

3. Ensuring political commitment and accountability

4. Forging country-level ACSM partnerships within the context of NTPs

5. Learning, adapting and building on good ACSM practices and knowledge exange

A five-point framework

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CapacitybuildinginACSMmustnotbeviewedasaone-offevent.ACSMcapacitybuildingneeds,asarticulatedbyoneexpert,“tocontinuetoreachindividualsandinstitutionsinallparts of a country; to influence different types of agencies,fromministriesandNGOstoadvertisingagencies;tospreadnewskillsandtechnologiesastheydevelop;andtoteachnewcohorts of communication professionals … [Training] needstocontinue,evenafterotherelementsoftechnicalassistancemay diminish or end” (43). In some circumstances, it maybe necessary to establish new country-level organizationsspecializing in ACSM. Past examples include centres forcommunication programmes developed by Johns HopkinsUniversity in Bangladesh, Bolivia, the Philippines, UgandaandZambia.

Basedona2002ACSMneedsassessment,themajorinter-nationalinvestmentrequiredinthisworkplanwillbemulti-yeartechnical service contracts to engage various internationalandnationalcommunicationpartners tohelpbuildsustain-able national and subnational capacity in ACSM. Thesemeasuresaredesigned toguarantee theprovisionofhigh-quality technical assistance required for the strategic plan-ning,implementation,monitoringandevaluationofACSM.

Themainaimsofthesecontractswillbeto:• Improve country partner access to timely and quality-

assuredtechnicalassistanceinagreedpriorityareas• Encourage a collaborative approach to the delivery of

technicalassistanceinsupportofcountrypartner-ownedandpartner-ledACSMplans

• Assist in the professional development of nationalinstitutions as well as national and regional ACSMconsultants.

Depending on country requests and resource availabilities,ACSMcapacitybuildingwillberolledout,startingwithfivecountries each year between 2006–2008 (Figure 1). NTPsnot immediately in receipt of this focused technical assist-ancewillbenefitfromregionalsupportactivitiesasdescribedbelow.Technicalservicecontractswillinitiallylastonaveragenomorethanthreeyears.Dependingoncountry-levelneed,however,somecontractsmayrequireextension.

Many international communication partners have alreadybeeninvolvedinprovidingtechnicalsupporttoTBcommu-nication-relatedactivities,andothersarearewellqualifiedtodoso(44).

Regionalandnationalcommunicationpartnersmightinclude:populationmediacentres;nationalcentres forcommunica-tion programmes; national social marketing organizations;advertising firms; NGOs, CBOs and patients associationswithcommunicationcapacity;traditionalhealers;andhealthpromotion/communicationdepartmentswithinministriesofhealth.

ThesecontractswillbepreparedbytheStopTBPartnershipincollaborationwithcountrypartners.Contractswillspecifycapacitybuildingneeds,preferredmethodsof trainingandsupport, togetherwithdeliverables,milestones,andevalua-tionrequirements.Eachthree-yeartechnicalservicecontractwillbewortharoundUS$175000.

Capacitybuildingactivitieswillbenefitfromrecentadvance-mentsintheartandscienceofACSM.Thereisanever-grow-ingliteratureoncross-cuttingissuessuchaspoverty,gender,stigmaandTB-HIV/AIDSpolicy(45-57). ACSMtrainingpro-


2006 2007 2008 2009 2010 2011

5 countries

Roll out of ACSM capacity building activities in endemic countries Focused support

5 countries5 countries

Figure1:Roll-outofACSMcapacitybuildingactivities(example)

5 countries

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grammes,short-courses,andcomputer-basedsoftwarehavemultiplied. Country-level advocacy tools designed for otherhealthissues,particularlyHIV/AIDS,couldbeadaptedforTB(58-59). There are several state-of-the-art information data-basesonACSMandfinally,therangeofevaluationmethods,indicatorsandtechniqueshassteadilyimproved(60).

Several research tools are available for ACSM planning aswellasstrategicplanningtoolsandmodels,fieldguidesthatprovidedetailedoperationalstepsandtipstoimprovestrate-gicplanimplementation(seeAnnex1).Thesetools,modelsandguidesallemphasizetheneedfor:• Adoptingevidence-basedplanning.ACSMinterventions

needtobebasedonanuancedunderstandingofreasonswhy different populations are not timely diagnosed orconfrontdifficultiesforcompletingtreatment.

• Havingamultiple-levelunderstandingofthefactorsthatexplaindelayindiagnosisandincompletetreatment.

• IdentifyingACSMstrategiesthatcarefullyconsiderlocalconditions(political,social,economic,cultural,etc.).

• Conductingregularmonitoringandevaluationofactivitiesto provide feedback to plans, adjust interventions, andmeasureimpact.

• Ensuring wide participation from a variety of politicaland social actors in ACSM activities to promote localownershipandsustainability.

• Combiningtheuseofdifferentstrategiesandchannelstomaximizeeffectiveness.

• Tacklingavarietyofcommunicationfactorsthataccountfor delay in diagnosis as well as lack of adherence tofull treatment. This includes not only knowledge andawarenessissuesbutalsoattitudesaswellasstructuralfactors. Also, ACSM need to address challenges atdifferentlevelsandamongavarietyofactors.Forexample,stigmaneedstobetackledamongpatients,familiesandgroups,andhealthworkers.

ApproachesdescribedindetailinAnnex1include:

• JohnsHopkinsUniversity’sP Process:laysoutalogicalframework for a communication intervention—analysis,strategicdesign,developmentandtesting,implementationand monitoring, and evaluation and re-planning, whichhasbeenappliedtoawiderangeofhealthissues.

• TheCommunication-for-Behavioural-Impact(COMBI)approach developed by the WHO Social MobilizationandTrainingTeam:anapproach tomobilizesocialandpersonal influences to prompt behavioural change andmaintenanceatindividualandfamilylevels.

• JohnsHopkinsUniversity’sOutcome Maptostrengthenthe DOTS strategy: a planning tool for matchingcommunication responses to programme needs, andforoutliningkeyplanningandmeasurement indicators.Theoutcomemapretrofitscommunicationinterventionson to thewell-establishedbutmedically-orientedDOTSstrategy for TB control. It enhances DOTS to includedemandgeneration forhigh-qualityDOTSservicesandsuggests strategies for encouraging adherence andtreatmentcompletion.

• AcademyforEducationalDevelopment’sCough to Cure Pathway: adiagnosticandplanningtooltohelpTBcontrolprogrammes identify where drop-outs are occurring.It identifies six steps to ideal behaviour in TB control,as well as the most common barriers at the individual,groupandsystemslevels.Itispremisedontheideathatunderstanding patients’ behaviours is fundamental todesigning interventions to strengthen NTPs, includingcommunicationinterventions.

• The Communication for Social Change approachadvocated by the Communication for Social ChangeConsortium: a process of public and private dialoguethrough which people define who they are, what theyneedandhowtogetwhattheyneedinordertoimprovetheirownlives.Itutilizesdialoguethatleadstocollectiveproblemidentification,decision-makingandcommunity-basedimplementationofsolutionstodevelopmentissues.It is communication that supports decision-making bythose most affected by the decisions being made andis especially appropriate for strategies where socialmores–suchasstigma–actasabarriertobehaviouralchange.

• Proposed by the patient advocacy organization “tbtv”,Positively Empowered Partnerships are agreementsof mutual technical assistance between organizationsof people with tuberculosis and/or HIV, and the health

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professionals seeking to control the diseases. Itpromotestheneedtoresearchanddevelopnewtoolstoincreasecasedetectionandadherence,andtomonitorandevaluate the impactofpatientparticipation;and toprovideastructureforfacilitatingresearchandstudiesofpatientparticipation.

ACSM strategies are only successful when they are cultur-ally and context specific. These approaches and tools arepresented in Annex 1 as options for deployment, adoptionandadaptationbycountriesandasexamplesofthetechni-calsupportthathavealreadybeendevelopedinresponsetocountry-levelrequestsforACSMsupport.DecisionsonwhichstrategiesandapproachesaremostappropriateneedtobetakenatacountrylevelwithinthecontextofNTPs.

Based on extensive ACSM capacity building experiencegainedbyUNICEFinthePolioEradicationInitiative,methodsofcapacitybuildingdetailed ineach technicalservicecon-tractmightincludeoneoracombinationofthefollowing:• Mentoring – one-to-one relationships between ACSM

specialists and in-country TB staff (government andnongovernmental).

• Training–well-organizedopportunitiesforparticipantstoacquirethenecessaryunderstandingandskillstocarryout one or more specific tasks. Training may occur inclassrooms,on-the-job,viaself-instructionalmaterials,orviaradioorothercommunicationtechnology.

• Networking – connecting in-country TB staff toprofessional networks, including regional meetings, e-mailexchange,andjointcountrymissions.

• Distance consultation and support – provision oftechnical assistance fromadistance, including transferof knowledge, provision of feedback and advice, andassistanceinaccessinginformationthatmightotherwisebedifficulttoobtain.

• Development and dissemination of support materials–seeAnnex2foranindicativelistofsuchmaterials.

• Strategic additionofpersonnel,equipmentorsuppliestoanorganizationtoenhanceitsperformance(61).

Attheregionallevel,themajoractivitiesforcapacitybuildingproposedbythisworkplanareensuringthatACSMexpertiseis included in DOTS Expansion Working Group monitoring

missions and that ACSM specialists and NTP communica-tionstaffparticipateinregionalTBmeetings.ForNTPsyettobereachedbycapacitybuildingactivitiesdeliveredthroughtechnical service contracts with communication partners(described above), regional communication workshops willalso be held to ensure good practices and lessons learntarefurtherdisseminated.Finally, fundingwillberequiredtodeploy regional TB strategic communication officers withtheprimary responsibilityof coordinating regional activitiesand communicating constantly with NTPs to ensure effec-tive global-to-national linkages are maintained. In additiontosupportingtheGlobalPlantoStopTB2006–2015ACSMmilestones,regionalactivitieswillensurethatby2010,ACSMsupportisintegratedwithregionalTBcontrolactivities.Thebudgetrequiredtoaccomplishtheseregionalactivitiesoverthe10-yearperiodisequivalenttoUS$0.6millionperyear.

7.1.1A handbook for communication programming

Acomprehensivehandbookprovidingguidance tocountrycommunicationprogrammeofficersisacriticalandincreas-inglyurgentresource ifcountry-levelACSMactivitiesare tobeexpandedandaccelerated.

Suchahandbookhasalreadybeencommissioned, follow-ing a bidding process, from the Academy for EducationalDevelopment/PATH by the Stop TB Partnership. Progressandproductionof thishandbookneeds tobeaccelerated,and needs to incorporate and describe a range of behav-ioural and social change methodologies and approaches.Thekeycomponentsof anexistingdrafthandbookon theCOMBI methodology (see above) should be incorporatedintotheoverallhandbooksothatthereisonekeyreferencedocumentandresourceforcountryprogrammeofficersandplanners.Thehandbookshouldbeupdatedregularlyasnewapproaches are developed, and this should happen everytwoyears.


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7.1.2Needs assessment tools

Any ACSM planning needs to be rooted in a thoroughcountry-led needs assessment. A needs assessment toolhasbeendevelopedbytheStopTBPartnershiptoassistincountry-levelplanning(62).

TheStopTBPartnershiphasalsoproducedanadvocacyandcommunicationchecklist,whichhasbeenproducedtoassistinasystematic reviewof theadvocacyandcommunicationcomponentofanNTP(63).ThechecklistshouldprovemostbeneficialtoNTPsthathavegoodDOTScoveragebutlowerthanexpectednumbersofpatientspresenting for initialTBdiagnosis and/or high numbers of defaulters among thosewhocommenceTBtreatment.

The Partnership has also developed planning guidance, asummaryofwhichcanbefoundinAnnex1.

7.2Fostering inclusion of patients and affected communities

Strategic activities and specific resource allocation arerequired to ensure the effective inclusion of patients (TB,TB-HIV, MDR-TB) and affected communities in TB control.Approachesthat includepatientsarenotonlymoreethical:theyarealsomoreeffective.

Amongthestepsnecessarytosupportthisare:• Thecreationofanenvironmentthatempowerspatients

and affected communities to participate effectively inprogrammedesign,implementationandmonitoring.

• Support for nurturing of TB and TB/HIV patientorganizationsandnetworks.

• Piloting and investment in methodologies and toolsdevelopedbypatientstoimproveTBcontrolprogrammes(forexample,themethodologyofPositivelyEmpoweredPartnerships-PEP-asoutlinedinAnnex1).

• TrainingprogrammesforpatientstobecomecommunityTBeducators,monitors,andadvocates.

• Capacity building for NTP staff at all levels in involvingpatientsinTBprogramming.

• Thedevelopmentandadvocacyofbehaviouralchangestrategiestargetedathealthworkerstoreducestigma.

• Operational research todocumentgoodand innovativeapproaches that empower and involve patients andaffectedcommunities.

• Employement of patient representative in the Stop TBSecretariattoactasafocalpointforaction,supportandrepresentation.

• Activesupportstrategiestoenablepatients/thosemostaffected toparticipateeffectively inprogrammedesign,implementationandmonitoring.

An important focus forACSMactivities instigma reductionneeds to be on health workers, and specific strategies forstigma reduction within the health-care system need to bestrengthened, insomecasesdrawingon the toolsoutlinedhereandthroughotherstrategies.

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7.3Ensuring political commitment and accountability

Advocacy isnecessaryatall levels, fromthenational tothesubregionaltothelocal.Advocacytoparliamentarians,minis-triesandministersofhealthandoffinance,businessleaders,religious leaders, civic and cultural institutions, civil societyorganizations and other decision-makers are necessary formobilizingpoliticalsupportandresourcesatthecountrylevelforTBcontrolefforts.

Often equally important are advocacy efforts aimed at lo-cal political and other leaders whose support is critical forthe successful implementation of TB control programmes.Advocacyeffortsneedtobesustainedandtimely.Thiswork-planfocusesonlyonthoseadvocacyeffortsmadewithintheframeworkofNTPsandsimilarstructures.Therearenumerousexamplesoftoolsandmodelsavailablefor effective advocacy (some of these are listed in Annex2). Tohelp generatepolitical andfinancial commitment foreffectiveTBcontrolamongdecision-makersat thecountrylevel,thesubgroupwilldevelopadetailedguideoneffectiveadvocacy activities that NTPs may adapt and apply to ad-dresstheir identifiedneedsandchallenges.Thisguidewillincludeawidevarietyofapproachesandactivitiesbutisnotintended to be an exhaustive list of all advocacy strategiesor a detailed prescription for implementation. Rather, theguidewillpresentNTPswithacomprehensivesetofeffec-tivemechanismsfromwhichtheycanselectbasedontheirspecificcontext,particularlytakingintoaccountexistinglev-elsofpoliticalcommitment,healthsystems,communicationenvironments,governmentstructure,etc.

Tools/strategiesmightincludethefollowing:• The establishment of formal and informal national

partnerships composed of a broad coalition ofstakeholders,includingrepresentativesfromtheaffected/infected community, academic institutions, donors,private sector, NGOs, media, etc. These partnershipsshould build upon the experiences and successes ofexistingnationalStopTBpartnerships.

• The promotion of TB champions from both withingovernment,specificallyinparliamentandtheministriesoffinanceandhealth,andoutsidegovernment(suchas

intheprivatesector).Promotioncantakeplacethrougharangeofactivitiesincludingpolicybriefings,fieldvisits,mediaevents,programmereviews,etc.

7.4Forging country-level ACSM partnerships within the context of NTPs

InmostcountriestheNTPsdonothavetheresources,knowl-edgeorcapacitytodevelopandcarryoutACSMstrategiesandactivities,andareinneedofinvolvingothernationalandlocal partners. In many countries there are local initiativesand capacity to carry out different components of ACSM.TheymaynotnecessarilybefocusedonlyonTB,buthaveex-perienceandknowledgefromworkingandempoweringthecommunities,andhavemoreinsightinsocialandculturalap-proaches.CreatinganenablingenvironmentwherealltheseimportantstakeholderscanparticipatecouldstrengthenthelocalandnationalcapacityforACSM.

TheNTPneeds to take the lead in forminganall inclusivepartnership at national level, where all stakeholders, fromboththehealthsectorandotherrelevantareas,areinvolved.This should include the affected community, CBOs/NGOs,health authorities and providers – both public and private,faith-based organization, media, etc. Membership shouldbe flexible and open for new stakeholders. The NTP doesnot necessarily have to continue to be the leading agencyofthepartnership.Itmightbeoneoftheotherstakeholdersthattakestheresponsibilitytocoordinatethepartnership.IntheabsenceofanationalStopTBPartnership,thiscoalitionmightbetheinitiatingforceforsuchanestablishment.Thereis a need to develop a legal and organizational frameworkin order for national partnerships to function smoothly andeffectively.

This partnership should participate actively in the regularplanningoftheACSMpartoftheNTP’sstrategicandannualworkplan.Thepartnershipwillbeanactivedriving force informingstrategies,definingactivitiesandinimplementation,monitoring and evaluation. Promoting operational researchwouldalsobeanimportanttaskofthepartnershiptoanalyseandevaluateactivities,documentbestpracticesandexplorenewand/ormoreinnovativestrategiesandactivities.


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7.5Learning, adapting and building on good ACSM practices and knowledge exchange

ManygoodACSMpracticeshavealreadybeendeveloped.Some of these are referenced above in the experiences ofMexico, Peru and Viet Nam. These and other experiencessuggest there isacommonfoundation forwhatconstitutesgoodpracticeincommunicationforTBcontrol.TheStopTBPartnership has developed an initial analysis documentingelementsofgoodpracticeinACSMprogramming,whichcanbefoundinAnnex1.

A critical strategy to build national and subnational ACSMcapacityistodocumentandsharegoodpractice.ThereisawealthofgoodcommunicationpracticeonTB,muchofwhich

resides within large international technical organizations.Thisworkplanproposesmechanisms (describedabove) tomake that knowledgeand expertise available to NTPs andothercountry-levelTBcontrolefforts.However,thereisalsoawealthofexperienceandknowledgecreatedandgeneratedfromwithinaffectedcountriesandcommunities,muchof itunknownbeyond thosecountriesandaverysmallnumberofpractitioners.

Mechanisms now exist for collecting, collating and makingavailablesuchexperiencesrelativelyinexpensivelyanddynami-cally.Knowledgeexchangefacilitiesworkwellonotherhealthcommunicationissues,anditisproposedthatsuchafacilitybeestablishedtocapturetheselessonsonTBcontrol.ExamplesareprovidedbytheCommunicationInitiative(www.comminit.com),HealthCommunicationExchangeandHDNet.

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“There are great numbers of unfortunate people who have tuberculosis, and many others who may contract the disease. We must let people know that there is help available. My task is to promote the prevention and treatment of TB. I’ll be like a bullhorn for the respected professionals at the Stop TB Partnership of WHO. Hopefully, the tandem of CHAIF and the Stop TB Partnership of WHO will change people’s lives for the better.”

Vladimir Shakhrin,Lead singer of the Russian rock group CHAIFRussian Federation’s Goodwill Ambassador of the Stop TB PartnershipGlobal Plan launch, Moscow, 27 January 2006

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Monitoring and evaluation (M&E) of this framework will oc-curatseverallevels.Atgloballevel,annualtechnicalreviewswillbecommissioned toanalyse theprogressbeingmadeinnationalACSMcapacitybuildingandthecontributionandcost-effectiveness of ACSM to the Global Plan to Stop TB2006–2015 goals and targets. ACSM Working Group andsubgroup meeting reports will also be used to track thisplan’sprogress.Frequentinternational,regionalandnationalmeetingswillbeheldtodocumentanddisseminateevidencetodate,goodpractices,andlessonslearnt.Regulartechnicaladvisorymissionsprovidedundertechnicalservicecontractswith highly experienced communication partners will offermany opportunities for NTPs to monitor and supervise na-tionalandsubnationalACSMactivities.Country-levelACSMinitiatives will develop their own participatory monitoringand evaluation processes, including appropriate indicatorsandreportingsystems.Finally,existinginformationsystems,methods, indicatorbanks,and techniquesusedwithinandbeyondNTPswillbeadaptedwherenecessarytostrengthenthe monitoring and evaluation of this workplan. Rigorouslyderivedevidenceofcountry-levelACSMcontribution toTBcontrolshouldbegintoaccumulatebytheendof2007.

Annex 3 presents a range of indicator sets and M&E proc-essestobefurtherdevelopedbyindividualcountries.

Monitoring and evaluation

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9.1The Global Fund to Fight AIDS, Tuberculosis and Malaria

TheGFATM,whichwascreatedtofinanceadramaticturna-roundinthefightagainstHIV/AIDS,TBandmalaria,willbeoneoftheprincipalsourcesoffinancingforglobalTBcontrolefforts.Together,thesethreediseaseskillover6millionpeo-pleeachyearand thenumbersaregrowing.The fundwasfoundedonthefollowingsetofprinciples:• Operateasafinancial instrument,notan implementing

entity.• Make available and leverage additional financial

resources.• Supportprogrammesthatreflectnationalownership.• Operate in a balanced manner in terms of different

regions,diseasesandinterventions.• Pursue an integrated and balanced approach to

preventionandtreatment.• Evaluate proposals through independent review

processes.• Establishasimplified,rapidandinnovativegrant-making

process and operate transparently, with accountability(64).

