AIDS Community

Health

Maternal and Child Health Community

AIDS Community

Maternal and Child Health Community

Consolidated Reply

Query: IEC Strategy for Health Sector, from Rosetta Stone Media, (Examples/Advice).

Compiled by E. Mohamed Rafique, Resource Person- AIDS Community and Meghendra Banerjee, Resource Person- Health communities

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Original Query: Deepak Mehra, Rosetta Stone Media, New Delhi

Posted: 11 January 2006

I am working with Rosetta Stone Media in Delhi. We specialize in creating media for development communication. It has been our experience that when we design IEC or Communication strategies it is with a particular target group in a particular disease setting like Polio, TB, Blindness Control etc., So, for a state program we break it into various levels and communities and then for the particular disease, set about designing strategies or materials. Presently, we are collaborating on designing an integrated IEC strategy in the whole health sector designed for the entire state. Namely one, that covers most of the vertical health programs and establishes linkages for the state IEC staff to successfully draw upon. This is working from micro to macro level. To this end, we have three questions for our colleagues:

1. Are any members aware of a common IEC resource base to dip into for communication materials, shared resources (finances & personnel), impact evaluation studies, etc.?

2. Is there some kind of IEC media pool across various state health programs?

3. Could any experts and NGO's working in multiple health vertical programs shed light on the success or shortcomings of a common IEC state strategy in India or any other developing countries? For example, we believe that West Bengal did a pilot some time back, through private consultants namely Price Waterhouse Coopers (PWC).

Looking forward to learning from your experiences.

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Responses were received, with thanks, from:

Shubhada Kanani, The M.S. University of Baroda, Gujarat. (Response1) (Response 2)
Rajeev Sadanandan, UNAIDS India, New Delhi.
Sanjeev Kumar, Hindustan Latex Family Planning Promotion Trust, Delhi . (Response1) (Response 2) (Response 3) (Response 4)
S. Narendra, R K Swami/BBDO Advertising Ltd, New Delhi. (Response1) (Response 2)
E. Mohamed Rafique, UNAIDS India, New Delhi.
Anil Agarwal, ICHAP, Jaipur.
Deepak Mehra, Rosetta Stone Media, New Delhi
M.S.R.Murthy, Sri Venkateswara University, Andhra Pradesh (Response1) (Response 2)
Ravishwar Sinha, USAID-MOST, New Delhi.
Rajesh Gopal, Gujarat State AIDS Control Society (GSACS), Ahmedabad
Umesh Kapil , Department of Human Nutrition, AIIMS, New Delhi
Arun Sharma, University College of Medical Sciences, Delhi. (Response1) (Response 2)
Baxi Rajendra K., Government Medical College, Gujarat.
Tanushree Soni, Plan International (India), New Delhi. (Response1) (Response 2)
Kusum Gopal, London School of Economics, UK (Response1) (Response 2)
H.S.Sharma, Gurgaon, Haryana.
Nigam Prakash Narain, Department of Paediatrics, Patna Medical College, Bihar.
P. N. Vasanti, Centre for Media Studies (CMS), New Delhi.
Swati Y. Bhave, Expressions, New Delhi
Arvind Mathur, WHO, New Delhi
Janaki Desai, Niramaya Health Foundation, Mumbai

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Summary of Responses

Members responded to this query with examples of state-level integrated approaches to Information Education and Communication (IEC) offering reasons why they are not more prevalent. They also suggested opportunities for strengthening integrated IEC approaches, and in particular in the context of the National Rural Health Mission.

Why an integrated IEC approach? The benefits of state-level IEC integration mentioned included wider health awareness in the communities, enhanced capacities for recognition of early symptoms preparedness and timely intervention in seasonal and chronic diseases, and increase in the demand for improved health services. Communication at the base of all IEC designs and strategies, and members stressed that for communication to be effective it should translate into attitudinal change leading to better health practices at the household level. Well designed IEC methodologies and strategies were not “one size fits all,” but took due cognizance of local communities’ present attitudes and needs in the context of the local culture, context, gender, age etc. To bring about attitude changes, contributors recommended an integrated package of critical messages delivered through multiple channels and for a sustained duration, with close monitoring and continued adjustment. In the family planning example, success was obtained when people fully assimilated the concept and recognized a clear personal benefit accruing from having a small family.

Integrated IEC programmes. With the exception of the work by PriceWaterhouse Coopers in West Bengal mentioned in the question, respondents to this query could not offer other cases of an integrated IEC strategy for the health sector at the state level. However, members cited several cases where less comprehensive approaches had been successfully introduced. One was a large scale BCC intervention, the Trials for Improved Practices (TIPS) of the Linkages project from the AED (Academy of Educational Development). The Gujarat State AIDS Control Society (GSACS) offered an model of focused IEC activities for the rural areas of Gujarat done by leveraging the Intensive Rural AIDS Awareness Project (IRAAP). And an approach adopted by Plan International involved training married young women who have passed high school as 'Sanjeevanis' on health data management, counselling skills, the HESA campaign and the RCH programme. Respondents also felt that a combined IEC strategy was a sensible approach during identified seasonal outbreaks such as for diarrhoeal diseases or Malaria, or if synergies could be identified with STI, HIV, TB and Leprosy programmes in, say, stigma and discrimination or another common denominator.

The above examples illustrated how designing a comprehensive state-level IEC integration strategy acquired a great deal of complexity when compared to strategies for vertical programmes. Among the challenges presented were

· The availability of IEC managers skilled in conceptualizing, strategizing and delivering integrated strategies;

· IPC training for health workers, para-medical staff and doctors;

· Identifying local talent and experiences;

· Working out supportive institutional plans;

· Synchronising IEC plans at the national, state and district level;

· Ensuring adequate budgetary provisions.

Since these conditions were often absent, the general view was that IEC successes had mainly been achieved in small pockets, and propelled by individual excellence, dedicated leadership, motivation, local involvement, continuity and creativity.

