PHA-Exchange> Mass communication and behavioral change

[claudio]

From: "DBanerjee" <nhpp at bol.net.in>

 REINVENTING MASS COMMUNICATION AS A TOOL FOR BEHAVIOUR CHANGE FOR DISEASE
CONTROL BY WHO

                                                                    Debarbar
Banerji

ABSTRACT
> Most of WHO's vertical programmes, because they were ill-conceived,
> ill-designed and
> defectively implemented, have fallen far short of the expectations.
However,
> these limitations
> have been doggedly ignored by it, although the authorities in India have
now
> realised that
> such vertical programmes are expensive and not sustainable. Launching of
> `communication
> for behavioural impact' appears to mark a desperate effort to revive their
> performance.
> It represents yet another sharp deviation from the mandate given to WHO.
In
> 1983,
> the then DG of WHO had warned against motivational manipulation of people
to
> sell
> health ideas. WHO has now brazenly come forward to look for help from the
> private sector.
> COMBI (for details see below) uses the jargon and language of the market
place to `market' health
> programmes.
> It calls this `cause related marketing'. WHO has been astonishingly
> ahistorical in
> conceptualising COMBI, as it has not learnt from the failure of the
earlier
> venture of UNICEF
> to market child survival by employing experts in social marketing to bring
> about
> `community mobilisation'. Going further, WHO ought to have reviewed the
> enormous body of
> literature on the work done in health social sciences, health education
and
> the many programmes based on the concept of `information, education and
> communication'.
> The pointed neglect of such key issues raises serious moral, ethical and
> human rights questions.
> The COMBI approach amounts to be a breach of trust - a threat to human
> dignity.

