We have just celebrated another World AIDS Day
Very clearly, there was nothing to celebrate. So many resources spoiled in celebrating the failure to achieve. In twenty years, 25 million people have died of AIDS, and 45 million are currently living or dying- with HIV/AIDS. The majority of the people infected and at risk are from poor segments of society, in poor countries of the world. HIV infection is easy to prevent through communication and education, however huge resources are invested in the curative side of the coin. Because of thousands of new infections added every day, the funds for hospitals and drugs will never be enough to keep the pace of the pandemic. Only prevention can stop the figures from growing. In spite of all the resources invested in HIV/AIDS, diverted from so many other important programmes that also kill millions of people, like malaria, and in spite of huge mediatic campaigns using radio, television and other high-visibility means, the situation is far from getting better.
The main problem is that the communication agenda for HIV/AIDS has been and is still imposed by the donor community in the North. European and North American organizations, as well as multilateral institutions such as the United Nations, are clearly dominated by a framework of communication that is confined to mass media.
Media campaigns usually give lots of visibility to the promoters in order to get more funding, but do not help at all to involve people in the real issues they are supposedly dealing with. The whole idea of the World AIDS Day is to make noise, but often the noise obscures the real issues, rather than putting some light on them(1). Campaigns are vertical and ignorant of local cultures, so they last very little in the minds of people, and they are never structured to promote dialogue or discussion. Their messages are launched in the empty.
The resistance of international organisations -as well as governments influenced by them, and even local NGOs and Civil Society Organisations who bend to receive the funding- to look at communication from a different perspective, results in much noise without real contents. Communication, according to most of these organisations, is limited to dissemination of messages. Most of the campaign-oriented activities are conducted by medical staff or bureaucrats that do not have a clue about communication, and believe communication is equal to mass media. They are unable to even make the distinction between communication and information, or between communication (the human act of communicating) and communications (as fax, telex, roads).
The United Nations organisations dealing with HIV/AIDS issues, usually hire low level campaign officers. The very title of the post is already a straightjacket. Conceptually, they are trapped into doing more of the same, business as usual even if business as usual has already shown that is not working at all. Bureaucrats believe that the problem is that they did not do enough noise, so they will allocate more and more funds to advertising agencies, television and radio networks and journals. They are blind to see the evidence: that approach doesnt work in third world countries. It may have worked in Europe or the US, but it doesnt mean it should also work in our countries.
We need to try new strategies that are not only mass-media based and only oriented towards public relations and institutional visibility. We need to involve communities in the decision-making process. We need to see communication as a process enabling participation, and not just a series of vertical marketing activities that are not sustainable. We need to look at other forms of communication that are closer to those that are the main victims of HIV/AIDS. It is not enough to advocate among decision-makers for more resources and official commitment. It is crucial to involve the society in its entirety, and in particular communities that are most affected by HIV/AIDS or more prone to be victims of the pandemic.
Other means, other ways
Communication is a vast field where mass media is only the visible tip of the iceberg. Below, there are enormous untapped resources. Community radio, for example, has been historically the most important means of communication among rural people in Asia, Africa and Latin America, this region being the one that has a wider experience and the largest number of community radio stations: near six thousand. In the poorest countries of South America, Bolivia, Ecuador, Peru, stations have multiplied by hundreds since the early sixties, and have contributed to community organisation and ownership of the development process. Africa and Asia are following. The recent development in India, favouring community radio, is encouraging. In just a few years from now, India will count the community based radio station by thousands.
Even more encouraging is the current convergence between community radio and new information and communication technologies, namely Internet and the World Wide Web. A couple of years ago, we discussed only a handful of examples of convergence between local radio and ICTs, we would mention the emblematic experience of Kothmale Community Radio in Sri Lanka(2) where rural communities benefited from both the radio and the search for contents that was done with Internet tools to satisfy the questions of the community on various issues. Internet has been also used in Indonesia, to facilitate the networking of local radio stations (private, since there is no legal recognition of community radio stations in that country). Although it doesnt incorporate community radio, the M. S. Swaminathan Foundation Village Knowledge Centres, soon expanding to thousands of villages in Southern India, are an example of the best ICTs can do when applied with a strategy that is born locally, responding to local needs and local culture. The key concept here is the creation of a local focused network as opposed to the world wide web that is not very relevant to the real needs of the local population. Value added knowledge centres capture the demand from the communities and build the web pages that respond to the needs of the population, be it the prices of products on the local markets, the weather for the week, or the cost of transportation to the nearby city. These items are 100% relevant to the users in the community, as opposed to the World Wide Web, which may be 99% irrelevant to women, peasants or fisher folks in the areas of Chennai.
The pioneering examples of convergence mentioned above have now been replicated in numerous countries and have paved the way for rich and varied approaches. ICTs are here to stay, and we better contribute from the beginning into a participatory model, rather than imported models that are ready-made and ready-to-use, but do not take into account the social needs and the particularities of local cultures. ICTs implementation has much to learn from community radio, and not the opposite. Process and participation are key words, not technology and funding.