ThepurposeoftheGFATMistoattract,manageanddisburseresources tofightAIDS,TBandmalaria. Itdoesnot imple-mentprogrammesdirectly,relyinginsteadontheknowledgeoflocalexperts.

As a financing mechanism, the GFATM works closely withother multilateral and bilateral organizations involved inhealthanddevelopmentissuestoensurethatnewlyfundedprogrammes are coordinated with existing ones. In manycases,thesepartnersparticipateinlocalcountrycoordinat-ing mechanisms (CCMs), providing important technicalassistanceduringthedevelopmentofproposalsandimple-mentationofprogrammes(65).

TheGFATMiscommittedtorelyingonexistingfinancialman-agement,monitoringandreportingsystems,wherepossible.

TheGFATMapplicationdoesnotmakespecificreferencetoACSMactivitiesnorindicatehowtheyshouldbeincludedaspartofacountryapplication.However,thereareanumberofentrypointsforcountriestoconsiderACSMaspartoftheirapplication.

The Stop TB Partnership Secretariat has produced a fulloutlineoftheACSM/GFATMconceptualframeworkandim-plementationplan,whichillustrateshowanACSMplancouldbedesignedandintegratedintoacountryapplicationforTBcontrol. Inadditiontotheconceptual framework,adetailedlist of examples of activities and indicators have been in-cludedinthisworkplan’sannexestoillustratepossibleACSMinterventions that could be framed to satisfy the reportingrequirementsoftheGFATM.TheCCMsshoulddeterminethebestmixofACSMactivitiesandindicators.

ThisworkplanrecommendsthatcapacitybuildingworkshopsareconductedtoassistCCMsinpreparingGFATMapplica-tionsmodelledonsuccessfulworkshopsalready facilitatedbytheStopTBPartnership.

9.2Other funding sources

WhiletheGFATMisclearlyacriticalactorinfinancingACSMprogrammes, many other donors are also able to play thisrole,andstrategiesneedtobedevelopedtodemonstratetoarangeofdonorsthevalueandimpactofACSMprogram-ming.Thisincludesbothbilateraldonors(suchasUSAIDandDFID)andmultilateralorganizations(suchastheWorldBankandtheAfricanDevelopmentBank).

Links to other development processes

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9.3National policy processes

Development policy and action are becoming increasinglycoordinatedasdonorspendingisfocusedmoreonchannel-lingfundsthroughbudgetsupporttogovernmentswithintheframeworkofnationallyagreedcomprehensivedevelopmentframeworks.Povertyreductionstrategypapers(PRSPs),forexample, originally initiated by the World Bank, have beenthemostwidelyusedoftheseframeworks.Suchframeworksaredesigned tobecountry led,anddevelopmentprioritiesareincreasinglydesignedtobeshapedbyprocessesdrivenfromwithinanddeterminedbycountries.

ForTBingeneral,andTBACSMefforts inparticular, tobeprioritizedinnationalhealthstrategies,bothadvocacyandef-fectiveplanningandengagementinPRSPsandsimilarproc-essesarerequiredatacountryleveltoensurethatnationalhealthplansincludeafocusonTBACSM.

9.4HIV/AIDS

TBasadiseaseisinextricablylinkedwithHIV.Inmanycoun-triescommunityandnationalactionandactivismonTBhavebeeninspiredorrootedinHIV/AIDScivilsocietymovements.HealthstrategiesonTBandHIVareincreasinglyconverging.ThecommunicationchallengesprovidedbyTBarenot thesameasthoseprovidedbyHIV,andthebehaviouralchalleng-es in particular of addressing sexual behaviour and moresposedifferentchallenges to thebehaviouralchallengessetoutinthisworkplan.Nevertheless,agreatdealcanbelearntfrom HIV/AIDS communication strategies, in terms of bothsuccessesandmistakes,and thekey lessonofcommunityinvolvementincommunicationprogrammingappliesstronglytoTBcontrol.Continuedcommunicationandlessonlearningbetweenthesecommunicationcommunitiesandstrategiesiscritical.AllTBACSMstrategiesneedtobedevelopedtakingintoaccountthestronglevelofcoinfectionbetweenthetwoepidemics,particularlybymaximizingACSM-relateddialoguebetweenNTPsandnationalAIDScontrolprogrammes.


“I know how debilitating this disease can be. I contracted TB at the age of 14 and was hospitalized for 20 months. I’m here to witness that TB is a curable and preventable disease. ... Treating patients and saving lives is a moral and ethical imperative. We need you to help, we have a global partnership, a global strategy and a new Global Plan, help us to stop TB!”

Archbishop Desmond Tutu

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10.1Strategic guidance

TheroleofthesubgroupistoprovidestrategicguidanceonregionalandnationalACSMactivities.Itcandothisby:

• Providingstrategicguidanceandframeworksfornationaland regional ACSM strategies, such as those found inthisworkplan,andbyprovidingoversightofinternationaltechnical agreements, progress of key elements ofrecommendationsmadeinthisworkplan,theproductionof key documents (such as an ACSM country-levelhandbook)andotherelementsofstrategicsupport;

• Helpingtoensurethatsufficient,andsufficientlysenior,humanresourcesareavailableatalllevels(internationalandnational) to implementandensuretheprioritizationoftheprogrammesoutlinedinthisworkplan;

• Providing an ongoing forum for discussion andlesson learning on the most effective and appropriatecommunication strategies and methodologies insupportingTBcontrolefforts;

• Commissioning regular technical reviews of ACSMcontribution to the Global Plan to Stop TB 2006–2015goals and targets based on country-level data andreports, including cost-effectiveness research and tooldevelopment;

• Making recommendations to theStopTBPartnership’sCoordinatingBoardandtheScientificTechnicalAdvisory

Group(STAG)onthestrategicdirectionandfinancingofACSMactivities;

• ActingasareferencepointforthewholeTBcommunityonACSMstrategiesandinitiatives;

• HoldingregularmeetingstomonitorprogressandensuretargetsaremetandACSMisdemonstratingitsvaluetomeeting thegoalsand targetssetout inGlobalPlan toStopTB2006–2015;

• Monitoring and understanding broader communicationandmediaprocessesand trends toensure thatACSMstrategies keep pace with rapidly changing media andcommunicationenvironments.

10.2Strategic relationships with other working groups

The ACSM WG will implement this framework in close co-ordinationwith theStopTBPartnership’sotheroperationalworking groups (particularly DOTS Expansion, DOTS-PlusforMDR-TB,TB/HIV),NTPs,academicinstitutions,civilsoci-etygroups,healthsectororganizations,andlocalleadershipatthegrassrootslevel,withtheaimofexpandingaccesstoeffectiveTBtreatmentforpoor,vulnerableandhard-to-reachpopulations.

Relatively fewstructuredmechanismsexist toensurecom-munication, interaction and mutual learning between the

The role of the country-level ACSM subgroupIn 2005, the Advocacy, Communication and Social Mobilization Working Group (ACSM WG) was established

as the seventh working group of the Stop TB Partnership to mobilize political, social and financial resources; to

sustain and expand the global movement to eliminate TB; and to foster the development of more effective ACSM

programming at country level in support of TB control. It succeeded an earlier Partnership Task Force on Advocacy

and Communications.

There are two subgroups within the ACSM WG – one focused on global advocacy, the other on country-level ACSM.

The role of the country-level ACSM subgroup is developing. Some suggestions are outlined below.

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ACSMandotherStopTBworkinggroups. It iscritical thatsuchmechanismsarecreatedandprioritized.ACSMactivi-tiesneedtosupportandbeintegratedintotheplansofotherworking groups, particularly the DOTS Expansion WorkingGroup(DEWG),andthereismuchtolearnfromtheexperi-enceoftheseworkinggroupsintermsofeffectivecommuni-cationapproachestoTBcontrol.

Similarly, other working groups have made important as-sumptions about the work of the ACSM working group,andifACSMactivitiesatthecountrylevelaretomeettheseexpectations and assumptions, consistent and structuredcommunicationwillneedtoexistbetweenthem.

This workplan has sought as much as possible to reflectrelevant country-level priorities of other working groups, butthis isnotacomprehensiveauditofexpectationsfromotherworkinggroupsandsuchanauditisnecessary.Inthecourseof producing this workplan it has been apparent that thereis a lack of clarity over the expected contribution of ACSMactivitiesandofgapsinunderstandingofthemethodologiesthatareproposedtosupportotherworkinggroupstrategies.A more structured and consistent process is required if theACSMWGistobesuccessfulinsupportingtheplansoftheseotherworkinggroups.

ThisframeworkrecommendsthatamutualACSMfocalpointbeappointedineachoftheotherworkinggroupsto:

• Identify how ACSM can contribute to relevant workinggroupstrategies;

• WhatthosegroupscancontributetoACSM;• Fostercommunicationmechanismsacross theworking

groups.

10.3Regional groups

The communication challenges, communication environ-mentsandTBrealitiesareverydifferentindifferentcountriesandregions.AgloballevelsubgroupfocusedonACSMstrat-egiescanreflectthisdiversityonlytoacertaindegree.Thereisanargumenttosuggestthatregional-leveladvisorygroupscouldalsoplayausefulrole.Suchagrouphasalreadybeen

convened in Latin America under the auspices of the PanAmerican Health Organization with support from the StopTBPartnershipSecretariatandfacilitatedbytheAcademyforEducationalDevelopment.Suchgroupscouldprovideanef-fectivemodelforfurtherdevelopmentandforotherregions.Itisalsorecommendedthat,wherestrongdemandexistsfromNTPsandotheractors,aregionalcommunicationcoordina-torbeappointedtocoordinateandactasalessonlearningandorganizationalfocalpointforregionalACSMinteraction.


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Itisnowclearthatcountry-levelACSMisfundamentalifNTPsaretoachieveandmaintainTBcontroltargets.NationalTBcontrolstakeholders,however,willultimatelyneedtodecidewhatleveloffundingforACSMisappropriategiventheuniquecircumstances and the particular status of their TB controlprogrammes.Whateverdecisionsaremade,NTPsneed tosecureor“quarantine”appropriateandsustainablefundsforACSMinadvanceratherthanhavesmallorsporadicamountsoffundingasiscurrentlythenorm.

Thetotalestimatedbudgetforglobaladvocacy,country-levelcommunication and mobilization, capacity building, moni-toringandevaluation, research,andACSMWorkingGrouprequirements is estimated tobeUS$3.2billion for the10-yearperiod.Support forglobaladvocacyequates to6%ofthe total budget. Support for country-level communicationandsocialmobilizationrepresents90%of thetotalbudget.Technical assistance constitutes 1% of the budget, opera-tions research, monitoring and evaluation around 2%, andACSMWGadministrativeandnetworkingrequirementsabout0.6%(Table1).

Itisassumedthatfundingforthecoordinationofglobalandregional strategicplanning, technical assistanceandevalu-ationwill come fromdonations to theStopTBPartnershipSecretariat from bilateral donors. The bulk of funding forcountry-level ACSM activities will come from the GFATMandbilateralsourcesintheshorttermandincreasinglyfromnationalgovernmentallocationsinthelongerterm.PartnersatcountrylevelshouldalsocontributebycommittingrealisticproportionsoftheirbudgetstoACSMactivities.

Atotalof90%oftherequiredfundingisdedicatedtosupport-ing in-country ACSM activities. This percentage representstheequivalentof5–15%oftotal investmentsinTBcontrol inparticularWHOregions.Thispercentagescalehasbeencal-culatedusingtwobenchmarks:• a careful analysis of the best developed proposals

submittedandreviewedbytheGFATM;• extensiveexperienceinotherhealthissuessuggestingthat

anoverall5–15%oftotalNTPsbudgetshouldbeallocatedtocountry-levelACSMactivities.

Annex4examinesthebudget justificationindetail. ItoffersadviceonhowtodetermineACSMbudgetsfromwithinthe5–15%rangeandhowtoallocatebudgetsacrossthestrate-gicmixACSM.

The budget and its justification

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Strategic plan budget (US$ millions)

ALL % 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 YEARS TOTAL Advocacy 10.5 12.5 14.5 17.5 20.5 21.5 23.5 23.5 24.5 25.5 194 6% Donorcountry(66) 1.2 2.4 3.6 5.8 8 9 9 9 9 10 67 Endemiccountry .8 1.6 2.4 3.2 4 4 6 6 7 6 41 Global&regional 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 9 86 Communication & social mobilizationin endemic countries 242 236 249 257 282 295 308 323 337 353 2882 90% AFRO-high 61 63 66 69 74 78 82 86 91 95 767 24% AFRO-low 30 31 32 35 37 39 42 44 46 49 386 12% EEUR 19 20 21 21 22 23 23 24 25 26 224 7% EMR 33 31 32 33 34 36 38 40 42 44 365 11% LAC 10 11 11 12 12 13 13 14 14 15 124 4% SEAR 57 57 59 61 64 67 70 73 76 79 663 21% WPR 30 23 26 26 38 39 41 42 44 45 353 11% ACSM WG & TA needs 11 11 12 14 15 13 13 13 14 14 130 4%

Technical assistance and patient empowerment (67) 2 2 3 4 3 2 2 2 3 3 27 1%

Strategic andtechnical support 0.8 0.8 1.3 1.7 1.4 .9 1.0 1.0 1.0 1.0 11 0%

Capacity building 1.2 1.2 1.9 2.6 2.0 1.4 1.4 1.5 1.5 1.6 16 1%

Monitoring and evaluation 3 3 3 3 4 4 4 4 4 4 37 1%

Impact 0.5 0.5 1.1 1.1 1.1 1.2 1.2 1.2 1.3 1.3 10 0.3%

Planning/ implementation 2 2.1 2.1 2.2 2.3 2.3 2.4 2.5 2.5 2.6 23 0.7%

Financial monitoring 0.2 0.2 0.2 0.2 0.2 0.3 0.5 0.5 0.5 0.5 3.4 0.01%

Operational research and policy development 5 5 5 5 6 5 5 5 4 4 49 2%

Working Group and subgroup operations 1 1 1 2 2 2 2 2 3 3 20 0.6%

TOTALNEEDS 263 260 278 291 318 330 345 360 374 391 3,208


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ANNEXES3

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1.Communication for behavioural change

Perhaps the best known and most widely utilized commu-nicationplanningtoolisthePProcessdevelopedbyJohnsHopkinsUniversityCentreforCommunicationProgramming.TheP Processisaframeworkthatenablestheuserhowtodevelopastrategichealthcommunicationprogramme.ThePProcesslaysoutalogicalframeworkforacommunicationintervention—analysis, strategic design, development andtesting, implementationandmonitoring,andevaluationandre-planning(FigureB).Communityparticipationandcapac-itybuildingareembedded intoeachstepof theprocess. Ithasbeenappliedtoawiderangeofhealthissues.

FigureB:ThenewP-Process,JHUCCP

Ateverystageofthe P Process,therearebasicprinciplesforstrategiccommunicationprogrammes:

• Strategic thinking: Identify communication not aspostersandbrochuresoreventelevisionspotsandradiodramas,butasacontinuous,direct,andmajorinfluenceonbehaviourandpolicy.Mobilizeanddeploythepowerof communication at all levels to promote and supportgoodhealthpractices.

• Leadership support: Buildsupportamongnationalandlocalleaderscontinuously,fromtheinitialassessmenttothesharingofevaluationresults.Enablepolitical,religious,and community leaders to share credit for programmeaccomplishments.

• Audience participation: Encourage your audienceto be actively involved at every stage assessing theirneeds,planningthestrategy,carryingoutlocalactivities,assisting inmonitoringandevaluation,andengaging inadvocacy. Develop key messages around the needs oftheaudienceandthebenefitsfortheaudience.

• Interdisciplinary approach: Work with people fromdifferentdisciplinesandbackgrounds,includingnurses,marketingprofessionals,socialscientists,auxiliaryhealthpersonnel, physicians, pharmacists, epidemiologists,anthropologists, and communication specialiststhroughoutthelifeoftheprogrammetosecurethediverseskillsandtechnicalexpertiseneeded.

• Coordination with service providers: Designcommunication programmes to identify and reinforceservice facilities and to promote access and quality.Encourageandtrainhealth-careproviderstouseorreferto appropriate materials and messages in dealing withclients. Encourage communication experts to highlighttheroleofgoodproviders.

• Public-private partnerships: Buildpartnershipsamonggovernmentagencies,NGOs,andthecommercialsectorto reinforce communication programmes and to sharematerials,messages,training,andotherresources.Learnfromoneanother.

• Multiple channels: Establishaleadagencyandaleadchanneltocarrythemessageandreinforceitwithotherappropriatemass,community,andinterpersonalmedia.

MODELS, APPROACHES AND TOOLKITS FOR TB COMMUNICATION PROGRAMMING

Planning models and approaches

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Use media that reach the intended audiences best toachievethemostcost-effectiveprogramme.

• Enter-educate approaches: Never underestimate thepowerofentertainmenttoreachandpersuadeaudiences,especially young people and those who are not healthprofessionals.Developandadaptentertainingmaterialsformassmediaandcommunitydistribution.

• Training and capacity building: At every step, trainindividualsandbuildinstitutionalcapabilitiestocarryouteffectiveprogrammes.Useeducationalsessionsandon-the-jobtrainingtocreateacriticalmassofcommunicationexperts.

• Monitoring and evaluation: Planforevaluationfromthestarttomeasurechangesintheintendedaudiencesandtoknowwhetherobjectivesareachieved.Monitorprojectoutputs regularly and make necessary adjustments.Sharefindingswidelytoimprovefutureprogrammes.

• Continuity and sustainability: Plan forcontinuity fromthe start with activities that can become sustainableover time. Expand programmes, services, activities,and coalitions as appropriate to build a larger base foradvocacyandcommunitysupport.

• Over 15 years of experience, the P Process has beenrevised to reflect better the needs of the field andimprovementsinknowledge.TherevisedP Processaddsthefollowingnewelementstotheoriginalformulation:o emphasisonnationalcommunicationstrategiesand

positioningofproducts,practices,andservices;o more effective message development using the

Seven Cs of Communication (command attention;Cater to the Heart and Head; Clarify the Message;communicate a benefit; create trust; convey aconsistentmessage;callforaction);

o managementforresults;o buildingapositiveorganizationalclimate;o theory-based impact evaluation with multiple data

sources;o and early planning for resource generation and

sustainability.

2.Communication for behavioural impact (COMBI)

Since2001,theWHOSocialMobilizationandTrainingTeam(SMT) has been applying an approach know as COMBI(Communication-for-Behavioural-Impact) in the design andimplementation of social mobilization and communicationplansfortheadoptionofhealthybehaviours.(68)

COMBI issocial mobilization directed at the task of mobiliz-ing all societal and personal influences on an individual and family to prompt individual and family action (69).Itisaproc-ess which strategically blends a variety of communicationinterventions intended toengage individualsandgroups inconsidering recommended healthy behaviours and to en-couragetheadoptionandmaintenanceofthosebehaviours.COMBIincorporatesthemanylessonsofthepast50yearsofhealtheducationandcommunicationinabehaviour-focused,people-centered strategy. COMBI also draws substan-tially fromtheexperienceof theprivatesector inconsumercommunication.

COMBI is an integrated programme made up of fivecomponents:• Publicrelations/advocacy/administrativemobilization:for

puttingtheparticularhealthybehaviouronthebusinesssector and administrative/programme managementagendaviathemassmedia–newscoverage,talkshows,soap operas, celebrity spokespersons, discussionprogrammes; meetings/discussions with variouscategories of government and community leadership,service providers, administrators, business managers;officialmemoranda;partnershipmeetings.

• Community mobilization: including use of participatoryresearch,groupmeetings,partnershipsessions,schoolactivities,traditionalmedia,music,songanddance,roadshows, community drama, leaflets, posters, pamphlets,videos,homevisits.

• Sustained appropriate advertising and promotion: inm-rip fashion – massive, repetitive, intense, persistent– via radio, television, newspapers and other availablemedia, engaging people in reviewing the merits of therecommended behaviour vis-à-vis “cost” of carrying itout.

A N N E X E S 3

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• Personalselling/interpersonalcommunication/counselling:involvingvolunteers,school,children,socialdevelopmentworkers, other field staff, at the community level, inhomesandparticularlyatservicepoints,withappropriateinformational literature and additional incentives, andallowing for careful listening to people’s concerns andaddressingthem.

• Point-of-servicepromotion:emphasizingeasilyaccessibleandreadilyavailableTBdiagnosisandtreatment.

TheCOMBIapproachassumesaseriesofstepsinhowpeo-plechangetheirbehaviourinresponsetoamessage.First,peopleHearaboutTB,itscauseanditssolution(presentingforasputumtestandtakingthedrugtreatment);then,theybecomeInformedaboutthedisease,itscauseandsolution.Later,theybecomeConvincedthatthesolutionisworthwhileadopting and decide to do something about their convic-tion,andtakeactiononthenewbehaviour.TheythenawaitReconfirmationthattheiractionwasagoodoneandifalliswell,theymaintainthebehaviour(returningforanotherspu-tumtestifthesameTB-likesymptomsappearagain).