> DEEPENING CRISIS WITHIN WHO

> Falling back on mass communication as a tool for bringing about behaviour
> change among people to get their acceptance of its programmes for
infectious
> diseases
> control (1), (2) gives an indication of the depth of predicament of WHO.
> Being an
> international political organisation, this predicament of WHO is rooted in
> the nature of the power structure that shapes the existing world order.
The
> Constitution of the WHO mandates it to work towards making health - in the
> classical form defined by it - as a fundamental human right for all the
> people
> of  the world. The World Health Assembly of WHO, constituted by some
> 190-odd Member States, is entrusted with this task. Though each one of its
> Member State has a single vote, their sheer diversity in terms of
> demography,
> geography, economics, politics, and health status, health behaviour and
> health
> services has made most of them vulnerable to manipulation by a few
powerful
> countries. This has come in the way of WHO making any worthwhile progress
> towards the tasks assigned to it. A handful of countries which dominated
the
> world political scene during the fifty-five years of existence of WHO,
have
> dictated the terms. WHO generally mirrored the global power structure.
>
> During the Cold War days, a series of pro-poor decisions by WHO culminated
> in the Alma Ata Declaration on Primary Health Care in 1978 (3). The
> Declaration
> marks a watershed in public health practice. However, the radical
> transformations
> that took place towards the end of the Cold War seems to have impelled WHO
> to
> violate even some of the basic postulates of well established principles
and
> practice
> of public health. Making what amounts to be almost irresponsible
`estimates'
> on
> incidence and prevalence of diseases in the absence of data of the
required
> validity and
> reliability, rank ordering countries on the bases of such data, use of
> epidemetric
> models which suffer from serious infirmities and WHO's persistence in
using
> such
> obviously untenable concepts as Disability Adjusted Life Years Saved
> (DALYS), are some
> examples of its gross violation of basic principles in the use of
scientific
> methods in public
> health (4). It is being contended that in terms of the single-minded
> imposition of the
> will of the rich countries on the poor, the present world order reflects
an
> even more
> malignant version of the McCarthysm of the 1950s, which has been rightly
> described
> by Vicente Navarro as practice of intellectual fascism (5). Use of
> `Communication for
> Behaviour Impact' (COMBI) is a recent instance of practise  such form of
> intellectual fascism.
>
> Expectedly, the response of the rich to the daring declaration of
> self-reliance by
> the poor of the of the world at Alma Ata was as sharp as it was swift.
Using
> flimsiest of scientific data base from a very poorly designed, conducted
and
> analysed
> field study in Haiti (6), they `invented' the term Selective Primary
Health
> Care
> (SPHC) to counter the profound public health philosophy contained in the
> Alma Ata Declaration.
> Following the dictates of politics and economics over commitment to some
> basic principles
> of scientific rectitude and fair play, the editorial staff of one of the
top
> learned
> (clinical) medical journals of the world,  The New England Journal of
> Medicine, showed unusual alacrity in publishing and assigning a prominent
> place to such a
> scientifically suspect public health paper in that journal. The
Rockefeller
> Foundation
> got the task of organising a high powered conference on SPHC in 1984 (7).
> This was attended
> by top officials from the rich countries and the bilateral health agencies
> and international
> agencies like WHO, UNICEF, World Bank and IMF and many world renowned, but
> conforming
> intellectuals, at their campus in Bellagio, Italy. It provided an aura of
> sanctity to
> the ideology of SPHC (Bellagio-I). A similar conclave of the faithful was
> held
> later at Cartaghena, Columbia (Bllagio-II) in 1986 to reiterate and
> replenish the ideology (8). All these efforts, however, did not carry
> conviction with a large
> body of public health scholars (9). They stand vindicated by subsequent
> events (4).
>
> That the sponsors of the Alma Ata Conference, UNICEF and WHO, were made to
> implement, (along with World Bank and IMF) an ideology which is the very
> antithesis
> of the Declaration, is an awesome demonstration of the power of the rich
> countries to
> force world organisations to conform to the line laid down by them.
> Dutifully,
> conforming to SPHC, UNICEF and WHO joined World Bank, to open a virtual
> barrage of `vertical' or `categorical' programmes on the poor countries of
> the world (10), (11), (12). UNICEF coined such `global initiatives' as
> Growth Monitoring,
> Oral Rehydration, Breast Feeding promotion and Immunization (GOBI). It
later
> added Food, Female education and Fertility control to make it GOBI-FFF.
> Later still
> some of these were broken into more focused `vertical' programmes as the
> Universal
> Immunization Programme (UIP) against the six diseases. When the UIP too
> failed to
> achieve its objectives, it was further confined it to the Global Polio
> Eradication Programme
> (with the assistance of Rotary International).International health
> organisations also
> promoted vertical programmes, such as control of Diarrhoeal Diseases,
Acute
> Respiratory
> Infections, AIDS, Tuberculosis and Malaria (12).
>
> Apart from very serious flaws in the policy formulation and cost
> effectiveness and
> efficiency, virtually all the major initiatives taken by the international
> organisations have fallen far short of the expected outcomes promised at
> the time of `selling' them to their `clients' in poor countries (4). Over
> and
> above, as these programmes were given overriding priorities over the other
> services provided by the general health services, the latter's neglect
> considerably increased what has been termed by WHO as the `burden of
> diseases' in communities (13). Ironically, in due course, the general
health
> services had become so weak in many countries that they were unable to
> provide even the operational base for implementation of the vertical
> programmes.
>
> WHO, UNICEF and other international organisations
> owe an explanation to the poor of the world for being instrumental in
> causing so much of damage to the infrastructure of the health services
> because of their dogged refusal to take cognisance of the bold writings
>  on the wall. On the contrary, they produced astonishingly outlandish
> arguments to underline virtues of vertical programmes. For instance,
> without caring to explain why the programmes have failed so conspicuously,
> in true tradition of salespersons, the proponents of COMBI have
> pontificated,
> without the backing of any scientific evidence, that `when more doctors,
> nurses and
> other trained health workers are posted to rural areas, they will not only
> confine
> their work to AIDS, TB and malaria, but will be there to meet the other
> health needs
> of  in the low-income communities they serve.'(1). Class interests of the
> rich to have
> vertical programmes comes out in the open when, elsewhere, they have
pointed
> out,
> `with increasing globalization of trade and travel, infectious diseases
pose
> a threat not only to the poor of the developing countries, but to the
> population
> of the wealthy countries as well. Bacteria, viruses and parasites can
easily
> cross
> borders, carried unknowingly by international travelers.'(1).
Significantly,
> the WHO Commission on Macroeconomics and Health (14) also saw many
> virtues in the vertical programmes and they strongly recommended
> their retention, citing many advantages they provide to `outside donors,
> who appreciate centralised technical and financial control that
characterise
> them and their tendency to be more easily assessed.'(p.68).
>
>  Apparently, the flaws of the `techno-managerial' programmes that are
> pushed by WHO and other international agencies have become so obvious
> that the government of a country like India, which had hitherto been
> faithfully
> following the  line laid down in the global vertical programmes, has been
> impelled to make a forthright `confession' in its National Health Policy
of
> 2002 (13)
> about the degree to which the health services have suffered because of
these
> programmes. It says:
> .
> "Over the last decade or so, the Government has relied upon a `vertical'
> implementational structure for its disease control programmes. Through
this,
>  the system has been able to make a substantial dent in reducing the
burden
> of
> diseases. However, such an organisational structure, which requires an
> independent manpower for each disease programme, is extremely
> expensive and difficult to sustain. Over a long range, `vertical'
> structures may only be affordable which offer a reasonable
> possibility of elimination  or eradication in a foreseeable time frame...
>
> "It is a widespread perception that  over the last decade and a half,
> the rural health staff has become a vertical structure exclusively for the
> implementation of family welfare activities.  As a result where there
> is no separate vertical structure, there is no service delivery system at
> all.
> The [ National Health] Policy will address this distortion in the public
> health system."(p.9).

