Report of the Communications Review
Pakistan Polio Eradication Programme
April-May 2012
This report presents the findings of the Communication Review panel, conducted for UNICEF Pakistan on behalf of
the national polio eradication programme. The panel worked in four teams to cover four critical areas of
communication and social mobilization:

Mass media (Rod Curtis, Amber Rana)

Interpersonal communication and community engagement (Jeff Bates, Susan Roe)

High-risk groups (Chris Morry, Hans Frey)

Monitoring and evaluation (Sue Goldstein, Seb Taylor)
This report primarily refers to the UNICEF polio communication programme. However, it is expected that, given the
critical importance of partnership in the polio programme as a whole between UNICEF and WHO, donors and local
counterparts, under the guidance of the Government of Pakistan, the report will provide useful information to all
relevant actors.
The panel worked in-country between 27 April and 8 May. The panel received full briefing on programme and
epidemiological status as at April 2012, before deploying to conduct brief province and sub-province level field
consultations (Peshawar (High-risk Groups Team), Sindh (Mass Media & IPC/Community Engagement Teams), and
Punjab (M&E Team).1
Pakistan Polio Communications Review Teams Members
Team Member
Background
Rod Curtis
Amber Rana
UNICEF polio communications, India
Creative Director, Go TV, Pakistan
Jeff Bates
UNICEF polio communications, New York
Susan Roe
UNICEF C4D, Kathmandu
Chris Morry
Programme Director, The Communication Initiative
Hans Frey
Sue Goldstein
Public Health and Communications, Soul City
Polio programme consultant
1
A briefing from the Balochistan team was provided in Islamabad, given prevailing security concerns in the province.
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Seb Taylor
Senior Professor, Area Study Centre, Quaid-i-Azam University Islamabad
Contents
Report of the Communications Review ............................................................................................................... 1
Pakistan Polio Eradication Programme .............................................................................................................. 1
Executive Summary....................................................................................................................................... 3
Acknowledgements................................................................................................................................... 3
Findings ..................................................................................................................................................... 3
Summary of Findings and Recommendations .............................................................................................. 5
Findings ..................................................................................................................................................... 5
Recommendations .................................................................................................................................... 7
Team Reports ................................................................................................................................................ 9
Team 1: Mass media ................................................................................................................................. 9
Team 2: IPC and Community Engagement ............................................................................................. 18
Recommendations .............................................................................................................................. 19
Team 3: High-Risk Groups ....................................................................................................................... 27
Recommendations .............................................................................................................................. 30
Team 4: Monitoring & Evaluation ........................................................................................................... 32
Recommendations .............................................................................................................................. 37
Annexes:...................................................................................................................................................... 38
Mass Media Team ................................................................................................................................... 38
Media Summary Areas and Recommendations.................................................................................. 39
IPC Team ................................................................................................................................................. 43
HRG Team ............................................................................................................................................... 44
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M&E Team .............................................................................................................................................. 44
Executive Summary
Acknowledgements
The review team would like to thank the many people who took the time to speak to us about their work with honesty
and candor. We would especially like to thank the polio communication teams in Islamabad, Khyber Pakhtunkhwa,
Balochistan, Sindh and Punjab for their assistance in making this review possible and for their work building this
programme in very difficult circumstances. What follows below is not a criticism of that work but an
acknowledgement of the very large strides that have been taken in 2011 and an attempt to help build on that
progress. Much has been done but much, of course, remains, and continuing to improve the programme’s
communication capacities over the coming months are critical to the ultimate success of the eradication effort in
Pakistan and the world.
Findings
Central to improving performance in the partnership is improvement in coordination and close collaborative
working of key programme partners (primarily WHO and UNICEF) under the aegis and leadership of the
Government of Pakistan (GoP), and with the backing of global donors. There remains room for improvement in
this – a situation widely acknowledged to be remediable with some simple measures including, for example,
more regular, systematic and frequent meetings at federal and provincial levels (mirroring close operational
relations in Districts and Union Councils); particularly important is joint participation in, and strategy development
from, surveillance review meetings.

On the mass media front, UNICEF now has the resources to fulfill its mandate as lead for programme
communication but will not be able to fully step into that role without further development of media relations and
a greater emphasis on coordinating the programme’s communication response.

In relation to front-line teams (including both vaccinators and local COMNet social mobilisers), there is an urgent
need to strengthen interpersonal communication (IPC) skills yet the training and related materials are yet to be
rolled out.

A high risk group strategy is in place and is beginning to demonstrate early signs of impact but it has yet to reach
full capacity in the critical province of Khyber Pakhtunkhwa. Further, transit points need to be placed more
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
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In general terms the review found that the significant increase in polio communication capacity over the past several
months and the momentum this is creating within the programme are positive and provide the strongest and most
comprehensive communication platform the programme has ever had. Foundations have been built for: focused
community mobilization through COMNet; a mass media campaign capable of reaching high risk populations; training
to strengthen inter-personal communication (IPC) skills for frontline workers; strategy to identify and reach high risk
and mobile populations more effectively; a significant new capacity to collect and analyse social data to pinpoint
contextual factors at the local level obstructing or supporting better programme performance; & a stronger emphasis
on monitoring and evaluation communications and social mobilization initiatives with regard to their contribution to the
programme as a whole. However, much of this capacity remains new and it is too early to see the impact of many of
the strategies and initiatives that are guiding implementation. Equally, there is still considerable room for
improvement, some critical gaps and areas where urgent action is required. The following are key summary
observations found to be common across all or the majority of the review teams’ experiences:
strategically. IDPs that do not stay in camps pose a major challenge and there is still no specific strategy for
FATA.

There is a very good new system (PRIME) being developed for gathering and analyzing social data. However,
the system should be focused on answering one core programme question – why are children being missed.
Further, this analysis should be produced and fed back into operational planning (critically through District and
Union Council campaign planning, microplanning and mapping). And social data should be combined with
operational and epidemiological data to produce a single shared analytical picture of programme performance by
District and UC, owned jointly by core operational partners.
As we finalise this report, we are also struck by flood warnings and the potential for significant disruption of the
programme and large scale displacement of people in the coming 2-3 months. We did not specifically focus on
disaster preparation or readiness but hope that as the recommendations below are reviewed consideration also be
given to prioritizing those elements of media, mobilization, training and reaching high risk and mobile populations that
will be useful should floods lead to large scale disaster and all that that will entail.
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Below you will find summary findings and recommendations though we hope that you will be able to find to read
through each teams full report where further dimensions of analysis and insight can be found.
Summary of Findings and Recommendations
Given the substantial overlap in the four programming streams, overall findings and recommendations are presented in matrix format to maximize coherence
between and among identified programme priorities, as well as national, provincial, District, Union Council and community levels of action.
Findings
Mass media
Top-line
Interpersonal Communication
High-Risk Groups
Monitoring &Evaluation
All teams reported significant operational strength – and highly positive up-scaling of engagement and investment – in polio eradication by UNICEF in the review period
Overview
Increased capacity now enables
UNICEF to fulfill its mandate for
polio communication but there
remains considerable opportunity
to develop media relations and
coordinate communication
response.
The Pakistan polio communication
programme has regained momentum and
now has an infrastructure capable of large
scale social mobilisation interventions in
key high risk districts. However, improving
IPC skills and tools remains a critical and
urgent need.
High-Risk Group strategy and activities are
developed but need to be fully implemented;
the programme needs to respond to fastmoving changes, e.g. conflict/natural
disaster disruption.
Capacity
Need to engage media through
workshops and meet and greets
to build trust in the programme
and capacity for polio reporting
There is a need to build IPC training and
materials for front-line workers (social
mobilisers and vaccinator teams) based
on standard social engagement activities.
Need to improve specialised IPC training for
vaccinator and transit point teams.
Community
engagement
Mass media has achieved high
levels of national reach but more
work is needed to engage media
at provincial and local level to
reach HRGs and to increase
threat perception.
There is evidence of high levels of
community commitment to the
programme; there is no sign of embedded
resistance to OPV in most districts.
Need to define in more detail ‘High-Risk
Groups’, to understand communication
needs of specific tribal, religious, nomadic
and mobile populations
Data do not support a continuing primary
emphasis on ‘refusals’ – and on
‘conversion’/‘influencer’ communication/social
mobilisation activities
COMNet offers a platform for engaging
hardest-to-reach communities/areas but
needs more materials designed for
frontline use and the roles of influencers
need to be more structured and expanded
beyond addressing refusals.
COMNet shows signs of potential impact
(i.e. Balochistan) but is not yet fully
operational in KP.
Focus COMNet on core programme challenges
e.g.: supporting vaccinator delivery (including
enabling vaccinator access in insecure areas
and engaging mobile & displaced populations)
COMNet
UNICEF are building an excellent system for
gathering social data for polio; all research,
monitoring and evaluation should be focused on
one issue: understanding and addressing
‘missed children’
Data
External review is required for
impact of mass media at national
and community-specific
awareness
Data (resolution, reliability and availability
at local level) remain a challenge and
should be better used for performance
analysis and operational strategy at the
micro-strategy level.
The lack of reliable data on reasons for
missed children in high risk districts and
amongst high risk groups remains an urgent
issue.
Social research and data-gathering instruments
(e.g. KAP) should be rapidly disseminated at
operational levels in combination with
technical/epidemiological data to support
microplanning
Operations
There is no media crisis plan and
a lack of coordination regarding
spokespersons.
UNICEF has strong presence at District,
UC and community levels, with parallel
WHO structures but more coordination is
needed to be able to adequately deal with
the scope of issues in high risk
communities.
A streamlined HRG strategy (currently over
50 activities) has been developed but not
yet implemented and these is still no
strategic communication plan for FATA.
Data analysis should be fed into operational
review and planning each round; the
Performance Cards are useful ‘dashboard’ for
fast-turnaround programme review and planning
Coordination
All partner activities in polio mass
communication activities should
be streamlined into ‘one voice’
There is evidence of collaboration
between MoH, UNICEF WHO and
community within UCs, though roles of key
actors at UC need to be modified.
Recent joint meetings between UNICEF and
WHO to develop a coordinated HRG
strategy, improve data collection and
strengthen working relations at the frontline
worker level are promising but much still
needs to be done to translate these
discussions into a more effective
programme.
UNICEF and WHO should be sharing data and
programme analysis more regularly and actively
(e.g. at national surveillance meetings and
District/UC microplanning level)
Recommendations
Mass media
Top-line
National
Interpersonal Communication
High-Risk Groups
Monitoring & Evaluation
Strengthen coordination (national, provincial, district, UC and operational) between UNICEF and WHO, under GoP leadership, with specific reference to regular, systematic meeting
to share data on PEI performance, analysis of barriers, and joint strategy to reduce missed children
Focus on building media
relationships, and strengthening
journalist PEI knowledge & reporting
capacity through media workshops,
take away media packs and more
pre-round media events.
Standardise community engagement
strategy and supporting materials, with
intensified approaches for HRGs
Complete and operationalise Islamabadbased HRG team (GoP, UNICEF, WHO,
partners) to coordinate implementation of
HRG strategy
Maintain and develop core PEI social data
instruments (KAP etc).
Regular provincial COMNet review
meetings to assess activities impact, and
support KP strategy design and roll-out
Refine evidence of mass media impact,
especially on identified HRGs
Develop a media crisis plan with
supporting materials.
Focus all PRIME research, data-gathering and
analysis functions on the core programme
question – why are missed children missed, and
what are the operational solutions to the
problem?
Ensure government is the leading
voice on polio.
Improve coordination between
partners through editorial meetings,
aligning media and communication
plans and improving staff training on
EPI and communication to improve
partner relations.
Province
District
Prioritize ongoing relationships with
key media houses, conduct regular
briefings with local media houses,
identify high profile local voices for
media events and work with local
medical associations to promote the
programme.
Increase media spend on terrestrial
channels and radio and reduce
spend on print while maintaining a
Develop and implement a FATA
communications strategy, emphasizing
enabling access to insecure areas through
local intermediaries.
Review and rationalize key operational
roles for front-line PEI workforce, with
particular emphasis on District and UC-
Develop high quality IPC materials and
activities for social mobilisers and
vaccinator teams, with specialized training
Modify ‘Performance Card’ to focus on: missed
children; causes of missed children; localized
comms/operational solutions to missed children
rolling evaluation of media habits of
HRGs.
Union
Council/Co
mmunity
level ‘teams’.
for transit teams
Strengthen training for core
communication and social mobilization
personnel (data analysis, IPC, vaccinator
support).
Ensure detailed mapping of disaggregated
HRGs at UC level, feeding into
microplanning for each round
Focus COMNet activities on core causes of
missed children (e.g. vaccinator IPC support,
insecure areas and access to high-risk and
mobile/displaced groups)
Team Reports
The following sections provide in more detail the areas of investigation, analysis, findings and recommendations from
each of the four review teams.
Team 1: Mass media (Rod Curtis, UNICEF India; Amber Rana, Go TV, Pakistan)
Background: With the highest number of polio cases globally in 2011 (a 15-year record), mainstream print media
has been vocal and critical about the polio eradication programme, and the media environment remains volatile.
Proactive engagement of the media is critical, with UNICEF and partners having recently introduced a number of
activities designed to positively influence the media environment and encourage factual, evidence-based reporting of
the programme. Recent investments in mass communication and outdoor advertising have reached approximately
100 million people in the last two months. Although internal assessments of scope, reach, penetration, and cost–
benefit analysis have been undertaken (% audience reach/penetration, exposure/impressions, GRP and CPRPs),
these mass communication and placement strategies also require an external review of impact on national and
community awareness, in particular in hard-to-access areas and among high-risk groups.
Key observations
1. Media Engagement:
UNICEF’s capacity to engage media and tackle media crises has been insufficient to date and this is acknowledged.
However, UNICEF has placed significant investment in the hiring of key staff, most notably the soon-to-arrive
International Polio Communication Specialist (Michael Coleman), in addition to 2xNOC positions, 1x NOB and
5xprovincial-level media staff, which will ensure UNICEF has the requisite capacity to fulfill its mandate to lead the
programme communications effort.
On balance, media tonality of the programme is relatively positive (92.5% positive or neutral reporting from 5
February-12 March). However, negative media has disproportionate impact on the programme, with misconceptions
in the community relating to vaccine safety and/or links with the USA/bin Laden capture. With Pakistan being firmly in
the global spotlight for polio eradication, negative English-language national media also places pressure on the
programme from abroad.
Ultimately, media engagement is a significant growth opportunity for the Pakistan polio programme, with key media
relationships yet to be established in major cities. An immediate strategy should involve casual meet-and-greets with
key health journalists, Directors of News/Editors and owners where appropriate to present the polio programme as a
strategic partner with media for a healthy Pakistan (we are also a client with a significant on-air spend). Engagement
of religious newspapers/ publications, which often feature negative content and are mostly published out of Karachi,
Multan and Lahore, can be an action point for HRG Coordinator Dr Shamsher Ali Khan.
Provincial-level media officers are in place and can quickly establish key relationships with provincial media, as well
as roll out media events prior to each round, with a view to ensuring unpaid, quality coverage (at first contact, media
should receive a media pack with basic programme info, spokesperson contact numbers and website information for
updated epi).
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Ultimately, the review team is confident the media environment is a huge growth opportunity and that an engaged
media will help eradicate polio in Pakistan, by promoting the programme, creating awareness, and even holding
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As strategic partners, the media must be proactively engaged with updates on the progress of the campaign. The
media alert being produced by WHO is a good product, updated regularly – full credit to WHO for launching and
maintaining this. It is also worth looking at the weekly media alert UNICEF was producing in 2009 for further ideas.
poor-performing districts/personnel to account. But improved planning/coordination/urgency is necessary to ensure
the GPEI drives the agenda proactively, not responds to it reactively.
Recommendations