TheCOMBIapproachhasalreadybeenpilotedinseveralcoun-tries,includingIndiaandKenya,andareviewhasbeencom-missionedby theStopTBPartnershipSecretariat toassessthe impactand lessons learnedfromthisexperience.AverydetailedexplanationoftheCOMBIprocess,andthethinkingitrestson,hasbeenproducedbytheStopTBPartnership.

3.Communication for social changeThisworkplanhasstressedthroughoutthatthecommunica-tionchallengeintacklingTBisnotsimplyabehaviouralone,itisalsoasocialoneandthatcommunicationstrategiesthatfocuspurelyonachievingnarrowbehaviouraloutcomeshavelittlechanceofsucceeding.

Mass education campaigns aimed at changing individualbehaviourplayanessentialrole,butexperienceshowsthatindividualchangeishardtosustainunlessbroadersocialandcommunity changes also occur. That is, individual behav-iouralchangemustbereinforcedbyshifts inwhatarecon-sidered acceptable beliefs and practices. This can include

suchthingsasculturaltraditions,commonlysharedstories,orhowthecommunitymembersthink,behave,talkandact.Theterm“changes incommunitynorms”areoftenusedtodescribe such shifts. Communication aimed at achievingsocialchangeoftenneedstocomplementandbeintegratedintobehaviouralchangeoutcomes.

Communication for social change (CFSC)isaprocessofpublicandprivatedialoguethroughwhichpeopledefinewhotheyare,whattheyneedandhowtogetwhattheyneedinor-dertoimprovetheirownlives.Itutilizesdialoguethatleadstocollectiveproblemidentification,decision-makingandcom-munity-based implementation of solutions to developmentissues.Itiscommunicationthatsupportsdecision-makingbythosemostaffectedbythedecisionsbeingmade.

CFSC’sfocusisonthedialogue processthroughwhichpeo-pleareabletoremoveobstaclesandbuildstructures-meth-ods tohelp themachieve thegoals theyhaveoutlinedanddefined.Ratherthanfocusingonpersuasionandinformationdissemination,CFSCpromotesdialogue,debateandnego-tiationfromwithincommunities.

CFSCpractitionersusea“bottom-up”approachbyplacingownership, access, and control of communication directlyin thehandsofaffectedcommunities.Thisshiftscontrolofmedia,messages,toolsandcontentofcommunicationfromthepowerful to thetraditionallypowerless.Ultimately,usingsuchskills,previouslypowerlesscommunitiescanbecome“self-renewing”–able tomanagetheirowncommunicationprocessesfortheirowngood.

Similartootherparticipatorycommunicationapproaches,theprocessofCFSCisoftenmoreimportantthantheproducts.CFSCdoesnotattempttoanticipatewhichmedia,messagesor techniquesarebetter.Theparticipation of social actors,whoareinturncommunicators,takesplaceswithinaprocessofcollectivegrowththatprecedesthecreationofmessagesandproductssuchasaradioprogramme,avideodocumen-taryorapamphlet.Messagesandtheirdisseminationarejustadditionalelementsofthecommunicationprocess.

ThedrivingforcesofCFSCcanbesynthesizedasfollows:• ThesocietiesinwhichTBhasthegreatestimpactarechang-

ingrapidly.Thewayinwhichpeoplereceive,interpretand

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actoninformation,thewayinwhichtheycommunicatewitheachother,thewayinwhichtheymaketheirvoicesheardwithintheirowncommunitiesandnationally–allthesehaveundergoneaprofoundtransformationoverthepastdecadeorso.Inmosthigh-burdencountries,themediahasunder-gonearevolution,withformerlymonolithicmediastructures(capableofdisseminatingsimplemessagestomuchofthepopulation)havegivenwaytomuchmorefragmentedmedialandscapes.Radio,oftenthemostimportantsourceofinfor-mationforpoorpeople,hasbeenparticularlytransformed,inbothitsstructureanditscharacter.Peoplelistenmoretotalkshows,phone-ins,conversations,andradioisarguablycatalysingarenewalof theoralcharacterandrichnessofmanydevelopingcountry societies. Informationandcom-munication technologies, although extremely restricted intheirreach,arealsocontributingtoamorehorizontal,noisy,anddiscussion-orientedcommunicationenvironment.Suchanenvironmentmakesthesimpleconveyingofmessagesthroughmassmediamoredifficult(becausetherearemorechannelsandpeoplehaveagreaterchoiceinwhattheypayattentionto)butalsoprovidesimportantnewopportunitiesforhealthcommunicationprogrammes.CFSCprogrammeshaveparticularlysoughttoadaptcommunicationstrategiestothesenewenvironments.

• During several decades the same models, messages,formatsand techniqueswereutilized–andstillare today–indistinctculturalcontexts.Thecommunicationprocesscannotignoreordenythespecificityofeachcultureandlan-guage;rather,itshouldsupportthemtoacquirelegitimacytherebysupporting“cultural renewal”(70).Cultural interac-tion, or the exchanges between languages and cultures,is healthy when it happens within a framework of equityandrespect,throughcriticaldialogue,debateofideasandsolidarity.

• Verticalmodelsofcommunicationfordevelopmenttakeforgrantedthatpoorcommunities indevelopingnationslack“knowledge”(71).Accesstoinformationgeneratedinindus-trialized countries is sometimes seen as a “magic bullet”.CFSCiscautiousofthelinearmodeloftransmissionofinfor-mationfromacentralsendertoanindividualreceiver,andpromotesinsteadacyclicprocessofinteractionsfocusedonsharedknowledgeandcollectiveaction.CFSCstrengthenslocalknowledgeandpromotesexchangesinequalterms,learningthroughdialogue, inaprocessofmutualgrowth.CFSCshouldbeempowering,horizontalversustop-down,

giveavoicetopreviouslyunheardmembersandbebiasedtowardslocalcontentandownership.

In short, CFSC is concerned with culture and tradition,respect towards local knowledge, and dialogue betweendevelopment specialists and communities. CFSC is aboutengagingpeopletowanttochange,todefinethechangeandrequiredactions,andtocarrythemout.ThegoalofCFSCisself-renewingsocieties.

Therearecomparatively fewexamplesofCFSCappliedtoTBcontrol.InBangladesh,theNGOBRACispioneeringanewproc-ess called Participation, Interaction and Mobilization (the PIMProcess). It is aimed at providing a comprehensive approachthat locates social empowerment as the critical engine of be-haviouralchangeandarguesthatsocialempowermentmeansactivecommunityparticipationbycivilsocietiesindiseaseman-agementbyprovidinghelptoformalhealthserviceprovidersaswellascommunityhealthagents.BRACusesShastho shebikas–keyhealthagents-whohaveemergedfromthecommunity.Throughaprocesscatalysedbythesehealthagents,communitymembersparticipateincreating awareness,mobilization,house-holdlevelvisitsandstigmareductionthroughsocial-interaction,disablingstigmagenerationandcreatingasenseofacommongoal.Itdoesnotreplaceanyagencyorapproachbututilizesthemeaningofpartnership.Itisgood,arguesBRAC,formonitoring,socialauditingandmessagesdelivery.Ultimatelytheapproachis aimed at transferring ownership and agency of TB diseasemanagementfromasmallergroupofhealthmanagersatvariouslevelstoincludecivilsocietyasawholeincludingvarioussocialsgroupslikeyouths,householdleaders,women,clubs,religiousgroups,etc.

CFSChasmanysimilaritiesandcomplementaritiestoacom-munityDOTSapproachandisparticularlyappropriatetotack-lingissuesofstigmaandcommunity inclusioninDOTS.AnyCFSCapproachdoesfocusessentiallyonthecommunicationprocess,whetherthroughmediaorataninterpersonallevel.

ManyofthebestexamplesofCFSCpracticearecreatedanddrivenatalocallevel.IthasbeenrecommendedthattheStopTBPartnershiphavea facility for trackinggoodpractice inall formsofcommunicationforsharingamongpractitionersandNTPs.Thisappliesparticularlytohighlightingexamplesatthecommunityaswellasthenationallevelwhichareoftenpoorlydetected.

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1.JHU outcome map to strengthen DOTS

JohnsHopkinsUniversityhasdevelopedan outcome map to strengthen the DOTS strategy to Stop TB (72). Thisisrecommendedasapotentiallyhighlyeffectiveplanningtoolformatchingcommunicationresponsestoprogrammeneeds,andforoutliningkeyplanningandmeasurementindicators.Theoutcomemapretrofitscommunicationinterventionsontothewell-establishedbutmedically-orientedDOTSstrategyforTBcontrol.Themodelincludessuggestedactivitiesandperformance indicators (Figure C). It does not replace orcomplicatetheDOTSstrategy;ratheritenhancesittoincludedemandgenerationforhigh-qualityDOTSservicesandsug-gests strategies for encouraging treatment adherence andcompletion. The model introduces the idea of a “TB-freecommunity,”whichallowsforownershipoftheentirestrategyatthecommunitylevelbycommunitymembersandhealth-careproviders. FigureC:ExtractfromJHUoutcomemapforTBcontrol

Diagnostic and planning tools

Advocacy Gov’tmakesTBcontrolhighpriority

Gov’tprovidesqualityDOTSservices

Monitoring Gov’tensuresadequatedrugsupply

Numberofcasesdrop

longterm

Communication HouseholdslearnaboutTBsymptoms,transmissionandtreatment

Gov’tcommunityhouseholdsteamuptoeliminateTBstigma

Providerscommunityandpeopleteamuptodetectpotentialcasesanddiagnosecorrectly

Providerscommunityandpeopleteamuptoencouragecorrecttreatmentregimen Numberof

TBfreecommunitiesincreasesPeoplewith

symptomsseekhealthcare

Socialmobilization

CommunityworkswithGov’t,householdstoeliminateTBinthecommunity

CommunityallocatesresourcesandnurtrutesappropriateenvironmenttoeliminateTBincommunity

Gov’tcommunityandhouseholdsintegrateintocultureappropriatehealthvaluesandpractices

STOPTB

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2.The cough to cure pathway

Understandingpatients’behavioursisfundamentaltodesigninterventions tostrengthenNTPs, includingcommunicationinterventions.Communication interventionsneedto identifykey challenges to control TB among intended populations.Toassistinidentifyingthesebarriersitisusefultomapthemout along a preferred behavioural continuum from the firstsign of symptoms (cough) to treatment completion (cure).TheAcademy forEducationalDevelopmenthasdevelopedadiagnosticandplanningtool: thecough-to-cure pathway(FigureD).

FigureD:TheCoughtocurepathway(AED)

The pathway is designed to help NTPs identify where TBdrop-outsareoccurring,andforeachstepofthepathwayitliststhemostcommonbarriersattheindividual,groupandsystemslevels.Itoutlinessixstepsandidentifiesthebehav-iouralbarrierstopeopletakingthesestepsateachstage.• First,toseektimelycare;• Second,togoaDOTSfacility;• Third,togetanaccuratediagnosis;• Fourth,tobegintreatment;• Fifth,topersistingettingtreatment;• Sixth,tocompletetreatment.

Baseline studiesneed tobeconducted to identify keybar-riers to completing ideal behaviours. Then, programmesneedtoweightherelevanceofdifferentbarriers inordertoprioritizecoursesofactionandthefocusofcommunicationinterventions.

A N N E X E S 3

Poor knowledge of TB symptoms

Poor knowledge of TB care and cure

Stigma related to TB diagnosis

Low-risk preception

Misperception of cost

Preference for non-DOTS health services

Attitude about health services

Social norms

Poor knowledge of diagnostic steps

Expectations about medical services (get meds not tested)

Poor knowledge of length of treatment

Stigma


Stigma


Stigma

Time cost, distance to DOTS facility

Lack of linkages between DOTS and other providers (non -DOTS & HIV care)

Missed diagnosis and / or lack of referral by non-DOTS providers

Time, cost and distance

Providers’ poor knowledge of correct procedures

Providers’ poor interpersonal communication

Lack of resources, including human resources

Poor quality of services (hours, wait-time)

Time, cost, distance to DOTS facility

Poor quality of services

Health providers fail to give adequate information

Lack of medication




Lack of medication




Lack of medication

SEEKCARE

GO TODOTS

COMPLETEDIAGNOSIS

BEGINTREATMENT

BEGINTREATMENTand follow-upsmears

COMPLETETREATMENTand final smear

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3.Developing positively empowered partnerships

Proposedbythepatientadvocacyorganization“tbtv”,positively empowered partnerships (PEP)areenvisagedasagreementsofmutualtechnicalassistancebetweenorganizationsofpeo-plewithTBand/orHIV,andthehealthprofessionalsseekingto control the diseases. They provide a framework in whichinnovativecollaborationcanflourish,andnewtoolstestedandbroughttobear.Thiscomponent’smainaimsare:• to research and develop new tools to increase case

detection and adherence, and to monitor and evaluatetheimpactofpatientparticipation;

• toprovideastructureforfacilitatingresearchandstudiesofpatientparticipation;

• to develop a leadership training programme of TB“champions”, empowering key patients from thecommunitytotakeresponsibilityforlocalinitiatives;

• toestablishandorganizepatient“clubs”toplayadynamicrole in localTBcontrol,educationandadvocacy/socialmobilization;

• toadvocate,ontheground,forthelocalimplementationoftheInternationalStandardsforTuberculosisCare(ISTC)anditsaccompanyingPatient’sCharterforTuberculosisCare;and

• to turnwords intoactions, implementedontheground,withpositiveresults,evidenced.

Each local PEP initiative would be developed around theleadingactivitiesoftwo“champions”,trainedandequippedtoperformundertermsofreferenceestablishedbythepart-ners.Theywillberesponsibleforsettingupandoverseeingacluboroutreachgroupintheircommunity,andtoliaisewithlocalpartnersandhealthauthorities.Duringtheinitialstage,TBTV.ORGwillprovide therequired legalstructure throughitsnetworkofregisteredstudios,aswellascommunicationssupport(73).

Thismodelhasnotyetbeentestedbut it isenvisagedthatthefirstPEPagreementswillbeimplementedinCameroon,DemocraticRepublicoftheCongo,Côted’IvoireandKenya,supported through localTBTVstudios, registered“in-coun-try”sectionsofTBTV.ORG.Ineachcommunity,aformofa“TBclub”willbeorganizedtotaketheleadinresearchanddevelopment.

4.Stop TB Partnership Secretariat: guidelines for planning ACSM components to the Global Fund proposals

ThenationalTBprogrammeand theCountryCoordinationMechanism(CCM)establishedfortheGFATMaretwoofthecentral strategic planning frameworks for communicationprogramming.Ingoingforwardwithplanningandimplemen-tation,theNTPsandtheCCMoftheGFATMcouldconsiderthefollowingasastep-by-stepguide.

1. Using the CCM, create a specific ACSM committee/task force/partnership charged with the planning,implementation and evaluation of all operational andprogrammaticactivitiesat thenationalandsub-nationallevel. (Disregard step one if such an entity alreadyexists.)

2. Conduct a systematic needs assessment to determinebehavioural goals, target audiences, social-behaviouralbarriers to treatment seeking or treatment adherencebehaviour,identifystakeholdersandavailableresources.Conductanalysisofmediaviewer-ship,listener-shipandreadershiptrendsandhabitsofsegmentedaudiences.

3. Using the results of the needs assessment, developa national strategic communication workplan andbudgetforTBcontrolwherebehaviouralgoals,targetedaudiences and activities are matched with appropriatecoverageandimpactindicators.Indevelopinganationalstrategic communication workplan and budget, effortsshould be made to encourage the establishmentbaseline and change indicators and use of qualitativeand quantitative technical and behavioural data in theplanning, implementation and evaluation of the overallnationalstrategicworkplan.

4. Directthedevelopmentofdistrictand/orprovinciallevelACSM work plans and budgets targeting sustainablebehavioural change. Work-plans must evidence-basedand results driven. Once approved, workplan budgetsshouldbefullyfunded.

5. Secure qualified communication focal point(s) in theNTPatnationalandsub-nationallevelstocoordinateandimplementnational/sub-nationalwork-plans.

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6. Develop,pre-testandproduceIECmaterials.ImplementACSMactivitiesaccordingtoestablishedandapprovednationalandsub-nationalworkplans.

7. ConfirmACSMbenchmarksandbaselinesandincorporateprocessandimpactindicatorsindistrict/provincial/nationalTB reporting formats. Establish tracking mechanisms toreviewprogressonanongoingbasis.

8. Develop and implement a communication capacity/competency-building plan to improve human resourceskillsandinstitutionalcapacity.

5.Stop TB Partnership Secretariat: elements of good ACSM practice

This is an evolving checklist of initiatives that have beenshowntoconstitutegoodpracticeinACSMprogramming.

• Engage NTPs in priority designation. Insofaraspossible,the subgroup will include NTPs as members, and willconsult others in identifying country-level priorities andneeded toolsdevelopment.Thiswill includediscussionregarding communication and social mobilizationprogrammes, as well as NTP advocacy vis-à-vis theprivatesectorandotheractors.

• Conduct multisectoral participatory planning. EngageasmanypertinentdivisionsoftheMinistryofHealthandotherministriesaspossible.ThiswillmobilizesupportinthefightagainstTBandacknowledge the linksamongvulnerability to TB and other illnesses and exclusion.Such planning would also avoid the development ofmessages that may clash with other ACSM initiatives,such as those around HIV/AIDS. NGOs addressingpopulations that are most affected by TB (includingpatient’s organizations) can complement informationgatheredduringassessments,providingneededinsightintosocialmobilizationpossibilitiesandcommunicationactivityappropriatenessaswellascommunitybuy-in.

• Orient the WG as well as country-level ACSM activities towards affected community empowerment. Programmeplanning and implementation should explicitly seekto increase health literacy and efficacy and to buildgovernmental and nongovernmental capacity in high-burdencommunities.

• Forge linkages among the community, state, and national level. Createconnectionsamongnational,state(or provincial) and community-based structures andprogrammestoexpandthescopeofTBcontroleffortsandto create a supportive social and political environment.Wheretheyexist,localhealthcommitteesshouldplayaroleindesigninglocality-specificACSMprogrammes.

• Combat stigma. Developorencouragethedevelopmentof societal-wide initiatives to address misperceptionsand stigma associated with TB and HIV. Including TB-affectedindividualswherefeasiblewouldalsocontributetoaffected/infectedcommunityempowerment.

• Develop clear policy messages. Prototype ACSMmessages,materials,imagesandstrategies–concurrentwithWHO’sTBcontrolpolicies–areessentialtobrand,market, and align global, national and local ACSMactivities.Forexample,theestablishmentofa“universalstandard for TB care” for public and private serviceproviders could facilitate commitment to improving thequalityofTBservices.Aimingfor“TB-freecommunities”couldmobilizecommunityinvolvementandcommitmenttoeradicatingTB.

• Utilize the influence of media. Themediaarecritical forfacilitating policy dialogue, debate and mobilization,and there has been a significant correlation betweenmediavisibilityand increased funding for thecontrolofinfectiousdiseases.Themediacanbeapowerfulpartnerin country level ACSM activities, as well as in fosteringglobalunderstandingoftheefficacyofACSMinfightingTB.

• Establish national TB partnerships. National TBpartnerships can provide the basis for building largerTBACSMcoalitionsand,inendemiccountries,improvecoordination of communication efforts designed toinfluencehealth-seekingbehaviour,buildhealthliteracy,andencourageclient-centeredcare.

• Engage TB patients and representatives from high-burden communities. Inclusion is intrinsically important,asitrecognizesthemoralimperativeofincludingpeoplewhoareaffected/infected.Moreover,itwilllikelyincreasethe feasibility andappropriateness ofplannedactivitiesandcontribute to thedevelopmentofhealthefficacy incommunitiesthatareparticularlyvulnerabletoillhealth.

• Foster parliamentarian or congressional champions. Organizingmissionsforelectedofficialstowitnessfirst-

A N N E X E S 3

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handglobalTBcontroleffortssignificantlyincreasestheir(andinturn,political)engagementandcommitment.

• Mainstream TB into larger health and development initiatives.The WG as well as country-level actors can increasesupportforcountry-levelACSM(aswellasforTBcontroloverall) by working to include TB in larger developmentinitiatives.InclusionofTBalsoprovidesleverageforNTPswishingtoillustratetheimportanceofTBcontroltooveralldevelopment.Finally,includingTBintheseplansfacilitatescooperation among actors addressing various elementsofhealthstatusandoveralldevelopment.Relevantlargerdevelopmentinitiativesinclude,amongothers,theMDGsand National Millennium Campaigns, PRSPs, future G8Summits, UNGASS, and the WHO Commission on theSocial Determinants of Health which will analyse andadvocateonthe“causesbehindthecausesofillhealth”.

• Develop ACSM guidelines and handbooks. These arelikely to include assessment and problem definitiontools, allowing NTPs and others to identify goals anddefinegapsinpoliticalcommitmentandcommunicationandsocialmobilizationopportunities.Materialswillalsoincludeconcretecountryexperiencesandtoolsrelatingtocommunicationprogramming,communityinvolvementin health, ACSM human resource development, patientinvolvement, strategic planning, operational research,monitoringandevaluationandothers.

