Local solutions solve local problems best.

1. Local solutions solve local problems best.

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

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

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

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

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

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

8. Somewhere in the future • Knowing that TB is contagious, Masri made sure that he got better and that he won’t infect his children. • Both Masri and Fitri are deeply concerned about the political and economic future of their country. They vote intelligently and always encourage their friends to do the same.

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

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

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

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

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

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

15. Why is there a difference? • Our challenge is to think deeply and then act.

16. Shared vision for TB – By 2015, • Households, communities and government are working together so that no person dies from TB in community X, Y, or Z. • There is universal knowledge about TB symptoms, the treatment process, and its availability. Those with disease symptoms seek care immediately and conform rigorously to treatment regimen. • There is strong family and community support to have any case of TB to be treated and stigma regarding the disease is absent. DOTS is implemented from a multidisciplinary and multi-sectoral perspective.

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

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

19. Why is there a difference? • Our challenge is to think deeply and then act.

20. Where do leaders operate? Beyond Imagination That’s Impossible Looks Difficult Easy to do

21. 1. How do we usually define “health problems? • 1. Deviation from “norm” or “indicator chasing” 2. Existing “solutions” in tool box • - Ideology • - Training • 3. Knee-jerk “lack of resources”

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

23. Use existing solutions - When we have a hammer, everything looks like a nail! • 1. Trainer - everything is a training problem. • 2. Manager - everything is a management problem. • 3. Community mobilizer - everything is a community mobilization problem. • 4. Medical doctor -everything is a medical problem.

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

25. Relationship between income and malnutrition

26. The “disconnect” between income and malnutrition Alternatively, Malnutrition “falls” independent of “rises” in income (among the lowest income countries)

27. Examples – Deviation from norm • Overall strategic objectives: • Detect at least 70% of active TB cases • Successfully treat at least 85% of TB cases detected

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

29. Analysis – Existing tools in our tool box • Communication – Which communication factors impact on case detection and successful treatment? • Which communication factors are weakest in the current situation? KAP?

30. Analysis – Lack of resources • Which communication activity impacts the most on case detection and successful treatment? • How much do we allocate for these activities?

31. 2. What is an alternative way to defining problems? • Define problems in terms of why there is a difference between what we want (shared vision) and what is happening (current situation) and how to bridge this difference.

32. Approach requires two things • 1. We need to know clearly what we want. • 2. We need to know clearly what is happening now.

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

34. Which approach is best for your country to STOP TB? • 1) Change conditions one at a time. • 2) Achieve doses of improvement in several conditions over time. • 3) Conduct local experiments and scale up • 4) Devolve or decentralize

35. Change one condition at a time No one dies from TB Universal Effective DOTS treatment Universal access to SSM Political will at all levels High TB mortality

36. Little changes in all conditions over time – Vietnam and Peru Improvements in access to SSM Less deaths from TB Improvements in effectiveness of DOTS treatment Improvements in political will at all levels High TB mortality

37. We improve through local experiments and scaling up No deaths from TB National scaling up Learning communities Local experiments High TB mortality

38. Devolve or decentralize

39. Who should be our audience in tuberculosis control and prevention campaigns? • 1. Audiences on the program side • 2. Audiences on the client side

40. Audiences on the program side • Policy makers • Influentials • Program managers • Health workers • Donor agencies

41. Audiences on the client side • 1. Everyone • 2. High risk groups • Those in areas with high • incidence and • prevalence of active TB • 3. Low risk groups • Those in areas with low • incidence and prevalence of active TB

42. Audiences on the client side –High prevalence areas • Those with low levels of education and access to mass media • “Connectors” • “Mavens” • “Salesmen” • Very young • Very old • Immunosuppressed

43. What is audience segmentation? • Audience segmentation categorizes audiences into logical groups to enhance a better fit among • Audiences • Messages • Media • Service or products

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

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

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

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

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

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

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