Casual meet-and-greets with key health journalists, Directors of News/Editors and owners

Provincial-level engagement with key media, including ‘media pack’ containing basic programme info,
spokesperson contact numbers and website info.

Pre-round ‘media events’ rolled out prior to each round in each province.

Close liaison with C&A chief and use of ICO’s media engagement experience.
2. Capacity building
The review team strongly encourages the rapid implementation of planned media workshops. These are an excellent
platform for developing long-term relationships between the media officers and their key media and subsequently
creating long-term media advocates for polio. Currently, 5 trainings x 30 journalists each are planned in Lahore,
Quetta, Peshawar, Islamabad and Karachi. We recommend greater emphasis on journalists at the session producing
a PSA/story to take back to their media house. It is also key that the programme does its homework to ensure the
initial 150 journalists invited are the key media for the GPEI in these cities. These then form the backbone of a
regularly updated/engaged Polio Directory of Journalists. Future media workshops should be systematically rolled out
according to strategic need: ie, according to epidemiological need or areas of poor media tonality (we recommend
orientating 400 journalists in 12 months = one workshop per month).
The concept of using an individual 3rd party is sound, as is their shared focus with polio on health environment, media
ethics (the need to quote multiple sources, etc) and editors’ requirements. However, UNICEF media staff and a WHO
technical focal point should attend. The Media Pack with key facts, Qs and As and identified spokespersons and
contact numbers is an important take-away.
There is an excellent idea of forming a ‘Journalists Against Polio’ group (other ideas were Mothers Against Polio,
Youth Against Polio), out of these trainings, which we believe would help to create the desired media ownership of
the polio programme and provide a further source of information about planned stories in the news cycle. It is worth
investigating a similar group successfully established by UNICEF in 2009. Other groups can also be tapped, such as
the Tribal Union of Journalists.
Roll-out of media workshops as a programme priority, with emphasis on production of polio story/PSA to take
back to media house, and production of a Media Pack.

Review of media tonality/clippings/language media, etc, to ensure 150 journalists in attendance represent key
media houses for GPEI.

Establishment of updated Polio Directory of Journalists, with names and contact numbers, emails (national and
provincial levels). List consolidated with WHO for media outreach through polioalert.info

Investigate alliance with Tribal Union of Journalists.
3. Media Crisis Management
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Recommendations
Media crisis management has been poor, and has resulted in division between partners. UNICEF’s response to the
Dunya TV crisis, where a leading TV anchor repeatedly called OPV safety into question, was far too slow. This
resulted in WHO moving to fill the media void in Pakistan. In time, UNICEF’s response to this crisis was thorough2,
but the point is that media crisis management requires immediate discussion and, where appropriate and agreed,
immediate response.
UNICEF has prepared a robust three-month Media Strategy and WHO has prepared a draft Communications
Strategy – both documents must be discussed and rapidly aligned. However, the review team was surprised that
there was no clear, agreed Media Crisis Plan in place, including designated partner focal points, OICs (to cover
against R&R absences or travel/after-hours absences, etc), and agreed processes to enable to GPEI to respond to a
perceived threat as one voice. There was also a perceived lack of agreed materials for media response, such as Fact
Sheets, Qs & As.
There remains a need to identify government spokespersons at national, provincial and DCO level and orientate
them to speak to media. (An excellent initiative has been the Advocacy & Communication section, under Chief
Kristen Elsby, conducting media training for the expanded polio team in May.) The spokesperson tree in polio
eradication is well established globally: Government speaks first, WHO speaks second, to technical queries when
required and UNICEF third, to the communications programme. The devolution of the Ministries of Health underlines
the need for trained government spokespersons to represent its programme, particularly in the provinces.
It would be beneficial to have a sound understanding of persistently negative media houses. An evolving Media
Matrix generated by daily/weekly/monthly tonality analysis highlighting positive and negative coverage can be used
for strategic targeting of media intervention, including identification of sites for media workshops. In terms of being
ahead of the curve, established relationships with journalists/editors are the best way of knowing about a developing
story (and potentially cutting it off at the knees before it goes to air). Increasingly social media like Twitter is useful for
getting leads on the news cycle’s plans.
Recommendations:

Develop Media Crisis Plan, including designated partner focal points, OICs (to cover against absences) and
agreed process for a media crisis response. Withdraw UNICEF Rep from the approval process.

Fact Sheets/Key Messages/Qs & As prepared (ICO can assist)
•
Align UNICEF Media Strategy and WHO (Draft) Communications Strategy
•
Identify GoP spokespersons and orientate them on programme/media training
•
Media matrix identifying publications/stations by positive/negative tonality
4. Partner relations/coordination on Media
Partner relations on media and polio have descended, in some instances, to active hostility, with ‘too many cooks’,
multiple websites and publications, etc, and no established editorial content coordination mechanism. It can be
expected that Michael Coleman’s arrival will deliver the required coordination between both the polio and
Communication & Advocacy Departments and partners. A recommendation for division of media roles has been
discussed with WHO and UNICEF and is at the end of this document.
UNICEF’S media response to the Dunya TV statement included: press conferences facilitated across the country on OPV safety, hosted by
the Medical Community; PPA at the highest level spoke publically on behalf of OPV safety; a media event with Jang Forum in Lahore; an IPC
reference guide was developed for vaccination teams to address potential doubts about vaccine safety; endorsements were distributed by the
General Secretary of PMA and other credible paediatricians to bolster credibility of vaccinators; the mass media campaign ran an endorsement
of OPV safety by PPA as an add-on.
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2
It is superfluous to have two active websites. WHO’s media website www.polioalert.info is user-friendly, well edited,
kept up to date, and should be promoted as the key contact point for media information in Pakistan. UNICEF’s
domain name - www.endpolio.com.pk – and content is suitable for general audiences (and with a .pk domain is more
local). We would recommend that polioalert.info sits behind endpolio.com.pk (which means you can still individually
access both sites), but that the endpolio.com.pk site becomes the GPEI’s principal website, with a ‘Journalists Go
Here’ tab directing media through the UNICEF site to polioalert.info. If this happens, the UNICEF site MUST be
updated regularly (there is little evidence to expect this as a matter of course) with up-to-date epi data presented in
the site.
It would be beneficial for UNICEF staff, many of whom are new to polio eradication, to receive a one-day
epidemiological training in order to better understand the epi dangers and opportunities, and how they correlate into a
communication strategy. This would enable UNICEF staff to be active participants in AFP/epi meetings (and not
question the SIAD strategy in a partnership meeting, as we witnessed), to guide the media accurately, respond to the
government keenly, and to speak WHO’s language. Concurrently, a one-day course covering behaviour change
communication and IPC principles would be beneficial for WHO focal points.
UNICEF’s strategic participation at the weekly AFP meetings is key. On the week the review team attended the AFP
meeting, it was suggested that every zero-dose AFP case should trigger an investigation conducted jointly by
UNICEF and WHO. The meeting also highlighted that while Lahore has not been reporting cases, 8 of 11 (or 73%) of
environmental samples were positive – a message that needs to be relayed to social mobilizers. The operational
quality of Peshawar campaigns is high, yet 7 of 7 environmental samples have returned positive. These are core
operational and programme issues. They speak directly to the chances of a turnaround in the fortunes of polio
eradication in Pakistan, and must be jointly understood and collaboratively dealt with by the core programme
partners.
Recommendations:

Weekly inter-agency editorial meetings to generate provincial media focus, produce content for website,
newsletters, etc.

Monthly Social Mobilization Working Group meetings (UNICEF, WHO, GoP, Rotary, USAID, BMGF) to analyse
Mass Communication strategy, media tonality analysis, plans for IEC, IPC, discuss upcoming visits, etc.

Consolidate websites.

Conduct epi training for UNICEF staff and how it correlates into a comms strategy and BCC/IPC training for
WHO staff.