The National Rural Health Mission and integrated IEC strategies: This query also offered members an opportunity to examine possible synergies offered through the proposed National Rural Health Mission (NRHM), an integrated health programme. NRHM would be moving similar functions of different programmes to a common resource centre where their needs would be addressed in a unified fashion. The strategy focused on synchronization and planning at district level, relying on an Accredited Social Health Activist (ASHA). ASHAs would be trained to do interpersonal communication regarding inputs of all the programmes, and would therefore be the key to delivery of a unified IEC strategy for the rural Health sector. Getting Panchayati Raj Institutions to use the same unified IEC strategy when they assume ownership of the health delivery system would then be the next step.

However, this aspect of the ASHA’s role would have to take account of the challenges noted above to presenting an integrated IEC strategy, Additionally, the present ICDS Anganwadi workers and ANMs who were seen as ‘Jack of all trades’, should have similar messages for health and nutrition education, so that community members would not get confused by contradictory messages. The failure of the Village Health Guide (VHG) and ANM who are overburdened with paper work was brought out too. A possible option suggested was to establish a specially trained cadre of IEC professionals who could establish the requisite rapport with the families and individuals.

To make further progress on this topic, Contributors suggested creating a forum where all the officials of the various Health Sector programmes could pool a portion of their resources for common purposes, and design a communication strategy that converges on the common user to deliver the key messages. A common platform within the Health Ministry for this purpose could resolve potential turf battles. In support of this suggestion members pointed out that the Communication Advocacy and Community Mobilization reports as well as the reports of the other working groups of NACP III did not clearly define the issues for convergence and separation between RCH, NRHM and HIV.

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Comparative Experiences

West Bengal

Price Waterhouse Coopers (From Deepak Mehra Rosetta Stone Media)

West Bengal did a pilot IEC integrated strategy for the entire health sector, through private consultants namely Price Waterhouse Coopers (PWC)

Gujarat

Academy for Educational Development (From Shubhada Kanani, M.S. University of Baroda)

Trials for Improved Practices (TIPS) of the AED Linkages project was quoted as an example of a large scale BCC intervention that was most effective in Dehradun.

Gujarat State AIDS Control Society (From Rajesh Gopal, GSACS, Ahmedabad)

The existing village level organizations like milk cooperatives like AMUL, agricultural produce committees, panchayati raj institutions, youth clubs, bhajan mandalis, mahila mandals are being used as the forums through involvement of their active members as the peer educators. Capacity building and implementation of the Integrated Rural AIDS Awareness Program (IRAAP) is through the link workers of the identified NGOs with support from the IEC funds of the Gujarat State AIDS Control Society (GSACS).The activity is to be commissioned in 13 districts and three of them may be funded through the DFID supported project being run by the UNICEF, Gandhinagar. Development of CBOs is visualized as an effective way to ensure the sustainability of the activities.

Uttranchal

Plan International (India), (From Tanushree Soni, Plan International, New Delhi)

They train identified married young women as 'Sanjeevanis' on health data management, counselling and facilitation skills, HESA campaign and in the RCH program, so that they are abreast with the health issues of their communities and develop linkages with ANMs and DOT providers. They organize counselling/IEC sessions at Self Help Group meetings. They also support PRIs for collection of health data of their village panchayat.

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Related Resources

Recommended Organizations

Price Waterhouse Coopers (From Deepak Mehra Rosetta Stone Media)

http://www.pwcglobal.com/in/eng/main/home/index.html e-mail: roopen.roy@in.pwc.com

Sucheta Bhawan, 11 A Vishnu Dighambar Marg, New Delhi. Tel: 91 11 2323-2916/2321-0891-99

PricewaterhouseCoopers Pvt. Ltd. provides industry - focused services to public and private clients.

The M. S. University of Baroda, Gujarat (From Shubhada Kanani, M.S.U., Gujarat)

http://www.msubaroda.ac.in/ E-mail : manojsoni@msubaroda.ac.in

Fatehgunj, Vadodara-390002. Tel: +91-265-2795600 Fax : +91-265-2793693

Does micro-level qualitative researches in behaviour change communication including evaluating IEC components of Government programs, especially in nutrition

Gujarat State AIDS Control Society, Ahmedabad (From Dr. Rajesh Gopal GSACS)

Tel: +91 79 268 0211-13 / 5210 Fax 079 268 0214 E-mail gsacs@icenet.net

GSACS 0/1 Block, New Mental Hospital Complex, Menghaninagar, Ahmedabad-380016

Has used the Integrated Rural AIDS Awareness Program (IRAAP) Model successfully

Rosetta Stone Media (P) Ltd., New Delhi (From Deepak Mehra Rosetta Stone Media)

http://members.tripod.com/~DeeM/index.htm E-mail: rosettastone@vsnl.com

74, Gautam Nagar, New Delhi-110 049 Tel:91- 11- 26523225, 26522792 Mobile:9811024636

Has a track record of 500 TV productions covering a wide range of informative, entertaining and imaginative programs for various Asian and International channels

Recommended Contacts

(From Dr. E. Mohamed Rafique UNAIDS, Delhi)

Rajeev Sadanandan

Contact: rajeev.sadanandan@undp.org UNAIDS, A2/35 Safdarjung Enclave, New Delhi-110 029.

He is working at UNAIDS India office on issues relating to NACP III planning.

Dr. Sanjeev Kumar

Contact: sanjeevkumar@hlfppt.org HLFPPT, 302, Hemkunt Chambers,89 Nehru Place, New Delhi.

He is head of Social Consulting at Hindustan Latex Family Planning Trust and was on a few Working Groups in NACP III including Condoms and TI.

S. Narendra

Contact: sunarendra@yahoo.com R K Swami/BBDO Advertising Ltd, New Delhi.

Formerly Information Advisor to five Indian Prime Ministers, he is now Executive Director of R K Swami/BBDO Advertising Ltd as well as a Media Advisor and Consultant.

Dr. Arvind Mathur

Contact: mathura@searo.who.int WHO India Office, 534, “A” Wing, Nirman Bhawan, New Delhi.

He works as National Professional officer for Health Systems and Community Health at WHO, New Delhi.

