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TB Notes 3, 2003
UPDATES FROM THE COMMUNICATIONS, EDUCATION
, AND BEHAVIORAL STUDIES BRANCH
Stop TB Partnership Advocacy and Communications
Assessment of the 22 High-Burden Countries
Background: Tuberculosis (TB) rates have been increasing in a number
of regions of the world owing to poverty, rapid population growth,
ineffective TB programs, and the HIV pandemic. In 2001, the World
Health Organization (WHO) laid out a global plan to stop TB; the
plan is known as the Stop TB Partnership. The first phase of this
plan, to be carried out during 2001-2005, involves (1) expanding
the currently available anti-TB strategy, known as directly observed
treatment, short-course (DOTS), to allow all people with TB to have
access to effective diagnosis and treatment; (2) adapting this current
strategy to meet emerging challenges of HIV and drug resistance;
(3) improving existing tools by developing new diagnostics, new
drugs, and new vaccines; and (4) strengthening the Stop TB Partnership
in order for proven TB-control strategies to be effectively applied.
The Stop TB Partnership developed a cross-cutting Advocacy and
Communications Strategy to help achieve these first-phase objectives.
A Task Force for Advocacy and Communications was established in
January 2002 to oversee implementation of the Strategy. At a Task
Force meeting in April 2002, members recommended undertaking a comprehensive
baseline assessment of advocacy and communications for TB control
in the 22 high-burden countries (HBCs) to better inform subsequent
activities. The assessment was initiated in July 2002 and is ongoing.
This article summarizes the findings reported to date.
One objective of this assessment is to improve the Strategy by
assessing current National Tuberculosis Programme (NTP) advocacy
and communications capacities and activities in the 22 HBCs and
by providing a baseline against which the subsequent impact of this
Strategy can be progressively measured. Another is to begin documentation
of national and subnational advocacy and communications activities,
leading to identification of best practices.
The methods used in this assessment were rapid desk analysis of
HBC TB control plans and relevant documents, in-depth review of
HBC TB control plans, and key informant interviews with NTP teams
from Kenya, South Africa, Cambodia, Indonesia, Philippines, Uganda,
United Republic of Tanzania, Myanmar, India, China, as well as with
Following are the main findings of the 10 in-depth country reviews
together with pertinent issues for all 22 HBCs.
Current advocacy activities: Six out of the 10 HBCs included
in the in-depth assessment have established reasonably strong national
advocacy mechanisms. However, advocacy for TB in Myanmar, UR Tanzania,
Uganda, and China is either limited to urban centers or is extremely
weak, especially at the district level. All 10 HBC program teams
requested assistance in strengthening advocacy activities at national
levels but especially at the district level where, as a consequence
of health reforms, many budgetary and human-resource decisions are
Current communications activities: The 10 HBCs included
in the in-depth assessment varied in terms of the intensity and
reach of communications activities currently taking place. All countries,
apart from Uganda, celebrated World TB Day 2002 at various levels
of society. World TB Day 2002 produced the following reported results:
new alliances between government departments and between governments
and NGOs (Philippines and Myanmar); an increased awareness in the
general public (Cambodia and UR Tanzania); and an anecdotal increase
in the number of new TB patients presenting for treatment (Kenya).
Other countries reported no specific impact resulting from World
TB Day 2002. Only Philippines, India, UR Tanzania, and Cambodia
reported any communications activities outside World TB Day (excluding
the ongoing work of health staff in their consultations with suspected
TB patients and patients currently on treatment).
NTP capacity to conduct advocacy and communications: Capacity
to conduct advocacy and communications activities depends upon having
the following: (1) designated managerial staff with appropriate
qualifications and experience; (2) access to appropriate agencies
from which technical advice can be regularly sought and to which
specialized work can be subcontracted; (3) a well-researched strategic
plan with a precise behavioral goal by which activities can be properly
coordinated, monitored, and evaluated; and (4) sufficient financial
resources to implement planned activities.
Managerial staff: Of the 10 HBCs assessed in-depth, only
Kenya, South Africa, and UR Tanzania report having a designated
advocacy and communications manager. The other countries report
using combinations of other staff and/or institutions.
Technical assistance: All 10 HBCs had access to Ministry
of Health and WHO Regional Public Relations Officers. Only India
and South Africa reported contracting with private-sector agencies
to assist with their advocacy and communications activities.
Strategic planning: All 22 HBCs have prepared plans
to address barriers to expansion of the DOTS strategy. Few of
these plans detail any comprehensive approach to advocacy and
communications activities. Of the 10 HBC countries assessed in
this baseline, only UR Tanzania reported having developed
a definitive plan to manage, monitor, and evaluate advocacy and
Financial resources: A few HBCs have been successful
in securing financial support through the Global Fund for AIDS,
TB, and Malaria (GFATM). Others receive support through the Global
Drugs Facility (GDF). A range of donors are actively supporting
several NTPs. NTP capacity to process external funds has proved
problematic in some HBCs.