> USE OF COMBI AS THE LATEST BID TO STEM THE SLIDE

> Over the past two years WHO has been applying the concept of
> ? COMBI in the design and implementation of behaviourally focused
> social mobilization and communication programmes for the elimination
> of leprosy in India and Mozambique, the prevention of lymphatic
> filariasis in India and Tanzania, and dengue prevention and control
> in Malaysia (1), (2).  Everold N. Hosein, Communication Advisor to
> Communicable Diseases Division of World Health Organisation says,
> ? `It is an approach, which may be well suited for achieving behavioural
> impact in confronting HIV/AIDS, TB and malaria. COMBI interprets
> social mobilization as the process, which judiciously and strategically
> ? blends a variety of communication interventions intended to `mobilize'
> ? the societal and personal influences, which prompt an individual to
> ? adopt and maintain a particular behaviour', he adds.
>
> According to him, `The private sector's dedication to being consumer
> ? focused  points the strategic way to influencing personal/community
> ? health behavour'. He concedes that: `In the public sector world of
healthy
> ? behaviour, there are not many examples to draw on, primarily because
> ? not many behaviourally-focused social mobilization and communication
> ? programme have been implemented in a substantial way. In the consumer
> ? world of the private sector, however, there are thousands of success
> stories that
> ? can serve as models'. The COMBI  exponents have coined yet another term,
> ? `cause related marketing' (CRM). It is a strategic positioning and
> marketing
> ? tool which links a company or a brand to a relevant social cause or
issue,
> ? for mutual benefit (1). The relationship of American Express with
> ? Share Our Strength (SOS), of Proctor and Gamble with ACTIONAID,
> ?  and UNICEF's relationship with British Airways are given as examples
> ? by Hosein (1). Apparently following public outcry all over the world,
> ? UNICEF's mercifully aborted relationship with Macdonald belonged
> ? to the same genus.
> ?
> ? It is claimed that COMBI, drawing on consumer communication
> ? experience,  begins with the `people' (clients, patients, beneficiaries,
> consumers)
> ? and their health needs, wants, desires, and a sharp focus on the
> behavioural
> result expected in relation to these needs, wants and desires. `It is
> rooted in people's knowledge, understanding and perception of the
> recommended behaviour', Hosein explains (2).
>
> Describing the methodology followed by COMBI programme, Hosein
> says, `the `market/community' is intimately involved from the outset
> through practical, participatory community research and situation
> analysis relating desired behaviour to expressed or perceived
> needs/wants/desires'. People are then engaged in a review and
> analysis of the suggested healthy behaviour through a judicious blend
> of integrated communication actions in a variety of settings,
> appropriate to the `market' circumstances and based on the community
> research, recognizing that there is no single magic intervention. The
> blend of communication actions include advocacy and public relations,
> administrative/managerial mobilisation, community mobilisation,
> sustained appropriate advertising, interpersonal communication/
> counseling/ personal selling, and point-of- service promotion.
>
> `We have just completed a small COMBI project for leprosy in three
> districts of Bihar with impressive results. We have also done a
> successful COMBI programme for Lymphatic Filariasis mass drug
> administration in Tamilnadu also,' says Hosein, who is very
> enthusiastic about extending the COMBI approach to TB control in
> India. `In TB we are just starting a COMBI programme in Kerala State
> as our first India demonstration project,' says Hosein.
>
> The Stop TB Task Force on Advocacy and Communications chose Kerala in
> India because it has high DOTS coverage and low detection rates, but
> nevertheless boasts of good infrastructure support in place to
> implement social mobilization activities.
>
> COMBI uses a variety of communication interventions to `mobilize' the
> target population into adopting and maintaining a particular desired
> goal - in this case, taking the sputum test. It also attempts to
> identify the barriers and constraints that may prevent people from
> taking up the treatment, and thereafter following it through to the
> finish (2).