• Invest in research and development. Commissionedstudies and operational research are needed todocumentgoodpracticesandconstantlyimproveACSMmethodology,particularlyatcountrylevel.ThiswillbuildglobalsupportforthenecessityofACSM,andwill

• Create a technical assistance framework. Develop atechnicalassistance frameworkamongACSMWorkingGroupmemberstoassistcountrieswithACSMplanning,activitiesandevaluation.

• Enhance web and electronic information sharing. Thisincludes increasing information exchange, discussionandtransparency;coordinatingtheparticipationofnewandexistingpartners;facilitatinglong-distancelearning;andencouragingcross-fertilizationofideas.

6.Other tools

ThereareawealthofothertoolsavailabletoACSMprogram-mersonTB.Country-leveladvocacytoolssuchastheAED’sPROFILESandtheAIDSImpactModel(AIM)fromthePOLICYprojectoftheFuturesGroupcouldbeadaptedforTB(74-75).There are several state-of-the-art information databases onACSM including The communication initiative’s anthologyof health communication materials and the communicationfor social changeconsortium’sbodyofknowledge.Amoredetailedandcomprehensivelistofresourcesiscontainedinannex2.

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Therefollowsalistofresourcesthatmayberelevanttocom-municationplannersandNTPprogrammemanagers.Fewofthesehavebeendesignedexplicitly forTBcommunication,but all are potentially relevant or helpful in compiling a TBcommunicationstrategy.Theyarereproducedheretogiveanimpressionofthewealthofmaterialsandresourcesthatareavailablebeyondthosealreadyhighlightedinthisworkplan.

Most of these have been compiled by the World AIDSCampaign 2005 and our thanks goes to the campaign forallowing us to reproduce them, and to the CommunicationInitiative where much of the research in compiling this listwascarriedout.AdditionalTB-specificresourceshavebeencompiled by Thaddeus Pennas and James Deane. ThesematerialsareavailableontheStopTBwebsiteat:

A N N E X E S 32

Communication materials and resources

www.stoptb.org/wg/advocacy_communication/sgcountrycommunication.asp

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STB advocacy and communication assessment checklist (W.Parks)

ACSM lessons learnt – Powerpoint:50yearsofdevelopmentcommunication (S.Waisbord)– Guidefortreatmentsupporters(WHO)– Familytreeofdevelopmentcommunicationstheories (S.Waisbord)– Theimpactofmedia-basedhealtheducation

ontbdiagnosis(E.Jaramillo)– Publiccommunicationcampaignevaluation(part1-4)

ACSM needs assessment checklist(StopTBPartnershipSecretariat--T.Pennas)

AED’s cough-to-cure pathway (S.Waisbord)

Cancun presentations– Powerpointpresentations(variouspresenters)– Finalreport(S.Sarkars)

COMBI for TB – ProjectoutlineKenya(H.Everold)– ProjectoutlineKerala,India(H.Everold)– COMBITBhandbook(W.Parkset.al.)

Communication indicators– Compendiumofindicatorsformonitoringand

evaluationforTBcontrolprogrammes(WHO)– Developingindicatorsforsocialmobilization

forTBcontrol(W.Parks)– Monitoringandevaluationtoolkitforgfatmapplications

Community-based TB care– CommunitybasedTBcare(WHO)

GFATM-ACSM project(CairoWorkshop)– Framework(T.Pennas)– Bangladesh(GFATMproposal)– CCP/JHU–ACSMTBoutcomesmaps(CairoWorkshop)– Finalreport(CCP-JHU)– GFATMworkshopforWHOtechnical

consultants(January2005)– PowerpointslidesformCairoACSM

consultantsworkshop(variousauthors)

JHU case studies– PeruACSMcasestudies– SummaryreportofPeruandVietNamcasestudies– VietNamACSMcasestudy

Stop TB Partnership Secretariat strategic communication initiative– Strategiccommunicationinitiative(T.Pennas)– Operationalworkplan(T.Pennas)– StrategiccommunicationinitiativeforTByear1 (T.Pennas)

Training workshops – AMROWorkshop(June05) (M.Luhan/T.Pennas/S.Waisbord)– Introductiontoadvocacy,communication,social

mobilizationworkshop(P.Heitkamp/T.Pennas)– EUROMoscow(February05) (M.BerdyM.Luhan/T.Pennas)– Kenyaneedsassessmenttrainingworkshop (September2004) Trainingworkshop(T.Pennas)– StopTBPartnershiptrainingworkshops(Syllabionly) Needsassessment(T.Pennas/P.Heitkamp) IntroductiontoACSM(P.Heitkamp/T.Pennas)

STOP TB PARTNERSHIP SECRETARIAT LIST OF ACSM DOCUMENTS,PRODUCTS AND TOOLS

2

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Communication programme planning worksheetisaformatthatsystematicallybreaksdownaprobableprojectintosub-componentssuchasidentificationofpartners, identificationofproblem,targetaudience,secondarytargetaudience,com-municationgoalsandobjectives,communicationchannels,evaluation,etc.ThisapproachwasdevelopedbyUNICEF.http://www.comminit.com/planningmodels/pmodels/planningmodels-22.html

Community driven development (CDD) principlesisasetofprinciplestoempowerpeople,entrustresponsibilityanddeci-sion-making in theirhands,andmake institutionsmoreaccountable to them.Thisapproachwasdevelopedby theWorldBank.http://www.comminit.com/planningmodels/pmodels/planningmodels-10�.html

EvaluLEAD framework is an approach to design and understand evaluation of leadership development programmes. Itstressesonflexibilityinevaluationdesignwhilelistingtwobroadtypesofevaluationapproaches,threelevelsofeffectsoflead-ershipdevelopmentinterventionoutcomesandsixdomainsofoutcomeelements.ThisapproachwasdevelopedbyPLP.http://www.popldr.org/pr/nlpdf/evaluleadframeworkweb.pdf

Future searchisanapproachthatbringsdiversepeopleinacommunitytogethertoreflectontheirpast,presentandfuture,toexpresstheirfearsandopinions,toascertaintheircommonneedsandtoformulateapathofaction.ThisapproachwasdevelopedbyFutureSearch.http://www.futuresearch.net/index.cfm

Involving local individuals and groups is a listof steps to involve local communitiesand individuals inprojectsandac-tivities.Thiscouldhelpabetterunderstandingoftheneedsofacommunityandassistingarneringthesupportofthelocalcommunity.http://erc.msh.org/mainpage.cfm?file=�.�.10.htm&module=health&language=English

Planning together: how (and how not) to engage stakeholdersisatoolthatlaysdownscenariosandcaveats(intheformamatrix)tohelpensurethatparticipationismeaningful,thatitmakesproceedingsdemocraticinsteadofbecomingatoolforthepowerful.http://www.community-problem-solving.net/CMS/viewPage.cfm?pageId=�00

Population leadership programme (PLP) leadership frameworkwasdesigned forglobalhealthprogrammesofUSAIDanddrawsontheories in transformational leadershiptoarriveatmeaningsof leadership,desirablesof leadership,andtheexpectationsofleadership.http://www.popldr.org/leadership/frame1.pdf

A guide to fundraisingisalistofstepstohelpsmallorganisationsraisefundsfortheiractivities.ItisbasedonthefundraisingmodeldevelopedbyErnieHayes.ThisguideisaproductofworkdonebyNetworkLearning.http://www.networklearning.org/books/fundraising.html

Community problem solving networkisanarenathatgivespeopleandinstitutionsaplatformtofacilitateworkonawidearrayofdevelopmentalandsocialissues.Itoffersstrategytools,programmetoolsandacommunitytointeractwith. http://www.community-problem-solving.net/cms/

INITIAL PLANNING RESOURCES

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CDCynergy, a multimedia CD-ROM used for planning, managing, and evaluating public health communication programmes, does not regard communication alone as the panacea to public health but places it in the larger context of issues, possible strategic options to choose from and a comprehensive plan to implement an identified strategy. Developed by CDC, it could benefit public health professionals.http://www.cdc.gov/communication/opportunities/opps_training.htm

COASTisamodelofcommunicationthatlaysgreatstressondialogueamongstakeholders,brainstormingtoidentifyalter-natives,mutualgoalandstandardssettingandthroughall thisbuildingof trustamongdiversestakeholders.ThistoolwasdevelopedbyRatzen,Payne,andMassett.http://www.comminit.com/planningmodels/pmodels/planningmodels-1�.html

COAST: a visual modelisanillustrateddiagramthatdepictsthelinkagesamongcommunication,identificationofoptions,dia-loguebetweenstakeholders,participatorygoalsettingandbuildingoftrust.ItwaspresentedbyScottRatzentotheCHANGEminiforum.http://www.comminit.com/planningmodels/pmodels/planningmodels-1�.html

Diffusion of innovationsisatheorythatattemptstoexplainwhyandhowsomeinnovations/newideasspreadandgetac-ceptedwhileothersdon’t.Itlaysdownsomeguidingprinciplesforchangeagentstobearinmind.ThistheorywasadaptedanddetailedbyEverettM.Rogers.http://www.med.usf.edu/~kmbrown/Diffusion_of_Innovations_Overview.htm

Eleven deadliest sins of knowledge managementisalistofpitfallsthatcanmakeknowledgeredundantorevencounter-productive.EnumeratedbyRYZEBusinessNetworking,thistoolcouldbenefitallthoseinvolvedinmanagingandtransmit-ting/managingknowledge/informationforchange.http://www.ryze.com/postdisplay.php?confid=��&messageid=��

Health campaigns: stages in planningisanillustrateddiagramdepictingvariousstagesofplanningandconductingahealthcampaign.ItwasdevelopedattheNationalCancerInstitute,USA.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

MARch approach to key features of successful behavioural interventionsdetailsthecomponentsofasuccessfulstrategytobringaboutbehaviouralchange.Itcouldthusbeaveryusefultoolfordesigningcommunicationorotherstrategiesaimedatbehaviouralchange.ItwasdevelopedbyGalavottietal.http://www.ajph.org/cgi/content/abstract/�1/10/1�0�

Population leadership programme (PLP) leadership frameworkwasdesigned forglobalhealthprogrammesofUSAIDanddrawsontheories in transformational leadershiptoarriveatmeaningsof leadership,desirablesof leadership,andtheexpectationsofleadership.http://www.popldr.org/leadership/frame1.pdf

Project HOPE - seven steps for planning a community initiativeisastep-by-stepguidetoidentifyproblemsbesettingacommunityandbuildingthecapacityofthecommunitytodesignandlaunchaninitiative.http://www.comminit.com/planningmodels/pmodels/planningmodels-�1.html

Annex 2RESOURCES FOR INITIAL ORGANIZATION

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Strategic planning (Veenema)isatooltoenableorganizationstodefinetheiraims,settheirgoals,implementplanningasatoolfororganizationalchange,etc.Inotherwordsitcouldbeusedasatoolforintrospectionbyandreorientationofanorganization.ItwasdevelopedbyPearlVeenema,ManagingDirectorofCampaignsUniversityHealthNetwork.http://www.canadianfundraiser.com/newsletter/article.asp?ArticleID=1�0�

Techniques and practices for local responses to HIV/AIDS: a UNAIDS toolkit isasetof toolsdevelopedbytheRoyalTropicalInstitute(KIT)tohelpactorsinvolvedwithHIV/AIDStolearnfromexperiencesaroundtheworld.Itprovidesahostofexamplesthatcouldbeadaptedtosuit localneedsasalsostepsfordocumentingexperiences, techniquesandmodusoperandi.http://www.kit.nl/frameset.asp?/development/html/publications_db.asp&frnr=1&ItemID=1��

Renewing our voice: code of good practice for NGOs responding to HIV/AIDSisadocumentthatlistsanumberofissuesthatorganizationsworking in theareaofHIV/AIDSshouldkeep in focussuchasprotectingandpromotinghuman rights,andapplyingpublichealthprinciplesinNGOwork.ThisdocumentwasPublishedbyTheNGOHIV/AIDSCodeofPracticeProjecthttp://www.ifrc.org/cgi/pdf_pubs.pl?health/hivaids/NGOCode.pdf

NGO capacity analysis: a toolkit for assessing and building capacities for high quality responses to HIV/AIDS,atoolkitfromHIV/AIDSAllianceaimstohelpfundingandtechnicalsupportorganizationstodevelopcapacitiesandreachofimple-mentingorganizations.http://synkronweb.aidsalliance.org/graphics/secretariat/publications/cat0�0�_Capacity_analysis_toolkit_eng.pdf

A N N E X E S 3

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CHANGE strategic approachemphasizestheneedtounderstandanissueanditscoreneeds,juxtaposethesetoavailableknowledge,toolsandmodelsofbehaviourchangetoarriveatnewtoolstobeimplementedinthefield.ItwasdevelopedbyAcademyforEducationalDevelopment.http://www.changeproject.org/

COASTisamodelofcommunicationthatlaysgreatstressondialogueamongstakeholders,brainstormingtoidentifyalterna-tives,mutualgoalandstandardssettingandthroughallthisbuildingoftrustamongdiversestakeholders.ItwasdevelopedbyRatzen,Payne,andMassett.http://www.comminit.com/planningmodels/pmodels/planningmodels-1�.html

COAST: a visual model isanillustrateddiagramthatdepictsthelinkagesamongcommunication,identificationofoptions,dia-loguebetweenstakeholders,participatorygoalsettingandbuildingoftrust.ItwaspresentedbyScottRatzentotheCHANGEminiforum.http://www.comminit.com/planningmodels/pmodels/planningmodels-1�.html

HIV/AIDS continuum of careisanillustrateddiagramdepictingthelinkagesbetweenandsynergiesthatcouldbedrawnfromdifferentlevelsandtypesofagenciesstartingfromindividualandpeergroupsandgoinguptospecializedtertiaryhealthcare.ThisisdocumentedbyWHO/UNAIDS.url:http://www.unaids.org/publications/documents/care/general/WHOUNAIDSCARE.doc


Strategic planning (Veenema)isatooltoenableorganizationstodefinetheiraims,settheirgoals,implementplanningasa tool fororganizationalchange,etc. Inotherwords itcouldbeusedasa tool for introspectionbyandreorientationofanorganization.ItwasdevelopedbyPearlVeenema,ManagingDirectorofCampaignsUniversityHealthNetwork. http://www.canadianfundraiser.com/newsletter/article.asp?ArticleID=1�0�

NGO capacity analysis: a toolkit for assessing and building capacities for high quality responses to HIV/AIDS,atoolkitfromHIV/AIDSAllianceaimstohelpfundingandtechnicalsupportorganizationstodevelopcapacitiesandreachofimple-mentingorganizations.http://synkronweb.aidsalliance.org/graphics/secretariat/publications/cat0�0�_Capacity_analysis_toolkit_eng.pdf

Annex 2RESOURCES ON MAPPING

2

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The “A Frame” for advocacygivesastepbystepguidetoadvocacyapproaches.Thisisforcivilsocietyactorsandhealthplan-nerstousewhenplanningadvocacycampaigns.ItwasdevelopedbyJohnsHopkinsUniversityinpartnershipwithUSAID.http://www.infoforhealth.org/pr/advocacy/index.shtml


Health promotion: Ottawa charter,throughanillustrateddiagramshowstheinterlinkagesbetweenpersonal,communal,andgovernmentalactiontoensureahealthylifeforindividuals.ThistoolissourcedfromtheCanadianPublicHealthassociation.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

Planning together: how (and how not) to engage stakeholdersisatoolthatlaysdownscenariosandcaveats(intheformamatrix)tohelpensurethatparticipationismeaningful,thatitmakesproceedingsdemocraticinsteadofbecomingatoolforthepowerful.ItwasdevelopedbyCommunityProblemSolving.http://www.community-problem-olving.net/CMS/viewPage.cfm?pageId=�00

Project HOPE - seven steps for planning a community initiativeisastepbystepguidetoidentifyproblemsbesettingacommunityandbuildingthecapacityofthecommunitytodesignandlaunchaninitiative.http://www.comminit.com/planningmodels/pmodels/planningmodels-�1.html

Campaigning toolkit for civil society organizations engaged in the Millennium Development GoalsisaCIVICUSmanualthataimstohelpcivilsocietyorganizationsinvolvedwiththeMillenniumDevelopmentGoals(MDGs)andprovidesthemwithaframeworktoplanacampaignstrategy.IttouchesonMDGs,frameworkforplanningacampaign,toolkitforacampaignandlinkstosupportorganizations.http://www.civicus.org/mdg/title.htm

Civil society planning toolkits,developedbyCIVICUS,isasetoftoolsaimedathelpingorganizationswithavarietyofissues,starting from writing skills and going on to developing media, handling media, planning, evaluation, financial control andbudgeting. http://www.civicus.org/new/civicus_toolkit_project.asp

Involving the community: a guide to participatory development communication,abookfromIDRCaimstoinstructre-searchersandpractitionersinwaystodesignparticipatorydevelopmentcommunicationandwaystoinvolvecommunities. http://web.idrc.ca/en/ev-��-�01-1-DO_TOPIC.html

AIDS toolkits: HIV/AIDS and community based natural resource management,developedbyDevelopmentAlternativesIncandUniversityofNatal isaimedatministries involvedwithNaturalResourcesManagement. It throws lightonhowtheministryanditsworkareaffectedbyHIV/AIDSandhelpsidentifyresponses.http://www.cbnrm.net/pdf/dai_001_aidstoolkit_v�.pdf

A N N E X E S 3

Annex 2RESOURCES FOR PARTICIPATORY PLANNING AND CONCEPTUALIZATION

�0


BEHAVE frameworkisabehaviouralframeworktoolforplannerstoachievemaximumeffectiveness.Itemphasizestheneedtoplaceaudienceatthecentreandacttomaximizethebenefitsaccruingtoaudiencefromanactivityandminimizebarrierstoaudienceacceptance.ItwasdevelopedbyAcademyforEducationalDevelopment,thistoolcouldbeusedbyplannersandprojectmanagers.http://www.childsurvival.com/documents/workshops/BEHAVE!/BEHAVE1.cfm


Involving local individuals and groupsisalistofstepstoinvolvelocalcommunitiesandindividualsinprojectsandactivities.Thiscouldhelpabetterunderstandingoftheneedsofacommunityandassistingarneringthesupportofthelocalcommunity.ThistoolwasdevelopedbyManagementServiceforHealth.http://erc.msh.org/mainpage.cfm?file=�.�.10.htm&module=health&language=English

Isang Bagsak: planning participatory development communicationlaysstressoncommunityinvolvement,fromthestageofinception,inaproject.Itemphasizestheneedtobuildthecapacityofcommunitywhileimplementingaproject/activity.Itpresentsaschematicdiagram,depictingstagesingettinginvolvedwithacommunityandimplementingaproject.http://www.isangbagsak.org/pages/intro.html

Participatory change: 10 steps in supporting grassroots rural development isalistoftenstepstoensuregreaterandmoremeaningfulparticipationoflocalcommunitiesindesigningandbringingaboutsocialchange.Thisapproachcombinesdevelopmentsinthefieldsofcommunityorganization,populareducationandparticipatorydevelopment.ItwasdevelopedbyCentreforParticipatoryChange.http://www.cpcwnc.org/

Planning together: how (and how not) to engage stakeholdersisatoolthatlaysdownscenariosandcaveats(intheformamatrix)tohelpensurethatparticipationismeaningful,thatitmakesproceedingsdemocraticinsteadofbecomingatoolforthepowerful.ItwasdevelopedbyCommunityProblemSolving.http://www.community-problem-olving.net/CMS/viewPage.cfm?pageId=�00


Soul city - developing partnershipsisaschematicdiagramthatstressestheneedforpeoplemanagingedutainmentprojects/programmestodevelopnetworkswithdifferentstakeholdersandresourcessourcestomakeedutainmentprogrammesmoreeffective.Centraltotheconceptistheassumptionthatpeoplemanagingtheprojectsareintouchwithtargetcommunitiesandthereforeunderstandtheneedsofthecommunitywell.ThistoolhasbeendevelopedbySoulCity.http://www.soulcity.org.za/

Annex 2RESOURCES ON HOW TO INVOLVE PARTNERS

2

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Supporting community engagement in antiretroviral treatment: a participatory toolisatoolthatintroducesgrassrootsorganizationstoHIV/AIDSandantiretroviral(ARV)treatment.ItisaimedtoprovidesuchorganizationswithtoolsandskillsthatwouldenablethemtohelpHIV/AIDSpatientsandtheircommunitiesbyoutliningthetreatmentoptionsavailabletopatients,amongotherthings.ThistoolhasbeendevelopedbyInternationalHIV/AIDSAlliance.http://synkronweb.aidsalliance.org/graphics/secretariat/publications/FS01.doc


Community problem solving networkisanarenathatgivespeopleandinstitutionsaplatformtofacilitateworkonawidearrayofdevelopmentalandsocialissues.Itoffersstrategytools,programmetoolsandacommunitytointeractwith.http://www.community-problem-solving.net/cms/


