Cross Borders - Discussion Starter

 Dear Atif and all,

Atif – thanks for your email and questions, which are helpful in pushing us towards more focused discussion. I wanted if I may (and pending fuller responses from Chris, Sahara and Warren or others) to come back on a few of the questions and to suggest a framing we might use in thinking about mobile populations in the Afghan/Pakistan bloc.

On questions:

1. I suppose there are distinct/focused plans for different groups of HRMPs, i.e., traveling for festivals and all that?

Yes. There is a large stock of analysis of HRMP by typology, seasonality, rationale for movement and route(s). The problem, I think, is that this analysis is not well converted into practical vaccine delivery strategies, either within or between SIAs. Microplans, as you will know, are the basic tool of local-area SIA planning and delivery monitoring. In spite of multiple quality assessments and process reviews, microplans tend still in many instances to be cut and pasted from one campaign to the next, such that even settled communities are missed over time, and mobile groups moving into an area are poorly enumerated and thus poorly reached.

2. If origin/destinations are mapped, then shouldn’t the HRMPs be covered during SIAs in areas with high concentration together with manning borders and major transit points?

They should. But the evidence – from intra- and post-campaign monitoring, and from environmental sampling and the profile of cases, as well as analysis of lineages and geographical transmission of virus – suggests strongly that HRMP children and households are missed and remain a high-risk susceptible group for maintaining circulation of polio. Border crossing and transit point vaccination are OK – but we know only absolute rates of vaccination, since we do not have a denominator against which to assess proportion covered. Thus, reliance on vaccination at interdiction points gives some but not complete confidence that all eligible children are covered (also because, as in framework below, there are likely HRMP moving across border outside of formal crossing and transit points).

3. Do we know what sources of communication HRMPs have, or they engage with, I have seen localized content broadcasted/placed from national/regional outlets? Have we done the 360-degree communication analysis of this group?

My understanding is that there is analysis of this, but that beyond analysis there is rather limited activity in engaging in and through such localised media sources.

 
4. With the border fence being erected, do we already see any impact of that?

Good question. It’s not clear. Partly because the program does not have, so far as I am aware, a clear sense of the scale of cross-border movement through what are by definition informal and unauthorized routes. I think it likely that the fence will have an impact on non-formal crossing over time, but that this may not yet have emerged.

 
5. With just one case found in Pakistan, does it mean the strategy they are implementing now is working, or COVID also played the role?  

Whilst the picture right now is much better than it was last year, we are coming out of low transmission season and so the numbers would be expected to be muted. Environmental sampling gives a slightly better picture of underlying virus. Equally, there is a tendency in the programme to interpret (or over-interpret) short-run improvement in circulating virus as evidence of positive impact (with the unfortunate effect of programmatic foot being taken off pedal prematurely and virus re-escalating). My feeling is that we need to see sustained downward trend in transmission before such claims can be made.
 

Re communications-specific tasks or objectives vis a vis HRMP – I think this can be fairly simply stated: that evidence suggests that HRMP families and communities are not being reached or engaged by the programme as effectively as other settled populations – this may relate to the fact of their mobility or the nature of their movement (e.g. not wanting to be enumerated). The programme is thus under-achieving in two respects – effectively communicating the availability, importance, necessity and safety of polio vaccination, and effectively engaging with communities to develop modes of vaccine delivery with which they are more likely to comply.

Re framework for HRMP. I’ve been thinking about some different dynamics in population movement which may help in structuring discussion (or may not so feel free to disregard!)
 

We can look at HRMP in four geographical manifestations, essentially moving outwards in waves from the physical border itself.

Cross-border communities – communities which effective sit on or straddle the physical border, and move fluidly for day-to-day purposes (or longer-term family or work matters) from one side to the other. They tend not to recognise the border as such, and exist in a kind of marginal state, to a degree disavowed by both countries. These communities may well include households engaged in illicit activity, as well as having interaction with groups hostile to government. By virtue of their geography, they tend to be relatively poorly mapped, enumerated and incorporated in programme planning. They can be missed or assumed to be the responsibility of the other country programme, thus falling between the two. Community leaders and those who exercise the strongest influence may reside on the other side of the border, creating challenges for genuinely integrate Afghan-Pakistan communication strategy.