 MANY SERIOUS FLAWS IN THE CONCEPT

> WHO's the concept of COMBI marks yet another low point in its downslide.
> The entire organisation has to take the responsibility for aIlowing
> this to happen.. It transports WHO to a surreal Brave New World projected
by
> Aldus Huxley in 1937. Does Everold Hosien want WHO to become an engine to
> sell to the poor of the world certain selected health activities, which
are
> fabricated in the
> rich countries for their vested interests? He strongly smells of a not
very
> clever salesman from the market place, though he tries to cover the odour
> with terms such as knowledge about the community, participatory research
and
> `strategically planned social mobilization and communication'. His
jumbled,
> incoherent
> thinking and his use of high sounding words may themsevles be a
> communication ploy to impress or confuse the `customer' to buy COMBI. In
> fact,
> when he considers such widely different groups as clients, patients,
> beneficiaries,
> consumers and the community at large, as his `targets' for selling what he
> calls
> `recommended behaviour', he betrays the extent of ambivalence in his
> thinking.
> He does not care to find out who makes the recommendations. COMBI amounts
> to what the then director-general of WHO, Halfdan Mahler had described in
> 1983 as
> `motivational manipulation' of people (15). What is the `evidence base'
> of the recommendations sought to be `sold' by Hosien? It is an assault on
> human dignity. It is a breach of trust. Such brainwashing, that too under
> the
> banner of an organisation like WHO, raises very serious
> moral, ethical and human rights issues. Probably, at the market place,
> where the mantra is to maximise sale of products, such issues are of
limited
> concern.
> That WHO is willing to jettison such values and coexist with social
> marketeers,
> for very questionable proposition of increasing the sale of its products,
> gives a
> chilling account of its decline and fall during the recent years. It did
not
> occur
> to WHO that the philosophy behind COMBI is light-years away from what was
> envisaged in the Alma Ata Declaration on primary health care.
>
> Over and above, Hosein has not paid attention to two fundamental
> requirements for developing the concept. One is to review the literature
> on the subject. The other concerns empirical evidence to support his
> contentions. Milan Kundera had rightly observed: Man's
> struggle against oppression is a struggle between memory and
forgetfulness.
> Hosein seems to have managed to `forget' the earlier experiences of
> motivational manipulation, apparently because WHO had to reinvent COMBI.
> After Bellagio-II, held at Categhna, Columbia, UNICEF, had launched a
> massive publicity drive to `market' a social `product' of the foredoomed
and
> now
> `forgotten' Universal Immunization  Programme (UIP). Has Hosein
`forgotten'
> that, apart from employing  experts on social marketing
> like R. K. Manhoff  (16), UNICEF also hired an eminent person like
> the Director of the Institute of Development Studies at Sussex University,
> Richard Jolly, to `recommend' that such marketing will result in massive
> `social mobilisation' (17), as is once again being peddled by him?. The
> expected
> mass mobilization for UIP did not take place. Despite all the high pitched
> salesmanship
> by Hosein, it is highly unlikely that the strategy of social marketing so
> fervently advocated by him will revive the intrinsically faulty vertical
> programmes
> launched by WHO.
>
> It will be even more far-fetched to assume that Hosein and WHO will
> retain the `memory' of the interdisciplinary research experience at the
> National Tuberculosis Institute at Bangalore during1961-63 (18), (19). It
> was
> based on a study of `going to the people to learn from them' to find a way
> of
> developing a people oriented tuberculosis programme for countries of the
> world. They will like to `forget' this to make way for `marketing'
> social marketeers to give yet another lease of life to the ill-conceived
> global
> programme on tuberculosis, with the DOTS approach as its centrepiece (19).
> Had Hosein
>  examined the series of studies, before venturing into his work on
> tuberculosis in the
> Kerala state in India, he would have found out that the sheet anchor of
that
> work was a sociological investigation of the people (18). It revealed
that,
> without
> any assistance from COMBI, even at that time, half of all sputum positive
> cases of tuberculosis in a community had sought help from health
> institutions, where they were summarily dismissed with bottles of
> useless cough mixture. Who needed behaviour change? the researchers asked.
> Because of serious administrative and organisational anomalies, even today
> literally millions of tuberculosis cases are being dismissed with bottles
of
> cough mixture (19).
>
> There were, in addtion, WHO's own experience from its Health Education
Unit,
> numerous instances of the now discredited community studies on
> Knowledge, Attitude and Practice (KAP) (20), the Report of the WHO Expert
> Committee on
>  New Approaches to Health Education (1984) (21) and the flood of actions
> based on
> the Information, Education and Communication (IEC) approach (22), which
> formed
> a major element of numerous health activities like Family Planning (23),
> (24),
> AIDS (25) and UIP (26). These too did not trigger the expected mass
> mobilization.
>
> Coming to the more recent period, before `recommending' COMBI, Hosein and
> WHO ought to have examined the `evidence base' of the formulation of the
> WHO's
> own Global Programme of Tuberculosis (27). Why did they not include COMBI
as
> a part of that programme? What happened to the solemn declaration of
> tuberculosis as a global emergency by WHO in 1995(28)?
>
> It appears that in the market driven world of globalisation and
> liberalisation, manipulators of international health are following a
> circular path. (1) It started with the social marketing phase of selling
> immunization (17); (2) then it invented health financing as the tool of
> health
> policy formulation (29);  (3) it then had the Report of the much
publicised
> WHO Commission on Macroeconomics and Health (Sachs Commission),
> which is not only exceedingly poor in conceptualisation and
> programme formulation, but it also conveniently `forgot' the Alma Ata
> Declaration, which ought to have stuck out from miles(14); (4) COMBI now
> completes the vicious circle of exercise of authority without
> responsibility. In branding WHO as having `the worst of both worlds', the
> management firm, Health Care Initiatives of Paris has observed that in the
> management ideology of WHO, `short-term results to satisfy the
stakeholders
> are justified at any cost' (30) ;  COMBI is a glaring example of this
> serious malady of WHO.

