Madagascar Polio Program Evaluation Trip Report

"Overall, more efforts will be required to fully realize the recommendations and their potential impact on ending the current [polio] outbreak and preventing future ones. Improvements in the quality and reach of training and supervision are cross-cutting needs that must be addressed....Formative research would be a valuable investment toward improving the effectiveness of communications and social mobilization, informing efforts to identify and overcome both active and passive resistance, and supporting future establishment of robust community-based active surveillance."

From October 8 to October 22 2015, independent consultant Ellen A. Coates participated in the second external evaluation of the Madagascar response to polio outbreaks and ongoing poliovirus circulation. As the emerging report indicates, Coates focused in particular on the communications aspects of the response - both in central-level meetings with the Ministry of Health (MOH), the United Nations Children's Fund (UNICEF), and the World Health Organization (WHO) in Antananarivo, and in a range of evaluation activities conducted in the Morondavo, Mahabo, and Belo-Tsirhibina districts of Menabe.

Coates was tasked, first, with assessing progress made to date vis-à-vis previous evaluation recommendations, including those of both the previous external evaluation team and T. Daniel Baker of the United States Agency for International Development (USAID). For instance, Coates found that progress is being made in the area of strengthening of surveillance programming, yet, "[g]iven weaknesses in the cascade trainings conducted so far, greater attention to the quality of the technical training as well as the training-of-trainer components will be needed. Relative to interpersonal communications components of the training, ensure that significant opportunities for role playing and feedback, as well as quality control measures such as pre-test/post-test surveys are included." To cite another of Coates' findings: "the international partners are creating a more coordinated and effective partnership and are actively exploring ways of strengthening the partnership with the MOH, capitalizing on what may be new openings for partnership at the central level."

"Given the cross-cutting weaknesses in training and supervision, the capacity challenges at the field level, and growing but still limited ownership of the polio response at the central level," Coates proposes one next step: a study tour of some kind, perhaps to India (which achieved zero polio status in March 2014), for selected MOH staff, possibly with the national Expanded Programme on Immunisation (EPI) officer posted to WHO and other selected staff from the international agencies.

Coates assesses the current status of social mobilisation and communications activities mounted in support of the polio eradication effort in Madagascar and makes recommendations. (A more complete set of the formal and informal advocacy, communications, and social mobilisation recommendations made over the past months can be found in the table in Appendix C of the document, which maps out past communication for development (C4D) recommendations, status, and recommended next steps.) Coates lists several strengths, such as a good national-level advocacy plan and regional-level training of journalists that has fostered the development of broadcast programmes to raise awareness of polio and the vaccination campaigns at the local level. Engagement of the Radio et Television Nationale has resulted in a wide diffusion of the spots at the national and sub-national levels. She also outlines areas for improvement. For instance, in many districts, posters and campaign banners appear only in the immediate vicinity of the district health office and the CSBs (Centres de Santé de Base). "The poster messages are either too numerous, too wordy, or not clearly related to polio vaccination. For example, in Menabe feedback from caregivers in the marketplaces as well as some CSB chiefs indicated that a poster with a photo of a schoolboy flexing his arm is being interpreted to mean that polio vaccine makes children strong."

For this reason, recommendations include conducting formative research to include social data and field-testing of all communications materials before final copies are printed. Along these lines, Coates suggests that the training and training of trainers on social mobilisation (and supervision) should includes quality control measures to assess the levels of learning and understanding achieved among training participants. She also recommends strengthening engagement of local influencers including the Chefs de Fokontany, Rotary members, and Red Cross and other non-governmental organisation (NGO) partners that can support access to very remote, hard-to-reach populations. A Crisis Advocacy and Communications Plan at the national level could be developed to address refusals and future calls for boycott, including facilitating journalists' and reporters' engagement of families affected by polio who are willing to serve as "the face of the epidemic".

Click here for the 18-page trip report in Word format.