Joint WHO/UNICEF investigation of every zero-dose AFP case.
5. Provincial-level media
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The provincial-level media officers we met were impressive: engaged and enthusiastic. The data indicate they are
working well (in Quetta, positive stories had risen from 60 in March to more than 140 in April) yet strategic
identification of critical, low-hanging fruit is yet to be fully harnessed. For instance, it is clear that Pashto-speaking
12
Both media officers we spoke with (Balochistan and Punjab) spoke of poor coordination with WHO – history shows
that it usually falls to UNICEF to reach out on partnership coordination at provincial level, and we would encourage
UNICEF field staff to adopt this mind-set. There also appeared to be little coordination between the 5 media officers –
a weekly con-call and quarterly media officer retreats to discuss strategies could be considered. This would be a
good opportunity to brainstorm a list of media events to generate coverage ahead of campaigns and between
campaigns, especially in the high season when fewer rounds are being held. A “theme of the month” could be a good
strategy for generating coverage.
communities favour radio, and particularly BBC Pashto and VOA. PTV Bolan and Spin Boldak area also key stations.
While the review team agrees VOA is best avoided at this stage, a relationship with BBC Pashto is a no-brainer. Yet
the media officer doesn’t know key personnel at BBC Pashto. Secondly, Balochistan is soccer-mad, and the Pakistan
national captain, Dr Issa, is from Killa Abdullah – this is an immediate opportunity for a media event ahead of the next
campaign. Another priority is provincial-level partnerships with the medical fraternity (paediatrician endorsement) to
reinforce the credibility of the message (consider SMS info-messages from paediatricians alerting parents of
campaign dates).
Provincial-level media officers should conduct pre-campaign, in-campaign and post-campaign briefings as standard.
Weekly/monthly provincial-level media outreach using one-pagers will generate free coverage – much of this content
can be generated centrally, with local inputs. Journalists should be encouraged to visit the field to witness a
campaign and vaccinate kids. The media officers spoke of a lack of advocacy brochures in local languages to provide
to journalists asking for background – our understanding is that many of these materials are available but may need
to be consolidated, translated and shared.
Recommendations:

Weekly con-call and quarterly planning retreat between five provincial media officers to generate themes/media
events.

Strategic identification of key media houses based on reach to HRGs for immediate engagement.

Engagement of Pakistan soccer captain Dr Issa in Killa Abdullah.

Provincial-level media partnerships with medical fraternity for media events/advertisements/IEC/SMS messages
from paediatricians to parents.

Weekly outreach to provincial-level media and pre-, in- and post-campaign briefings.

Organize journalists’ field trips to campaigns.
6. Media buys: Interflow
While the media buys agency Interflow presented as very competent, particularly at a national mass communication
level, there is a need to further analyse the media habits of our HRGs/HRAs at provincial level to generate a listing of
priority media. Media habits at the local level appear extremely varied (consider that in Killa Abdullah, out of 400,000
households only 1,000 have cable subscriptions, whereas in Quetta, out of 1,140,000 households, 350,000 have
subscriptions) and will allow for strategically targeted media buys to ensure maximum bang for our buck.
Presentation of Interflow data needs to be presented both in terms of national reach and HRG reach, with
geographical presentation of media buys/reach.
The media placement plan as it stands (TV/cable 71%; Radio 9%; Print 20%) appears to overplay print and
underplay radio, especially when you consider radio costs per contact are one quarter of TV (50 cents v $2).
31%
Regional language channels
33%
Terrestrial channels
20%
Entertainment
16%
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Cable TV allows for a targeted spend and therefore is a good medium for SNIDs and SIADs. Terrestrial channels
appear under-utilized, with Radio Pakistan and PTV having wide reach. PTV is the only channel available in KPK,
and also popular in FATA:
Recommendations:

Provincial-level analysis of media habits of HRGs, especially Pashtuns.

Presentation of HRG data geographically.

Increased spend on terrestrial channels and radio, reduced spend on print.
7. Mass communication campaign
The mass communication campaign employed in Pakistan is comprehensive, and the review team commends the
Pakistan programme for its investment. We were regularly told that the most recent PSA, featuring vaccinators,
directly resulted in increased respect for teams.
There is a lingering need to approach the mass communication campaign at two levels: the current national approach
to create a country-wide enabling environment for polio immunization, and a more focused, local approach, targeting
clearly defined groups on clearly defined channels.
With three PSAs remaining on the current contract (cricketing megastar Shahid Afridi will consume one of the PSAs
in the contract), the review team recommends that the PSAs address three specific needs as identified by the KAP
Study.
It is recommended that the campaign increase threat perception. Every Pakistani we interviewed said that the
campaign would not work if it was too “nice”. (In a recall test about the first PSA, 90% of respondents said the first
thing they remembered was the child in the wheelchair). Given KAP results show that less than 1 in 3 parents believe
their child is at risk of contracting polio, the campaign needs to be direct about the risk of polio and the fact there is
no cure, only prevention. In areas of active transmission, even consider the message: ‘Polio is transmitting in your
village. When polio is discovered in your neighbourhood, the whole neighbourhood is at risk.’ It should also aim to be
more “gritty”, targeting our key HRGs (production agencies are consistently too ‘glossy’ – consider taking key players
at Spectrum and Interflow agencies to the field).
The Balochistan team complained that the most recent PSA was not culturally sensitive – the female vaccinators’
heads covered with a cap was not appreciated. Perhaps the Shahid Afridi approach, where separate Urdu
(mainstream) and Pashto PSAs are shot, is a workable option. Multiple respondents spoke of the effectiveness of
real-life testimonials of polio-affected families. Real-life testimonials of mothers, pregnant mothers and fathers who
received OPV as a child can tackle the infertility misconception.
The review team applauds the colour transition of banners and posters to Pakistan green (the same shade as the
vaccinators wear) and orange, with colour images. The red-stripes-on-white banners unnervingly resembled the US
flag in many instances, and reportedly remind many of communist propaganda.
Every banner and poster should carry a key message that is a call to action understandable by all but especially the
highest risk groups. Many of these are word-heavy, despite literacy figures indicating many of our HRGs are nonliterate.
Identify 3 areas of specific need from the KAP and tackle in remaining 3 PSAs.

Increase threat perception through more gritty appearance, demonstration that polio cripples and kills, polio is a
threat to your village.

Separate PSAs for Urdu/Pashtu-speaking audiences.
Page

14
Recommendations:

Arrange for Spectrum/Interflow to witness SNID in the field.

Review the logo

Reduce words on posters/banners
8. Transit campaign
There is a need to produce materials targeting mobile and migrant populations on the move at key transit points, on
buses, rickshaws, etc, and to support the 250 additional permanent transit posts being established from 23 April.
These materials should be largely pictorial-based (Pakistan’s average literacy rate is 55.5%3, for HRGs and migrant
groups it must be significantly lower). It was discussed that Pashtuns control the transport network, with buses
stopping at known fixed points, and that there are two main transportation routes. Transport owners can be
approached for IEC materials inside buses/on tickets, etc, transit stops can boast IEC/IPC, and the two main
transportation routes should have saturation hoarding coverage.
UNICEF India is contracting a company to produce focused non-literate materials and the TORs should be expanded
to include Pakistan/Afghanistan. As part of this package, visually simple animations and cards/games explaining the
virus, its consequences and prevention, can be helpful tools for social mobilizers targeting nomads, whether at home,
in camps, or on the move.
Recommendations:

Transit campaign produced targeting people on the move (“Wherever you are, wherever you go, two drops,
every time.”)

Approach transport owners for fixed IEC inside buses/on tickets/T-shirts for conductors/on paper cups, etc

Identify main transportation routes for targeting banner/hoarding buys with non-literate materials.

Work with UNICEF India on production of campaign targeting non-literate communities.
9. Handling change of dates (NEAP)/SIADs
There is no easy solution to the late change of immunization dates due to NEAP standards. The easiest solution is
for the GoP to better understand the difficulties this poses for communication, and to balance the benefits of delaying
the round against this when possible.
3
hdrstats.undp.org/en/countries/profiles/PAK.html
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With SIADs, the communication challenge is to relay the message that multiple, quickly administered rounds are a
proven strategy for stopping transmission, and the reason SIADs are being conducted in your area is because it is a
15
Presently, printers must receive art work 45 days prior to campaigns. This is too long. Local printing houses should
be identified (to minimize transportation time) and solutions determined with S&P to enable UNICEF to comply with
the two-week window a NEAP announcement provides (first week share art work, complete print run; second week
transport posters, paste posters no later than four days before the round). It should also be possible for
WHO/UNICEF to identify likely culprits for NEAP delays ahead of time and delay printing for these areas. Where
rounds are being held on staggered dates, PSAs should include a scrolling ticker or 10-second tail outlining change
in campaign dates, where activities are taking place, etc. Other options include dateless posters, provincial media
focal points to alert media to changes via press release, increased use of van miking, mosque announcements and
other local-level media.
high-risk area for polio - we intend to quickly maximize your child’s immunity to polio by conducting multiple
campaigns. Advance notice (say, a quarterly calendar) of SIADs would assist social mobilizers.
Recommendations:

Identify local printing houses/address S&P bottlenecks to reduce 45-day! printing lag time to the necessary two
weeks.

Seek to identify poorly performing districts ahead of time and delay printing for these areas.

Introduce scrolling ticker/tail for PSAs with voiceovers outlining which areas are conducting rounds.

Proactive IPC for SIADs
10. The Pashtun challenge: more FATA, less Facebook
While mass communication must reach as many people as possible (98,668,203 individuals exposed at least thrice
to the March TV PSA is outstanding), it is the review team’s firm belief that the communication focus in Pakistan
should be “more FATA than Facebook”. We need to cut to the chase. With Pashto-speaking populations representing
77% of cases, and 71% of cases being in children below 2, the key target group in Pakistan is Pashto-speaking
parents and caregivers of children under 2.
The question is: How do we use media/ IEC and IPC to make the Pashto-speaking communities want to own the
polio programme, or at the least, tolerate their children being immunized? More effective use can be made of
saturation coverage of polio immunization efforts in the highest-risk areas, with large, targeted media buys, heavy
use of posters and banners and persistent local-level efforts (mosques giving announcements, etc).
Comprehensive engagement of Pashto-speaking media is lacking. For example, the programme must quickly
establish a partnership with BBC Pashto, with polio eradication featured daily; during campaigns they can provide
saturation support. The Spin Boldak station at the border crossing in Afghanistan is also popular and until now,
untapped. In all areas, messages in pashto from pashtuns to pashtuns will be most effective.
Recommendations:

Develop Pashto-speaking communications strategy with actions matrix.

Identify highest-risk areas/transportation routes for saturation coverage.

Establish partnership with BBC Pashto/Spin Boldak radio.
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Considering the fact that UNICEF was concurrently planning a re-introduction of the polio health awards it first held in
2009 and that there was no partnership discussion that the WHO awards would be launched, this is a regrettable
development. Given the need for UNICEF to be at the forefront of media engagement in Pakistan and to be
understood by health media as the key focal points for polio eradication media engagement, these awards should be
presented as joint WHO-UNICEF awards. This requires joint coordination planning meetings, the logos of both
agencies on the awards themselves and on the backdrops, and key speakers at the event representing both
agencies. This is a much-needed opportunity for WHO to promote UNICEF in the media environment and should be
pursued at the highest levels.
16
11. WHO Health Journalism Awards 2012
In 2013, any media awards should be jointly held by the GoP, UNICEF, WHO and Rotary. In addition, Mishal are
working towards establishing journalism awards with a polio bent both this year and next, and discussions need to be
ongoing with them to ensure relevance/coordination.
Recommendations:

WHO/UNICEF Reps to agree to conduct joint awards.
12. The Call Centre
The call centre is a concept in limbo. Current levels of financial and human resources leave it ineffective. The call
centre has no tool to measure the call volume. It has no facility to record conversations, or geographical locations of
calls, or whether these are individual call attempts or repeated calls. It has no disaggregated data, no way of knowing
or recording how many families are from HRGs. It uses 10 ageing computers housing old software, with 10 phones
and 10 staff, working 9-5. In the March round, of 45,000 attempted calls, 7,000 were answered and 38,000 missed.
Many calls were to ask questions, such as “What colour is the vaccine meant to be?”
Recommendations:
17
The call centre requires substantial investment to be relevant. The review team would recommend a partner
discussion to determine whether to invest in the call centre, outsource it to a 3rd party company to manage and
operate it, or (preferably) close it down.
Page

