Mobilizing Demand for MNT Immunization: Reaching Women in Pakistan
Bruce Rasmussen and Nabeela Ali
A version of this paper will appear in the volume, Shaping Policy in Safe Motherhood and Newborn Health: A Compendium of Case Studies, authored by Maternal and Newborn Health (MNH), Save the Children, and Family Care International and scheduled for publication in October 2003 by MNH/JHPIEGO.
Bruce Rasmussen is former Director of the Pakistan Field Office of Save the Children and is currently Program Operations Director for Pakistan/Afghanistan. Dr. Nabeela Ali is Saving Newborn Lives Program Manager at Save the Children US in Pakistan.
Susan Howard, Managing Partner/Director, Howard Delafield International, contributed to this article.
Saving Newborn Lives (SNL) initiative, led by Save the Children US, is funded through a generous grant from the Bill & Melinda Gates Foundation. SNL promotes affordable and sustainable solutions to maternal and newborn health problems in communities and countries where newborn death rates are highest and people have limited access to known, life-saving interventions.
For more information, please contact: Save the Children Federation, 2003
"It is not possible for government only to work on projects like this...[N]on-government organizations...can persuade people and educate people...[T]here should be collaboration with non-governmental organizations, donors, planners [and] policy-makers..."
Dr. Abdul Malik Kasi, Former Federal Minister for Health, Pakistan, regarding MNT immunization; interview with Save the Children, 2002
Pakistan has the third highest number of neonatal tetanus deaths globally, after India and Nigeria. This is hardly surprising given that nearly 80 percent of newborns are born at home, often without the benefit of clean delivery practices. Most pregnant women receive inadequate antenatal care and lack skilled assistance at delivery. Only about half of all women of childbearing age show serological evidence of adequate immunization against tetanus (SOWN: Pakistan, 2001). As a consequence, in 1999 alone, neonatal tetanus killed nearly 22,000 newborns, as well as countless mothers, in Pakistan (World Health Organisation, MNT website).
In 1997, when planning for MNT elimination began in earnest, more than half the districts in the country, 57 at the time, were identified as having pockets of high risk based on reported cases of neonatal tetanus and on low rates of child immunization coverage. These high-risk areas included nearly five million women of childbearing age, most of them living in inaccessible and socially conservative communities. Just the sheer number of women to be reached with three successive doses of TT was a challenge to the Ministry of Health (MoH) and its partners in terms of mobilizing funds and human resources. In early 2001, the government of Japan contributed 15 million doses of vaccine.
Planners were immediately confronted with the question of how to overcome social barriers to vaccinating unmarried women and married women who were not pregnant. Save the Children's Saving Newborn Lives (SNL) initiative joined with the MoH, UNICEF, WHO and JICA to help implement the program. Based on its earlier success with community mobilization for improved women's health at district level in Pakistan. SNL took on the project of creating demand among at-risk women, thereby addressing a key gap in Pakistan's MNT elimination program, which was primarily focused on the logistics of making the vaccination available.
This demand creation strategy achieved groundbreaking results. For the three rounds of MNT immunization conducted in 2001-2002, coverage of women of childbearing age was well over the international standard of 80 percent, reaching a total of 4.2 million women, and during the 2003 campaign, reached an additional 80 percent - a total of 12 million women all told. Lady Health Workers (LHWs) were trained and deployed as vaccinators in large numbers for the first time, establishing a reliable connection between the health care infrastructure and at-risk women with limited access to health care.
Broadly speaking, there were four steps to this demand generation strategy that employed a marketing approach to generating consumer demand: research, development and testing of messages and materials, implementation, and monitoring and evaluation.
Gathering accurate and relevant information from women and from decision-makers at household and community level was the foundation of this approach. Formative research was conducted in two randomly selected districts in each of the country's four provinces, ensuring representation of a wide spectrum of ethnic groups. Nine categories of target audience were identified, and focus groups--72 in all--were conducted by specially trained staff of local NGOs.
The information gathered from these focus groups was useful for overall program planning as well as for developing specific messages and strategies to increase awareness and demand for MNT immunization. It became quite clear that a door-to-door campaign, conducted by female vaccinators, would be required to effectively reach most women. Furthermore, it would not be enough simply to raise demand among women themselves. It was necessary to reach the decision-makers in each community -- including fathers and husbands, mothers-in-law, community leaders, religious leaders and teachers -- in support of the campaign.
Using data from the formative research, a marketing and communications specialist and a leading commercial advertising firm worked together to develop the messages, while consulting regularly with the program planners (mainly staff of the MoH, UNICEF and WHO) to ensure that program objectives were being met.
Communication materials were developed, including posters and leaflets for public display and distribution as well as targeted information leaflets for specialized audiences, such as religious and community leaders. Other materials were distributed at girls schools. A kit was developed for Lady Health Workers (LHWs) including an injector card for each woman vaccinated; and distinctive scarves and caps for female and male health workers to wear during the immunization campaign. Detailed implementation guidelines and a video docudrama, were also produced for use in training LHWs.
Implementing the communication strategy in 57 districts was a daunting logistical challenge that required strict organization, and the close cooperation of the MoH, SNL and UNICEF. Careful preparation of all campaign participants were planned well in advance. District health teams were key to ensuring carefully timed dissemination of materials and messages to every district. Orientation meeting were held for community leaders to LHW team leaders from each of the province's target districts, followed by visits of resource persons to each district. Just prior to the campaign launch, printed materials went out to each target audience, while announcements were broadcast from local mosques and mobile vans.
Monitoring and Evaluation
In order to monitor the effectiveness of the demand generation strategy, SNL conducted a rapid assessment following the first two doses of immunization, which were given one month apart at the beginning of the program. Hundreds of people, representing each of the nine categories identified for the initial formative research, were surveyed in randomly selected target districts in each of the four provinces. Data thus collected resulted in several recommendations that led to intensified support to the communication campaign at district and sub-district level. For round three, conducted six months after round two, a coordinator for each district was identified and district health staff was given additional orientation.
A decision was made to expand the program to cover the entire population, not just high-risks pockets, of the initial 57 districts, along with several additional districts, which extended coverage to an additional 10 million women of childbearing age. The MoH, UNICEF and SNL agreed to continue their partnership and again achieved coverage rates exceeding the 80 percent target - reaching 12 million women.
Although Pakistan has not yet achieved MNT elimination, the fact that over 12 million women of childbearing age in the highest risk areas of the country, have received protective MNT immunization represents substantial progress. It is essential, of course, for Pakistan to continue to give high priority to routine MNT immunization as well as clean delivery practices. Only the combination of these measures will result in achieving and maintaining MNT elimination throughout Pakistan.