Formal HRMP – families with eligible children moving along major routes, including formal crossing point (Torkham, Friendship etc) and within each country along well-documented transit routes (and thus generally quite available for pick up at formal crossings and transit points). These may be the least problematic group, although (as above) there is a degree of uncertainty about whether the programmes are maximising coverage of eligible at crossing points or whether better comms and vaccine delivery infrastructure could be developed.

HRMP at destination sites – most effort in the programmes goes to catching children in transit. The programme is somewhat less effective in accessing all transient additional children where they arrive from transit to settle for a period. These may be classed as ‘guest children’ insofar as frequently HRMP at destination will stay within a known household. Microplans are supposed to enumerate additional incoming HRMP and vaccinators are tasked to include ‘guest children’ in their microplans. However, evidence continues to show guest children being missed at a relatively high rate. Equally, HRMP staying in marginal areas of e.g. Rawalpindi have been consistently missed as microplans are less attentive in mapping some temporary, unofficial and slum-type settlements.

HRMP as the effect of sudden displacement – over the last few years, as a result of insecurity and active fighting on both sides of the border, we have seen quite large rapid cross-border movement of families and households, either dispersing into extended family or into more formal IDP/refugee camps. The programmes have developed quite good intelligence on prospective movements, and some engagement with other international and domestic agencies responsible for refugee/IDP care in order to extend vaccination to these groups. However, it is not clear that this area of coverage is as effective or systematic as it could and should be.

 
For discussion as we develop a sense of where we feel the key issues in HRMP lie. Overall, I think the programmes have an awful lot of information and analysis around HRMP. The problem is not knowledge. It is putting knowledge into effective practice in these critical areas. This, I think, is what I meant by suggesting that we may want to focus on implementation science as a methodological framing for our collective thinking.

 
Best
Seb

Hi Chris, 

Thank you for sharing the updated note. 

Sorry for my ignorance, I still don't fully understand where exactly and precisely communication needs and challenges are identified in the document and where are the communication objectives stated to overcome those needs and challenges. This is how at least my mind starts operating. Of course, communication needs to be integrated throughout the programme strategy and must not be a stand-alone element, but I'm sure you will agree that PEI is not only a communication project, like any other vaccination effort. Just so I understand your perspective, let's say if the vaccination centres at major entry/exit points or transit routes aren't staffed, don't have vaccination to offer, etc. are you considering this as a communication challenge? Or the document is what we must work with, communication objectives or not?  

 Just a few more questions for my further clarity; or I can refer to NEAP for more information.

1. I suppose there are distinct/focused plans for different groups of HRMPs, i.e., traveling for festivals and all that?

2. If origin/destinations are mapped, then shouldn't the HRMPs be covered during SIAs in areas with high concentration together with manning borders and major transit points? 

3. Do we know what sources of communication HRMPs have, or they engage with, I have seen localized content broadcasted/placed from national/regional outlets? Have we done the 360-degree communication analysis of this group? 

4. With the border fence being erected, do we already see any impact of that?

5. With just one case found in Pakistan, does it mean the strategy they are implementing now is working, or COVID also played the role?  

Thanks, Atif

Dear All,

Allow me to join the conversion at the last moment and to add my 2 cents.

I agree with Sebastian’s point about the gap in knowledge translation in the field.   There might be attempts and even successful such instances and it will be necessary to learn not only the outcomes but also the process of knowledge translation in this context and within a program with long history in this region. 

An important question is about the implementation challenges experienced when strategies are applied and how these challenges then become translated into knowledge to feed into and  refine subsequent strategies.  The goal would be to achieve more contextualized approaches and I am not sure if knowledge flow over the years has allowed this to happen organically.

It is obvious that community engagement and participatory approaches were not fully applied in these programs. The aim of these approaches can be more than the identification of community assets and the mobilization of influencers but rather on investing in co-designing/co-creation of strategies within these communities.  This needs long-term investments and horizontal programing.  If there are any such experiences it will be important to learn from them for future discussion.

Another important question is how much polio related communication activities are integrated in non-polio related services and whether there are untapped opportunities to consider such strategies. The vertical ways in which programs are established and funded often don’t allow for such flexibility.  This compartmentalization is also clear in the governance of programs and it comes in contrast with people’s experiences with health, wellbeing, and eventually health care at different levels.

I am happy to continue this discussion as we develop our ideas further through this process.

Best,

Tamar