Behavioral Change Communication Strategy

Focus Field: Mother and Child Health

Level of Intervention: Secondary Care Services
Focus Area: Khyber Pakhtunkhwa

Martina Merten – Health Specialist

OUTLINE

1. MNCH in Pakistan and in KP: an overview

2. Utilization of Reproductive Health Services in Pakistan and KP: facts and figures
3. Healthcare Seeking Behavior
4. BCC around MNCH and its challenges
5. A Strategic Communication Agenda: what would be the main needs?
- For the demand side
- For the supply side
- For cross cutting issues
6. Key Messages
7. How could communication results be monitored?
8. Roadmap: A potential way for successful implementation
9. Workshop Agenda

© 2018 Martina Merten - Health specialist 1

PART I: SITUATIONAL ANALYSIS – WHY DO WE NEED
A BEHAVIORAL CHANGE COMMUNICATION APPROACH?
MOTHER AND CHILD HEALTH IN PAKISTAN

I. High Maternal Mortality Ratio II. High infant and under 5 mortality
(MMR): 178 per 100.000 live birth
rates: 72 per 1000. (58/1000 in KP)
(2015) – 206/100.000 in KP

IV. Poor nutrional status: 44

MNCH in percent of Pakistani children suffer
from stunting. A fifth of pregnant
III. High stillbirth rates: 43 per 1000 Pakistan – an women and children under five have
overview severe Vitamin D deficiency

VI. Poor health access: only 52

V. Poor routine vaccination status:
percent (48 in KP) of deliveries take
almost half of children do not receive
place in the presence of a skilled
a full course of vaccinations.
birth attendant

© 2018 Martina Merten - Health specialist 3

UTILIZATION OF REPRODUCTIVE HEALTH SERVICES IN PAKISTAN
AND KP: FACTS AND FIGURES

 Preference of private over public facilities

 Lack of trust in the public sector
 High use of outpatient services
 Increase of Antenatal Care Visits (ANC) over the last 20 years: from 14
percent in 1990-1991 to 37 percent in 2012-2013. Nonetheless still 24
percent of women received no ANC at all (38 percent in KP). Higher
incidence of ANC in urban than in rural settings.
 ANC from a skilled birth provider: 73 percent of women age 15-49
received ANC from a skilled provider for their most recent birth (60.5
in KP, in rural settings 56 percent).

© 2018 Martina Merten - Health specialist 4

UTILIZATION OF REPRODUCTIVE HEALTH SERVICES IN PAKISTAN
AND KP: FACTS AND FIGURES

 Assistance during delivery: 52 percent of deliveries took place in the

presence of a skilled birth attendant (48 in KP overall, 44 percent in
rural settings).
 34 percent of uneducated women occurred in a health facility for
delivery. 52 percent gave birth at home (similar picture for KP).
 38 percent of women had no postnatal check up (60 percent in KP, in
rural settings 65.9 percent).
 52 percent of newborns in Pakistan did not receive three check-ups
within seven days after delivery (73 percent in KP, 77 percent in rural
settings).

© 2018 Martina Merte

Merten – Health Specialist 5
HEALTHCARE SEEKING BEHAVIOR

Reasons for not seeking (the right) care:

 No financial means (49 percent of people in KP are considered to be

poor)
 High Out of Pocked Expenditures (especially in KP)
 Gender issues
 Difficulties in accessing the health facility
 Poor health education and education in general
 Poor health education/communication within facilities
 Low health insurance coverage

© 2018 Martina Merten -– Health Specialist 6

BCC AROUND MNCH AND ITS CHALLENGES

 Shift from sporadic awareness raising

I. BCC in Pakistan information, education and communication
(IEC) to strategic, evidence-based behavioral
change communication (BCC)
 First health education activities: formally
initiated during the 1960s Malaria control and
small pox eradication programs

© 2018 Martina Merten - Health specialist 7

BCC AROUND MNCH AND ITS CHALLENGES

 First communication strategy: outlined for

Population Welfare and Family Planning
II. BCC around MNCH under the 6th national plan (1983-1988).
 The IEC campaigns were continued under
the 7th national plan (1988-1993).
 From 2004-2010 USAID funded The Pakistan
Initiative for Mothers and Newborn
(PAIMAN). Aim was to improve MNCH. One
component: health communication and BCC.

© 2018 Martina Merten - Health specialist 8

BCC AROUND MNCH AND ITS CHALLENGES

 Based on the PAIMAN strategy the National

Communication Strategy for MNCH was
II. BCC around MNCH designed. Goal: to improve MNCH at all
levels of care.
 In 2016 the Minimum Health Services
Delivery Package for Secondary Care
KP was published as part of the
development of a provincial Health Sector
Strategy.
 These Package proposes a number of
activities for promoting BCC within secondary
care facilities. However, the package hasn’t
been implemented yet.
 Other projects were implemented (for
example in Sindh), but not with a focus on
MNCH and secondary level care in KP.