Roopen Roy

Contact: roopen.roy@in.pwc.com PWC, Sucheta Bhawan, 11 A Vishnu Dighambar Marg, Delhi.

He is the Managing Director of Price Water House Coopers in India.

Recommended Documents

(From Dr. E. Mohamed Rafique UNAIDS, Delhi)

IEC strategy crucial to improving health sector (Price Waterhouse Cooper)

http://www.pwcglobal.com/gx/eng/about/ind/gov/ifi/pdf/w_bengal_iec_strategy.pdf [308 KB]

This document speaks of integrated IEC strategy for the state of West Bengal

AED/LINKAGES/India - Report (1997–2004) (From Shubhada Kanani, M.S.U., Gujarat)

http://pdf.dec.org/pdf_docs/Pdacd544.pdf [565 KB]

Shows how to field test innovative approaches to introduce and reinforce simple, culturally appropriate, and effective nutrition practices.

Behavior Change - Tools and Approaches: Trials of Improved Practices (TIPS)

http://www.changeproject.org/tools/xchangetools/tx_tips.htm

These tools developed by CHANGE help program planners select and "pretest" the actual practices that the program will promote

National Population Policy of India

http://www.unescap.org/esid/psis/population/database/poplaws/law_india/india3.htm

It gives a good overview of using Decentralized Planning, Convergence of Service Delivery, meeting unmet needs, as well as using integrated IEC

Evaluation Findings: IEC Support in MCH/FP (UNFPA)

http://www.unfpa.org/monitoring/pdf/n-issue2.pdf [47 KB]

The document shows how IEC evaluation can help change attitudes and behaviour or solve institutional issues for better integration of MCH and FP services.

Recommended Websites

(From Dr. E. Mohamed Rafique UNAIDS, Delhi)

National Rural Health Mission

http://mohfw.nic.in/national_rural_health_mission.htm

All about NRHM ASHA, PRI and Convergence between various programmes of the Department of Health and Family Welfare

Accredited Social Health Activist (ASHA)

http://mohfw.nic.in/eag/accredited_social_health_activis.htm

The all-informative page on ASHA, from Selection, to integration with ANM and other functionaries including Compensation mode.

NHRM Newsletter on HIV

http://mohfw.nic.in/syqnrhm.pdf

Integrating HIV/AIDS with NRHM at grassroots level by Dr. SY Quraishi then Special Secretary & Director General, NACO.

INFORMATION EDUCATION & COMMUNICATION

http://health.nic.in/iec.htm

The Indian Government’s IEC strategy and integration plans over the years at different levels to promote the Family Welfare program

Dept of Health and Family Welfare, Government of Punjab

http://punjabgovt.nic.in/GOVERNMENT/govt754Strategies.htm

Gives succinct Details of Punjab S tate NRHM, ASHA, Integration of various Health components at delivery levels

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Responses in Full

Dr. Shubhada Kanani , The M.S. University of Baroda, Gujarat.

I read with interest your recent work being initiated for the state for developing integrated IEC strategies for the Health sector. I would like to respond to your third query since I have been doing micro-level qualitative researches in behaviour change communication including evaluating IEC components of Government programs, especially in nutrition:

Since IEC, which aims at not just information transfer but also attitude and behaviour change, is very region specific, culture specific, it is unlikely that a common IEC strategy will be effective for the country as a whole; or even for the state; given the ethnic and cultural diversity of our country. A common framework with at most district specific strategies may prove effective for real and lasting change to occur; provided it is implemented long enough, monitored closely, has in-built flexibility to change course over time, is given priority and adequate time by the implementing supervisors and workers.
Thus, I believe that no matter how good the IEC strategy, unless the managerial, implementing and monitoring mechanisms are in place and functioning with commitment towards the IEC component, change at household level will not be significant even if knowledge improves.
I was associated as a consultant and trainer with the AED-Linkages project (Linkages is a nutrition improvement project of the Academy for Educational Development) where I was a trainer for an important component of IEC, namely, Trials for Improved Practices which is better known as TIPS. The AED Linkages project has conducted large scale BCC interventions; one of the most effective being in Dehradun. You can get more information on the India report from http://pdf.dec.org/pdf_docs/PDACD544.pdf
We all know that large sums are spent on wonderful IEC materials, multimedia and audio-visuals. In order that these be most effective, I also believe that sustained advocacy efforts are required to facilitate Governments to invest not just in the IEC Materials but to also allocate resources and time for appropriate communication, training and implementation-monitoring strategies which are given time to show results. We are somehow in a hurry to see results; and behaviour change takes time. Yet, it is the only long-term answer.

Hope to learn from your experiences as well.

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Rajeev Sadanandan, UNAIDS India, New Delhi

The National Rural Health Mission was set up with the intention of integrating different health programmes to achieve synergy. The aim is to move similar functions of different programmes to a common resource centre where their needs would be addressed in a unified fashion. IEC will be one of them. Similarly the Accredited Social Health Activist (ASHA) will have a set of graduated capacity building so that it is able to do interpersonal communication regarding inputs of all the programmes. The prototype being followed for this is the “Mitanin” programme in Chattisgarh.

An integrated IEC cannot lose focus and deal with short attention spans. So timing of messages would be important. For instance if there are identified seasonal variations (e.g: Diahrreal diseases, Malaria) the messages would concentrate on that. If chronic conditions are being addressed then the less crowded periods would have to be used. If there are synergies (e.g: reproductive health and HIV) combined IEC can make use of the synergies in prevention messages. Since the target audience is the same for most of the messages it makes sense to have a combined strategy. But IEC managers have to develop higher order skills to manage integrated IEC which is a lot more difficult to manage than stand alone messaging.

Dr Sanjeev Kumar, Hindustan Latex Family Planning Promotion Trust, Delhi

I think what has been raised is an important and critical question. The policy decision to integrate the IEC/BCC functions under one umbrella under the NRHM has its desirable as well as the not so good points.

As Rajeev has pointed out for one IEC manager to accomplish this will require higher order skills to conceptualize, strategize and deliver integrated strategies. This is not easy. Already the skill and competency level in individual programs are a question mark. So, one can only imagine if this is now going to be integrated and requiring even more strategic thinking.