Team 2: IPC and Community Engagement (Susan Roe, C4D Specialist (Polio), UNICEF
Regional Office for South Asia (ROSA); Jeffrey Bates, C4D and Research Specialist (Polio), UNICEF HQ)
Background
The Pakistan polio eradication effort has accelerated in the past year with an expanded team and strategy revisions
to improve opportunities to reach the remaining under-immunized children. These strategic changes include a
refreshed focus on underserved or high risk groups, better data collection and management and the creation of a
community based communication network called COMNet. COM Net provides an infrastructure and the necessary
human resources for large-scale communication and social mobilization interventions aimed at polio eradication in
the 33 high risk districts of Pakistan. Planning and activation of the network began in mid-2011 and continues to date
with a focus on capacity building and staff development at multiple levels (e.g. district, UC and community / area).
The ability to engage with local community members is a critical skill for both vaccinators and COMNet staff,
especially for high risk groups who have less access to various forms of mass media outlets and more limited social
networks through which to gain information regarding polio immunization. According to the latest KAP (2012) survey
of high risk districts, every second person in Balochistan (48%) finds out about polio campaigns from a vaccinator
and in Sindh, one out of four people (22%) do so through interactions with Lady Health Workers.
Further, community engagement and vaccinator performance at the doorstep are crucial to ensuring caregivers
accept OPV and actively participate in polio eradication efforts and to also ensure vaccinators have the skills to
present themselves in a professional fashion, answer questions and ensure all children in a household are accounted
for during the doorstep interactions. For example, it is estimated that up to 50% of children missed due to no team
are not immunized because vaccinators failed to seek them out during house to house interaction while providing
OPV to children who were more accessible. Accordingly, roles, responsibilities and skill development and
opportunities for collaboration and further enhancement of IPC approaches for these front-line workers needs
continued attention and focus.
The review provided an opportunity to quickly assess gaps and strengths in the programme in the cutting edge where
the global GPEI engages with communities and households. Thus, the review team examined the following areas:



The skills and tools essential for successful interpersonal interaction of front line workers with parents and
community members,
The capacity of front line workers to engage with parents and community members, including their
relationship to the community, basic competencies and administrative issues such as work load,
Support structures, processes such as training and materials in place to develop front line worker capacity.
The following report offers a brief analysis of the current programme in terms of how it engages with communities,
with a focus on improving interpersonal communication and opportunities for enhancing local ownership and
participation in the polio programme to promote acceptance of and demand for OPV and routine immunization.
Key Observations

Resolution, reliability and availability of data to guide responses to local issues and evaluate impact of social
mobilization activities or vaccinator interactions with caregivers;
Poor IPC training for vaccinators - while included in training programs, IPC sessions are often shortened or
minimized due to time constraints in favour of more operational topics / needs and COM Net staff are
expected to support training activities with limited understanding and training materials available at this time;
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
18
Based on review activities completed during the available review time-frame, the following key issues have been
identified and emerged as basic challenges to community engagement and enhanced IPC:





Lack of materials for front line workers (some under development) – at this time basic materials are
available (Fatwa booklet mentioned as an excellent resource) all staff eagerly awaiting the production and
roll out of the planned social mobilization kit;
Ambiguous and retroactive role of influencers – identification of a number of influencers has been completed
(and contact lists compiled), use and engagement of these community level allies remains unstructured and
limited primarily to addressing refusals;
Absence of standard social engagement activities – teams themselves develop a number of different
approaches and activities for use but this requires thought / time and needs further attention in order to
enhance, streamline and standardize;
Limited personnel to address the scope of issues in high risk communities – HR UCs and areas contains
large numbers of and diverse population groups which are expected to be reached by limited numbers of
COM Net staff (Gadap example: 1 UCO and 4 SMs);
Variable coordination of communication and operational partners–repeated recommendations and
suggestions from both Com Net staff and polio partners link to the need for strengthening and improvement
of this dimension on multiple levels but especially peripherally.
Recommendations
The following recommendations were crafted to address the above listed challenges and enhance the capacity of
front line workers to engage communities, facilitate OPV acceptance at the doorstep and improve vaccinator team
performance in reaching all children when houses are accessed. The recommendations come in three inter-related
areas which focus on:



Revising aspects of COMNet and vaccinator training, both in terms of content and approach,
Developing a standard set of community engagement tools with support materials,
Modifying the roles of communication workers primarily at the UC and community levels
Additionally, the recommendations include an approach to identifying very high risk UCs based on social barriers to
immunization and intensifying training and planning activities in these areas. The report will first discuss the
conceptual framework that guides these components then offer specific recommendations under each category.
Conceptual framework
The tripartite conceptual framework outlined above requires that the three areas of training, polio worker roles and
the development of standard activities and materials be approached as a single intervention package. This approach
is necessary as the finalized engagement packages will guide modifications in the roles of front line workers, and a
completed training package will be required to facilitate these two programme modifications. Thus, the first
programmatic challenge is to define the communication toolkit, then the report will discuss polio worker roles, and
finally offer recommendations on training.
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19
To enhance community engagement, recommendations cover three areas of inter-related and reciprocally influential
activities. These include elements of training, modifying the roles of campaign workers and standardizing a tool box
of community engagement activities and a roll out of an intensive approach to implementation in the highest risk
Union Councils.
Figure 1: 3 inter-related IPC strategies
Revised Training
1. Standard training activities
 UCO
 Social mobilizer
 Vaccinator
 Influencer
2. Enhanced training (very high risk UCs)
Standard Package of
Engagement Activities
 Activity guide
 Support materials
 M&E / reporting
Modified Roles
 UCO / UCMO /
UCPW
 SM
 Influencers
1. Standard community engagement activities
Page
Further, the availability of a standard set of approaches to community engagement would allow for more rapid
planning and implementation as necessary to address social issues that inhibit delivery or update of OPV in the
remaining Pakistan polio sanctuaries. These standard packages would offer ready-made options for engagement, but
would not limit communication teams to these efforts. On the contrary, these materials would complement local
initiatives or could be modified as needed for a specific context and allow COMNet and other polio staff, who have
been trained to deliver these interventions, to roll out activities as necessary based on analysis of local conditions
and needs. A standard package would also promote the development of monitoring / process and outcome indicators
that would provide assessments of social mobilization activities as measurements would be standard and reporting
frameworks could be supported across the entire COMNet structure.
20
Pakistan supports a number of activities in their communication and social mobilization efforts, including line listing
and engaging community influencers, house-to-house visits, mosque announcements and school participation.
Although standard approaches to some of these engagements models exist, or existed in previous polio programme
iterations, they are not currently standard within the COMNet strategy. A Social Mobilization Kit is under
development, but needs additional materials / guidelines which could form a standard package of community
engagement activities and would complement both materials under development and COMNet staff actions related to
ensuring quality planning and implementation across the full spectrum of outreach efforts.
Development of standard package or tool kit of engagement models would require first that a set of activities relevant
to the Pakistan context, with particular attention to high risk areas, be defined. The following table describes some
possible activities and the component support mechanisms required for each one The final COMNet package should
be determined based on priorities identified by the Pakistan PEI partnership with an emphasis on sustaining current
partnerships and creating new ones that will address common barriers to reaching children, especially in high risk
areas.
Standardizing Community Engagement Strategy & Activities
Activity
Community
dialogues
Compound
meetings
Religious
council
Target
Engagement objectives
Materials
Males, decision
makers,
community
leaders
To increase knowledge and
ownership of the eradication initiative
and overcome issues related to OPV
safety or negative attitudes towards
polio eradication and to clarify
caregiver roles in ensuring all children
are immunized
Instruction sheet
for facilitator
Females
including child
caregivers, inlaws and
community
influencers
To increase knowledge of the
eradication initiative and overcome
issues related to OPV safety or
negative attitudes towards polio
eradication and to clarify caregiver
roles in ensuring all children are
immunized
Instruction sheet
for facilitator
Religious
leaders
To create ownership of the polio
eradication effort, clarify roles of
religious leaders for supporting PEI
and discourage resistance based on
religious grounds
Instruction sheet
for facilitator
Visual aids
Monitoring form
Visual aids
Monitoring form
Mosque
announcement
guide
Personnel
Local leaders,
medical
professionals or
other respected
individuals
LHW, midwives or
TBAs, health
workers or other
respected women
in the community
Religious scholars,
imams or leaders
in the community
Visual aids
Monitoring form
UC level
Missed children
and child
caregivers
Local political
leaders
To increase knowledge and
ownership of the eradication initiative,
increase access and safety in
insecure areas and overcome issues
related to OPV safety or negative
attitudes towards polio eradication
Instruction sheet
for facilitator
To increase knowledge of the
eradication initiative and improve the
ability of health workers to identify and
immunize missed children
Instruction sheet
for facilitator
To increase political commitment, set
the local agenda and encourage local
Inauguration
Visual aids
Tribal or other
respected
community leaders
Monitoring form
School flier
Monitoring form
School head
masters /
mistresses
Madrassa Imams
UCMO or other
21
School
programme
Tribal and
community
members (male)
Page
Tribal council
inaugurations
influential
community
members as
well as the
general public
leaders and community members to
engage in PEI activities
guidelines
respected leader
Banner
Certificates of
congratulation
Community dialogues (males): this set of activities has proven helpful in many country settings and can be
supported by films (such as the Majigi in Nigeria), visual aids and the presence of influential facilitators
determined by the nature of the challenges in the focal community. Dialogues offer an opportunity for community
members to learn about the GPEI, ask questions and see that local leaders endorse immunization. A set of
standard guidelines for dialogues exist and could be modified for the Pakistan context.

Compound meetings (females): in many conservative societies, women do not participate in public gatherings
to the extent of males. They also usually have less media access and more limited social networks. These
meetings are similar to the community dialogues, but offer women the same opportunities to learn about the
GPEI as dialogues offer men. Special efforts to reach females have been successful in the Pakistan PEI, and
are currently part of the polio efforts in Afghanistan and Nigeria, and materials could be quickly updated or
modified for the Pakistan programme.

Religious leaders / scholars forums: partnerships with religious institutions and the visible support of ground
level religious persons is an essential component of all GPEI programmes, and has been a crucial component of
the Pakistan programme. Reviving the standard approach to engaging religious representatives with specific
tasks for them in their community, such as speaking at Friday prayers or converting refusals, would help
overcome some of the remaining suspicions and nurture positive attitudes towards polio eradication.

Jirga / tribal leader forums: these events have also been a strong part of the Pakistan PEI effort, but are
currently not standard elements of the social mobilization package. These types of forums can be particularly
useful for gaining access to insecure areas or ensuring the safety of PEI workers. They also serve the same
functions as dialogues as well as demonstrate commitment and nurture ownership among tribal groups.

School partnerships and child to child activities: a standard activity in many programmes, the polio school
partnership was initially developed in Pakistan and has spread to many other programmes under a variety of
titles. These efforts, similar to partnerships with scouts and guides, can greatly amplify efforts to reach
community members through children who spread awareness of the campaign and also improve coverage
through their efforts to immunize siblings and identify missed children. Multiple packages for school programmes
exist in Urdu and other languages.

Standard UC level inaugurations: campaign inaugurations or other opening ceremonies are also standard
across the polio programme, but they often take place at high levels, such as on national or provincial stages. A
UC level inauguration can increase awareness of a campaign, foster local commitment and serve to provide
social rewards to polio workers—such as when vaccinators or influencers are recognized in these events.
2. Modify roles of COMNet, Health Staff and Local Influencers
The current COMNet and PEI worker roles focus on an approach to planning and community engagement that has
helped the programme make progress in reaching more children in the high risk areas of Pakistan. However, some of
the challenges outlined above emerge from the nature of these roles and the limitations on community engagement
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
22
Monitoring form
inherent in the TORs, training, organizational approaches and human resources available in the field. The following
section offers recommendations that focus on modifying the role of PEI workers and community influences in high
risk areas to overcome some challenges and create more opportunity for community engagement and ownership of
the PEI. These modifications will dovetail with the standard package of community engagement activities, and will
require revisions in training to develop their capacity accordingly.

