What are some of the recent milestones and challenges in global health equity?
Rafael: As part of its emphasis on equity, UNICEF has been working with regional and country offices to increase focus on the most marginalized and disadvantaged populations, and to ensure that those who are typically left out of the reach of social services or programmatic interventions are brought into the picture, and benefit from them. For instance, the global initiative A Promise Renewed, which focuses on accelerating the achievement of the Millennium Development Goals (MDG), has mobilized stakeholders towards efforts in this direction, and a number of countries have made additional progress towards achieving the MDG, particularly goal four (reduce child mortality) and five (improve maternal health). Polio eradication efforts, especially the recent success in India, are an example of how the international development community has made significant progress in improving the lives of children by bringing in the equity focus.
However, we continue to face challenges surrounding most of the basic indicators that reflect the well-being of children in many parts of the world. Along with other vulnerable populations, children placed within some of the various dimensions of poverty and discrimination are more likely to be affected by disease or by various disparities and conditions. The challenge, then, is to ensure that our programs reach out to these children, and those that belong to marginalized groups.
Benjamin: Some of the places where we are really struggling to realize equity are where people are affected by insecurity and violence, and where we are trying to get basic access to the population. This is the case in the Central African Republic, federally administered tribal areas of Pakistan, some parts of Afghanistan, Syria, and northern Nigeria—some of the areas where the last reservoirs of circulating wild poliovirus are.
How have communication strategies helped achieve these successes, or how can they be used to address these challenges in health disparities settings? Can you provide some specific examples?
Rafael: Communication, specifically Communication for Development (C4D), is a key component in UNICEF's work across the whole development spectrum - from the introduction of new vaccines, to polio eradication efforts, maternal and newborn health, child health and well-being, basic hygiene, and prevention of mother to child transmission of HIV. It provides UNICEF the opportunity to advocate with different stakeholders and partners, mobilize communities, and implement strategies that address social and behavioral determinants, and promote healthy practices and behaviors.
Benjamin: As an example of innovative programming, we have been using mobile theaters in Mozambique to communicate with communities about the importance of immunization, and also to listen to the communities and record their voices. Through an iterative process of listening and communicating, we have refined the delivery of immunization services in Zambezia, a region of Mozambique with high population density and very low access to communication channels, including radio. We have packaged the immunization services with other essential health services that the communities are asking for, such as water, sanitation, nutrition, and antibiotics.
Rafael: Another interesting development has taken place in Niger, West Africa, where we have been working over the last six years to implement an essential family practices package. This is a community-based, action research approach, involving several components—community meetings, household visits, community radios, advocacy with religious leaders—and focuses on the promotion of eight life-saving practices, including having children sleep under insecticide-treated mosquito nets, hand washing, and exclusive breast feeding. Through a systematic approach, we ensure that families begin to integrate some of these practices into their daily routine. This process has now been taken as a model for World Bank's implementation of the cash-transfer component of their social protection scheme. This particular experience is relevant for several reasons: it is a community-based, participatory process; dialogue-driven; draws on principles of communication for development and social change; it has gone to scale; has shown measurable results in improvement of children's well-being; has become sustainable, having been integrated into the broader government system; and has reached some of the most marginalized communities in Niger. Recent surveys have shown significant improvements in maternal and child health in intervention zones, and it is expected that by 2015 the program will reach over 350,000 households. As mentioned earlier, communication and social mobilization have also been key components of the polio eradication success story.
Can you share examples of what has not worked, as well as lessons learned from recent communication interventions?
Rafael: In order to make interventions sustainable in the long run, it is important to also focus on strengthening the capacity of governmental and non-governmental partners in the effective use of communication strategies. One of the lessons we have learned is that failing to invest in systems strengthening can take us back to zero; we know that research-driven and evidence-informed communication strategies can facilitate social and behavioral change, but we need to ensure that strategies, to the extent possible, are designed and implemented with the highest level of quality and rigor on a consistent basis. We are making the shift to a more systematic and integrated approach to strengthening capacities of teams responsible for implementing Communication for Development strategies within sectors.