Mainstreaming is the current buzz word. But can IEC be mainstreamed? Yes and No! A second question again has to be asked - whether we need to mainstream IEC? while at one level using the common platform and one window delivery mechanism like through the health delivery system for services is a good idea. The combining of IEC can pose its own problems as well as could be counter productive. Take for example the joint communication committee for all nationalized banks and how miserably it failed. The commercial banks and international banks realized the potential of individual identities and positioning. Sometimes for all means for none and benefits no one. it is now that individual banks are realizing that they need their own identities to grow.

Well, what I am saying is that if the idea is to economize or make things efficient, then we should think for the effectiveness as well. There has been rather no thinking on the process and operational issues in common integrated IEC strategies. In the given situation it is desirable that we also look at the efficiencies as well as effectiveness, cost as well as result, process as well as outcome. We do need a larger debate on this.

S. Narendra, R K Swami/BBDO Advertising Ltd, New Delhi.

Many thanks for provoking a reply from me. Integration and convergence for its own sake has its draw backs. I had provided a concept note to Health Secretary some time ago on the subject. What is required is a stakeholders forum among all the officials of the Health Sector programme management for pooling a portion of resources for common purposes and designing and delivery of key aspects of communication that converges on the common user. A common platform within the Health Ministry for the purpose would suffice and could resolve turf battles. It could also confer scale advantages for Ministry of Health and Family Welfare (MOHFW). Such an arrangement should not take away the core communication tasks of NACO. The opposite also holds good, in that NACO should not take over components of the traditional RCH program.

The analogy of pooling in Public Sector Undertaking banks is not a good one because of the commercial nature of the transactions and branding needs involved. But it did help in category promotion. I had an opportunity to study the way Bank communication was being handled in my capacity as the Communication Officer for Ministry of Finance, soon after nationalization of banks.

The Communication Advocacy & Community Mobilization report as well as the reports of the other working groups of NACP III did not clearly define the issues for convergence and separation between RCH, NRHM and HIV/AIDS. As you have rightly pointed out, strong leadership with a clear vision will guide rightly the process required for achieving convergence in communication within the MOHFW.

Dr. E. Mohamed Rafique, UNAIDS India, New Delhi

Thanks [to Rajeev] for reviving this discussion. I agree with you that the key to delivery of a unified IEC strategy for the Health sector under the National Rural Health Mission (NRHM) lies in the hands of the Accredited Social Health Activist (ASHA). Therefore the crucial question would be on what her capacity building is done and by whom. This has added significance if we see that the very backbone of NRHM consists of the strategy to train at the household level some thing like three lakh ASHAs. Getting the Panchayati Raj Institutions to use the same unified IEC strategy when they assume ownership of the health delivery system is the next step. Needless to say the final act of strengthening the existing triad of Sub-Centers, Primary Health Centers, and Community Health Centers which are the stages on which the NRHM play would be launched would assume utmost importance.

One more point that I would like to recount here is the lessons learnt from our National program for Hansen's Disease (Leprosy) which began as National Leprosy Control Programme in 1955 with the objective of controlling Hansen's Disease with help of Dapsone. It was redesigned as National Leprosy Eradication Programme (NLEP) in 1983 after Multi-Drug Therapy (MDT) became available for effective treatment of Hansen's Disease. In 1991, WHO and its member States committed themselves to eliminate Hansen's Disease as a public health problem by the year 2000. Almost similar is the history of the Control Programs for Venereal Diseases, which became known as Sexually Transmitted Diseases and now we use the terms Sexually Transmitted Infections and Reproductive Tract Infections. All along we also had our TB control programs. Two decades after the advent of HIV, we now see the need for refocusing, redefining, reviewing and now integrating. Stigma and Discrimination to varying extents, is one of the common denominators in all these four diseases. There are other similarities and associations too. Yet, we still do not have a unified IEC strategy, common plans, or any kind of integration for these inter-related diseases which are dealt by just a couple of departments in the Medical Colleges Hospitals and other Government Hospitals above the Taluk level. Integration is brought about easier in the Sub-Centers, Primary Health Centers, and Community Health Centers where there is mostly a single-window approach.

Dr. Shubhada Kanani , The M.S. University of Baroda, Gujarat

With regard to ASHA in the NRHM, its true that an integrated IEC strategy is far more challenging and difficult than IEC for a vertical program; and if its the ASHA worker who is to do a significant bit of the IEC, not only is the question of who will train her important, but equally important, how will her various job functions be organized so that she is able to truly work towards facilitating behaviour change; by giving timely and relevant messages using effective communication skills with timely monitoring and constant improvements. This applies to any grassroots functionary and her supervisor.

One major challenge; among many, for effective IEC to bring about any significant and lasting behaviour change, is the challenge of work organization of the trained workers such that they are able to give the minimum if not optimal attention to implementing and monitoring IEC activities; not simply for coverage as is the case at present but for behaviour change as well. And one way to make sure that the training is actually implemented is to simultaneously modify or develop job functions and supervision mechanisms. Hence the job expectations in real life in the field and training must be in alignment. Unfortunately we do the training well and do not look beyond to see what happens after the training. For IEC in particular, which often loses out in the face of 'faster and tangible quick solution vertical interventions', it is critical to ensure that IEC does not remain a mere capacity building exercise; and that there is accountability expected for its effective implementation.

Another challenge is, while keeping IEC integrated in principle and flexible to respond to changing needs and seasonal changes as Rajeev has pointed out, there has to be focus, at a given point of time, to only a few critical messages, for a reasonable period of time, to give a chance for change to occur. And community needs, feasibility for change and other program factors, rather than priorities set by outsiders alone, should govern the decisions of which messages will be the focus and at what point of time. Frequently changing agendas have done a great damage to IEC is my view. An integrated package of critical messages delivered effectively through multiple channels for a long enough time with constant monitoring is what is needed. In attempting many changes, we end up changing nothing at all !