© 2018 Martina Merten - Health specialist 9

BCC AROUND MNCH AND ITS CHALLENGES

 High illiteracy
II. So far challenges to  Limited reach of mass-media
BCC  Extreme diversity within Pakistan and KP
 Gender inequality/patriarchal society
 Religious perceptions and beliefs about
health and illness
 No coordination of existing BCC strategies
 No implementation of the existing National
MNCH communication strategy on all levels
of care
 Focus on primary care BCC interventions, not
on secondary care interventions
 Not enough advocacy for BCC

© 2018 Martina Merten - Health specialist 10

PART II: STRATEGIC COMMUNICATION AGENDA –
WHAT WOULD BE THE MAIN NEEDS?
STRATEGIC COMMUNICATION AGENDA

 Demand Side: Mothers and their family

I. Overall Strategy for all  Supply Side: health professionals working
at secondary care facilities
audiences needed
 Cross Cutting: provincial and federal
bureaucrats; media

© 2018 Martina Merten - Health specialist 12

STRATEGIC COMMUNICATION AGENDA

Demand Side:
I. What is needed for
each audience? How can mothers/families be reached? How can
they be taught about the right level of care?

Possible solutions:

 conduct formative research to identify

contextualized BCC messages around MNCH
focusing on secondary level care
interventions

© 2018 Martina Merten - Health specialist 13

STRATEGIC COMMUNICATION AGENDA

Supply Side
I. What is needed for
each audience? How can health professionals working in
secondary health facilities make changes? How
can they address mothers/families more
effectively?

Possible solutions:

 Assign BCC focal persons at all levels of

health care;
 Identify tasks of the respective BCC focal
persons (like organizing health education
sessions, identifying communication needs of
mothers etc.)

© 2018 Martina Merten - Health specialist 14

STRATEGIC COMMUNICATION AGENDA

Supply Side
I. What is needed for
each audience? How can health professionals working in
secondary health facilities make changes? How
can they address mothers/families more
effectively?

Possible solutions:

 Implement the concept of BCC into the

curriculum of undergraduates, post
graduates and continuing education

© 2018 Martina Merten - Health specialist 15

STRATEGIC COMMUNICATION AGENDA

Cross Cutting
I. What is needed for
each audience? How can district, provincial and federal
bureaucrats makes changes on BCC?

Possible solutions:

 Train IEC people to become BCC advocates

 Create a forum comprising of provincial
health department, directorate of health,
registrar, PMDC, PNC, Medical Directorate et
al

© 2018 Martina Merten - Health specialist 16

STRATEGIC COMMUNICATION AGENDA

Cross Cutting
I. What is needed for
each audience? How can media make a change on BCC?

Possible solutions:

 Develop a media campaign to ensure the

right care at the right level for
mothers/families and their children

© 2018 Martina Merten - Health specialist 17

 STRATEGIC COMMUNICATION AGENDA: EXAMPLE

Goal Key Current Program Materials

behavior status interventio
n
Improve health • Proportion of • Less than half of • Design and To be researched
seeking behavior of women seeking deliveries (48%) conduct formative
mothers and healthcare at the take place in the research to
families visiting right time from presence of a identify BCC
skilled birth messages around
secondary care appropriate level;
attendant; MNCH focusing on
facilities • Proportion of
• 38 percent of secondary level
mothers with women in KP do care interventions;
children attended not receive ANC; • Design BCC
by a skilled birth • Those who messages around
attendant; received ANC utilization of MNCH
• Proportion of often do not services focusing
maternal deaths receive enough on secondary level
averted through components of care;
timely provision; ANC and often not
by a skilled
provider

© 2018 Martina Merten - Health specialist 18

STRATEGIC COMMUNICATION AGENDA

V. How can Monitoring Results for Demand Side

communication results Interventions:
be monitored?
Changing the behaviour of mothers/families and
children
 How many women have been informed
about the importance of medical attention at
the health facility by LHWs, CMWs or TBAs?
(tracking starts in a model district)
 How many women have been informed
about the need to visit a secondary facility in
case of complications by LHWs, CMWs or
TBAs? (tracking starts in a model district)
 How many women have been effectively
informed by a health professional working in
a secondary health facility about appropriate
ANC, postnatal care and delivery practices?

© 2018 Martina Merten - Health specialist 19

STRATEGIC COMMUNICATION AGENDA

Monitoring Results for Demand Side

V. Monitoring for Interventions:
Communication Results
 How many men and mothers in law have
been effectively informed by a health
professional working in a secondary health
facility about appropriate ANC, postnatal
care and delivery practices for their wife or
daughter in law?