Role of UCO
UNICEF and WHO staff at district, Union Council and community levels collaborate to ensure all children in their
target areas receive OPV, including a reliance on COMNet staff to facilitate the IPC component of the vaccinator
training. COMNet staff TORs outline a role for monitoring IPC training, but these front-line workers often go further
and act as the facilitators. Vaccinator IPC training is often left out of campaign preparations as the traditional trainers
come from a health background and in the rush to prepare for campaigns, focus on the core operational issues.
However, vaccinator performance is consistently identified as a barrier to reaching children in their performance (not
explaining PEI issues or asking about children in the house) as well as community perceptions (low skills, too young,
not from the community and so forth). Improving their IPC skills is a vital step towards reducing missed children due
to service delivery failures of this sort.
Given that UCOs already facilitate IPC training in many areas, they could assume this role as an official function with
the assistance of SMs who could also benefit from participation in the vaccinator trainings and eventually develop the
skills to facilitate the IPC components themselves. Along with additional training of trainer activities for IPC, this
would requirethe UCO TOR to be modified to endorse this role, and for supervisors at the district and provincial
levels to support, monitor and evaluate their performance.

Role of Social Mobilizers
Many high risk UCs have a limited number of social mobilizers (SM), with very high risk ones having up to four, but in
most UCs only one SM is deployed (this situation might not be the same across all high risk areas, but was the case
in Sindh). The SM actively identifies influencers, produces social maps, line lists intervention points and engages
communities. The presence of a standard set of community engagement activities will greatly enhance the ability of
the SM, in discussion with the UCO, to plan appropriate interventions in priority areas to reduce missed children
during polio SIAs. However, the limitations on the SMs prohibit them from wide scale engagement as necessary in
large populations. With additional training and support, however, SMs can utilize the presence of active influencers to
extend the reach of mobilization activities by multiplying the number of actors working in the PEI. Thus, the SM would
modify their role to become a planner, facilitator and monitor of multiple activities in high risk communities rather than
the primary implementer. SM’s could also be more actively involved in vaccinator IPC training, drawing on their
knowledge of local conditions, and experience of barriers to vaccination (including vaccine delivery and household
access) from past rounds.

Role of Influencer
Page
To switch from a passive to an active role in promoting PEI efforts in Pakistan, the influencers must be first selected
based on a revised profile that will ensure that the resource pool matches the needs for supporting the standard
engagement package. For example, adequate numbers of religious leaders need to be identified in high risk areas to
23
Community influencers are line listed at UC and community levels, and contacted when an SM or other PEI worker
encounters issues in the field, such as a refusal they cannot convert, or a school that will not allow vaccinators to
enter. Influencers are extremely important in accessing and making use of local community social networks,
however, the influencer role as currently supported is passive, and their engagement is typically only sought when
they are asked to help overcome difficulties. These influencers can be instrumental in extending the reach and
credibility of the polio effort, and need to be more pro-actively engaged in the eradication programme in the days
leading up to campaigns which requires a reversal of how they are currently involved. Influencers can also be
considered as a medium for improving recruitment, retention, recognition and motivation of vaccinator teams.
ensure that if a religious leaders’ forum is planned, an appropriate facilitator can be identified and supported. Once a
line list is created, influencers should be contacted as is the current practice to ensure their support. However, once
community engagement plans are developed, the appropriate influencers should be asked to play a pro-active role in
facilitating the engagement activity. Not all influencers will be willing to volunteer their time, but some will, and these
are the ones whose good will needs to be cultivated and who should be called upon to support the PEI pro-actively.
In order to not monetize their support, cooperative influencers should be recognized with a certificate of appreciation,
be invited to receive this certificate or some other recognition at a local inauguration or be given such non-monetary
rewards as would be appreciated.

Role of UCPW, UCMO and other Partners
In very high risk Union Councils (see notes on enhanced training below), PEI partners beyond the COMNet staff will
participate in the planning, implementation, monitoring and evaluation of community engagement activities. This can
happen through their participation in the very high risk UC level training and planning of all activities for the upcoming
SIAs. This will improve overall coordination and outcomes for not only the upcoming SIA, but with the increases
skills, the scope of coordination and communication planning will ideally remain a part of the UC PEI efforts over the
course of the next year.
3. Strengthen training
The recommendations on training focus on two main themes related to the development of a standard package of
community engagement approaches and the modified roles of COMNet personnel and other polio partners in
supporting communication and social mobilization activities. The following describes specific recommendations for
the standard training package as well as for enhanced training that will take place on in the very highest risk UCs.

Standard Training
The standard training package for COMNet staff at the district, UC and community level is being modified to prepare
them for the duties in their TOR as it presently exists and does including training activities related to communication,
advocacy and use of IPC. However, in order for the recommendations in this report to be implemented, the COMNet
training package will need to be adjusted to ensure they have the capacity necessary to perform their modified duties
which will become less focused on implementation, and aim more towards the ability to:






Utilize data to define needs at the community level,
Prescribe and support the standard community engagement packages,
Facilitate vaccinator IPC training and
Provide orientations and support to influencers
Monitor and report upon activities
Evaluate intervention outcomes
Enhanced / Intensified Training
In a select number of very high risk UCs, chosen based upon challenges emerging from social issues amenable to
community engagement, a longer, more intensive and inclusive training package will be rolled out. This enhanced
training can be as long as necessary to cover similar topics as in the standard training for COMNet activities that
Page

24
Formats related to training activities, along with participatory / interactive methods currently in use, may also include
use of videos which demonstrate various IPC scenarios and strategies for response, interactive engagement with
trainees and also ensure more standardized training packages for intended staff and participant audiences. In
addition, incorporation and reflection of real life experiences, stories and strategies evolved from social mobilizers,
vaccinators and influencers could be included to enhance both relevance and practical application. Results or
findings for the Positive Deviance Pilot study currently being carried out in Sindh may also be another source for
further revision of training packages including sharing of local micro-innovations.
involve the standard community engagement activities and modified roles of polio workers, but will reserve time (half
a day?) to complete a comprehensive micco-plan for the UC. The training will include the UCMO, UCPW and other
partners to ensure they have the capacity to support communication activities in that UC, and will coordinate the
inputs all of GPEI partners in drafting the micro-plan to ensure coordination of operational and communication
activities, with clear roles for all participants. Joint training and planning involving both WHO and UNICEF together
will also not only contribute to a wider and enhanced skills base of peripheral level stakeholders but also provide an
excellent opportunity to further strengthen partner cooperation and collaboration at multiple levels.
4. Contributions to Routine Immunization and Convergence
Discussions related to strengthening of RI through polio out-reach activities revolved around experiences from Baldia
when SMs visit families to provide information on upcoming polio campaigns, most children were found children with
0 routine immunization coverage. Based on this, RI vaccination programmes were also arranged and two rounds
completed by April 2012 for these high risk groups. Through use of COMNet staff and influencers – along with
improved IPC training for vaccinators and others involved – promotion of RI services could be further enhanced and
strengthened but it is also critical to note that service delivery mechanisms must be fully in place and provide quality
services in response to demand creation.
As also discussed with UNICEF Sindh Provincial staff, the new approach described above also aligns with key
components of the Reaching Every District (RED) especially related to increased engagement and use of key
influencers within HR communities. Appreciation here was given to the pro-active role these influencers could
assume and how these small but significant changes proposed in staff structures and capacity building could benefit
both polio and EPI as well.
Finally discussion both in Sindh and back in Islamabad also highlighted that if the approach and mechanism is
successful for polio eradication, there is also great potential for further strengthening of communication and social
mobilization not only for RI but other important convergent health issues and replication to a wider range of HR areas
/ districts. While it was noted that during initial stages the focus must remain on polio work, moving forward with these
changes should also highlight and acknowledge the use of COMNet and community level partners in addressing
critical health issues and other priorities / needs raised by community members themselves.
Suggested order of activities for rolling out the recommendations
If suggested changes / revisions are accepted and agreed to move forward on, work will need to be accelerated and
completed within a proposed period of three months in order to ensure that recommended changes can be applied
as quickly as possible in order to accelerate impact. This will required discussions between UNICEF / CHIP and
WHO and perhaps the enlistment of a consultant to work on revision / enhancement of training materials needed.
Possible use and inclusion of the ICO SM Net staff (Dr.Anis) who is coming out in the next few weeks may also be
useful as he would be an excellent resource and could assist in moving forward with proposed changes.


Internal group discussion of priorities and workplanning and activities (also determine whether consultancy
support is needed) and develop specific action plan / timeline.
Select priority community engagement approaches that will maximize access, community acceptance of
OPV and ownership of the local PEI activities and revise current models or develop new materials for the
standard package of community engagement activities and begin design and production of materials
Complete review / revision of current TORs – and develop new (simple) TOR for community influencers to
ensure capacity for supporting community engagement activities and facilitating vaccinator IPC training.
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25
The proposed steps form a suggested sequence related to this but can be adapted or changed based on the team’s
needs, and several activities can be implemented concurrently.


26

Begin work on training components (for COMNet staff, vaccinators and community influencers) – including
monitoring – evaluation tools related to community engagement templates and to provide a training of
trainers for COMNet staff for both vaccinator IPC and influencer orientation.
Select highest priority UCs for intensified training / planning, and develop agenda and materials for this
activity.
Initial (on the job?) pre-testing of community engagement guidelines / templates (at the field level for one
SIA, then complete revisions).
Roll out full scale implementation of the standard training package and high risk intensified training.
Page

