Advocacy, Communication and Social Mobilization to Fight TB: A Ten-year Framework for Action

This 96-page document sets out a 10-year strategic framework for country-level advocacy, communication and social mobilisation (ACSM) activities as a complement to strategic work at the global level designed to exert pressure on governments and other high-level authorities to prioritise tuberculosis (TB) control. The resource is offered by the ACSM Working Group (ACSM WG), which was established in 2005 as the seventh working group of the Stop TB Partnership.

Intended to serve as a key supporting document to the Stop TB Partnership's Global Plan to Stop TB 2006-2015, the report emerges from the observation that there is an increasing wealth of experience and evidence demonstrating the value of ACSM in making progress toward meeting the Millennium Development Goal (MDG) related to TB (MDG #6) by: mobilising political support and leadership for TB control strategies at all levels (including at country level), empowering people affected by TB, improving case detection and boosting treatment adherence, and tackling stigma.

The workplan is divided into two parts: first, a call to action, which describes central challenges to be addressed, defines key terms (e.g., what is "communication"?), summarises the current evidence of ACSM contribution and lessons learned, and sets out the key principles underpinning the workplan. Part 2 includes a framework for action, which explains the vision, goals, objectives and targets of the country-level ACSM strategic framework; outlines the framework's basic components; examines how progress could be monitored and evaluated; explores key partnerships and roles; and presents and justifies the budget.

The ACSM WG details a number of strategies as part of the framework, which involves intensively supporting ACSM activities in 5 high-TB burden countries (Bangladesh, China, India, Indonesia and Nigeria) per year over the next 5 years, and then sustaining that support throughout a 10-year period. The framework is designed to implement intensive, sustainable and detailed communication strategies, yet does not attempt to provide a rigid blueprint for countries to follow (since decisions on the most appropriate ACSM strategies will need to be informed by specific situations and demands of TB-affected countries). That said, the framework does advance a series of interrelated approaches and tools - which centre on the following mix of 5 key strategic components (described in detail within Part 2 of the document):

1. Building national and subnational ACSM capacity
2. Fostering inclusion of patients and affected communities
3. Ensuring political commitment and accountability
4. Forging country-level ACSM partnerships
5. Learning, adapting and building on good ACSM practice.

The document indicates that there is "a substantial body of good practice to draw upon in designing effective TB communication programming" at the country level. A key strategic lesson shared here is that ACSM strategies are most effective when their design is led by and appropriate to specific country processes and experiences. Two such successes are described here, both of which began from an understanding and clear articulation of the context of TB - especially poverty:

• "In the project areas of Mexico, communication mechanisms have been implemented at the community level in the form of networks of community facilitators, health promoters and
  local authorities, that are supported by the use of appropriate community and local mass media. Communities, health promoters and health experts jointly analyse and create collective knowledge about the population's health situation, assess community knowledge about available services and their quality, maintain continuous communication between
  the government and the community, share information and experiences, and finally evaluate progress jointly. The overarching theme of the entire process is that information must be translated into knowledge, and knowledge into a permanent change in behaviour....Mexico recently achieved and surpassed international case detection and case cure targets for TB control."
• "In Peru, the patient-centred mobilization revealed the inherently unequal power relations between health personnel and patients. However, the process of organizing the patients into groups/networks was in itself transformative at many levels. Aside from creating spaces for patients to exchange information and share concerns, the process also helped in resolving their sense of isolation and exclusion. Besides treatment and cure, the process empowered poor and marginalized sections of society to demand their rights. The growing voice and public presence of the TB patients in the wider society helped create citizenship awareness about the complexity of TB, and brought in the commitment of new actors in the fight against TB."

The authors stress that the central strategic challenge in applying good practice to future communication programming is matching the technical methodologies designed to achieve behavioural change with the social processes required to ensure strong political and community ownership. Fundamental principles for action, detailed in the document, stress that knowledge of TB is critical, but not enough in itself to succeed in changing behaviour. A number of barriers that the "vast majority of people affected by TB" encounter are outlined here; they are "exacerbated by and are particular obstacles to those living in poverty" and "need to be addressed in any effective communication strategy." Also, ACSM should be integral and proportionate to National Tuberculosis Programmes (NTPs), be nondiscriminatory and rights-based, and be informed by a country-led approach that is supported by investment in national and subnational capacity (Editor's note: Approaches for capacity-building are described on pages 30-33, and detailed within Annex 1.)

Monitoring and evaluation (M&E) of this framework will occur at several levels; Annex 3 presents a range of indicator sets and M&E processes to be further developed by individual countries.