Benjamin: One recurring challenge is that if your communication is driven by siloed interventions, you are often not giving the communities what they really need. On the other hand, with a dialogue-based approach to communication, we are able to use the communities' priorities and needs to inform our programming and advocacy, and give our governmental counterparts the tools to deliver to communities the services they are asking for.
What is the role of communities in global health equity, health communication, and development? How can communication strategies act as a catalyst to generate meaningful community dialogue and action around health disparities and health equity? Can you share some experiences?
Rafael: Communities must be at the center of global health equity, communication, and development—this is very much in line with UNICEF's human rights-based approach to programming. We believe that the voice of communities is critical to facilitate change at a social and behavioral level, and have focused on mobilizing communities, creating space for communities to be part of the dialogue, engaging communities around key family practices, and looking at innovative ways that would allow UNICEF to engage with communities.
For example, U-Report (http://www.ureport.ug/), one of the communication components of an initiative developed in our Uganda country office, is an SMS-based platform that allows community members to provide feedback and information in real-time, and influences how providers, governments and agencies make decisions on improving various aspects related to the well-being of families, communities and children. The U-Report platform is now being introduced in Nigeria, Zambia, and Rwanda, Burundi, Democratic Republic of Congo, South Sudan, among other country contexts. By giving space and voice to communities, we can speed up the process of addressing health inequalities.
How can we build health communication and other capacity in disadvantaged settings?
Raphael: Capacity building has been one of UNICEF's core strategies, and a priority area for the C4D team. We believe that by empowering communities and individuals with information, and by developing skills and capacities at a local level, we also strengthen the capacities of communities to engage with providers and demand more and better services to address their challenges. We use a two-tier approach: a more formal effort to strengthen local capacities by strengthening systems and organizations, as explained earlier; and engaging and empowering local communities to address health disparities and inequities. Both these aspects are important in low-resource settings to give marginalized populations the space to mobilize themselves and address their challenges.
Closing thoughts
Rafael: As your readers may know, UNICEF's current strategic plan for 2014-2017 emphasizes equity and focuses on three dimensions: (1) creating an enabling environment in terms of legislative frameworks, systems, budgeting, social norms and other aspects; (2) facilitating the demand and use of services; and (3) ensuring service provision and availability of commodities. Communication will continue to play an important role across all three domains.
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Disclaimer: The opinions expressed in this interview are solely those of Drs. Obregon and Hickler and do not necessarily reflect the views, opinions, or positions of UNICEF.
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Rafael Obregon, PhD is Chief of the Communication for Development Section, United Nations Children's Fund, New York. Prior to joining UNICEF he was an Associate Professor in School of Media Arts & Studies, and Director of the Communication and Development Studies Program, Center for International Studies, at Ohio University. He has an extensive teaching, research and professional experience in development and health communication, and international development. He is a member of the review board of several journals, including the Journal of Health Communication, and serves as guest reviewer of Social Science Medicine, Health Policy Journal, and BioMed Central. He is a member of several international associations including the International Communication Association and the Latin American Association of Communication Researchers, and has authored or co-edited numerous books, peer-reviewed journal articles, book chapters, and technical reports, including the Handbook of Development Communication and Social Change, Wiley, 2014, and The Handbook of Global Health Communication (2012).
He earned a doctorate in Mass Communication, Pennsylvania State University, an M.A. in International Affairs, Ohio University; and a B.A. in Social Communication and Journalism, Universidad Autonoma, Colombia.
Benjamin Hickler, PhD currently works as a Communication for Development Specialist in the Health Section of UNICEF Programme Division, New York. He received his academic training in Medical Anthropology from the University of California San Francisco and Berkeley and specializes in mixed-method design research and user-centered, community-based approaches to tailoring health service delivery to the unique needs of marginalized or otherwise difficult-to-reach populations. His current work focuses on building in-country capacity for advocacy, social mobilization, and behavior change communication for increasing equitable access to and uptake of routine immunization services, using this as a platform to improve broader aspects of health service delivery systems.
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Interviewed by Radhika Ramesh, MA, Editorial Assistant, Journal of Communication in Healthcare (JCIH): Strategies, Media, and Engagement in Global Health. The interview was solicited and organized by the Journal's Editor-in-Chief as part of a series of expert interviews JCIH publishes on topics of current interest, and their implications for health communication.