A N N E X E S 3

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AED’s process for building a communications capacityisadetailedflowchartthatenumeratesstepstomatchgoalsandobjectivesofanorganizationwithitsexternalandinternalenvironment,withtheaimtobuildcommunicationscapacity.ItwasdevelopedbyAcademyforEducationDevelopment.http://www.comminit.com/planningmodels/pmodels/planningmodels-�.html

Audience participation based message design emphasizes the need to assess the topic of campaign and lifestyle ofaudience(s)indetailtochoosethemediumofcommunication.Itlaysdownstepstosetgoalsandmeasureimpactforfutureuse.ItfeaturedinDevelopmentCommunicationReport79.http://www.comminit.com/planningmodels/pmodels/planningmodels-10.html

BEHAVE frameworkisabehaviouralframeworktoolforplannerstoachievemaximumeffectiveness.Itemphasizestheneedtoplaceaudienceatthecentreandacttomaximizethebenefitsaccruingtoaudiencefromanactivityandminimizebarrierstoaudienceacceptance.ItwasdevelopedbyAcademyforEducationalDevelopment.http://www.childsurvival.com/documents/workshops/BEHAVE!/BEHAVE1.cfm


COAST: a visual modelisanillustrateddiagramthatdepictsthelinkagesamongcommunication,identificationofoptions,dia-loguebetweenstakeholders,participatorygoalsettingandbuildingoftrust.ItwaspresentedbyScottRatzentotheCHANGEminiforum.http://www.comminit.com/planningmodels/pmodels/planningmodels-1�.html

COMBI design process (CDP) isaseriesofstepstodesignCOMBI,astrategyforsocialmobilizationthataimstogarnerallpersonalandsocietalinfluencesonindividualsandfamiliestoencouragethemtoadopthealthybehaviourandmaintainit.COMBIdrawsonpeoplecenteredapproachesinthefieldsofhealtheducationandcommunicationthataimatchangingbehavioursofpeople.http://www.comminit.com/pdf/Combi�-pager_Nov_1�.pdf

Community action in the health field: a general framework by the European Unionisasetofreflectionsonthepurposeofaid,theobjectivesofaid,andthegoalsandprioritiesofaid.Thoughpreparedforbilateralaid,itcouldbebuiltuponandadaptedtomicrolevel.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

Community driven development (CDD) principlesisasetofprinciplestoempowerpeople,entrustresponsibilityanddeci-sion-makingintheirhands,andmakeinstitutionsmoreaccountabletothem.ItwasdevelopedbytheWorldBank.http://www.comminit.com/planningmodels/pmodels/planningmodels-10�.html

Future searchisanapproachthatbringsdiversepeopleinacommunitytogethertoreflectontheirpast,presentandfuture,toexpresstheirfearsandopinions,toascertaintheircommonneedsandtoformulateapathofaction.ThisapproachwasdevelopedbyFutureSearchandcouldbeofhelptosocialworkersandhealthworkers. http://www.futuresearch.net/index.cfm

Annex 2RESOURCES FOR SELECTING OBJECTIVES

2

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Soul City - developing partnershipsisaschematicdiagramthatstressestheneedforpeoplemanagingedutainmentprojects/programmestodevelopnetworkswithdifferentstakeholdersandresourcessourcestomakeedutainmentprogrammesmoreeffective.Centraltotheconceptistheassumptionthatpeoplemanagingtheprojectsareintouchwithtargetcommunitiesandthereforeunderstandtheneedsofthecommunitywell.ThistoolhasbeendevelopedbySoulCity.http://www.soulcity.org.za/

Strategic planning (Veenema)isatooltoenableorganizationstodefinetheiraims,settheirgoals,implementplanningasa tool fororganizationalchange,etc. Inotherwords itcouldbeusedasa tool for introspectionbyandreorientationofanorganization.ItwasdevelopedbyPearlVeenema,ManagingDirectorofCampaignsUniversityHealthNetworkhttp://www.canadianfundraiser.com/newsletter/article.asp?ArticleID=1�0�

Community problem solving networkisanarenathatgivespeopleandinstitutionsaplatformtofacilitateworkonawidearrayofdevelopmentalandsocialissues.Itoffersstrategytools,programmetoolsandacommunitytointeractwith.http://www.community-problem-solving.net/cms/

A N N E X E S 3

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AED’s process for building a communications capacityisadetailedflowchartthatenumeratesstepstomatchgoalsandobjectivesofanorganizationwithitsexternalandinternalenvironment,withtheaimtobuildcommunicationscapacity.ItwasdevelopedbyAcademyforEducationDevelopment.http://www.comminit.com/planningmodels/pmodels/planningmodels-�.html

Agents for changeisanarticleoncommunicationstrategiesandmodelsadoptedbyThompsonsocial,acommunicationsgroupinIndia,tobringaboutsocialchange.ItwaswrittenbyKunalSinha.http://www.comminit.com/planningmodels/st�00�/thinking-��.html

Audience participation based message design emphasizes the need to assess the topic of campaign and lifestyle ofaudience(s)indetailtochoosethemediumofcommunication.Itlaysdownstepstosetgoalsandmeasureimpactforfutureuse.ItfeaturedinDevelopmentCommunicationReport79.http://www.comminit.com/planningmodels/pmodels/planningmodels-10.html


CDC’s health communication wheel issimilartoAudienceParticipationBasedMessageDesign.Itisastep-by-stepguidetodesign,launchandmonitorcommunicationstrategies.ItwasdevelopedbyCentreforDiseaseControl,Atlanta.http://www.comminit.com/planningmodels/pmodels/planningmodels-1�.html

CDCynergy,amultimediaCD-ROMusedforplanning,managing,andevaluatingpublichealthcommunicationprogrammes,doesnotregardcommunicationaloneasthepanaceatopublichealthbutplacesitinthelargercontextofissues,possiblestrategicoptionstochoosefromandacomprehensiveplantoimplementanidentifiedstrategy.ItwasdevelopedbyCDC.http://www.cdc.gov/communication/opportunities/opps_training.htm

Communication programme planning worksheetisaformatthatsystematicallybreaksdownaprobableprojectintosub-componentssuchasidentificationofpartners, identificationofproblem,targetaudience,secondarytargetaudience,com-municationgoalsandobjectives,communicationchannels,evaluation,etc.ItwasdevelopedbyUNICEF.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

Consumer based health communicationisacommunicationmodelthatbringstogetherresearchinthefieldsofhealthandconsumerbehaviourtoformulateacommunicationstrategytobringaboutdesiredbehaviouralchange.ItfeaturedinPublicHealthReports,Nov/Dec1995,Vol.110.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

Designing communication strategies: guiding principlesis,asthenamesuggests,guidelineforeffectivecommunication.It laysstressonadaptingcommunicationstrategyto localneedsandincorporatinglocalcontentwhereverpossible. ItwaselaborateduponbyRicardoRamirez,TheInternationalSupportGroup.http://www.comminit.com/majordomo/faocomm/msg000��.html

Health campaigns: stages in planningisanillustrateddiagramdepictingvariousstagesofplanningandconductingahealthcampaign.ItwasdevelopedattheNationalCancerInstitute,USA.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

Annex 2RESOURCES FOR DEVELOPING A COMMUNICATION STRATEGY

2

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Health communication: 12 generalizations about organizational factorsisalistoffactorsthatcouldhaveabearingonthesuccessorfailureofahealthcommunicationcampaign.Itpertainstotheorganizationresponsibleforthecampaign.ThelistisbyBackerandRogers.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

Health communication strategiesisalistofbroadcategoriesofstrategiesthatcouldbeadoptedtobringaboutbehaviouralandsocialchange.DevelopedbyScottRatzan,itcouldbehandyforplanners,media,andcivilsociety.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

JHU/CCP’s communication strategy outlineisaschematicdiagramfordesigningacommunicationstrategy.Itoutlinesfourimportantaspectsandpresentsastep-by-stepguideforeachoftheseaspectsofcommunicationstrategy.ItwasdevelopedbyJohnsHopkinsBloombergSchoolofPublicHealth/CentreforCommunicationProgrammes.http://www.jhuccp.org/pubs/fg/0�/0�.pdf

Seven C’s of effective communicationisalistoffeaturesthatmakeacommunicationeffectiveandtothatextentshouldbeincorporatedinanycommunicationstrategy.ItwasdevelopedbyJHU/CCP/PCS.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

Social Marketing - A 7-step approachisatoolthatattemptstodispelthenotionthateducation/awarenessalonecanleadtobehaviouralchange.Itthenlistsasetofconditions(eachexpressedasbarriertochange)whosesequentialfulfillmentcouldbringaboutbehaviouralchange.Italsostressestheneedtoresearchintobarrierstochangeandgivespointersinthatdirec-tion.ItwasdevelopedbySocialChangeMedia.http://www.socialchange.net.au/

Social marketing -implementingisastep-by-stepguidetoimplementingasuccessfulsocialmarketingstrategy.Itlaysstressondetailedresearch,realisticandobjectivegoalsettingandproperprofilingofaudienceandoptions.ItwasdevelopedbyCommunityToolbox.http://ctb.ku.edu/ADS/generalsearchresults.jsp

USAID diverse communications channels: different benefits and challengesisaschematicdiagramthatarrangesvariousmediaalternativesalongtheparametersofeaseofboundarycontrolandtheeaseofmessagecontrol.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

A field guide to designing a health communication strategy,amanualdesignedbyJHU/CCP.ItliststheessentialsofagoodstrategiccommunicationandlaysdownstepstodesigningastrategiccommunicationinitiativeemployingProcessofBehaviourChange(PBC)framework.http://www.jhuccp.org/pubs/fg/0�/

Involving the community: a guide to participatory development communication,abookfromIDRCaimstoinstruct inwaystodesignparticipatorydevelopmentcommunicationandwaystoinvolvecommunities.http://web.idrc.ca/en/ev-��-�01-1-DO_TOPIC.html

A N N E X E S 3

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Audience participation based message design emphasizes the need to assess the topic of campaign and lifestyle ofaudience(s)indetailtochoosethemediumofcommunication.Itlaysdownstepstosetgoalsandmeasureimpactforfutureuse.ItfeaturedinDevelopmentCommunicationReport(79).http://www.comminit.com/planningmodels/pmodels/planningmodels-10.html

Communication programme planning worksheetisaformatthatsystematicallybreaksdownaprobableprojectintosub-componentssuchasidentificationofpartners, identificationofproblem,targetaudience,secondarytargetaudience,com-municationgoalsandobjectives,communicationchannels,evaluation,etc.ItwasdevelopedbyUNICEF.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

Community action in the health field: a general framework by the European Unionisasetofreflectionsonthepurposeofaid,theobjectivesofaid,andthegoalsandprioritiesofaid.Thoughpreparedforbilateralaid,itcouldbebuiltuponandadaptedtomicrolevel.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

Soul City’s guide to ‘how to make edutainment work for you’ isamodelthatdividesaprogrammeintobroadcategoriesofactivitiessuchasplanning,development,production,marketing,andevaluationandassignstimetobespentoneach.http://www.soulcity.org.za/

Strategic planning (Veenema)isatooltoenableorganizationstodefinetheiraims,settheirgoals,implementplanningasa tool fororganizationalchange,etc. Inotherwords itcouldbeusedasa tool for introspectionbyandreorientationofanorganization.ItwasdevelopedbyPearlVeenema,ManagingDirectorofCampaignsUniversityHealthNetwork.http://www.canadianfundraiser.com/newsletter/article.asp?ArticleID=1�0�

Sustainability focus - ways to incorporate into strategyisatoolthatcombinesstrategicanalysisandstrategicplanningtodeterminefundingtrends,issuesthatneedtobesustainedandwaystomakesustainabilitycentraltoprojectdesign,imple-mentation,andmonitoring.ThistoolwasdevelopedbyHarvardFamilyResearchProject.http://www.gse.harvard.edu/hfrp/eval/issue��/theory.html

Civil society planning toolkits,developedbyCIVICUS,isasetoftoolsaimedathelpingorganizationswithavarietyofissues,starting from writing skills and going on to developing media, handling media, planning, evaluation, financial control andbudgeting.http://www.civicus.org/new/civicus_toolkit_project.asp

Annex 2RESOURCES FOR DEVELOPING A WORKPLAN

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Involving local individuals and groupsisalistofstepstoinvolvelocalcommunitiesandindividualsinprojectsandactivities.Thiscouldhelpabetterunderstandingoftheneedsofacommunityandassistingarneringthesupportofthelocalcommunity.ThistoolwasdevelopedbyManagementServiceforHealth.http://erc.msh.org/mainpage.cfm?file=�.�.10.htm&module=health&language=English

Participatory change: 10 steps in supporting grassroots rural development isalistoftenstepstoensuregreaterandmoremeaningfulparticipationoflocalcommunitiesindesigningandbringingaboutsocialchange.Thisapproachcombinesdevelopmentsinthefieldsofcommunityorganization,populareducationandparticipatorydevelopment.ItwasdevelopedbyCentreforParticipatoryChange. http://www.cpcwnc.org/

Project HOPE - 7 steps for planning a community initiativeisastepbystepguidetoidentifyproblemsbesettingacom-munityandbuildingthecapacityofthecommunitytodesignandlaunchaninitiative.http://www.comminit.com/planningmodels/pmodels/planningmodels-�1.html

Soul City - developing partnershipsisaschematicdiagramthatstressestheneedforpeoplemanagingedutainmentprojects/programmestodevelopnetworkswithdifferentstakeholdersandresourcessourcestomakeedutainmentprogrammesmoreeffective.Centraltotheconceptistheassumptionthatpeoplemanagingtheprojectsareintouchwithtargetcommunitiesandthereforeunderstandtheneedsofthecommunitywell.ThistoolhasbeendevelopedbySoulCity.http://www.soulcity.org.za/


Community problem solving networkisanarenathatgivespeopleandinstitutionsaplatformtofacilitateworkonawidearrayofdevelopmentalandsocialissues.Itoffersstrategytools,programmetoolsandacommunitytointeractwith. http://www.community-problem-solving.net/cms/


A N N E X E S 3

Annex 2RESOURCES FOR CONSULTING A WORKPLAN

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CDCynergy,amultimediaCD-ROMusedforplanning,managing,andevaluatingpublichealthcommunicationprogrammes,doesnotregardcommunicationaloneasthepanaceatopublichealthbutplacesitinthelargercontextofissues,possiblestrategicoptionstochoosefromandacomprehensiveplantoimplementanidentifiedstrategy.ItwasdevelopedbyCDC.http://www.cdc.gov/communication/opportunities/opps_training.htm


Community action framework for youth developmentisaframeworkforthedevelopmentofyouth.Itaimstoproceedbyidentifyinggoals/targetsforyouth,indicatorstomonitorprogress,estimationofresourcesneeded,andchangesthatacom-munitymustinitiatetoprovidesupport,resources,andaconduciveenvironmenttoyouth.ItwasdevelopedbyGambone&Associates/InstituteforResearchandReforminEducation.http://irre.org/pdf_files/connell.pdf

Dynamic facilitationisanapproachwherebyafacilitatordoesnotsteerandmanagechangebutallowschangetoorganizeitselfalongatrajectory.Thisisachievedbyenablingpeopletoappreciatewhattheydesireandhowtheyintendtoachieveit.ItwasdevelopedbyJimRoughandAssociates,Inc.http://www.tobe.net/

HEALTHCOM’s 5-step methodologyisastep-by-stepguidetodesignaneffectivecommunicationstrategyandmonitorit.http://www.comminit.com/planningmodels/pmodels/planningmodels-��.html

HIV/AIDS Continuum of Careisanillustrateddiagramdepictingthelinkagesbetweenandsynergiesthatcouldbedrawnfromdifferentlevelsandtypesofagenciesstartingfromindividualandpeergroupsandgoinguptospecializedtertiaryhealthcare.ThistoolwasdocumentedbyWHO/UNAIDS.url:http://www.unaids.org/publications/documents/care/general/WHOUNAIDSCARE.doc

Isang Bagsak: planning participatory development communicationlaysstressoncommunityinvolvement,fromthestageofinception,inaproject.Itemphasizestheneedtobuildthecapacityofcommunitywhileimplementingaproject/activity.Itpresentsaschematicdiagram,depictingstagesingettinginvolvedwithacommunityandimplementingaproject.http://www.isangbagsak.org/pages/intro.html

MARCH approach to key features of successful behavioural interventionsdetailsthecomponentsofasuccessfulstrategytobringaboutbehaviouralchange.Itcouldthusbeaveryusefultoolfordesigningcommunicationorotherstrategiesaimedatbehaviouralchange.ItwasdevelopedbyGalavottietal.http://www.ajph.org/cgi/content/abstract/�1/10/1�0�

Annex 2RESOURCES FOR DEVELOPING CAMPAIGNS

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SCOPE - from JHU/CCP PCS,acomputersimulationprogrammeisusedfordesigninganimplementinghealthcommunica-tionprogrammes.ItusestheP-Process,thefive-stagecommunicationplanningprocessofJHU/CCP.http://www.jhuccp.org/

Social marketing - implementingisastep-by-stepguidetoimplementingasuccessfulsocialmarketingstrategy.Itlaysstressondetailedresearch,realisticandobjectivegoalsettingandproperprofilingofaudienceandoptions.ItwasdevelopedbyCommunityToolbox.http://ctb.ku.edu/ADS/generalsearchresults.jsp

Sustainability focus - ways to incorporate into strategyisatoolthatcombinesstrategicanalysisandstrategicplanningtodeterminefundingtrends,issuesthatneedtobesustainedandwaystomakesustainabilitycentraltoprojectdesign,imple-mentation,andmonitoring.ThistoolwasdevelopedbyHarvardFamilyResearchProject.http://www.gse.harvard.edu/hfrp/eval/issue��/theory.html

HIV/AIDS NGO/CBO support toolkit,electroniclibraryofresourcesaboutNGO/CBOsupport,accessibleonCD-ROMaswellasonthewebsite,isatoolkitforpeopleestablishing,managingorstudyingsuchHIV/AIDSNGO/CBO.ItisdesignedforprogrammesthatdeliverfundingortechnicalsupporttolocalNGOs.ItisaresourcefromInternationalAIDSAlliance.http://ngosupport.aidsalliance.org/ngosupport/

A N N E X E S 3

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Communication for social change (2005). Who measures change?: an introduction to participatory monitoring and evaluation of communication for social change.http://www.communicationforsocialchange.org/

ThisreportisanintroductiontoestablishingaParticipatoryMonitoringandEvaluation(PM&E)processtoassistinthemeasure-mentofCommunicationforSocialChange(CFSC)initiatives.ItisbasedonthepremisethatCFSCpractitionersshouldfacilitatethedevelopmentofMonitoringandEvaluation(M&E)questions,measuresandmethodswiththosemostaffectedandinvolvedratherthanapplypre-determinedobjectives,indicatorsandtechniquestomeasureCFSConthosemostaffectedandinvolved.Thereport’sprimarypurposeistosupportcommunicationstrategiesfollowingCFSCprinciplesinHIV/AIDSpreventionandcareprogrammes.Theinformationcontainedinthisreport,however,mayhavebroaderapplications.AfterdefiningCFSCandthebroadpurposeofmonitoringandevaluation,thereportexplainswhyaparticipatoryapproachtomonitoringandevaluatingCFSCisuse-ful.ItgoesontodiscusskeyPM&Eprinciplesand«moments»orstepsinestablishingaPM&Eprocess.Two«tools»areofferedtohelpreaderstolearnmoreaboutanddiscuss:(1)potentialmonitoringandevaluationquestionsandindicators;and(2)PM&Edatacollectiontechniques.AdditionaldocumentsonthesamesiteincludeMeasuring Change,andWho Measures Change?

EvaluLEAD framework is an approach to design and understand evaluation of leadership development programmes. Itstressesonflexibility inevaluationdesignwhile listing twobroad typesofevaluationapproaches, three levelsofeffectsofleadershipdevelopmentinterventionoutcomesandsixdomainsofoutcomeelements.ItwasdevelopedbyPLP.http://www.popldr.org/pr/nlpdf/evaluleadframeworkweb.pdf

Communication for social change: an integrated model for measuring the process and its outcomes www.communicationforsocialchange.org

Gender evaluation methodology (GEM) for Internet and ICTs isanapproach toevaluate the impactof InformationandCommunicationTechnologyonthelivesofwomenandgenderrelations.DevelopedbytheAPCWomen’sNetworkingSupportProgramme,itismorethananevaluationtool;itcouldbeusedtoensurethatgenderissuesareassimilatedinprojectplanning.url:http://www.apcwomen.org/gem/

Monitoring and evaluation manual for NGOs working in HIV and AIDSisatoolthatelaboratesontheimportanceofmoni-toringandevaluationandoffersorganizationswithguidelinesandindicatorstodesigneffectiveandaffordablemonitoring,evaluation,andreportingsystems.ThemanualwasdevelopedbyPact.http://www.pactworld.org/reach/documents/building_mer_systems.pdf

Civil society planning toolkits,developedbyCIVICUS,isasetoftoolsaimedathelpingorganizationswithavarietyofissues,startingfromwritingskillsandgoingontodevelopingmedia,handlingmedia,planning,evaluation,financialcontrolandbudgeting.http://www.civicus.org/new/civicus_toolkit_project.asp

Monitoring and evaluation: some tools, methods and approaches,preparedbytheWorldBank,isaguidetomonitoringandevaluationandprovidestools,methods,approaches,andotherdetailstomonitoringandevaluation.http://lnweb1�.worldbank.org/oed/oeddoclib.nsf/��cc�bb1f��ae11c��0�00�a00��/a�efbb�d��b��d��b1e00��c�a�/$FILE/MandE_tools_methods_approaches.pdf

Monitoring and evaluation toolkit: HIV/AIDS, tuberculosis and malaria isamanualbyWHOthattargetspolicymakersandprogrammemanagers.Itaimstosensitizethemtobasicconceptsandframeworksinmonitoringandevaluation,specificindicatorsforthethreediseases,andcrosscuttingindicators.http://www.dec.org/pdf_docs/PNACY��1.pdf

Annex 2RESOURCES FOR MONITORING AND EVALUATION

2

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Thepurposeofthisannexistopresentkeysetsofindicatorsand monitoring and evaluation (M&E) processes to assessprogressmadebyNTPstowardstwokeybehaviouralgoals–stimulatinguseofDOTSservicesandassuring treatment

adherence.Theseindicatorsetsandprocessesarelinkedasinputs, outputs, and outcomes contributing to increases incase detection and case cure rates according to followingframework(76).