Dr. Anil Agarwal, ICHAP, Jaipur

In designing or selecting an IEC strategy there are many issues. IEC most of the time focuses on particular target groups. So, to have IEC that is across the board for all target groups would require crafty designing and sound testing. I have seen waves in IEC like if we see IEC material for electronic media then it floods the market. Similarly, if people are making printed IEC material then for a time the focus is only on that. There is a need for adopting a multi-pronged approach for an effective IEC strategy across diverse target groups spread across different geographical areas in a single state. In a country like India, no single strategy be it electronic media, or print, would work because we have electrification of only around 55% while the rest 45 % of households don't have electricity leave alone the Television or cable. On the other hand literacy rate is also not very high. So we need to bear all these factors as these affect choice or design of IEC strategy for an entire state.

Integration of HIV and AIDS program in the NRHM is a must. This is because both HIV and RCH can have common IEC material centered around Sexual and Reproductive Health issues. If we focus on IEC for RCH than not only HIV but also other STI would be covered.

Deepak Mehra, Rosetta Stone Media, New Delhi

Thank you for the feedback and suggestions. I do agree that the exercise of a unified IEC strategy is challenging, to say the least.

I think, currently ANM's are already handling integrated IEC tasks at the grassroots level for a population of five thousand normally and about three thousand five hundred in hilly and tribal areas. The introduction of ASHA workers should significantly help, as they would focus on a thousand people each. However, as pointed out, IPC training is a crucial pre-requisite at the service delivery end for health workers, para-medical staff and doctors to contribute to the success of such an initiative. Where as for the people, an integrated IEC approach should spread awareness about symptoms and early detection of diseases both seasonal and chronic. Eventually all this translates into good health practices. This in turn would create a consistent demand for improvement in local health services.

Yes! I do agree that there maybe many implementation and competency challenges on the way; but in principle, I think, this is what a unified communication strategy should strive to achieve.

Prof. M.S.R.Murthy, Department of Population Studies and Social Work,Sri Venkateswara University, Andhra Pradesh

ASHA is a good concept. However, people are not properly motivated to see what the government is doing to them. IEC strategies depend on the enthusiasm and motivation of the implementing agency. Here the motivation of the motivator and client are very important. We cannot put IEC health interventions totally under scrutiny, nor make it readable. Nor can it be by itself motivating. We can reach the mid point of the road. The other half has to be traversed by the client.

The Government also change strategies during the time period of the program, once too often, creating confusion and disgust among the motivated. Therefore, IEC strategies should be given time to mature as well as be local-specific. In this regard we have to involve local motivators to draw up plans for integration of more components of Health Sector in the local IEC strategy.

Sometimes we have to leave the strategies to local people to innovate and implement. Many teachers modify their teaching methods slowly to suit the students capacity and needs. Therefore we have to give more importance to individual talents of the motivators and their methods in reaching the diverse target groups.

Dr. Sanjeev Kumar, Hindustan Latex Family Planning Promotion Trust (HLFPPT), New Delhi

I have been going through several of the last additions to the query on IEC. I think it is a critical question and needs a serious deliberation. Unfortunately conceptually IEC is still trapped into material production and dissemination. People who grew up with IEC in seventies and eighties and even early nineties are somehow still in favour of bettering the production process. “more or better” is their mantra. And that is only part of the problem. The second issue is coming from this movement towards integration or convergence. Here the question is not whether integrated IEC is a desirable idea or not, the question is whether we can deliver what we are suggesting, even to the tune that do we really understand what are we proposing? Is it just a cost-saving, efficiency idea or have we also thought of the mechanism, institutional and operational issues. One might say, should that scare us or bother us so that we do not try what is basically a good idea!

Communication is power. Communication is process. Communication is a tool. Communication is a lot of hard work. Given the complexity, diversity of our country, the structure and weaknesses of our current delivery system, the kind of importance give to communication efforts and people, it is imperative that we look at the two issues; namely the material and activity trap and the issue of integrated platform, far more seriously than we are doing now. Where are the monitoring and evaluation reports of IEC in FW, RCH –I, NACP, NACP-II, ICDS, TB, Leprosy, Malaria, Poverty Alleviation, Water and Sanitation, Health and Hygiene and other programmes proposed to be integrated in the NRHM umbrella. Where is the process by which we thought that this is a desirable and doable thing. Where are the institutional delivery analysis and mechanism developed for this to happen? How much money do we currently spend on communication in all health programmes. Why is it that there are no repositories or resource centers for communication. Where are the data bases, formative and qualitative researches that we have based our work on? Where is the model where a comprehensive and integrated communication have been tried at a reasonable scale? Where are the models where synergies between mass media and on ground activities have been successful. Where are the communication people who understand the needs and designs from a people’s perspective and not from a donors requirement? Why is it that we after so many decades do not have confidence and clarity on the methods and outcome attributable to IEC?

Well, that is lot of questions; not to say that I am not in favour of the idea of integrated communication efforts. But yes, if someone thinks that just by creating a cadre of ASHAs one has or will be able to do the job, then that is a big miscalculation! Communication is not about delivery vehicles, or about copy or about visual or about the quantity or quality of production, it is about effect, about the change, about the stir about the relationship that you are able to create, nurture and take forward. It is the understanding that you have or produce. It is the perception you are able to decipher from the other’s perspective. It is the glint in the eye you see and ignite in the other.

Communication is the art of listening with your eye and seeing from your ear. It is the art of touching the heart, head, heel and hands. It is about action. Messages have created a lot of mess down the ages, let us not bother about the integration or the material but the net result, the accountability of our efforts, the transparency of our actions and the realty of processes.

Today let us take a deep breath and look inwards without fear or favour and ask: have we done our job well in the past, “more or better, together or separate” the point is, are we ready to be hanged if we do not get the end result?

I am sure the word will be seen and taken in the spirit of sincerity with which they are written.

Dr. Ravishwar Sinha, USAID-MOST, New Delhi.

This is a very stimulating discussion and thank you [Sanjeev] for it. May I put forth my views based on my experiences as a doctor and HIV and AIDS state program officer.