 STRUGGLE OF THE POOR TO GAIN ACCESS TO HEALTH

> The poor of the world find themselves in a more difficult situation under
> the
> existing world order. They are made to pay a heavier price when the ruling
> classes in their countries agreed to implement the WHO agenda of vertical
> programmes. Over and above, their submission to the dictates of
> organisations
> like the World Bank, the IMF and the WTO has led to rapid growth of the
> private
> sector in medical care, which limits its access only to those who can
manage
> to
> meet the enormous cost. As has been pointed out in the foregoing, this led
> to
> serious erosion of the infrastructure of the health services provided free
> of cost by the state.
> Under the circumstances, it is possible to identify through the haze of
> their frustration and
> dejection three of the ways to fight for their rights:
>
> 1. This has often led to sustained struggle by the people against the
> baneful
> consequences of the vertical programmes. For instance, as mentioned in the
> foregoing,
> in a country like India, which has a substantial proportion of the disease
> load among
> the poor of the world, such a struggle has impelled the government to
> recognize these
> consequences and take a policy decision against adopting vertical
programmes
> (13). The task
> ahead of the poor is to ensure that the policy does get implemented and
the
> infrastructure gets strengthened. For other countries, which should
include
> China, the
> struggle has to be to continue to get the discredited vertical programmes
> discarded.
> Incidentally, the unbridled spread of the epidemic of Severe Acute
> Respiratory Syndrome
> (SARS) in China and many other countries in East Asia and elsewhere from
> around the middle of March 2003, shows the fragile state of the public
> health systems
> in these countries.
>
>  2. Concurrently, as a part of their democratic struggle to work towards
> making
> health as a fundamental human right, as envisaged in the Constitution of
> WHO, the
> poor face the uphill task of compelling their countries to join together
as
> WHO
> Member States to correct the very serious deviations that have taken place
> and
> renew its commitment to the Alma Ata Declaration.
>
>  3. Probably the most worthwhile move on the part of the deprived sections
> will be to
> cultivate self-reliance among themselves to cope with the health problems
> faced
> by them, and at the same time, use their democratic strength to ensure
that
> they get
> referral support for those health problems which are beyond their coping
> capacity.
> Ensuring intersectoral action for health and acquiring social control over
> the
> public health services could be identified as other fields for action.
>
> Acknowledgement:
> I would express my deep gratitude to Dr Caudio Shuftan for providing
details on the launching  of the COMBI programme by WHO.

> REFERENCES (available from the author directly.

> Debabar Banerji
> Emeritus Professor,
> Jawaharlal Nehru University,