A N N E X E S 3

EachindicatorsetisdescribedinthecontextofthetwomainNTPgoals:70%TBcasedetectionand85%TBcasecure.Formostindicators,thedatarequirementsaresummarized,and reference is made to the instruments required or toolkitsalreadyavailable.Theseindicatorscouldbeincludedincomprehensivemonitoringandevaluationguidelineswhichcouldalsostrengthenin-countryM&Esystems.

TheannexisintendedtofosterdebateandnegotiationamongTBprogrammestakeholdersaboutwhattheyenvisagewillbeachievedbyACSMinrelationtoTBandthuswhatmightbemeasured. The collection is not intended to be exhaustive

buttoactasastepinthelonger-termprocessofcompilinga more comprehensive set of approaches, indicators andquestions. One proviso would be that programme teamsonly “dip into” thisannexwhenstakeholdersarestrugglingtodeterminewhatshouldbemeasured.Discussionovertherangeofframeworkspresentedheremayresultinaselectionof indicators that supplement locally created measures ofdialogue,communitycommunicationcapacity,andownershipofcommunicationprocesses.

Research,plans,resources,supplies,staff,etc.

Social mobilization and communication activities, knowledge, policies, laws, incen-tives

Sputum-testing, reduced stigma, reduced discrimination, other significant social changes

Increase case detection rates

Research,plans,resources,supplies,staff,etc.

Social mobilization and communication activities, knowledge, policies, laws,incentives

Treatment adherence, reduced stigma, reduced discrimination,other significant social changes

Increase case cure rates, decrease TB incidence,decrease TBmortality, reduce risk of MDR-TB, improve quality of life

Case detection Input Outputs Outcomes Impact

Case cure Input Outputs Outcomes Impact

Monitoring and evaluating ACSM for TB control

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Annex 3ASSESSING SOCIAL MOBILIZATION AND COMMUNICATION CAPACITY / inputs

N° Indicator Calculation Level Meansofcollection

1 %ofdistricts/provinceswithdesignatedsocialmobilizationandcommunicationstaffwithappropriateexperience1λ

Numerator:#ofdistricts/provinceswithdesignatedstaffforsocialmobilizationandcommunicationDenominator:Total#ofdistricts/provincialTBcontrolunits2∗

ProvincialDistrict

InterviewwithsampleofProvincialandDistrictTBmanagers

2 DesignatednationalTBsocialmobilizationandcommunicationmanagerwithappro-priateexperience

Yes/No NTP InterviewNTPmanager

3 %ofdistricts/provinceswithaccesstoso-cialmobilizationandcommunicationstaffwithappropriateexperience

Numerator:#ofdistricts/provinceswithaccesstostaffforsocialmobilizationandcommunicationDenominator:Total#ofdistricts/provincialTBcontrolunits

ProvincialDistrict


4 Accessatnationalleveltosocialmobiliza-tionandcommunicationstaffwithappro-priateexperience


5 %ofdistricts/provinceswithwrittensocialmobilizationandcommunicationplanwithclearlystatedbehaviouralgoals3ϕ

Numerator:#ofdistricts/provinceswithso-cialmobilizationandcommunicationplanDenominator:Total#ofdistricts/provincialTBunits

ProvincialDistrict


6 WrittennationalTBsocialmobilizationandcommunicationplanwithclearlystatedbehaviouralgoals


7 %ofdistrict/provincialplansderivedfromanin-depthunderstanding(e.g.,viasitua-tionmarketanalysis,needsassessment,qualitativeresearch)ofcurrentbehavioursandactionsneededtopromotedesiredbehaviours

Numerator:#ofdistricts/provinceswithresearch-basedsocialmobilizationandcommunicationplanDenominator:Total#ofdistricts/provincialTBunits

ProvincialDistrict


Thefirstindicatorsetrelatestoprogrammecapacitytodesign,implementandevaluatestrategicsocialmobilizationandcom-municationplansthatstimulateuseofDOTSservicesandas-suretreatmentadherence(thetwokeybehaviouralgoals).Assuch,thisindicatorsetcanbeconsideredindicativeofDOTSserviceinputsintermsofresearch,planning,staff,supplies,and resources required to design, implement and evaluatesocialmobilizationandcommunicationactivities.

Other indicators (simultaneously measuring advocacy ef-forts)mightinclude:• Percentage increase of national budget spent on TB

controlactivitiesovertime.• Percentage of national budget spent on advocacy,

communication,andsocialmobilization.

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A N N E X E S 3

N° Indicator Calculation Level Meansofcollection

8 Nationallevelprovidesguidelines,training,supervisionandfundingtoencouragesub-nationalplanningandimplementationofsocialmobilizationandcommunication


9 100%ofallrelevantlevelshaveactiveinter-agencycommitteesorteamscontributingtotheplanningandmanagementofsocialmobilizationandcommunication4α

Numerator:#ofdistricts/provinceswithactiveinter-agencycommitteescontributingtotheplanningandmanagementofsocialmobilizationandcommunicationDenominator:Total#ofdistricts/provincialTBunits

ProvincialDistrict


10 Nationalsocialmobilizationplanderivedfromanin-depthunderstandingofcurrentbehavioursandactionsneededtopromotedesiredbehaviours


11 %ofdistrict/provincialunitsthathavedetailedoperationalplansforsocialmobili-zationaswellasmoregeneralplans5π

Numerator:#ofdistricts/provinceswithdetailedoperationalsocialmobilizationandcommunicationplanDenominator:Total#ofdistricts/provincialTBunits

ProvincialDistrict


12 Nationalprogrammehasdetailedoperatio-nalplanforsocialmobilizationaswellasmoregeneralplan(ifnecessary)


13 %ofdistrict/provincialunitsthatregularlyreview,monitorandupdatesocialmobiliza-tionandcommunicationplans

Numerator:#ofdistricts/provincesconduc-tingregularreviewsofsocialmobilizationandcommunicationplanDenominator:Total#ofdistricts/provincialTBunits

ProvincialDistrict


14 Nationalprogrammeregularlyreviews,monitorsandupdatesthenationalsocialmobilizationandcommunicationplan


15 %ofallrelevantlevelswithsufficienttrainedcommunicationpersonneltoconductplannedactivities6β

Numerator:#ofdistricts/provinceswithsufficienttrainingcommunicationperson-nelDenominator:Total#ofdistricts/provincialTBunits

ProvincialDistrict


16 %ofallrelevantlevelswithsufficientcom-municationmaterialstoconductplannedactivities

Numerator:#ofdistricts/provinceswithsufficientcommunicationmaterialsDenominator:Total#ofdistricts/provincialTBunits

ProvincialDistrict


17 %ofallrelevantlevelswithsufficientfun-dingtoconductplannedactivities

Numerator:#ofdistricts/provinceswithsufficientfundingforsocialmobilizationandcommunicationactivitiesDenominator:Total#ofdistricts/provincialTBunits

ProvincialDistrict


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Example of ACSM activity Possible indicators

Useofradio,TV,printmediaasadistancelearningtool(PublicServiceAnnouncements-PSAs) #PSAsproduced

Point-of-servicepromotion #brochureslistinglocationofDOTScentresdistributed

Patientinformationcards #ofcardsdistributed

Interpersonalcommunication(IPC)skillsdevelopment #ofserviceproviderstrainedinIPC #ofserviceproviderstrained #ofpeereducatorsactive

Civilsocietyengagement #oforganizationsreached #oforganizationsactive #community-basedorganizationsdistributinginformation #numberofcommunityworkshops/forums

TBpatientactivism #ofTBsupportgroups #ofworkshopsforpublic/private/professional andNGOsapatient-centeredcare.

Useofradio,TV,printmedia #ofTV,radioandprintprogrammesproduced #ofbroadcasttimeornewspaperspacedpurchased

Pressconferences #pressconferencesorganized #ofarticlesgeneratedJournalismtrainingsandworkshops #ofjournaliststrainedinTBissues

WorldTBDaypromotionalmaterials #promotionalmaterialsdistributed

Supportorexpandnationalandlocalnetworksofadvocates #oforganizationsreachedandchampions #oforganizationsactive

Annex 3ASSESSING DELIVERY OF ACSM ACTIVITIES / outputs

This second set of indicators measures the delivery of theaboveinputsintermsofsocialmobilizationandcommunicationactivitiesoroutputs.Someknowledgeindicatorsareproposedandrelatetoknowledgethatachroniccough(coughingfor3weeks)couldbeasignofTB,knowledgethatsputum-testingisthebestwaytodiagnosisTB,knowledgethatsputum-testingisfreeatDOTSfacilities,knowledgeofnearestlocationforfreesputum-testing,knowledgethatTBiscurable,andknowledgethatTB-treatmentthroughDOTSisfree(seenextpage).

Whilethesecouldbeconsidered“outcomes”ofACSMactivi-ties, theyare includedhereasoutputsbecausetheultimatemeasureofACSMsuccessiswhetherthereissustainablebe-haviouralandsocialchange.Knowledgechange,itwasnotedearlier,whilecritical,isnotenough.

OtherpossibleindicatorstoassessexamplesofACSMactivityinclude:

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A N N E X E S 3

No. Indicator Calculation Level Meansofcollection

1 %ofdistricts/provinceswith

establishedandactivemonitor-

ingsystemforsocialmobilization

andcommunicationactivities

Numerator:#ofdistricts/provinceswith

establishedandactivemonitoringforsocial

mobilizationandcommunicationactivities

Denominator:Total#ofdistricts/

provincialTBcontrolunits

Provincial

District

Interviewwithsample

ofProvincialand

DistrictTBmanagers

2 %ofpopulationwhoare

awarethatachroniccough

(coughingfor3weeks)

couldbeasignofTB

Numerator:#ofpeoplewhocorrectlyidentify

coughthatlastsfor3weeksaspossiblesignofTB

Denominator:Total#ofpeoplesurveyed

Population DHSTBModule?

3 %ofpopulationwhoknow

thatsputum-testingisthe

bestwaytodiagnosisTB

Numerator:#ofpeoplewhocorrectlyanswerthat

sputum-testingisthebestwaytodiagnosisTB




thatsputum-testingis

freeatDOTSfacilities

Numerator:#ofpeoplewhocorrectlyanswer

thatsputum-testingisfreeatDOTSfacilities




thelocationoftheirnearest

sputum-testingfacility

Numerator:#ofpeoplewhocorrectlynamethe

locationoftheirnearestsputum-testingfacility




thatTBiscurable

Numerator:#ofpeoplewhocorrectly

answerthatTBisacurabledisease



7 %ofpopulationwho

knowthatTBtreatment

throughDOTSisfree

Numerator:#ofpeoplewhocorrectlyanswer

thatTBtreatmentthroughDOTSisfree



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Assessing sputum-testing Outcomes

A suitable combination of indicators already proposed byUSAIDandWHOforsmeardiagnosiscanbeusedtomeasurethebehaviouraloutcomeofsocialmobilizationandcommu-nicationactivities in termsofpeoplepresenting themselvesorfamilymembersforsputum-testing.Fromasocialmobiliza-tionandcommunicationstandpoint(asopposedtoaclinicalstandpoint),behaviouralimpactissimplythemeasureofthenumbersofpeoplewhopresentatDOTSfacilitiesrequestingtheTBsputumtest.Whethertheyreceivethetestornot,andwhetherthetestisaccurateornotisnotasocialmobilizationandcommunicationissueandrequiresotherindicators!

NTPs could develop their own measures for monitoringbehavioural impact. For example, an NTP could establishabase-linemeasureof thecurrentnumberofpeoplecom-ing in for the test at a random sample of “sentinel clinics”in the three month period before a social mobilization andcommunicationprogrammeisimplemented.TheNTPcouldthenmonitorthenumberspresentingatthesesentinelclinicsduringadefinedperiod(e.g.1year)andafinalcomparativefigurecanbearrivedattheendoftheyear.TheNTPcouldissueinterimreportsat4monthsand8monthsintothesocialmobilizationandcommunicationprogramme.

Assessing treatment adherence Outcomes

A suitable combination of indicators already proposed byUSAID and WHO for DOTS (e.g. % of new smear-positivecasescured(curerate),%ofnewsmear-positivecaseswhocompleted treatment (completion rate), proportion of allcases underDOTS following DOT as described in nationalguidelines, etc.) can be used to measure the behaviouraloutcomeofsocialmobilizationandcommunicationactivitiesintermsofTB-patientscomplyingwithtreatment.Monitoringsmear-conversion from positive tonegative smear after theinitial2–3monthsoftreatmentisthemosteffectivewaytoassess that the patient has taken prescribed medications.Indicatorsthatproviderelevantdataonasampleoftreatment“drop-outs”atvariouslevelsofthehealthsystem(thosewhoare diagnosed smear positive but do not commence treat-mentorthosewhoarediagnosedsmearpositive,commencetreatment,butdonotcomplete)needstobeconsidered(e.g.

%ofnewsmearpositivecaseswhodefault,%ofnewsmearpositivecaseswhoweretransferredtoanotherdistrict.)(77).

Thisindicatorsetshouldalsocontainanindicatororindica-tors thatmeasure theestablishmentand implementationofpro-poor incentiveschemes toencourage treatmentadher-ence. For example, % of districts/provinces that have active pro-poor incentive schemes for TB patients on DOTS.

“Incentives”giventopatientsorapatient’sfamily(e.g.donatedgifts,freefood,smallfinancialinvestmentsthataccrueinter-estduringthetimeapatientisontreatment,etc.)toencour-agepoorormarginalizedpopulationstocompletetreatmentareexamplesofpossibleoutputsofsocialmobilizationandcommunication(e.g.persuadingprivatebusinesstodonategifts,arrangingforlocalcommunitygroupstoprovideregularmealsforpatients,etc.).Atthesametime,onecouldconsiderincentivesasaformofinputiftheyareviewedas“resources”aprogrammeprovides(butwithoutwell-plannedsocialmo-bilizationandcommunication,theseresourcescouldnotbegeneratedinthefirstplace).Theessentialpointistheneedtorecognizeincentivesasassistingtreatmentadherence(78).

Assessing stigma and discrimination Outcomes

The efforts being made to expand DOTS services shouldhelptoreducestigmaanddiscriminationandindicatorsusedtomeasuretheprogresstowardsDOTSexpansioncanactasproxiesforreductionsinstigmaanddiscrimination.

Nevertheless, strengthening the legal framework to protectthehumanrightsofpeoplewithTB (andHIV/AIDS) isalsoseen as paramount. A human rights framework providesavenuesforpeoplewhosufferdiscriminationonthebasisoftheiractualorpresumedTB-positivestatustohaverecoursethrough procedural, institutional and monitoring mecha-nisms.Atnationallevel,theseincludecourtsoflaw,nationalhuman rights commission, ombudsmen, law commissionsandotheradministrativetribunals. Input/output indicators measuring the establishment of these legal institutions could be developed. Simultaneously,communitiesneedtobeempoweredtounderstandandusepolicyandthelawtoobtainthecareandsupporttheyrequire.Outcome indica-

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A N N E X E S 3

tors measuring use of these legal institutions could be considered.

Policyandlegalreform,however,willhavelimitedimpactun-lesssupportedbyvaluesandexpectationsofasocietyasawhole.Widespreadandenduringchangesinsocialattitudesare required ifweare tomakeheadwayagainstTB-relatedstigmaanddiscrimination. It is thusconsideredvital tocre-ate supportive environments to reduce TB-related stigmathrough national and community-based social mobilizationand communication initiatives to combat fear and misinfor-mationandtoincreaseuseofDOTSservices.Variousindica-torsproposedinIndicatorSetBcouldbeusedtomeasureimplementation of social mobilization and communicationinitiatives directly addressing stigma and discrimination. Inaddition, indicatorscouldbedeveloped tomeasure theex-tent towhich socialmobilizationandcommunication plansandactivitiesaddresstopicssuchasTB/HIV,discriminationagainstfemalepatients,andtheprofessionalconductofpri-vatephysicians,governmenthealthworkers,prisonstaff,andemployers.

Indicatorstoconsiderinthissetmightinclude:• % of people expressing accepting attitudes towards

peoplewithTB,ofallpeoplesurveyedaged15-49.ThiscouldbebasedonhypotheticalquestionsaboutmenandwomenwithTB–itreflectswhatpeoplearepreparedtosaytheyfeelorwoulddowhenconfrontedwithvarioussituationsinvolvingpeoplewithTB.

• % of formal-sector employers sampled with non-discriminatorypoliciesandnon-discriminatorypracticesinrecruitment,advancementsandbenefitsforemployeeswithTB.The indicatorshouldbedisaggregatedto lookseparatelyatcompanypoliciesandpractices.

• % of district/provinces that have established the legalframework to protect the human rights of people withTB.

• % of district/provinces that organize communicationactivities (e.g. training programmes) to empowercommunitiestounderstandandusepolicyandthelawtoobtainthecareandsupporttheyrequireforTBpatients.

• % of district/provinces that can show evidence ofenforcing current legislation against mandatory TB-testingandtestingwithoutconsent.

• % of districts/provinces that have set in place codesof ethics and professional conduct for health workers(both government and private) such as confidentialityandmechanismsfortheireffectiveimplementationatalllevels.

• %ofnational/provincial/districtlevelhealthworkertrainingcurricula that teach codes of ethics and professionalconductastheyrelatetoTB(andHIV/AIDS).

• % of district/provinces providing training and supportfor existing legal aid institutions, alongside creation oflawyers’collectivesspecializinginTB-relatedconcerns.

Measuring most significant changes Outcomes

Themostsignificantchange(MSC)techniquewasdevelopedbyRickDaviesinBangladeshin1994 (79).MSCisasystem-aticmethodologyinwhichallstakeholdersinaprogrammeorinitiativeareinvolvedindecidingthesortsofchangetoberecorded.MSCissystematicinthatthesamequestionsareasked of everyone and resulting stories are rigorously andregularlycollected.Thesestoriesarethensubjecttoanalysis,discussionandselection,verificationanddocumentation.

ThereareatleastfourdifferencesbetweenMSCmonitoringandconventionalmonitoringpractice:• MSCfocusesontheunexpected–itdrawsmeaningfrom

actualevents,ratherthanbeingbasedonindicators.• Information about unexpected events is documented

using text rather than numbers. The stories capturechanges in the lives of “beneficiaries”, their colleaguesand in the character of their participation. The methodalsohelpstoidentifywhychangehappens.

• Analysisofthatinformationisthroughtheuseofexplicitvaluejudgmentsmadebystakeholdersinaparticipatoryprocessofreviewanddebate;

• Aggregation of information and analysis takes placethroughastructuredsocialprocess.

MSCinvolvesatleastthreestages(thelatestMSCguidede-scribes10steps):(1)establishdomainsofchange;(2)setinplaceaprocesstocollectandreviewstoriesofchange;and(3)secondaryanalysisofthestoriesandmonitortheprocess.M&E teams may move backwards and forwards betweeneachStage(80).

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Stage one: establishing domains of changeThis stage of the process involves TB control programmestakeholders identifying the “domains” of change that theythinkneedtobemonitored:forexample,changesincommu-nitycommunicationcapacity.Theprocessofidentifyingthedomainsofchangecanbethroughinterviews,groupdiscus-sions,meetings,workshops,orshortquestionnaires.Forex-ample,inthepeople’sparticipatorydevelopmentprogramme(PPRDP)intheRajshahizoneofwesternBangladesh,thedo-mainsofinterestdecideduponbyshomiti(association)mem-bersworkingwiththeChristianCommissionforDevelopmentinBangladesh(CCDB)werephrasedasfollows:• “Changesinpeople’slives”• “Changesinpeople’sparticipation”• “Changesinthesustainabilityofpeople’sinstitutionsand

theiractivities.”

Initially field level staff of CCDB were left to interpret whatissues (in thestories that theysubsequentlycollected fromshomitimembers) they feltwasachangebelonging toanyone of these categories. One additional type of changewas included – “any other type of change.” The intentionwas to leave one completely open window through whichfield levelstaffcoulddefinewhatwas importantandreportaccordingly.