The issue of vertical programs and synergy of programs has been hanging fire for long and no doubt both have their merits. However, there is an agreement of getting the maximum part of the limited resources to the beneficiary. I believe the NRHM strategy focuses on synchronization and planning at district level. The NRHM mission does not obliterate the individual program needs and necessities. It rather respects the local needs strongly and the focus is on decentralized planning at the district level.

Coming to the point of BCC and IEC efforts for HIV and AIDS, I think the efforts at district level communications would have that in focus as an overall need. In areas where the epidemic is advanced the efforts would be comprehensively more intensified, for prevention is the sheet anchor of the HIV and AIDS program.

Coming to those that are affected, this is both a medical and social problem. The medical problem of management and access to drugs needs to be communicated and this would be requiring BCC efforts for the service providers and beneficiaries. Apart from the retroviral therapy availability, which has to be very much strengthened, the management basically is of the clinical status of the patient, namely the diarrhoea, fever, infections and nutrition in a timely manner, so as to keep the patient in the best possible condition, enabling him to do his work and carry on his responsibilities to sustain himself. This has to be an integrated health effort, supplemented by the community. Health, ICDS, Education, Community leaders and NGOS have a big role. The BCC requirements would in this case be integrated. This would be achieved only by optimizing the efforts and outcomes of the existing systems and community, which needless to say would need to be augmented. The local strategy as put forth in the NRHM would be the tool to achieve it.

I think the NRHM has not restricted but has facilitated the service delivery of individual programs by enhancing the base. Attendant efforts that need to go with BCC are integral to it. Building responsiveness and strengthening ownership is the BCC challenge that is needed to stem the HIV and AIDS epidemic. NRHM is perhaps the biggest integrated effort in this regard.

Dr. Rajesh Gopal, Gujarat State AIDS Control Society (GSACS), Ahmedabad

Thanks for the correction of the typographical error. That error had converted ASHA from an activist to an agent. However there is no doubt that she would definitely be an agent of social change!

We have planned intensive awareness and focused IEC activities for the rural areas of Gujarat in a comprehensive manner leveraging and using the IRAAP model. The existing village level organizations like milk cooperatives (of AMUL fame), agricultural produce committees, panchayati raj institutions, youth clubs, bhajan mandalis, mahila mandals are being used as the forums through involvement of their active members as the peer educators in direct collaboration regarding the capacity building and implementation of the IRAAP through the link workers of the identified NGOs with strong rural presence with support in terms of remuneration etc. from the IEC funds of the Gujarat State AIDS Control Society(GSACS).The activity is to be commissioned in 13 districts and three of them may be funded through the DFID supported project being run by the UNICEF, Gandhinagar. Development of CBOs is visualized as an effective way to ensure the sustainability of the activities.

Dr. Umesh Kapil, Department of Human Nutrition, AIIMS, New Delhi

At present the ASHA cadre of health workers is yet to become functional and so is NRHM. Presently it is the ICDS Anganwadi workers and ANMs who are the Jack of all trades. The ICDS Anganwadi workers and ANMs should have uniform strategy as well as similar messages for health and nutrition education to the community at large.

In order to have uniform messages for ANM and AWW they are being trained. These cadres have been tried for the last twenty years. However, the simple messages delivered by the AWW and ANM on common nutrition and health problems are at times contradictory and often the mothers get confused rather than benefited.

Dr. Arun Sharma, University College of Medical Sciences, Delhi

ASHA is definitely a good concept but let us look at the performance of the voluntary health workers in the government set up in the past. You will recall that Village Health Guide (VHG) was appointed with similar aspirations and objectives, but it failed to take off even in one state. Next, we had the Multipurpose Health Worker/ANM. She became the pivot for all health activities at the Sub Center level. However, studies now point out that she is so overburdened with paper work and field responsibilities that even her basic work of providing RCH services is far from satisfactory. I am afraid that ASHA will have a similar fate, unless we are cautious about understanding the responsibilities that a village health representative is capable of handling. IEC is a very specialized area. I am of the opinion that IEC trained people will have more focus on methods and means of providing IEC health interventions. These IEC workers may be trained in important fields like TB, Malaria, HIV, Life style diseases for disseminating various IEC/BCC interventions. Now that we have district and block level health societies, it is quite possible to develop IEC/BCC teams at the block level and training facilities at the district level under the National Rural Health Mission (NRHM).

Baxi Rajendra K., Government Medical College, Gujarat.

A lot of ideas and issues have been raised about an unified IEC strategy in the health sector. I am with Prof. Murthy when he recommends use of local talents and experiences besides language, reference and relevance which ought to be local when we talk of IEC. Too much of science and technology may please be kept out of it. Abstract art and science of communication may be fine for an apex research institute working on the designs of IEC. In fact the original query, was looking for such a resource: an IEC media pool across various state health programs. Let us also remember that a man convinced against his will is of the same opinion still. We need to create a will and that is best done in the formative years, namely while shaping the IEC strategy.

Dr. Sanjeev Kumar, Hindustan Latex Family Planning Promotion Trust, Delhi

This is definitely an exciting debate. I think I sense those of us who are having this discussion are having an exciting time on what is being proposed, but... and that but is because we all in our heart of hearts have a lingering apprehension: is it once again going to be rhetorical action? My point is not that small pockets, individual excellence and leadership by some force has time and again demonstrated that when done well, with evidence, with dedication, with local involvement, with continuity and creativity, the communication efforts have yielded absolutely wonderful results. Yet, read again, small, individual and with conditions. Yes, platform is there, but it was always there, yes, opportunity, but was it not always there. My question is this time we are harping on ASHA to be the panacea, previously we did this for funds or infrastructure or for capacity building.

No doubt a cadre of a large voluntary workforce is a good idea, but what else has changed, where else we have ensured changes. It is easy to put a person on board like it is easy to do a material production in IEC and that becomes the end in itself. Is ASHA the end in itself. What else is needed to work it out and push it into action. It is this that bothers me. The intent has always been right, the language has always bee correct, but the concerted efforts, and the quality of efforts and accountability and transparency of the process is a question we need to address.