© 2018 Martina Merten - Health specialist 20

STRATEGIC COMMUNICATION AGENDA

Monitoring Results for Supply Side

V. Monitoring for Interventions:
Communication Results
Select BCC focal persons

 X number of departments have assigned BCC

personal
 X number of BCC personal are equipped with
BCC materials
 X number of BCC personal has conducted
trainings

© 2018 Martina Merten - Health specialist 21

STRATEGIC COMMUNICATION AGENDA

Monitoring Results for Supply Side

V. Monitoring for Interventions:
Communication Results
Conduct surveys to receive feedback about the
level of information and satisfaction with the
work of the BCC people in the respective
departments.

 x percent of patients are satisfied with the

information being given by the BCC people

© 2018 Martina Merten - Health specialist 22

STRATEGIC COMMUNICATION AGENDA

Monitoring Results for Supply Side

V. Monitoring for Interventions:
Communication Results
Establish a forum of health providers from all
levels of care. It is to convene once a month to
exchange BCC work experience.

 Proportion of selected health providers who

participated in the forum
 Proportion of selected health providers who
said the forum is helpful for their work

© 2018 Martina Merten - Health specialist 23

STRATEGIC COMMUNICATION AGENDA

Monitoring Results for Cross Cutting Issues:

V. Monitoring for
Communication Results District, Provincial and Federal Civil Servants are
quite familiar with BCC.

 Proportion of civil servants who are well

familiar with BCC and willing to include the
concept into their work

© 2018 Martina Merten - Health specialist 24

STRATEGIC COMMUNICATION AGENDA

Monitoring Results for Cross Cutting Issues:

V. Monitoring for
Communication Results KP Media spreads regular messages around
MNCH.

 Proportion of TV Channels that regularly

promotes the right MNCH practices
 X percent of women in the model district
watched and understood the TV messages

© 2018 Martina Merten - Health specialist 25

MAIN NEEDS FOR A STRATEGIC COMMUNICATION AGENDA FOR
SECONDARY HEALTHCARE SERVICES IN KP

Why do we need a new BCC Agenda?

Insufficient knowledge and communication about MNCH practices at
secondary care facilities

What are the main needs for such a agenda?

To the point – to the people – simply designed around target audiences

How can results be monitored?

Definition of key indicators, conducting of surveys

© 2018 Martina Merten - Health specialist 26

THE WAY TO GO: ROADMAP
STRATEGIC COMMUNICATION AGENDA

 Conduct a Workshop to discuss a potential

I. Roadmap BCC strategy with government stakeholders
and BCC communication experts
 Identify model districts
 Identify a time frame for implementation in
each model district
 Identify a focal person for the
implementation at each model district

© 2018 Martina Merten - Health specialist 28

STRATEGIC COMMUNICATION AGENDA

Develop specific district level plans

I. Roadmap
 The respective stakeholders on model district
level will get together and work on concrete
implementation plans
 This process can be facilitated by
consultants.

© 2018 Martina Merten - Health specialist 29

STRATEGIC COMMUNICATION AGENDA

Develop the Monitoring and Evaluation

I. Roadmap Framework

 The communication agency will establish a

framework for monitoring and evaluating of
the communication results for each target
group.
 Ideally this will happen shortly after the
model district meetings
 If needed, the various stakeholders from the
model districts will be invited to the meetings
so that they will understand the framework
for evaluation and communication.
 The overall team has to agree on concrete
process indicators for the monitoring
framework.

© 2018 Martina Merten - Health specialist 30

BEHAVIORAL CHANGE COMMUNICATION – MAIN SOURCES

 KP Government Health Sector Strategy 2010-2017 (Draft)

 Khyber Pakhtunkhwa Population-2014. Facts At-A-Glance.
 Multidimensional Poverty in Pakistan. Ministry of Planning, Development and
Reform, June 2016.
 National Health Vision, Pakistan 2016-2025.
 Pakistan Demographic and Health Survey 2012-2013.
 Pakistan Demographic and Health Survey 2015-2016.
 Pakistan National and Health Survey 2012-2013.
 Pakistan National Health Accounts 2013-14
 UNICEF Pakistan Annual Report 2015.
 PAIMAN (2006) “Communication, Advocacy and Mobilization Strategy”

© 2018 Martina Merten - Health specialist 31

BEHAVIORAL CHANGE COMMUNICATION

Contact Information of ADB Consultant:

Martina Merten
Berlin, Germany
www.martina-merten.de
Info@martina-merten.de

Contact Information of Supporting ADB Consultant:

Dr. Zahra Ladhani

Islamabad, Pakistan
ladhani.zahra2@gmail.com

© 2018 Martina Merten - Health specialist 32