Stage two: collecting and reviewing the stories of changeThenextstage involves thecollectionandreviewofstoriesofsignificantchange(accordingtothedefined‘domains’ofchangethathavebeennominatedinstageone).

Generating storiesStories are generated by asking a simple question in thefollowing form: “During the last [time period, e.g., month],inyouropinion,whatdoyou thinkwas themostsignificantchangethattookplaceinthelivesofpeopleparticipatingin[theproject/initiative]?”

Answersareusually recorded in twoparts.Thefirstpart is descriptive: what happened, who was involved, where didithappen,whendid ithappen?The intentionshouldbe togather enough information so that an independent personcouldvisitthearea,findthepeopleinvolvedandverifythattheeventtookplaceasdescribed.

Thesecondpartoftheanswerisexplanatory.Therespond-ent explains why they thought the change was the mostsignificantoutofallthechangesthattookplaceinthattimeperiod. Inparticular,whatdifferencedid itmakealready,orwillitmakeinthefuture?

Collecting and reviewing storiesThestoriescanbecollectedbyagroupofTBprogramstake-holders.Storiescanbecollectedfromdiaries,interviews,orgroupdiscussions.Aseriesofreviewforaarethenarrangedtoallowselectionofthosestoriesthatstakeholdersthinkrep-resentthemostsignificantaccountsofchange.Storyselec-tionmaytaketheformofaniterativevotingprocess,whereseveralroundsofvotingoccuruntilconsensusisachieved.Atthevariousreviewfora,participantsarerequiredtodocumentwhichstoriestheyselectedandwhy.Thisinformationisthenfed back to the original storytellers and wider networks ofstakeholders.ItisintendedthatthemonitoringsystemshouldtaketheformofaslowbutextensivedialoguethroughoutthenetworksofTBcontrolprogrammestakeholders.

Annually,allthestoriesthathavebeenselectedovertheyeararecirculatedamongststakeholders.Thestoriesareaccom-paniedbythecriteriathatthereviewforausedinselection.

Stage three: secondary analysis of the storiesIn addition to the production of a document containingselectedstoriesandreaders’interpretations,thestoryproc-essitselfismonitoredandadditionalanalysisiscarriedout.Jessica Dart reports that monitoring of a 12-month MSCprocess implementedbyagricultureextensionstaffanddi-ary farmers involved in a statewide dairy extension projectinVictoria,Australia,revealedseveraloutcomesbeyondtheidentificationofsignificantchanges.Forexample,extensionstaff felt that theygainedabetterunderstandingof impactandamorefullysharedvisionbetweenalltheprojectcollabo-rators.Feedbackfromtheprojectcommitteessuggestedthatlearningalsooccurredintermsofincreasedskillinconcep-tualizingandcapturingimpact;overtheyear,thestorytellersbecame better at capturing impact and responding to thesuggestions that were provided in the feedback from thestoryreviewprocess.

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BasedonDart’s insights, theaimsof theMSCprocessap-pliedtoTBASCMmonitoringmightbeto:

• Move towards a better understanding between allNTPstakeholdersas towhat isoccurring for individualprogrammebeneficiariesandgroups.

• ToexploreandsharethevariousvaluesandpreferencesofNTPstakeholders.

• Togainaclearerunderstanding(asagroup)ofwhatitisand is notbeingachievedbyACSMandtoclarifywhatstakeholdersarereallytryingtoachieve,sothattheNTPcanmovetowardswhatisdesirableandmoveaway fromwhatisundesirable.

MSCisavaluablewayof“dignifyingtheanecdote”–creat-ingalegitimatespaceforstorytellingandgivingthesestoriesvalidity.MSChasalreadybeenappliedindevelopedandlessdeveloped economies, in participatory rural developmentprojects,agriculturalextensionprojects,educationalsettings,andmainstreamhumanservicesdelivery.

Measuring social change communication Outcomes (81)

Indicator Questions

Expanded public and private dialogue and debate

Whatincreasehastherebeenin:• Familydiscussion?• Discussionamongfriends?• Discussionincommunitygatherings?• Coverageanddiscussioninnewsmedia?• Problemsolvingdialogue?• Focusanddiscussioninentertainmentmedia?• Debateanddialogueinthepoliticalprocess?

Increased accuracy of the information that people share in the dialogue/ debate

• 5piecesofdataoverwhichthereisgeneralconsensus• 4differentperspectivesontheissue.Testtheextenttowhichtheseareaccuratelyreflectedinthelocationsfordialogueanddebatementionedaboveamongfriends,withinthefamily,etc.

Supported the people centrally affec-ted by an issue[s] voicing their pers-pective in the debate and dialogue

• Whichgroupsinrelationtotheissueofconcernaremostdisadvantaged?• Howweretheysupportedtogivevoicetotheirperspective?• Whathappened?

Increased leadership role by people disadvantaged by the issues of concern

• Whomakesthemajordecisionsconcerningtheprioritiesandactivitiesofthecommunicationintervention?• Howarethepeoplecentrallyaffectedbythoseissuesengagedinthedecisionmaking

process?• Whataresomespecificexampleswheretheinvolvementofthatgrouphasinfluencedstrategicorfinetuningdecisions?

Resonates with the major issues of interest to people’s everyday interests

• Whichweretheissuesthatprovidedthefocus?• Towhatextentwerepeopleenergizedbytheseissues?• Whatactionsfollowed?

Linked people and groups with similar interests who might otherwise not be in contact

• Whichgroupsareinvolved?• Whataretheirinterests?• Havetheybeenlinkedtogether?• Howdoesthatlinkingtakeplace?• Isthereanalliance?• Howdoesthealliancework?

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TB social change indicators Outcomes

Arvind Singhal and Everett Rogers in their important book“CombatingAIDS:CommunicationStrategiesinAction”suggestedarangeofsocialchangeindicatorsassociatedwithHIV/AIDS(82).AdaptedtoTB,theseindicatorsmightbeasfollows:

• WorkplacesinthecommunityimplementTBpreventionprogrammes.

• Thecommunityinitiateshome-basedcareprogrammes.• LocalhealthservicesofferTBtestingandcounseling.• Localhealthservicesensure,andprovideaccessto,aTB

testingandtreatment.• Local prisons and military establishments institute TB

preventionprogrammes.• LocalschoolsadoptaTBeducationcurriculum.• PeoplelivingwithTBorhavingsufferedpreviouslyfrom

TBarepartof“mainstream”society(employedinregularjobs,workingascounselors,etc.).

• Individuals living with TB or having suffered previouslyfromTBareprotectedbylawsdesignedtoupholdtheirrights.

• ThequalityoflifeofthoselivingwithTB,andthosecaringforthem,isenhanced.

• CommunitymembersopenlydiscussTBissuesinpublicmeetings.

• New community-based programmes are launched toaddressTBprevention,care,andsupport.

• NewcoalitionsemergeamongcommunityorganizationstoaddressTBissues.

• Community members collectively make decisions orpassresolutionstocombatTB.

• GrassrootsleadershipemergesfromwithinthecommunitytotackleTBissues.

• ReligiousorganizationsandspiritualleadersareinvolvedinTBpreventionandtreatmentprogrammes.

• The community engages with the local administration,servicedeliveryorganizations,NGOs,andothersonTBissues.

• The community’s cultural activities (sports, folk media,festivals, celebrations, songs, etc.) engage with TBissues.

• ThemostvulnerablegroupsatriskforTBinthecommunityareempowered to takegreatercontrolof theirexternalenvironment.

• MediacoverageandmediaadvocacyforTBincreases.• The community becomes TB-competent in terms of

preventionandtreatment.• %ofTB-freecommunitiesincreases.• Multi-sectoral involvementexistsatthenational levelfor

TBcontrol.

Monitoring and evaluating advocacy Outputs/Outcomes

AccordingtoJenniferChapmanandAmbokaWameyo, themonitoringandevaluationofadvocacyandinfluencingworkishighlyunderdeveloped(83).Sotooistheabilitytomonitororevaluatetheroleofcivilsocietyinbringingaboutsustain-ablechangethroughitsinfluencingandadvocacyactivities.ChapmanandWameyorecentlyconductedascopingstudyto identifyanddocumenthowvariousagenciesand institu-tions have approached the assessment of advocacy. Thefollowingaretwooftheapproachestomonitoringandevalu-atingadvocacyexaminedintheirstudy:• USAIDConceptualFramework.• Integratedframeworkonpolicy,civilsociety,andpolitical

space.

USAID conceptual frameworkThis framework identifies three different components of acomprehensive advocacy strategy, conceived of as looselycorrelated with stages ranging along a continuum, movingfromcitizenempowerment(transformational),tocivilsocietystrengthening (developmental), and concluding with policyinfluence(instrumental).A longlistof indicatorsforeachofthese stages can be found in Advocacy Strategies for Civil Society (84).

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A N N E X E S 3

Stage Questions

Transformational Towhatextentarethemarginalizedordisadvantagedabletochallengethestatusquo?Aretheygainingasenseoftheirownpower,includingthecapacitytodefineandprioritizetheirproblemsandthenactingtoaddressandresolvethem?

Developmental Towhatextentarecitizensableorganizethemselvescollectivelytoaltertheexistingrelationsofpower?Aretheyprovidingthemselveswithalastinginstitutionalcapacitytoidentify,articulateandactontheirconcerns,interestsandaspirations,includingtheabilitytoachievespecificandwell-definedpolicyoutcomes?

Instrumental Towhatextent isagrouporaregroupsabletoapplyasetofskillsandtechniquesforthepurposesofinfluencingpublicdecision-making

Dimension of work Indicatorsofprogress Indicatorsofchangeandlongertermimpact

1. Policy change e.g.LegislativechangePolicychangeChangeinlaw

• Increaseddialogueonanissue• Raisedprofileofissue• Changedopinion(whose?)• Changedrhetoric(inpublic/private)• Changeinwrittenpublications

• Changedpolicy• Changeinlegislation• Policy/legislationchangeimplemented• (and in the very long term)positivechangeinpeople’slives

asaresultofthepolicy/legislationchange

2. Strengthening civil society by working with:NGOsMovements/networksCommunity-basedorganizationsPopularorganizationsPartnerorganizations

• Changeinindividualmembers’skills,capacity,knowledgeandeffectiveness?

• Changeinindividualcivilgroups’capa-city,organizationalskills,effectiveness?

• Greatersynergyofaims/activitiesinnetworks/movements

• Changeincollaboration,trustorunityofcivilsocietygroups

• Increasedeffectivenessofcivilsocietywork• Civilgroupsactiveininfluencingdecision-makersinways

thatwillbenefitpoorpeople

3. Enlarging democratic space or the space in which civil society groups can effectively operate in society

• Greaterfreedomofexpression• Greateracceptance/recognitionofcivil

groups• Existenceofforaforcivilgroupstoinput

intoawiderrangeofdecisions• Increasedlegitimacyofcivilsociety

groups

• Increasedparticipationofcivilsocietygroupsininfluencingdecisions

• Changeinaccountabilityandtransparencyofpublicinstitu-tions

4. Supporting people-centered policy-making

• Greaterawarenessofindividualrightsandthepowersystemsthatwithholdrights

• Changeinlocalpeople’sskills,capacityandknowledgetomobilizeandadvo-cateontheirownbehalves

• Improvedaccesstobasicrightssuchashealth,housing,waterandfood

Integrated framework on policy, civil society and political spaceRos David has proposed four dimensions and associatedindicators of advocacy work: policy change; strengtheningcivil society; enlarging democratic space; and supportingpeople-centrepolicymaking(85).

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This workplan’s budget has been calculated using twobenchmarks:• a careful analysis of the best developed proposals sub-mitted and reviewed by the Global Fund for AIDS, TB andMalaria.• extensive experience in other health issues suggestingthatanoverall5–15%of totalTBcontrolprogrammeeffortsshouldbeallocatedtocountrylevelACSMactivities.

Global Fund application analysisApplications for ACSM funding for TB that have been pro-ducedthroughextensivecountry-levelconsultationssuchasEthiopia,Pakistan,Bangladesh,andKenyaofferinsightsintothe specific amounts NTPs are now seeking to ensure thebest outcomes for Strategic Communication. Analysis of asampleoftheseapplicationssuggestthatACSMfundingre-quiredfromGFATMbycountriesrepresentsbetween5–15%oftheirtotalNTPannualbudgets.

Experience with other health issuesWhile we should not rush to make direct comparisons be-tweenACSMforTBandACSMforotherhealthproblems,thefirstpointtomakeisthatdocumentationonACSMbudgetshas generally been extremely weak. Referring to cost-ef-fectivenessofACSMinHIV/AIDSprogrammes,McKeeet al(2004:40)note:

One difficulty in establishing cost-effectiveness is the dearth of rigorous research, to date, on either the cost of HIV/AIDS communication interventions or their impact in specific set-tings. In the absence of exact numbers, planners can, none-theless, make rough estimates in comparing the relative return on communication through different channels. To move from cost-effectiveness as a concept to a criterion for decision-making in HIV/AIDS programming, it will be necessary for the organizations to fund such work so researchers can refine their methods for measuring cost-effectiveness in relation to communication interventions. With greater efforts in this type of research, we expect in the future to be able to more ac-curately respond to the question: “How can additional funds be allocated with the greatest effect to achieve and sustain healthy behaviour? (86)

The 2002 ACSM needs assessment highlighted earlier, re-portedthefollowing:

Current budget breakdowns are extremely difficult to obtain. Specific budgets for advocacy and communications activities are only available for Indonesia and Kenya (Indonesia’s budget is requested only and not actually committed). These budgets equate to US$1.5-2.0 allocated to [ACSM] activities in sup-port of each TB case (2002 estimates for each country). In other HBC, this amount is likely to be significantly less given the stated budgets are for all NTP activities (staff salaries, drugs, laboratory equipment, transport, training, etc.) not just for advocacy and communications. NTP capacity to process external funds has proved problematic in some HBC(87).

Animportantpointhereistheneedforbetterdocumentationandrecord-keepingofACSMbudgets–acapacity-buildingissue.

ACSMbudgetbreakdowns(ifavailable)tendtousesuchunitcostsasUS$perpatient,US$perpersonatrisk,orUS$perheadofpopulation reached(88).Measuring thecost-effec-tivenessofACSMisespeciallychallenging.ACSMinitiativesalone–withoutanenablingenvironmentoffacilities,suppliesandpersonnel–canprobablynotachievelastinghealthbe-haviouralandsocialchanges.Measuringcost-effectivenessmusttakeintoaccountotherfactorsbesidesACSMthatmayhave contributed to the observed results (techniques suchas Contribution Analysis can help here) (89). For example,an evaluation of a Philippine media campaign to promotecontraceptives in 2000-2001 showed a net effect that wasabouthalfthecrudeincreaseincontraceptiveprevalence–anetadjustedincreaseinmoderncontraceptiveuseof3.6%or196141newadoptersofmoderncontraceptivemethodsaftertakingaccountofotherfactors.Cost-effectivenessofACSMwas calculated at US$2.79 per new acceptor of a modernmethod(90).

ResearchontheexperienceofACSMinitiativesinsupportofvarious healthprogrammes (e.g. immunization, family plan-ning, malaria control) show that the scope and intensity ofactivities, and therefore unit costs, vary according to local

ACSM budget analysis and justification

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A N N E X E S 3

conditionsaswellastheoverallapproachchosenfordiseasecontrol.Forexample,campaign-intensiveinterventions(suchaspolioandmeaslesvaccinationcampaigns)requireshort-term, nationwide social mobilization to reach all caretakersa few times per year.TB control, instead, typically requiressustainableandregularcommunicationactionsaddressedtovariouspopulations(e.g.peoplelivinginprisons,seasonalmi-grants,workersinspecificeconomicsectors)whoaremorelikely tocontractTBand/orare less likely togetdiagnosedandadheretofulltreatment.

WHOexperienceswithACSMinthepreventionandcontrolof communicable diseases such as dengue fever, leprosy,malariaandlymphaticfilariasishaveshownthatACSMunitcostsofbetween$US0.05and$10.00pertargetedpopula-tionper yearmustbe invested inorder tobringaboutandsustain behavioural results. These figures equate approxi-matelyto5-15%ofoveralldiseaseprogrammebudgets(91, 92, 93, 94).

Insum,experienceinotherpublichealthprogrammessug-gestNTPsneedtocommitbetween5%–15%oftheirnationalTB budget allocation to achieve the best outcomes fromACSM.

Determining ACSM budgets from within the 5–15% range

Selecting%allocationfromwithintherecommended5-15%rangewilldependonseveralparametersincluding:• currentlevelsofHIVtransmissionandassociatedstigma;• currentlevelsofTBtransmission,burdenandassociated

stigma;• MDR-TBissues;• the accessibility and efficiency of decentralized health

systems(DOTSservices);• culturaldiversity;• factorsinfluencingtreatment-seekingbehaviourincluding

local knowledge systems, gender, and therapeuticpreferences;

• socioeconomicstatusofaffectedpopulations;• levelsofcivilunrest;• whether TB affects in hard to reach groups (ethnic

minorities,mobilepopulations);

• populationdistribution;• population segmentation (whether the programme’s

focusisonvulnerablegroupsorthegeneralpopulation);and

• ACSM resource availability including skilled staff, thetypes of communication channels, and communitynetworks (such as faith-based organizations and othernon-government agencies), and the relative costs ofmobilizingsuchresources.

These and other parameters, of course, vary enormouslyby country and data on specific issues may not be readilyavailable.

In order to determine adequate funding, NTPs need a re-search-basedunderstandingoftheepidemiological,commu-nicationandsocialchallengesthat justifyspecificamounts.Although it is impossible topre-determine levelsof fundingforallNTPswithintherecommended5%–15%,experiencesuggestsifTB/HIVstigmaishigh,HIV/TBprevalenceishigh,and other factors present significant challenges to healthservicedelivery,thenNTPsshouldbeinvestingattheupperendofthebudgetrange(towards15%)forACSM.

Experience also suggests that if the “absorptive” is initiallylow(i.e.systems,humanresources, infrastructureorACSMcapacityneedtobebuilt),thenincrementalmovementshouldbemadeasquicklyaspossibletowards15%.Increasedre-sources(towardsthe15%endofthebudgetrange)willalsobe requiredwhenACSM initiativesarestartinguporwhenintensifiedeffortsareneeded(e.g.whenanewdiagnosticortreatmenttoolisintroducedorMDR-TBisdetected).

As ACSM begins to tackle stigma, gender inequality, treat-ment-seeking behaviour, communication skills of healthworkers, andsoon, soannualNTPbudgetproportionsal-locatedtoACSMmightdecrease,butonlyifthereisevidencetosuggestCaseDetectionRatesandCaseCureRatesarereachingrequiredlevelsandbeingmaintained.

If TB/HIVstigmaislow,TB/HIVprevalenceislow,andotherfactors are not presenting significant challenges to healthservicedelivery,thenNTPsshouldbeinvestingatthelowerendofthebudgetrange(towards5%)forACSM.

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Of course, as time goes by individual programmes mayfluctuatebetweenthesetwomarginsdependingonevalua-tionresults.ImproveddocumentationofACSMbudgetsandincreasedemphasisonACSMcost-effectivenessstudieswillassistinfine-tuningannualbudgetaryallocations.

Allocating ACSM budgets at country level

Obviously,calculatingACSMbudgetsonapercentagebasisof totalTBprogrammingdoesnotaccount forbudgetvaria-tionsthatmaybenecessaryfordifferentactionareaswithinthe“strategicmix”:ACSMactivitiesinanyspecificcountry.

Politicalwillatthehighestlevelsisfundamentaltohaveaposi-tive impactonDOTScontrol targets,appropriate funding foradvocacywoulddependon thestrengthofpoliticalcommit-mentatbothnationalandlocallevel.Forexample,substantialfunding for advocacy would be needed in countries whereTB issues are absent in public and policy agendas, govern-mentandpartners’supportforTBcontrolislow,thenationalprogramme is under-funded (compared with other healthprogrammes nationally and other TB control programmesglobally), current levels of DOTS expansion are substantiallybelowexpectedgoals,andseriouslogisticaldifficultiesham-perthefunctioningofTBclinics.Conversely,lessfundingforadvocacy may be required where political commitment andoverallperformanceindicatorsarestronger.

Likewise, the level of funding for communication and socialmobilizationislikelytovaryaccordingtoepidemiologicalandsocialconditions.CommunicationprogrammesfacetougherchallengeswhereHIV/TBco-infectionandHIVratesarehigh,andmulti-drugresistanceisextended.Similarly,programmesconfrontmoreseriousobstacleswhenhighTBstigmastronglydeterspeoplefromgettingtestedanddisclosinghavingactiveTB,knowledgeofTBsymptomsandriskperceptionarelow,andpopulationstypicallyseekhealthcarefromnon-DOTSpro-vidersandhavelongdelaystoseekassistanceatTBclinics.