Training and materials development needs: Representatives
of each NTP from the 10 HBCs selected for this assessment stated
they would welcome training on a range of advocacy and communications
issues, including planning Information, Education, and Communication
(IEC) campaigns, generating media coverage, spokesperson media training,
communicating to public officials, creating coalitions and partnerships
with community groups to impact elected officials, and producing
brochures for general distribution, press kits or press releases,
and briefing papers for elected officials.
Recommendations to Date
1. Additional effort must be made to assess the impact of World
TB Day (in terms of specific indicators such as increased case detection
rates and increased funding) given the quantity of resources dedicated
to this exercise.
2. NTPs should ensure that the complex, multilevel advocacy and
communications activities required to support DOTS expansion is
managed by a designated, full-time, well-qualified staff member
or team. If required, there should be further in-country assessment
of the capabilities of designated staff and institutions.
3. More in-country advocacy is required to ensure adequate resources
are available to support social mobilization and communication for
behavioral impact, especially at sub-national level. NTPs should
use local resources as thoroughly as possible, and only afterwards
seek external resources – first elsewhere in the country, and finally
internationally. Capacity building in financial management may be
required for managers or teams responsible for implementing TB control
at national and especially at subnational levels.
4. NTPs should be actively encouraged to seek support from multinational
and national corporations, not just in cash or other resources but
in terms of skills. These linkages may result in substantial
benefits to NTPs as well as serve as a useful public relations exercise
for the corporations concerned. Resource groups that are available
within country to help plan, develop, and implement advocacy and
communication activities need to be identified. These would include
media professionals, production agencies, patient organizations,
NGOs, and other professional bodies.
5. Comprehensive training programs are urgently required to build
capacity in strategic social mobilization and communications planning,
implementation, and monitoring. Training should also emphasize evaluation
of advocacy and communications strategies, e.g., pretesting interventions,
process evaluation, outcome evaluation, and impact evaluation. Training
programs could include short courses, in-service distance education,
and on-the-job technical assistance to field staff. Centralized
or regional training teams could be established so that one or more
teams of "master trainers" travel to various locations
to deliver high-quality training.
6. More detailed assessment is required of the current and potential
advocacy and communications linkages between NTPs and HIV/AIDS programs
in the 22 HBCs.
7. Based on this present assessment, the Task Force for Advocacy
and Communications recommended the following HBCs for Stop TB Partnership
support to strengthen their advocacy and communications capacities
and activities: Cambodia, Indonesia, Myanmar, South Africa, Uganda,
Acknowledgments: This report was prepared by Scott McCoy (CDC),
Tim Raftis (American Lung Association), Ninan Varughese (TBP/WHO),
and Will Parks (SMT/WHO). The project was coordinated by Ninan Varughese
and Michael Luhan (STB/WHO). Other WHO staff who assisted in compiling
information for this report were Kraig Klaudt, Petra Heitkamp, Everold
Hosein, and Elil Renganathan. A number of National TB Program managers,
staff, and advisers also provided detailed data.
—Reported by Scott McCoy, MEd
Div of TB Elimination
TB Behavioral and Social Science Research
Planting the Seeds for Future Research
DTBE is pleased to announce plans for a Tuberculosis Behavioral
and Social Science Research Forum to be held December 10 and
11, 2003, in Atlanta, Georgia.
The Institute of Medicine report, Ending Neglect: The Elimination
of Tuberculosis in the United States, identified the need for
further behavioral and social science research in a number of areas,
including the determinants of health-seeking and treatment-adherence
behaviors of patients, health care provider behaviors, and the organizational
structures that affect the control of TB. The proposed Forum will
build on the foundation of a previous workshop, Tuberculosis
and Behavior: National Workshop on Research for the 21st
Century, held in 1994. It will also bring together behavioral
and social science researchers and health professionals interested
in the enhancement of TB control and services.
The goals of the proposed TB Behavioral and Social Science Research
Forum are as follows:
- Establish an ongoing partnership among national, state, and
local governmental and nongovernmental behavioral and social science
researchers focusing on TB;
- Create a mechanism for ongoing communication among TB behavioral
and social science researchers;
- Identify and prioritize TB behavioral and social science research
- Develop a feasible, goal-oriented research agenda that will
guide TB behavioral and social science activities.
If you would like more information or if you have any specific
questions on the Forum, please send an e-mail to TBBSForum@cdc.gov,
or contact Nick DeLuca at (404) 639-8988 or Robin Shrestha-Kuwahara
at (404) 639-8314.
—Reported by Nick DeLuca, MA
Div of TB Elimination