Team 3: High-Risk Groups (Chris Morry, The Communication Initiative; Dr Hans Frey. Quaid-i-Azam
University Islamabad)
Background
About 73% of polio cases in Pakistan over the last 5 years have been attributed to Pashto speaking communities.
Pashto-speakers have been identified as high-risk groups, requiring special coverage and communication strategies.
Migrant and nomadic populations are an additional group requiring specific strategies. A high-risk group strategy has
been outlined in June 2011. In the past several months a number of partnerships specifically targeting high-risk
groups have been put in place, including mobilization of prominent religious leaders and influencers specific for such
groups. In addition, there have been attempts to catch these families on the move through vaccination transit points
on migratory routes and national highways. While all these initiatives have been expanded, recent TAG meetings
have noticed inadequate operationalization of the high-risk group strategy. Immediate expansion of the strategy is
urgently needed.
Figure 2: Movement Patterns for Mobile Population in Af/Pak sub-region
Key Observations
Page
“The key epidemiologic characteristics of polio cases include that majority below 2 years of age with predominance
in males, 77% are from Pashto speaking families, 23% belong to refusal families, 88% live in multiple family
dwellings, more than half the cases are inadequately immunized, some of them having not received any doses of
OPV, among the polio cases Pashto speaking cases had larger proportions of un-immunized and under-immunized
children in 2010 and 2011as compared to other ethnicities and 63% of the polio cases reported from FATA belonged
to areas which could not be visited by the vaccination teams for long time due to insecurity. Nearly 30% of the
non-polio AFP cases reported from FATA and Balochistan each were reportedly either un-immunized or under-
27
The Pakistan TAG recently defined the average polio case in Pakistan in the following way:
immunized against polio. This warrants urgent attention to address these children. In fact, more than 70% polio
cases were either reported from or genetically linked to the three transmission zones.”4
Given these characteristics the HRG Strategy focuses programme resources on 33 districts where virus circulation
persists, significant clusters of refusals exist, there is poor Routine EPI and SIA coverage’s, AFP surveillance data
points to low coverage and accessibility during SIAs has led to significant numbers of children being missed. It
further focuses on particular populations which have proven to be particularly vulnerable to the virus – Pashtu
speakers in non-Pashtu speaking areas (such as Karachi), Pashtu speakers in Pashtu majority speaking areas
(KP/FATA) and migrant/mobile and transit populations. Its central strategies are to strengthen the quality of
campaigns, enhance community outreach and improve data collection and use down to the microplan level via
COMNet and to reduce the numbers of missed children who are travelling.
The above focus is appropriate and sufficient to the present needs of the programme though it is urgent that further
steps be taken to fill gaps and make full use of the basic elements that are now in place. The review team noted a
very strong staff team and significant progress in Balochistan where a lot of work has been done in a short period of
time to further define HRGs down to the UC level and identify influencers from strategic local groups such as tribal
leaders, religious groups and political parties. Innovations have been developed such as the ‘Polio Walk’ which
brings together leaders from different political parties, tribal groups and religious sects to march together against
polio. Some progress has been made on vaccinator team makeup in Killa Abdullah (moving away from child
vaccinators) and while only 20% of teams are female work is ongoing with local influencers to add more females or
where this is not possible to develop other ways to reach all children in each dwelling. Progress in Balochistan will
need to be measured over the coming months and there is still significant work to do in areas like team composition
and microplanning.
The team also heard that while the use of Google maps and GPS for accurately mapping vaccinator team and social
mobiliser areas are useful tools, they have created distrust and reduced the security of polio staff in some areas due
to concern in some communities that they are being used to identify targets for attack. It would be advisable to use
these very carefully and to not allow staff to take such maps into the field. Techniques like tracing the maps for use
in the field may be one way of applying the technologies without endangering staff.
KP/FATA is somewhat behind due to issues that have delayed hiring all the staff. However, the management and
District level staff are in place with the Social Mobilisers to be hired quickly. There is considerable tension between
some sectors of government regarding staffing decisions for the COMNet and also disagreement on the number of
accountable vaccinator teams available which may or may not be related. This has resulted in staggered campaigns
in Peshawar District which adds to local confusion regarding campaign dates and necessitates the use of vaccinator
teams from outside local communities. IDP camps present their own set of challenges as the majority of Internally
Displaced Persons (IDPs) do not use them and those that do often register and then stay in other places.
Immunizing children in the camps is relatively easy but tracking and identifying IDPs who have decided to stay
elsewhere is more difficult. This will require better mapping of where IDPs stay and stronger IPC skills for teams to
ensure they access all children in dwellings where several families reside. It will also require a sharpening of Transit
Point placement and activities to ensure higher coverage of children as they move out of conflict zones and before
they disperse into the community.
4
Emphasis added.
Page
However, progress is uneven, some areas need to be expanded and/or systematised and there are still key problems
related to poor collection of data on reasons for missed children, limited use of social maps in conjunction with
microplans, inadequate IPC training, somewhat unfocused transit point planning, the lack of a specific
communication strategy for FATA and limited mapping of mobile populations below the District level.
28
There has been real progress in key areas such as the identification of HRGs, the establishment of COMNet, the
expansion of transit points and geographic focus. There are early signs of improvement in team makeup,
partnerships with government, tribal, religious and NGO groups and some interesting innovations and initiatives (at
least in Balochistan) in identifying ways to reach women.
Findings and Recommendations
1. What’s Working


This is a fast moving area of programme development. During the week the team reviewed the HRG Strategy
two important meetings were held to review and plan future activities for both the overall HRG Strategy and the
Transit Point Strategy. Best efforts have been made to incorporate the results of these meetings and to reflect
both what is in place at present and what is planned for the near future.
Progress over the past several months has been significant and it is clear that the communication strategy for
HRGs has built a strong and appropriate platform to improve coverage of missed children in and amongst HRGs.
The COMNet is now operational in Balochistan and Sindh and nearly so in KP/FATA. A range of new
partnerships are being developed with groups such as medical associations, government at various levels,
religious organizations, NGOs and where COMNet is in place amongst local influencers and leaders. All of the
above suggests not only progress but a real and positive sense of momentum.
2. What Needs Improvement










Many of the new activities for both the HRGs (there were nearly 50 activities to be implemented or substantively
underway by the end of May) and Transit teams will need to be rolled out very quickly – this will place strain on
staff and require a major focus on coordination not just within UNICEF but with WHO and government.
The HRG Strategy indicators require some review and revision particularly in the following areas:
Plans to track increasing trends in # of children vaccinated in transit, # of children vaccinated during out-of-house
activities (festivals, weddings, shrines, etc) and # of children vaccinated in nomadic/slum settlements, brick kilns,
farms, etc should be reviewed. While it is clearly important to track actual numbers of children covered through
these activities using increasing trend to serve as an indicator of success is problematic because the numbers of
children vaccinated will go up and down based on a range of external factors such as conflict or disaster leading
to increased IPDs, whether it is a major festival season or periods of nomadic movement.
Minimum standards for micro-plans should have a target of 100% rather than 90% given the numbers of children
that could be involved in the 10% that are not up to standard. It is worth considering an indicator that has two
milestones – one to 90% and another to 100%.
There should be an indicator that tracks the number of inaccessible areas that are accessed and to the extent
possible the number of children covered. This would involve mapping and tracking the inaccessible areas.
The HRGs are not yet defined well enough to reflect the specific communication needs of tribal, religious,
nomadic and mobile populations down to the Union Council level.
COMNet is showing signs of early impact where it is fully operational but it is urgent that KP/FATA get its Social
Mobilisers in place.
Social Mapping of HRGs is not yet being translated to the microplan level and this also needs to happen
urgently.
Accurate collection of data on refusals and reasons for missed children remains an urgent issue for the
programme as a whole and results in a lack of essential communication data. This is being discussed
throughout the programme but remains an pressing requirement.
There is no strategic communication/advocacy plan for FATA in spite of the unique challenges the area
presents. This should be an area of priority programme development.

There are many activities planned and the programme as noted is fast moving with a short time frame for filling
existing gaps, scaling up and implementing essential elements of the strategy. This will require a lot of
commitment and very strong management together with much improved coordination between UNICEF, WHO
and government.
Conflict provides an ongoing challenge and its unpredictability will be a constant threat to programme gains. This
will need to be planned for as much as possible but cannot be predicted. Equally, as the flood season
approaches there is a strong possibility that large numbers of people will be displaced and flows of IDPs will
Page

29
3. Challenges
increase significantly. The extent of a flood emergency is difficult to predict but given recent history plans should
be in place to cover the possibility of a major natural disaster.
4. Opportunities




COMNet, where it is in place is showing signs of real impact and innovation and provides an opportunity to build
on growing community level partnerships and develop much more detailed and localised understandings of
HRGs.
Recent joint meetings between UNICEF and WHO are providing a better basis for coordination within the
programme and therefore stronger planning of activities and analysis of what’s working and how to respond to
problems as they arise.
Lessons from existing transit point experience are being reviewed to develop plans for an expanded and more
systematized approach with more permanent points, improved cross border coverage, train based teams and
better placement to capture IDPs and more mobile populations in FATA.
UNICEFs communication expertise in areas of IPC training and IEC materials development can be applied to
training teams to improve skills and coverage at transit points and accessing children in multi-family dwellings.
Milestone
Outcome
1. HRG Strategy: Prioritise the identification of focal
points and a representative team in Islamabad
(UNICEF, WHO and government) to coordinate and
plan the activities.
By mid-May
This will provide the overall
coordinating and
implementation structure
needed to implement activities
quickly and effectively.
2. Mapping: Prioritise the detailed mapping and
disaggregation of HRGs to the UC level linking them
to microplans (incorporate specific activities for
mapping and reaching brick kiln and other temporary
worker settlements).
By end-May to
early-June
This is in the strategic activity
plan and will allow for more
accurate targeting of HRGs for
COMNet and also for
campaign planning and
implementation.
3. COMNet: Regular (monthly) meetings (face to face
or teleconference) should be conducted amongst
senior COMNet staff across provincial level to ensure
sharing of experiences, initiatives and identifying
approaches that have demonstrated impact and in the
short term to support KP as it becomes operational.
Ongoing
Allows for regular information
and lesson sharing amongst
the provincial COMNet teams,
immediate support to KP and
identification of innovations for
scale up and/or expansion to
other areas.
4. FATA: Develop and implement a communication
strategy for FATA working through religious, local
government, community and tribal leadership and
focused on increasing coverage, access and
encouraging mobile populations to immunize their
children when they travel.
By end-May
A focused and strategic plan
and activities for FATA allows
for targeted intervention and
planning for improving access
and/or increasing coverage of
children as they move out of
inaccessible areas.
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Recommendation
30
Recommendations
Improved coverage for multifamily dwellings and at transit
points plus increased team
retention and commitment to
do their jobs well.
31
By end-June
Page
5. Teams: Develop high quality IPC materials and
motivational activities for teams in cooperation with
WHO paying attention to vaccinator teams and
specialized training needed for transit teams.
Team 4: Monitoring & Evaluation (Sue Goldstein, Soul City; Sebastian Taylor, theIDLgroup)
Background
To support evidence-based action towards the current polio eradication targets, UNICEF has invested in
considerable scaling up in its data-gathering and M&E capabilities dedicated to PEI in Pakistan. Central to this
investment is the PRIME System (Programme Research, Information, Monitoring and Evaluation). Figure 3, below,
sets out the main elements of this system. Four modes of research, data-gathering and analysis support programme
M&E and, as a result, a more evidence-driven approach to communications and social mobilization as a contributory
element of polio eradication.
Figure 3
The data flow process is intended to ensure that data are used for programmatic reporting and performance reviews,
as well as analysis, response and planning at the community, union council and district levels. As a whole, the
PRIME System is designed to produce better data in two key respects: first, evidence relating to the effectiveness
and impact of communication and social mobilization activities in themselves; second, social data – to complement
operational, technical and epidemiological data – explaining household attitudes to polio and to the campaign, and
the role of these social dynamics in facilitating or obstructing effective programme delivery.
Key Observations
Page
In order to support maximizing the utility of data and analysis produced by PRIME, it is important to ensure that all
research, monitoring and evaluation protocols are focused on answering a few core operational questions: which
households are being missed during campaign rounds? What are the reasons for households/children being missed?
What are the likely effective actions to be taken within the programme to reduce incidence of missed
household/children?
32
Overall, the system is impressive and comprehensive. Capacity has been built at the national and provincial levels.
However, there is a need to ensure that programme personnel at lower levels (District and UC primarily) are able to
administer data-gathering, quality check data gathered, and contribute to localized analysis; and there is an equal
need to ensure that, as a result of this local capability, social data and analysis are being fed back into operational
planning and microplanning before, during and after each campaign round.
Findings and recommendations, below, are given in four areas:




Design and use of the research workstream within PRIME
Use of District and UC reporting and monitoring data
M&E for mass media
M&E for COMNet
1. Research
A key research tool (the Knowledge, Attitudes and Practices (KAP) study) has been developed and deployed under
the PRIME System. Two areas will be critical to the utility of this tool in strengthening overall programme
performance. First, the evidence content generated by the KAP can be further developed, e.g.:

Include more substantive questions on non-polio attitudes and experiences among respondent households.
Polio is only one among a wide range of risks being managed by often extremely resource-poor households and
families; it is important to understand where polio (as risk) and polio vaccination (as risk mitigation) sits within the
wider set of health and non-health threats people perceive, in order to see where and how communications and
social mobilization efforts can either raise the risk perception or increase the value of risk mitigation (OPV).

Break down some of the group categories being applied in the research (and in the programme more widely.
High-Risk Groups are frequently construed in broad social categories (‘Pashto’, ‘Pashtun-speaking’, ‘mobile’,
‘nomadic’). However, within these categories there are liable to be significant variations of actual condition,
attitude and behavior. Research attempting to identify accurately the types of social condition that correlate with
higher chance of households and children being missed during a campaign will need to classify in more detail
what kinds of Pashto households, what level of non-Pashto linguistic ability, what periodicity of mobility is most
strongly associated with un- or inadequately vaccinated children, in order to design or support the most effective
programmatic responses. Multivariate analysis could be better used to demonstrate the relative strength of such
associations, providing robust evidence as to which elements of the programme as a whole may be most
important to invest in programme strengthening.

It may be useful, in validating UNICEF’s investment in COMNet, to conduct KAP-type research in Districts or
UCs where COMNet is operational and others where it is not, in order to determine whether, over a number of
campaign rounds, there are discernible differences in the quality of programme delivery, household reception,
and consequent rates of missed household or children.