Is ASHA - a voluntary worker- the magic bullet? Is one window for all health programme the solution? Yes, may be and may not be. The point is where is the supportive action? Where is the supportive institutional plan? Where is the evidence base we are talking about? Where is the operational plan for the IEC at national, state and district level? Where is the exercise in rethinking, strategizing, positioning and execution? Where is the commitment and conviction that is going to drive this revolution? What budget have we earmarked for the renewed efforts? Just to pick up from your response - Building responsiveness and strengthening ownership is the BCC challenge that is needed to stem the HIV and AIDS epidemic’ where is that? Don’t get me wrong- I am not being cynical or a wet blanket, I am trying to be really sure this is not window dressing? I am hopeful it is not, but I would still want to see real efforts beyond ASHA? Are you aware of any such processes in motion. I am ready to listen to that.

Tanushree Soni, Plan International (India), New Delhi

I'm looking after Plan International (India)'s operations in Uttranchal. Plan is an international humanitarian, child centered development organization without religious, political or governmental affiliation. Child sponsorship is the basic foundation of the organization.

I would like to add something on our approach. Under our Community Health Programme we have identified married young women who have passed high school, within the communities per panchayat and are training them as 'Sanjeevanis' on health data management, counseling and facilitation skills, HESA campaign, RCH program. The idea is to train these 'sanjeevanis' to be abreast with the health issues of their communities and develop linkages with ANMs and DOT providers. They organize counseling/IEC sessions at MMD (SHG)meetings. They support PRIs for collection of health data of their village panchayat. Once ASHA is on ground these women could be the readily available trained resources for the programme.

Dr Kusum Gopal, London School of Economics, UK

In all these exchanges with reference to IEC and communication many useful points have been raised. But what is missing is the recognition that all people in India and indeed, the Indian subcontinent remain pressed in by western colonial thinking.

We need very much to focus on listening to people, local, regional and national, be it a village, tribal or, in many urban pockets where slum dwellers and also where civil servants reside. It is important to value their integrity and not impose from above what cannot be accepted. Communication must include a brief introduction on colonial history and also lessons from traditional medicine and its values. As indeed, ideas about the gendered body, health and disease. Documentaries can be made at a low cost and possibly Bollywood celebrities can be brought in to spread the messages.

H.S.Sharma, Gurgaon, Haryana.

I am most surprised that Anganwadi workers are being used to combat HIV and AIDS. During the recently held meeting with the Anganwadi workers at AIIMS last month, I had occasions to interact with them. it came as a shock to me when I learnt of the fate of the medicines meant for distribution which were collected by them. As some of the Anganwadi workers are not literate in English and as the wrappers of medicine are in English, they were thrown into the dust bin after some time! While this may not hold true of all Anganwadi workers, it is one of the factors to be taken into consideration. Ways and means to counteract this practice must be adopted while planning IEC strategy for the whole health sector in an entire state.

Dr. Nigam Prakash Narain, Department of Paediatrics, Patna Medical College, Bihar.

I have been reading the views of my distinguished colleagues. I strongly feel the need for some drastic transformation in our health delivery system as this has rusted in the last few decades. Recent hope of all 'ASHA' is definitely a marvellous philosophy to reach the beneficiaries, but it needs a thorough introspection of what we wish these ASHAs to deliver for us and the content of these critical issues should be discussed at national level with multi-centric approach as problems may be place specific. IEC has to be given the top priority in all these discussions.

Dr. Arun Sharma, Dept. of Community Medicine, University College of Medical Sciences, Delhi

I would like to reflect on Plan International's approach in Uttaranchal. To me, this appears to be the most reasonable and logical contribution to IEC activities, as is rightly pointed out that the Sanjivanis will be the readily available, pre-trained candidates for ASHA, but there is a limitation: will the commitment and motivation be sustained once the affiliation shifts from Plan International to Government. Probably a team of such parallel workers joining hands with regular Government health functionaries like ANM/DOTS provider etc. will be more meaningful then their becoming ASHA(s). If the question of sustainability of such functionaries arises, then the Block Health Societies can take care of them. Is Plan International planning a replication of this project in other states also?

P. N. Vasanti, Centre for Media Studies (CMS), New Delhi

I have three points to bring to this interesting and crucial discussion.

1) Whether it is ASHA worker or ANM or the local doctor or a Health worker, they become friends of a family or individual. This process needs nurturance and all possible support which includes understanding, capacities, responsibilities, services, infrastructure and resources. Communication is part of service delivery process. By creating distinction through different designations or departments the very purpose is defeated. At the household level or even individual level, whoever is the contact point for delivery of service also needs to be the communication person carrying the correct messages. At different times in a person’s life, the different information and also medical needs go hand in hand. These needs must be understood and accordingly provided. Remember the ‘Family Doctor’ concept. Though we live in an age of super specialization yet for every other information and household medical needs, it is the family doctor that still plays an important role. Research has also shown time and again that people prefer to get their information from such sources as the General Practitioner or Health worker.

2) The accountability and monitoring of the communication components needs to re-emphasized. The communication or IEC as it is generally known is a component of most programs today. It no longer just plays a support role, but has become a critical program component. The aim of the communication component is to influence attitudes, understanding and ultimately the behaviour. While some of the programs seem to undertake and acknowledge this and work to induce this change, most others seem to take it for granted and have been using it in their documents more as a lip service.

3) Most often the communication component becomes just a way of positioning or developing the brand of the organization or funding agency. This has also brought up a mismatch of messages, priorities and objectives. Even at NACO level, the lack of consistent briefs and strategies is telling. From the audience viewpoint, the various often non-complimentary messages and campaigns may cause confusion, apathy and even scepticism. The importance of consistent and complimentary communication brief, objectives and messages, at all levels, also needs to be highlighted.

I also take this opportunity to thank all contributing in this interesting discussion which has given us valuable inputs for developing NACP III communication strategy.