Also,thetaskofcommunicationissubstantiallymoredifficultincountrieswherehighTBratesare foundamongmigrantsandotherhard-to-reachpopulationswho,typically,cannotbeeffectivelyreachedthroughconventionalhealthsystemsandcommunicationchannels.Additionally,specificdemographicissuesmayalsoaffecttheamountoffundingforcommunica-

tion.Ahigherpercentageof fundsmaybeneeded incoun-trieswithalargepopulation,weaklarge-scalemediatoreachprioritypopulations,linguisticandethnicdiversity,widespreaddistrustofhealthsystems,andlowqualityofhealthservices.

Underthesecircumstances,experiencesuggeststhataseriesofregular,multi-levelcommunicationactivitiesareneededtoreachpopulations throughspecificchannelsandmessages.Given the complexity of the issues at stake, typical informa-tionalactivitiesthataimtoraiseawarenesswouldnotneces-sarilydeliverexpectedresults.Ahigherleveloffundingmayberequiredtoproperlyfundcommunicationactivitiestodealwithadiversityofchallenges.

Incontrast, less fundingoncommunicationmaybeneededwhenNTPsfacedifferentepidemiologicalconditions(e.g.lowHIVratesconcentrated inspecificpopulations),communica-tionindicators(e.g.highawarenessaboutTBsymptomsandcure,highriskperception),andsocialanddemographiccon-text (e.g.highdegreeofculturalhomogeneity, limitedcross-borderpopulationmovements).Inthosecircumstances,stud-ies show thatbasic informationcampaignscansuccessfullyincreaseTBcasefindingand reduce the levelsofprejudiceagainstpeoplewithTB.Forexample,asix-weekcampaigninCali,Colombiaproducedanincreaseof64%inthenumberofdirectsmearsprocessedbythelaboratoriesandanincreaseof52%inthenumberofnewcasedofpositivepulmonaryTBwithrespecttothepreviousperiod(95).Unfortunatelythere-sultsofthecampaignwereshort-lived.Thesefindingshaveatleasttwoimportantimplications.First,passivecasefindingislikelytobeinsufficientstrategytoreachtheoperationaltargetsofdiagnosticcoverage.Secondly,providingbasicinformationaboutearliestsymptomsofTBandtheproceduresofdiagno-siscanincreasediagnosticcoverage.

Besidesadvocacy,communicationandsocialmobilizationac-tivities,thereareotherACSMbudgetitemsthatNTPsshouldconsider, including:ACSMstaff salaries;ACSMplanning in-cludingformativeresearch;stafftraining;messageandmate-rialdesign,pre-testingandproduction;ACSMmanagement;andparticipatoryandconventionalmonitoringandevaluation.ExamplesofNTPapplicationstotheGFATMprovideaclearinsight into some of the precise budget lines required forACSM.

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A N N E X E S 3

λ “Appropriatequalifications”referstoasetofcriteriasuchas:tertiary-levelhealthcommunicationstraining,fieldexperienceinmanagingcommunicationsprogrammes,etc.

∗ Definitionofunitwilldependoncountrycontext.Couldbeindividualhealthcentres,clustersofhealthcentres,TBcontrolteamsspreadoutacrossseveralcentres,etc.

ϕ Behaviouralgoalreferstoaspecific,measurable,appropriate,realisticandtimeboundstatementsuchas:“Toprompt,overtheperiodofayear,approximately500000individuals(men,womenandchildrenofanyage)throughoutBangladesh(butparticularlythoseinruralareas)whohaveacoughthatdoesnotgoawayafterthreeweekstocome/betakentooneofthe500designatedgovernmenthealthfacilitiesforTheFreeTB(Sputum)Test.”Statementsreferringto“raisingawareness”or“changingknowledge”or“increasingcommunityparticipation”arenotprecisebehaviouralgoals.

α Activewouldneedtobedefined.

π Operationalplansdetailspecificactivities,responsibilities,completion/implementationdates,andbudget.

β Sufficientwouldneedtobedefined.Primaryhealth-careworkersshouldreceivebasictraininginTBcontrolsuchashowtorecognizethesymptomsofTBandrefersuspectedpatientsforaccuratediagnosisandtreatment.Inmanycountries,communityleadersandvolunteerscanalsobesuccessfullyinvolvedinTBcontrol.CommunitiescanencourageTBpatientstogoforsputum-testingandtocompletetreatment.

Annex 5NOTES

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6 WaisbordS.(2005)Behaviouralbarriersintuberculosiscontrol:Aliteraturereview,TheCHANGEProject/AED,Draftdocument2005

7 AHumanRightsApproachtoTB:StopTBGuidelinesforSocialMobilization,WHO2001

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20 Tweedie,I.,Boulay,M.,Fiagbey,E.,Banful,A.,&Lokko,K.(2002).Ghana’sStopAIDSLoveLifeProgramPhase1:EvaluationReportFebruary2000-June2001.Accra:GhanaSocialMarketingFoundation.Baltimore:JohnsHopkinsBloombergSchoolofPublicHealth,CenterforCommunicationPrograms.

21 PanAmericanHealthOrganization,SpecialProgramforVaccinesandImmunization(1995)TheImpactoftheExpandedProgramonImmunizationandthePolioEradicationInitiativeonHealthSystemsintheAmericas:FinalReportoftheTaylorCommission.P.14andP.17.

Annex 5ENDNOTES

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22 Fraser,C.andRestrepo-Estrada,S.(1998)CommunicatingforDevelopment:HumanChangeforSurvival.London:I.B.TaurisPublishers.

23 Servaes,J.(2003)ApproachestoDevelopment:StudiesonCommunicationforDevelopment.Paris:CommunicationandInformationSector,UNESCO.

24UNICEFRegionalOfficeforSouthAsia(2005)StrategicCommunicationforBehaviourChangeinSouthAsia.Nepal:UNICEFROSA.

25 Mozammel,M.andSchecter,G.(2005)StrategicCommunicationforCommunity-DrivenDevelopment:Apracticalguideforprojectmanagersandcommunicationpractitioners.Washington,DC:WorldBank.

26Snyder,L.B.,Diop-Sidibé,N.,&Badiane,L.A(2003).Meta-AnalysisoftheImpactofFamilyPlanningCampaignsConductedbytheJohnsHopkinsBloombergSchoolofPublicHealth/CenterformCommunicationPrograms.PresentedattheInternationalCommunicationAssociationannualmeeting,SanDiego:May2003.

27 Snyder,L.B.,&Hamilton,M.A.(2002).Meta-AnalysisofU.S.HealthCampaignEffectsonBehaviour:EmphasizeEnforcement,Exposure,andNewInformation,andBewaretheSecularTrend.InR.Hornik(Ed.)PublicHealthCommunication:EvidenceforBehaviourChangepp.357-383.Hillsdale,NJ:LawrenceErlbaumAssociates.

28Hornik,R.(2002).Publichealthcommunication:Evidenceforbehaviourchange.Mahway,NJ:LawrenceErlbaumAssociates.

29 StopTBPartnership(2003)Reportofthe2ndadhocCommitteeontheTBEpidemic.Geneva:StopTBPartnership.

30Experts’ConsultationonCommunicationandSocialMobilization:AReport,,June29–July1,2003,Cancun,Mexico,StopTBSecretariat

31 Llanos-Zavalaga,F,et.,al.(2004)TheRoleofHealthCommunicationsinPeru’sFightagainstTuberculosis.CommunicationInsights.Baltimore:HealthCommunicationPartnershipbasedatJohnsHopkinsBloombergSchoolofPublicHealth/CenterforCommunicationPrograms.

32 ThuyD.O.etal(2004)TheRoleofHealthCommunicationsinVietNam’sFightagainstTuberculosis.CommunicationInsights.Baltimore:HealthCommunicationPartnershipbasedatJohnsHopkinsBloombergSchoolofPublicHealth/CenterforCommunicationPrograms.

33 Berman,P.,Kendall,C.andBhattacharyya,K.(1994)‘Thehouseholdproductionofhealth:integratingsocialscienceperspectivesonmicro-levelhealthdeterminants.’SocialScienceandMedicine,38:2,pp.205-215.

34QuotedinAHumanRightsApproachtoTuberculosis:GuidelinesforSocialMobilization,WHO2001

35 GuidetoCOMBI,draft

36 TheCovenantonSocial,EconomicandCulturalRightsandtheGeneralCommentbytheUNCommitteeonEconomic,SocialandCulturalRightonarticle12(ontherighttohealth)oftheInternationalCovenantonEconomic,SocialandCulturalRights,quotedinSpecialRapporteur:Economic, Social and Cultural Rights. The right of everyone to the enjoyment of the highest attainable standard of physical and mental health.NewYork,UnitedNations;2003.

37 AHumanRightsApproachtoTB,StopTBGuidelinesforSocialMobilization;WHO,2001

38 CommunityContributiontoTBCare:ReviewofexperienceofcommunitycontributiontoTBCareandRecommendationstoNationalTBProgrammes,StopTBDept.WHO,Geneva2003

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39 Parks,W,McCoy,S.andtheStopTBPartnership(2002)AdvocacyandCommunicationsAssessmentofthe22HighBurdenCountries.Geneva:StopTBPartnership.

40McKee,N.,Bertrand,J.T.andBecker-Benton,A.(2004)StrategicCommunicationintheHIV/AIDSEpidemic.NewDelhi:SagePublications.

41 Renganathan,E.,Hosein,E.,Parks,W.,Lloyd,L.,Suhaili,M.R.,andOdugleh,A.(2005)‘Communication-for-Behavioural-Impact(COMBI):AreviewofWHO’sexperienceswithstrategicsocialmobilizationandcommunicationinthepreventionandcontrolofcommunicablediseases.’InHaider,M.ed.GlobalPublicHealthCommunication:Challenges,Perspectives,andStrategies.JonesandBartlettPublishers,Inc.

42Piotrow,P.T.,Rimon,J.G.II,PayneMerritt,A.,&Saffitz,G.(2003).AdvancingHealthCommunication:ThePCSExperienceintheField.CenterPublication103.Baltimore:JohnsHopkinsBloombergSchoolofPublicHealth/CenterforCommunicationPrograms.

43Piotrow,P.T.,Rimon,J.G.II,PayneMerritt,A.,&Saffitz,G.(2003).AdvancingHealthCommunication:ThePCSExperienceintheField.CenterPublication103.Baltimore:JohnsHopkinsBloombergSchoolofPublicHealth/CenterforCommunicationPrograms.Pp.69-70.

44Thosewhocouldpotentiallyassistinbuildingcountry-levelcapacitymightinclude,interalia:TheAcademyforEducationalDevelopment;BASICS;CommunicationforSocialChangeConsortium;InstituteforSustainableHealthEducationandDevelopment;theInternationalFederationofRedCrossandRedCrescentSocieties;JohnsHopkinsUniversityCentreforCommunicationPrograms;PATH;PANOSInstitute;tbtv;UNICEF;andtheWHOMediterraneanCentreforVulnerabilityReduction(WMC).

45 Narayan,D.,Patel,R.,SchaffiK.,RademacherA.,andKoch-SchulteS.,(1999).Cananyonehearus?Voicesfrom47countries.Washington,D.C.:WorldBank.

46Brock,K.,(1999).“It’snotonlywealththatmatters–it’speaceofmindtoo”:areviewofparticipatoryworkonpovertyandillbeing.Washington,D.C.:WorldBank.

47 WHO(2003)TBandPoverty.DiscussionPaperforthe3rdMeetingoftheStrategicandTechnicalAdvisoryGroupforTuberculosis.Geneva:WorldHealthOrganization,23-25June2003.

48Narayan,D.,Chambers,R.,Shah,M.andPetesch,P.,(1999).Globalsynthesis:consultationswiththepoor.Washington,D.C.:WorldBank.

49 HansonC.(2002)Tuberculosis,povertyandinequity:areviewofliteratureanddiscussionofissues,(unpublished).

50 SpenceD.P.S.,HotchkissJ.,WilliamsC.S.DandDaviesP.D.O.(1993)Tuberculosisandpoverty.BritishMedicalJournal,Vol.307:759-761.

51 Kanji,N.,(2003).MindtheGap:Mainstreaminggenderandparticipationindevelopment.London:InternationalInstituteforEnvironmentandDevelopment(IIED)andtheInstituteofDevelopmentStudies(IDS).

52 Guijt,I.andShah,M.K.Eds.(1998).TheMythofCommunity:GenderIssuesinParticipatoryDevelopment.London:IntermediateTechnologyPublications.

53 UplekarM.W.,RanganS.,WeissM.G.,OgdenJ.,BorgdorffM.W.,HudelsonP.(2001)Attentiontogenderissuesintuberculosiscontrol.IntJTubercLungDis5(3):220-224.

54MorankarS.,DeshmukhD.(2001)Socio-culturalaspectsoftuberculosisamongwomen:ImplicationsforDeliveryofServices.ThefoundationforResearchinCommunityHealth,Pune/Mumbaiunpublishedreport.

55 Aggleton,P.andParker,R.(2002)WorldAIDSCampaign2002-2003.Aconceptualframeworkandbasisforaction:HIV/AIDSstigmaanddiscrimination.Geneva:UNAIDS/02.43E.

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56 InternationalCenterforResearchonWomen(2002)UnderstandingHIV-relatedStigmaandResultingDiscriminationinSub-SaharanAfrica.ResearchUpdate,June.

57 Pinet,G.(2001)GoodpracticeinlegislationandregulationsforTBControl:AnIndicatorofPoliticalWill.Geneva:StopTB,WHO.WHO/CDS/TB/2001.290.

58 Burkhalter,B.,etal.(1998)PROFILES:AData-BasedApproachtoNutritionAdvocacyandPolicyDevelopment.PublishedforUDSAIDbytheBasicSupportforInstitutionalisingChildSurvival(BASICS)Project.Arlington,VA.

59 WorkplacePolicyBuilderdevelopedbyTheFuturesGroupwww.futuresgroup.comandthePOLICYProjectwww.policyproject.com

60SeeinparticulartheCommunicationInitiativewebsitewww.comminit.comandtheCommunicationforSocialChangeBodyofKnowledgewww.communicationforsocialchange.org

61 Naimoli,G.(2002)CapacitybuildinginCommunications:AnexaminationofthePolioEradicationInitiative.CHANGEProjectandPartnersonCommunicationforPolioEradication.

62 TheNeedsAssessmentToolandChecklist,StopTBPartnership,2005

63 StopTBAdvocacyandCommunicationChecklist,StopTBPartnership,2005

64WebSite,GFATM www.theglobalfund.org/en/about/how

65 Ibid.

66Basedonfundinglevelsandpreliminaryresultsinfourdonorcountrypilotprojects.

67 Selection,trainingandequippingofcivilsocietyadvocacypartnerin4donorand8endemiccountries

eachyearbetween2006–2010,andcommunicationandsocialmobilizationpartnersin5countrieseachyearbetween2006–2008,withcontinuedTAinsubsequentyears.ACSM-WGproposestouse3-yearTAcontractsinitiallyawardedforeachcountrythat,dependingonthescaleandinitialcapacityofeachcountryrequestingsupport,willbeworthapproximatelyUS$175000each.


69 ForinformationonCOMBIsee:www.who.int/infectious-disease-report/2002/behaviour.htlmandwww.comminit.com/pdf/Combi4-pager_Nov_14.pdf;WorldHealthOrganizationWesternMediterraneanCentre(forthcoming)AManualforDesigningaCommunication-for-BehaviouralImpact(COMBI)PlanofAction.Tunis:WHOWesternMediterraneanCentre.

70 Nair,K.S.andWhite,S.A.(1994)‘ParticipatoryDevelopmentCommunicationasCulturalRenewal.’InWhite,S.A.withNair,K.S.andAscroft,J.(eds)ParticipatoryCommunication:Workingforchangeanddevelopment.NewDelhi:SagePublications.Pp.138-193.

71 IIRR.1996.Recordingandusingindigenousknowledge:Amanual.InternationalInstituteofRuralReconstruction,Silang,Cavite,Philippines.

72 HowcancommunicationandsocialmobilizationhelptheDOTSstrategy?AnoutcomemaptostrengthenDOTSStrategytoStopTB,JohnsHopkinsUniversity,CentreforCommunicationPrograms,HCPStopTBTeam,BenjaminV.Lozare,2005(Powerpointpresentation)

73 PersonalcommunicationfromCaseGordon,TBwww.tbtv.org

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74 Burkhalter,B.,etal.(1998)PROFILES:AData-BasedApproachtoNutritionAdvocacyandPolicyDevelopment.PublishedforUSAIDbytheBasicSupportforInstitutionalisingChildSurvival(BASICS)Project.Arlington,VA.

75 WorkplacePolicyBuilderdevelopedbyTheFuturesGroupwww.futuresgroup.comandthePOLICYProjectwww.policyproject.com

76 AdaptedfromUNAIDS(2000)NationalAIDSProgrammes:Aguidetomonitoringandevaluation.Geneva:UNAIDS/00.17E.

77 TakenfromUSAID’sproposedindicatorlistpresentedinGeneva,18/12/02.

78 Smallincentivescouldalsobeorganizedtoencouragesputum-testingashasbeenproposedinsocialmobilizationandcommunicationforbehaviouralimpact(COMBI)plansinKenya,India(KeralaState)andBangladesh.

79 InformationonMostSignificantChangeisdrawnfrom:Dart,J.(1999)‘AStoryApproachformonitoringchangeinanagriculturalextensionproject.’PaperpresentedattheConferenceoftheAssociationforQualitativeResearch,Melbourne,July,1999;thewritingsofRickDaviesin:Mosse,D.,Farrington,J.,andRew,A.(1998)DevelopmentasProcess:ConceptsandMethodsforWorkingwithComplexity.London.Routledge/ODI,Pp.68-83;andinImpactAssessmentandProjectAppraisal,16(3):243-250;andDavies,R.andDart,J.(2005)TheMostSignificantChange‘MSC’Technique:AGuidetoItsUse.www.mande.co.uk/docs/MCSGuide.pdf

80Davies,R.andDart,J.(2005)TheMostSignificantChange‘MSC’Technique:AguidetoItsUse.

www.mande.co.uk/docs/MCSGuide.pdf

80Davies,R.andDart,J.(2005)TheMostSignificantChange‘MSC’Technique:AGuidetoItsUse.http://www.mande.co.uk/docs/MSCGuide.pdf.

82 Singhal,A.andRogers,E.(2003)op.cit.,pp.351-353.

83 InformationonisdrawnfromChapman,J.andWameyo,A.(2001)MonitoringandEvaluatingAdvocacy:AScopingStudy.www.actionaid.org/resources/pdfs/asp.doc;andRoche,C.(1999)ImpactAssessmentforDevelopmentAgencies:LearningtoValueChange.LondonOxfam.

84Fox,L.M.andHelweg,P.(1997)AdvocacyStrategiesforCivilSociety:AConceptualFrameworkandPractitioner’sGuidepreparedforTheCentreforDemocracyandGovernance,USAID.

85 David,R.andCoates,B.(200)DraftArticleonMonitoringAdvocacy.Unpublished.

86 McKee,N.,Bertrand,J.T.andBecker-Benton,A.(2004)StrategicCommunicationintheHIV/AIDSEpidemic.NewDelhi:SagePublications.P.40.

87 StopTBPartnership(2002)AdvocacyandCommunicationsAssessmentofthe22HighBurdenCountries.Geneva:StopTBPartnership.

88 WarrenC.RobinsonandGaryL.Lewis(2003)“CostEffectivenessAnalysisofBehaviourChangeIntervention:AproposednewapproachandanapplicationtoEgypt”.JournalofBiosocialScience,Vol.35,Iss.4,pp.499-512.

89 Mayne,J.(1999)AddressingAttributionthroughContributionAnalysis:UsingPerformanceMeasuresSensibly.OfficeoftheAuditorGeneral,Canada.

90Kincaid,D.L.,&Do,M.P.(2003).Causalattributionandcost-effectivenessofanationalcommunicationcampaign:FamilyplanningpromotioninthePhilippines.Aworkingpaper.Baltimore:JohnsHopkinsBloombergSchoolofPublicHealth,CenterforCommunicationPrograms.

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81 AdaptedfromworkpostedbyWarrenFeekontheCommunicationInitiative:www.comminit.com

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91 Mohd.RailiSuhaili,Hosein,E.Mokhtar,E.etal(2005)‘ApplyingCommunication-for-Behavioural-Impact(COMBI)inthepreventionandcontrolofdengueinJohorBahru,Johore,Malaysia.’DengueBulletin,SpecialSupplement,Volume28.


93 Parks,W.andLatiri,Z.incollaborationwith:theRepublicofSudanFederalMinistryofHealth,NationalProgrammeforMalaria,Leishmaniasis,SchistosomiasisControl(NPMLSC);WHOCountryOffice/Sudan;andtheEasternMediterraneanRegionalOfficeofWHO,Egypt(2003)Communication-for-Behavioural-Impact(COMBI)PlantoScaleUptheUseofInsecticide-TreatedNets(ITNs)intheControlofMalariaintheRepublicofSudan.Tunis:WorldHealthOrganizationMediterraneanCentreforVulnerabilityReduction.

94 WHO(2003)TheZanzibarStory.Geneva:WorldHealthOrganization.

95 Jaramillo,E.(2001)‘Theimpactofmedia-basedhealtheducationonTBDiagnosis.’HealthPolicyandPlanning,16(1):68–73.

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