Finally, there is a plan in place to conduct regular KAP-type surveys over the course of 2012 (and possibly
beyond). This is important in order to show trend in surveyed Districts. But it is equally important to ensure that
KAP survey data and analysis are being produced in a sufficiently timely manner to be able to feed into
campaign operational planning.
Page
Where the study can be improved in the next round is in 3 categories:
33
The first KAP study is a fairly large piece of work, with a sample of over 5000 respondents in high risk areas. There is
a lot of useful information gathered in the study and this can be broken down to the district and sub-district level. The
results of the study show impressive knowledge levels about polio but also very clear gaps that need to be
addressed. The study also showed generally positive attitudes and willingness to not only be vaccinated but to be
part of mobilising the community. This overarching finding has an important bearing on what kinds of communication
and social mobilization activities UNICEF invest in to support PEI – and, indeed, what kinds of operational
improvement may be needed more broadly (e.g. strengthening composition, training and IPC skills of vaccinator
teams).

Sampling: in FATA for example the majority of the sample is women (85%), but the majority of decision
makers about vaccination are men (78%). Thus in FATA the KAP could focus more on the men to enable
access.

Theory and Questionnaire design: the study is a great opportunity to measure the reach of the
communication programme as well as the potential access to media that high risk groups might have. This
can assist in more detailed targeting of media and messages. In addition the theory used to conceptualise
the behaviour change (or social change) should be stated and the questionnaire designed to include the
theoretical constructs. KAP studies tend to assume a direct association between knowledge and behaviour
change, or a consistent association between attitudes and behaviours; neither of these assumptions have
evidence that supports them.

Analysis: there is a huge amount of data in the study, but the key question is what the barriers to vaccination
are? Analysing through multivariate analysis will assist in understanding the differences between those who
have not immunised their children and those who have. The groups not reached here are the most
important so the analysis can focus on these – at a district and sub-district level (where numbers will allow).
Good analysis of impact data (trends) will enable cost-effectiveness analysis to be determined, and thus
strengthening planning.
There are a number of other research products already produced or planned, including a study of motivation among
vaccination teams, a study of OPV refusal in Balochistan and KPK, and a high-risk group study in Sindh. There is no
doubt that these are important areas of focus in supporting optimal programme performance. It is important, however,
to ensure that a) studies, especially where qualitative, are sufficiently robust methodologically to allow for direct
translation into programme management and operation at the local level, and b) studies are all designed to address
the primary programme objective – how to reduce the number of missed children in each campaign round.
Recommendations for Research




To continue the tracking KAP and to add in questions to assist with improved targeting and focus.
To further drill down into the data using multivariate analysis.
To ensure that the data is easily available at a district level
To encourage the use of data at the district and UC level
2. District and UC reporting and data collecting system
Monitoring and reporting at District and UC levels under the PRIME System falls into two key forms: first,
maintenance of activity logs on the part of COMNet operatives; second, production of a ‘Performance Scorecard’ for
District and Union Council relating to the quality of conditions and preparations for campaign rounds.
The COMNet personnel log books are useful in ensuring monitoring of planned activities. This is largely a function
internal to UNICEF. The major point of crossover between COMNet internal planning and activities documentation
and the wider programme is the social maps produced at UC level.
Page
Overall, data collection and management at local levels is now much stronger than at any time in the past. However,
improvements in the content, structure and use of those data are still possible. First, the Performance Scorecard
could be reorganized to prioritise data on missed children. This is the core problem of the programme, and arguably
should be the major emphasis of the scorecard. Given that much evidence suggests that household refusal is not a
major cause of missed children, data on refusals is given too much prominence in this, as in other research, data and
34
The Performance Scorecard, by contrast, assembles data along a range of indicators (some specific to UNICEF
activities but others relating to actions and expectations of other operational partners (for example indicators on
campaign preparation and support set out in the National Emergency Action Plan (NEAP)).
M&E instruments. Following a section on missed children, the scorecard could provide data and evidence from wider
research and/or evaluation of recent campaign rounds, to identify major barriers to effective vaccine delivery
(whether this is a matter primarily of supply side, e.g. vaccinator teams, or demand side, e.g. household refusal or
absence). Following this, the scorecard could report on operational and logistical aspects of District/UC campaign
preparedness (as required by NEAP).
Second, the red/amber/green scoring system for the scorecard may need to be reconsidered in respect of certain
data. For example, a UC with no ‘resistance schools’ would necessarily score red on ‘% resistance schools
converted’. Where government leadership in campaign management has been considerably enhanced, red scores
may result in disciplinary action, with reportedly little opportunity, often, for personnel to explain in detail possible
causes of low score. This could result in unjustified punitive action against staff, or create perverse incentives to
manipulate data.
Third, the true utility of the Performance Scorecard, and the social map, is at the UC level, in the analysis of missed
children in the last campaign round, and microplanning for the next round which is driven by evidence and focused
on the evidence base about the location and characteristics of missed households, the reasons they were missed,
and – hence – the appropriate campaign adjustments that will see the incidence of missed households and children
reduced. For scorecards, social maps and microplans to be properly integrated in UC campaign operations (including
use of PCM/PCR data), they need to be used jointly and collaboratively by WHO and UNICEF working together
under GoP leadership at District and UC levels.
Recommendations for the District and UC data system



Continue to build and use the excellent system
Reorient the scorecard layout to focus on the key issue in Polio Eradication i.e. missed children
At the UC level, integrate the data (social maps, micro-planning maps; PCM data, PCR and the district
scorecard) in operational/campaign appraisal and planning
3. M&E for Mass Media
Mass media continues to draw a significant proportion of polio communications spending in Pakistan. This may well
be appropriate for a somewhat volatile social context in which maintenance of a clear positive message,
comprehensively delivered nationally, supports the continuing, broadly positive household perception of PEI.
However, with limited resources, and increasing pressure on the programme for results, all programmatic
expenditures have to justify their cost by demonstrating their direct contribution to the core programme objective –
increased levels of vaccination (or reduced rates of unvaccinated children).

Ensure clear objectives for mass media investments (national awareness, national support for PEI, sub-national,
local and targeted influence with high-risk and hard-to-reach groups inter alia).
Page
Recommendations
35
Under current circumstances, media audience monitoring data suggest that messages are achieving very high rates
of nationwide coverage. However, it is less clear that these wide-ranging messages are being effectively delivered in
locally-acceptable form (linguistically, visually, conceptually), or that they are being deployed through the local media
channels most widely used by core target (high-risk) groups, or that those groups are being positively impacted by
messages, and responding with the kinds of OPV and campaign-positive behavior that is likely to lead to falling rates
of missed children in high-risk areas. In order for mass media to demonstrate its continuing value to the national
programme, it needs to demonstrate where how, and with what effect, it is penetrating into small, specific areas of
high-risk populations, as well as high-risk populations on the move.

Use research and survey tools to complement national media monitoring, to investigate local channels of media
usage, delivery and impact of existing messages in current high-risk and hard-to-reach groups.
4. M&E for COMNet
Existing, accredited data in Pakistan suggest that, aside from a few distinct areas (e.g. some Districts/UCs in
Balochistan), ‘refusal’ is a very small proportion of the principal reasons households or children are missed each
round by the vaccinator teams. Much more prominent reasons appear to be to do with poor vaccinator performance
on one hand, and what might be described as household and community ambivalence towards the campaign
(resulting in absence from household during rounds, or inattention to ensuring all children are vaccinated each round)
on the other.
Under these circumstances, the continuing emphasis in the deployment of COMNet personnel at the District and UC
level on converting refusals appears to be working against the grain of the evidence. This may then result in suboptimal programme benefit from the considerable investment the COMNet has received. A strong focus on ‘working
with influencers’ for example, is consistent with conditions in which such influencers are required to persuade
resistant households, but is less relevant where the households are (more or less) willing, but the vaccinators are
unable (or unwilling) to deliver.
COMNet personnel should be tasked to address the localized causes of missed children, and to be evaluated in their
ability to effect positive change in those local causes. In this respect, one clear area in which the COMNet could be
more strongly deployed is in supporting vaccinators in doorstep IPC. This could be either through supporting the
quality, content and delivery of training, or through accompanying vaccinators in targeted high-risk neighbourhoods
within a given UC.
A second clear area in which COMNet activity could be directed is in negotiating access to insecure or hitherto
closed areas, in particular in FATA. The continuing inability of vaccinators to enter certain areas of the agencies (in
one instance as far back as 2009) is clearly creating a point of major vulnerability to the success of the whole
programme. Given that communication is probably the most viable programme strategy with regard to access in such
areas, this is a field in which COMNet could set itself very clear objectives, against which its effectiveness could be
very clearly gauged. Of course, this is a considerable challenge, but is of sufficient importance to the programme as a
whole that it should be core to COMNet strategy and targets.
A third area in which COMNet could be more closely engaged is making and maintaining communications contact
with mobile populations. This is likely to become more critical in the middle of 2012, as flooding (and continuing
violence) may cause large-scale population displacements.
Recommendations

36

Reconsider core tasks of COMNet, based on evidence of major causes of missed children (and reducing
emphasis on refusal-related activities).
Increase COMNet support to vaccinator teams (in particular through support to IPC training but also support to
direct household delivery where feasible).
Develop COMNet capacity and objectives in FATA/KP to strengthen programme access in hard-to-reach areas
and with High-Risk Groups, including mobile populations.
Page