Dr. Swati Y Bhave, Expressions, New Delhi

It is good in principle to do all the work through Anganwadi workers and now we are adding the ASHA workers. While in many of the Ministry and UNICEF meetings I have attended it is suggested that every plan is to be implemented through Anganwadi workers, the ground reality is that they are poorly paid and are over burdened with multiple tasks. Unless their numbers are increased and minor incentives are given it is unrealistic to hope they will fulfill the increasing demands made on them. Same will be the fate of ASHA.

S. Narendra, R K Swami/BBDO Advertising Ltd, New Delhi.

Have gone through the ongoing debate I feel everyone seems to be anxious to see communication for AIDS prevention make a good impact.

I share Dr.Sanjeev Kumar's misgivings. Most of the good work seems to come from stray individual initiatives and a common drive is missing in current communication. Many of the initiatives raise issues of their sustainability overtime. An effective communication strategy is one where the people take over the idea. This has happened in the area of family planning, although the various components of family welfare did not share this good fortune. That was because Family Planning got tied to one personal benefit idea, the small family benefit.

In HIV and AIDS one is yet to see such a powerful positioning, and various programme components linking themselves to such a central idea. Also, linking the components to the frame of reference of the diverse sections of the people has not taken place. Too much emphasis on the science of HIV prevention, and very little on the art of communication.

Prof. M.S.R. Murthy, Department of Population Studies and Social Work, Sri Venkateswara University, Andhra Pradesh

The idea of training educated house wives in villages and making them help their own sisters, is a good one. Some support is needed for these women to sustain their interest and motivation. In fact house wives desire work outside home for small pecuniary benefits. Let us use some more youth in the village to help others in different aspects of health or other issues. In this way we can instil brotherhood and promote income generating habit in them. This will prevent frustration in the youth and promote a sense of nation-building in them. Good going.

Dr Arvind Mathur, WHO, New Delhi

Integrated or Focused/specific IEC, in my opinion needs to be reviewed from the points of view of both client and provider as well as the system. Based on my earlier experience of working with NGOs and communities, I am taking the liberty of sharing the experience. It certainly makes logical sense to think of resource pool at state or district or block level almost like a 'clearing house' where the expertise of IEC resources could also be pooled. But one would have to keep in mind that the IEC or communication channels or the modality may differ from disease to disease, condition to condition and audience to audience. I think the IEC strategy needs to take this into account and possibly one reason why it has almost always been thought best to develop the specific or focused IEC was the underlying assumption that it would get integrated at the provider level, namely at the Health Worker or the Medical Officer level, which usually does not happen.

Undoubtedly the communicator also needs to be kept in mind since this role is most often played by several health personnel and not alone by the IEC or block extension educators. These multi-tasking workers are not necessarily equipped with right mix of skills and competencies for integrating the messages and so it makes sense to develop some thing concrete in certain areas like, how to link Reproductive health, maternal, newborn and child health IEC, HIV/AIDS, TB and other communicable diseases. However, the question remains as to how does one addresses different age and sex segments with such messages? We have not as yet had the message of dual protection of condom across masses, leave apart a comprehensive integrated IEC strategy for health sector.

Dr. Janaki Desai, Niramaya Health Foundation, Mumbai

I agree with Dr. Mathur that the messages are to be delivered by the Health workers, Community workers or Medical officers and not by the IEC developers. As such the materials have to take into account the communication skills of these people. Secondly the language of the materials should be familiar to both the client and the provider. Having State or District pool of IEC materials would put fewer burdens on field NGOs both in terms of human and financial resources provided that IEC materials are easily accessible to them.

Also, I am in agreement that Anganwadi workers do work of Nutrition supplements, education etc. However the reality is that due to overwork Anganwadis are not able to do what is needed. there are Private NGOs who are doing micronutrient supplements and nutrition education to many balwadis who run parallel to Anganwadis esp. in urban slums. ASHA is a very good concept and if she is given limited families she may be an answer to some of the issues facing the communities.

Dr. Kusum Gopal, London School of Economics, UK

It is essential to train men along with women. The husbands of these women could be also trained and unmarried men. This way they would treat their wives and daughters better.

Tanushree Soni, Plan International (India), New Delhi

Training village housewives is just one aspect of our work, we are also working with adolescent groups exclusively with girls and also a mixed group. We do impart the health related information and training to them. For e.g. the adolescent girls groups are trained (TOTs) on identifying symptoms of anaemia and impart IEC training in self help groups and others adolescent groups. The purpose of imparting comprehensive and integrated health training to only married women is that since these ladies would continue to live in those communities they would be available for further reorientation and training and they would continue to get support from the network.

The commitment and motivation comes from the fact that these sanjivanis are from those communities and they are getting recognition due to their new role. Once these women are trained they will charge, like the TBAs for the services rendered by them. But yes, I agree with you that the risk of being type cast in a "work for payment" mould is always there. Looking at states like Uttranchal and other similar remote areas, where inaccessibility to not only secondary and tertiary level but even primary level of health services is a fact, its difficult to fathom how the ASHAs would accompany or take the 'cases' to the hospitals? Has the government thought of bringing the hospitals nearer to the communities?

Dr. Sanjeev Kumar, Hindustan Latex Family Planning Promotion Trust, New Delhi

Let me carry the discussion forward and ask ten simple questions about the IEC actions and operations in the new set of things:

1. What new and different efforts are being made for ASHA along with ANM and AWW to be the key player in IEC/BCC/IPC?

2. What efforts (new and different) are being done at central, state and district levels to restructure systems, processes and guidelines that get guided by Utilization Certificates?

3. What changes are being made in having a professional planning process that is available publicly?

4. What mechanism, processes and linkages are proposed for a synergized response at all players level and all efforts levels?

5. What increase is there in the funding for IEC and how is it proposed to be made best use of other than media spend ?

6. What efforts are being done to develop local capacity/institutional capacity which is not just trainings?

7. What researches are being conducted for formulation of BCC strategies that are rigorous and available publicly?

8. What M & E is being put in place that captures quality and impact indicators beyond numbers of production and distribution, recall and visibility of IEC materials and activities?

9. How gender and culture contexts are being factored in?

10. Last but not the leas