Milestone
Outcome
1. Maintain and develop research product
(KAP)
Iterative KAP surveys in priority
areas, preferably every 3 months
KAP findings converted into
OPV delivery strategy in all
covered priority areas
2. Modify Performance Card to focus on
missed children, causes of missed children,
and joint comms and operational response
Revised version of Performance
Card produced and adopted
Performance Cards used as
evidence base for DPEC/UPEC
campaign review and planning
each round
3. Refine evidence of mass media
investment (especially in HR groups)
Mass media impact evidence in HR
groups presented
Clear mass media objectives
supporting OPV demand and
delivery showing positive impact
in HR areas
4. Focus local COMNET/SM strategy on
major causes of missed children (e.g.
vaccinator teams, insecurity access,
emergency displacement)
New SM strategy for HR areas
developed
Increase in COMNET direct
support to increased delivery of
OPV in HR areas, and reduction
in missed children
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Recommendation
37
Recommendations
Annexes:
Mass Media Team
Objective
To review the Media Engagement & Mass Communication strategies in Pakistan.
Questions to the Review Team
The review team was specifically asked to address the following issues. These questions will be individually
addressed in the following sections, as well as by area in the Recommendations.
Media
1. Given Pakistan’s media environment, is the current media engagement strategy appropriate and relevant to
create enabling public discourse in support of polio eradication?
2. To what extent does the current media engagement capacity building strategy address the needs of
stakeholders in the media?
3. What additional risk mitigation and crisis preventive measures should be put in place with media
stakeholders?
4. Is the media strategy clearly communicated and understood amongst all GPEI partners? How can
coordination be further streamlined among the partnership, ensuring that the programme speaks publicly in
one voice? Are identified spokespersons appropriate and diverse enough to generate objective,
depoliticized voices speaking on behalf of the programme? Are roles amongst the partnership related to
media engagement clear and appropriate?
Mass Media
1.
2.
3.
4.
5.
Are the adopted mass communication materials adequate to communicate identified messages?
Are the media placement strategies adequate and relevant to reach intended audiences?
What additional mass communication products are needed to ensure maximum interest and penetration?
Have mass communication strategies led to increased results in campaign awareness and knowledge?
What adjustment to mass communication strategy and media placement will need to be accommodated to
ensure optimal coverage (highest ROI)
6. Given ubiquity of mass communication, how to tailor mass communication strategies to sub-national
coverage of NIDs? To what extent each communication channel should be used?
7. Similarly what are the strategies to accommodate NEAP’s “stop campaign” principle during mass
communication campaign, when vaccination is delayed in selected areas due to lack of preparation? How
can the programme mitigate and respond to the shifted campaign timeframes?
Itinerary of visits and persons met
MONDAY,
Silvia Valentini, Communications Officer, WHO
30 APRIL 2012
Michael Bociurkiw, Communications Consultant, UNICEF
Mazher Nisar, Prime Minister’s Health Advisor (Communications)
1 MAY 2012
Anis ul Husain, UNICEF Call Centre Consultant
Islamabad
Masooma Qurban, Media Officer, UNICEF Balochistan
Page
TUESDAY,
38
Islamabad
Amir Jahangir, Puruesh Chaudhary, President and CEO, Mishal Inc, Journalist’s Workshop
Coordinators
WEDNESDAY,
Sindh CommNet team
2 MAY 2012
Raabya Amjad, UNICEF C4D Specialist, polio
Karachi
Interflow Communications, Media placement agency
Spectrum Y&R Communications, Campaign design agency
Aziz Memon, National Chairman, Rotary Polio Plus Committee
Dr Mazhar Ali Khamisani, Program Director, EPI, Government of Sindh
Dr Zubair Anwar-Bawany, UNICEF Public Private Partnership Consultant
THURSDAY,
Kristen Elsby, UNICEF Chief of Advocacy & Communication
3 MAY 2012
Altaf Khan : UNICEF Pakistan media consultant
Islamabad
Media Summary Areas and Recommendations
Area/challenges
Key Recommendations
Time
frame
Responsible
stakeholders
Conduct meet and greet/lunches with key decision
makers of targeted media houses (director of
news/editors) at national and provincial level. Provide
media pack containing basic programme
info/spokesperson contact numbers/website
information.
Q2
UNICEF
Prioritize roll-out of media workshops at provincial level
to proactively launch relationship building and develop
long-term advocates for polio in highest-risk areas.
Ensure initial 150 journalists are key media in Pakistan.
Target further workshops at areas of highest
risk/negative tonality. Lift number of trained journalists
from 150 to 400.
Q3
UNICEF,
Mishal
Use Media Workshops to launch Journalists Against
Polio group. Investigate alliance with Tribal Union of
Journalists
Q3
UNICEF,
Mishal
Pre-round media events at provincial level to generate
positive, non-paid coverage.
Q2
UNICEF
Prioritize ‘quick wins’, such as establishing ongoing
relationships with key media houses such as BBC
Q2
UNICEF
Focused, provinciallevel media approaches
Page
Media not optimally
engaged – lack of trust
between media and
programme.
39
Media Engagement
to maximize local voice
in a culturally relevant
context
Pashto, PTV Boldan, and conducting a media event
with Pakistan soccer captain Doctor Issa in KillaAbdullah.
Specific strategy for medical fraternity/Pakistan
Pediatrician Association to routinely promote the
programme.
Q2
Pre-campaign, in-campaign and post-campaign
briefings with provincial media houses.
Q2
UNICEF
WHO
PPA
UNICEF
WHO
GoP
Media Crisis Management
Unpredictable media
environment:
provincial, national and
international and lack
of agreed media crisis
response
strategy/materials.
Develop Media Crisis Plan, including designated
partner focal points (on-call 24/7), OICs (to cover
against absences) and agreed process for a UNIFIED
media crisis response. Withdraw UNICEF Rep from the
approval process.
Q2
Media crisis response materials (FAQs and fact sheets
covering AFP/OPV vaccine safety, etc) produced,
signed off by partners.
Q2
UNICEF
WHO
ROTARY
GoP
UNICEF
WHO
ROTARY
GoP
Need for Government
to be leading voice on
polio eradication
Agreed Government spokespersons identified and
orientated at national and provincial level. Agreed
programme spokespersons on technical issues (WHO)
and programme level (UNICEF) in place when
Government not available/appropriate.
Q2
UNICEF
GoP
Partner Relations/ Coordination on Media
Weekly inter-agency editorial meetings to determine
agenda, share information, generate provincial media
focus, produce content for website, newsletters, etc
working from Media Strategy with clearly determined
roles and responsibilities
Q2
Monthly Social Mobilization Working Group meetings to
analyse Mass Communication strategy, media tonality
analysis, plans for IEC, IPC, discuss upcoming visits,
etc.
Q2
UNICEF
WHO
UNICEF
WHO
GOP
DONORS
40
ROTARY
Page
Partnership overlap
and internal overlap
requiring clearly
outlined, understood
and supported roles
Align UNICEF media plan and WHO draft
communications strategy into a joint communications
strategy, with action points managed by UNICEF
through Social Mobilization Working Group meetings.
Q2
Weekly AFP Meeting the focal point of partnership
response. All zero-dose AFP cases to trigger joint
WHO/UNICEF investigation.
Q2
UNICEF staff to undergo epi training and how it
correlates to BCC. WHO to undergo BCC and IPC
principles training for better understanding of partner
roles and to enable both parties to speak each other’s
language.
Q2, 3
Unify websites, with www.endpolio.com.pk the face of
the programme and www.polioalert.info maintaining its
focus on weekly media alerts. Both websites should
point to each other.
Q2
WHO Health Journalism Awards presented as joint
WHO-UNICEF awards to promote UNICEF’s
partnership media role.
Q2
Presentation of round analysis according to
HRGs/HRAs/geography.
Q2
Rolling evaluation of media habits of HRGs, especially
Pastho-seaking communities, and media spend
targeted accordingly.
Q2
Increased spend on terrestrial channels and radio,
reduced spend on print.
Q2
UNICEF
WHO
UNICEF
WHO
GOP
UNICEF
WHO
UNICEF
WHO
UNICEF
WHO
Media Buys: Interflow
Underexposure of highrisk groups to mass
media
UNICEF
INTERFLOW
UNICEF
INTERFLOW
UNICEF
INTERFLOW
Mass Communication Campaign
Low threat perception
(children not at risk for
polio)
Increase threat perception through stronger/more
emotional delivery/gritty appearance, demonstration
that polio has no cure but is preventable.
Q2
Theme for MC strategy
is sound but
Identify three specific needs as identified by the KAP
Study and integrate in the current planned PSA
Q2
UNICEF
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UNICEF
41
SPECTRUM
opportunity for
increased evidencebased response
schedule
SPECTRUM
Diverse population
requiring specific
approaches with
cultural relevance
Strategic focus to approach mass communication at
two levels: national and focused on Pashto-speaking
populations, with specific PSAs (eg, Afridi PSA shot in
both Urdu and Pashto) to maximize impact and allow
for cultural sensitivities. Arrange for Spectrum/Interflow
to witness SNID in the field.
Q2
Logo lacks relevance,
materials too wordy
New impactful logo required, including key message to
immunize children <5 every time. Reduce words on
posters/banners, being mindful of non-literate
communities.
Q2
Develop and roll out specific mass communication
strategy for migrant populations targeting people on the
move, with emphasis on non-literate materials, for
placement at key transit points, bus stops, on and in
buses, and to support the 250 additional transit points
established from 23 April.
Q3
Approach transport owners for fixed IEC inside
buses/on tickets/T-shirts for conductors/on paper cups,
etc
Q3
UNICEF
Identify main transportation routes for targeting
banner/hoarding buys with non-literate materials.
Q3
UNICEF
Work with UNICEF India on production of campaign
targeting non-literate communities
Q2
UNICEF
Identify local printing houses/address S&P bottlenecks
to reduce 45-day! printing lag time to the necessary two
weeks.
Q3
UNICEF
Seek to identify poorly performing districts ahead of
time and delay printing for these areas.
Q2
UNICEF
UNICEF
SPECTRUM
UNICEF
SPECTRUM
Transit Campaign
Limited strategy
tackling populations on
the move
UNICEF
WHO
WHO
Handling Change of Dates (NEAP/SIADS)
WHO
Introduce modifiable scrolling ticker/tails for radio/TV
PSAs with voiceovers outlining which areas are
conducting rounds.
Q3
UNICEF
42
GOP
Page
Campaign staggering,
or shifting dates, due to
postponements
generated under
National Emergency
Action Plan
Programmatic
resistance due to
SIADs
Prioritize local approaches (mosque announcements,
public miking) and generate media alerts
Q2
UNICEF
As much as possible, give advance warning of SIADs
through understanding of future campaigns.
Q2
UNICEF
Develop Pashto-speaking communications strategy
with actions matrix, for saturation coverage in Pashtospeaking areas and along transit routes frequented by
Pashtuns.
Q3
UNICEF
Establish partnership with BBC Pashto/Spin Boldak
radio.
Q2
UNICEF
India to share IPC materials produced for targeting
nomadic non-literate communities.
Q2
UNICEF
Partner meeting to evaluate investments, for
example, impact of call centre and either:
Q2
GOP
Convey message that SIADs are being conducted due
to threat of transmission in immediate area and multiple
rounds have been proven to rapidly raise immunity to
that threat.
The Pashtun Question
Need for focused
media/mass
communication
strategy targeting
Pakistan’s key HRG
WHO
GOP
The Call Centre
Call centre is underutilized.
•
Invest necessary funds to make it
worthwhile;
•
Contract call centre out to professional 3rd
party;
•
Close it down.
UNICEF
WHO
IPC Team
Thematic Focus, Objectives and Key Questions:
Desk review of available documents and materials, two-day field mission to Sindh, with a focus on high risk areas in
Karachi (Gadap 4 UC and Baldia Town) multiple interviews and discussions with community members, partners,
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Methodology
43
Enhancing communication planning, IPC skills and amplifying reach in very high risk areas
UNICEF staff (including C4D, health, nutrition and external relations) government and GPEI staff including DHSCOs
(10), UCO (15) and SMs (7). Additionally, interactions with Female Community Volunteers (FCVs) – locally recruited
women vaccinators who also support social mobilization activities provide insight as to local community perceptions
of OPV, the eradication initiative and effect approaches to community engagement and vaccine delivery.
HRG Team
Theme:
The team was asked identify areas for immediate operationalization and expansion of the High Risk strategy for
Pashto, IDP, migrant and nomadic groups.
HRG Key Questions
 Practically, how well are high-risk groups that require special communication approach defined at federal,
provincial and local levels? To what extent does the strategy articulate the communication needs of such
groups and movement patterns?
 Do current communication initiatives targeting high-risk groups (partnerships with religious leaders and
community groups) comprehensively address the needs of the programme?
 What high-risk groups remain uncovered? What are the immediate scale-up opportunities to outreach to
these high-risk groups?
 Are communication approaches and IEC materials culturally and contextually relevant to these groups?
 Are vaccination teams and social mobilizers able to reach out to their group given their IPC skills and
composition (age, gender, language)?
 Are these groups adequately identified and mapped in microplans?
 Do supervisory structures adequately focus on increasing coverage in these groups?
Documents reviewed, people and organizations met, places visited.
During the review the team:






Received briefings in Islamabad from the Islamabad Polio Communication and Balochistan teams.
Reviewed a range of documents including the recent KAP, research into HRGs at provincial level, training
packages, communication materials, the Fatwa booklet and a draft version of the HRG Strategy.
Participated in a joint meeting of UNICEF and WHO which reviewed the Transit Point strategy.
Traveled to Peshawar for a briefing with the KP/FATA UNICEF communication team, government and WHO
and was able to observe a community meeting with Mullahs, meet with a group of leaders from an
Afghanistan refugee and IDP camp and meet with the CDO and EDO for Peshawar.
Upon returning from Peshawar the team received a more recent version of the HRG strategy that
incorporate activities and indicators established at a joint planning meeting (UNICEF, WHO and
government) held on Thursday May 3 (the day the team returned from Peshawar.
An initial debriefing session was held with Islamabad polio communication staff on Friday May 4 and a final
presentation of the recommendations was held on the morning of May 7.
The Review was conducted by discussions with the M& E team at head office, reading the research documents,
looking at the various data capture forms and reports, meeting with staff at the Punjab regional office, meeting with
staff at UC level (UCSO and Social mobilizers) looking at data collection tools, observing data monitoring and
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Methodology
44
M&E Team
verification. In addition meetings were held with the regional WHO polio X (Dr Deborah) and the Government EPI
officer Dr Tanwir, Rotary International District Governor Mr Anthony Richards
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45
Debriefing discussions were held with the Punjab UNICEF staff and the National office staff, the final report and
recommendations were then compiled.