However, for the major cooperation agencies, both bilateral and multilateral, and for many governments that are so sure they know what is best for developing countries, these different approaches to communication for development are not a good option, at least not for HIV/AIDS. The global agenda for HIV/AIDS is set in iron characters and nobody seems to dare to change anything. Conference after conference, high level meeting after high level meeting, summit after summit, things remain the same and HIV/AIDS continues gaining terrain.
Any views that are against the business-as-usual approach to communication for HIV/AIDS are repressed or ignored. Not only the larger amounts of resources are allocated to the wrong type of communication (or rather information & dissemination), but even the small amounts dedicated to other approaches in communication are looked from above as lacking of effectiveness, without even having the opportunity to be tried. Ive been personally involved in the design of a communication strategy to combat HIV/AIDS in Mozambique, which was in the end sabotaged by the very institutions that initially recognised the need of been creative and doing differently. The UNICEF office in Maputo, and the National Council to Combat HIV/AIDS, were in the end scared by an approach that would give room to participation and communication initiatives that instead of being in the hands of advertising agencies and mass media houses, would be in the hands of people, including those living with HIV/AIDS. Ill refer to this sad experience later in this article.
Evidence of what doesnt work
A courageous report issued by PANOS in 2003 critically examines the successes and failures of 20 years of global response to HIV/AIDS. The report focuses on communication issues, as they are part of the larger analysis on AIDS, and provides formidable information about the lack of understanding on the role of communication in contributing to an integrated approach based on dialogue and participation. The PANOS report is clear:
Building on principles that have been grouped together under the banner of Communication for Social Change, we believe that participation, ownership and accountability should be central to the response to the epidemic. Approaches need to go beyond the expert-led public health campaigns and the generally inadequate processes of participation and consultation that currently typify how HIV/AIDS is being tackled. Too many information, education and communication campaigns designed to change sexual behaviour have been short-term, non-empowering, top-down and lacking in long-term impact (3).
During years the search for institutional visibility has lead to a competition between agencies and donors to show success in countries of Africa, Asia and Latin America. Country showcases that have been publicized as impeccable examples seem to have been exaggerated for political or financial considerations. Self-evaluations and biased self-reporting have lead to the creation of myths that PANOS questions in its report:
Many argue that successes in Uganda (which provides a particular focus of this document) have been exaggerated and even mythologised. None of the other examples are straightforward to interpret either. Senegal had strict social control over sexuality, partly because of its largely Muslim population. In Thailand, sexual behaviour may have recently taken a turn for the worse. In Brazil, although medicines for AIDS are now available, because of stigma and lack of testing, the majority of those living with HIV remain undiagnosed and untreated. In some settings, success may be tied to particular contexts and lessons may not be transferable.
The priority to condom distribution and social marketing vertical approaches has done more harm than good, because it has established a donor model that every country is supposed to follow. The social marketing focus for preventing HIV/AIDS has been found inadequate in various reports. People are treated as objects of change rather than agents of their own change; behaviour change has focused on individual behaviours rather than addressing policies, culture and social norms and has concentrated in disseminating messages from experts or leading personalities instead of placing accurate information into dialogue and debate; the focus on individuals has also attempted to persuade people to do something, rather than negotiate the best way forward in a partnership process. These critical remarks and much more are contained in the report from the 8th Communication for Development Roundtable, held in Managua (Nicaragua) in November 2001, which focused on HIV/AIDS(4).
Similar critical views on communication are shared in reports from other international organisations who play a leading role in combating HIV/AIDS. The UNAIDS framework published in 1999 reached the conclusion that most of the prevalent models of communication and information currently applied to HIV/AIDS programming, did not provide an adequate foundation on which to develop communications (sic) interventions for HIV/AIDS
(5) After reviewing the various models and approaches (such as the Health Belief Model, Theory of Reasoned Action, Social Learning and Cognitive Theories, AIDS Risk Reduction Model, Stages of Change, Hierarchy of Effects, Diffusion of Innovation and Social Marketing), the report points incisively on the weaknesses of the above approaches. Here are is selection of those remarks:
- The simple, linear relationship between individual knowledge and action, which underpinned many earlier interventions, does not take into account the variation among the political, socio-economic and cultural contexts that prevail in the regions.
- The emphasis on quantitative measures (rather than qualitative inferences or a combination of both) results in distorted interpretation of the meanings and realities in observed behaviours.
- External decision-making processes that cater to rigid, narrowly focused and short-term interests tend to overlook the benefits of long-term, internally derived, broad-based solutions.
- The assumption that individuals can or will exercise total control of their behaviour has led to a focus on the individual rather than on the social context within which the individual functions and a disregard for the influence of contextual variables, such as culture and gender relationships.
- There is an assumption that creating awareness through media campaigns will necessarily lead to behaviour change.
- There is an assumption that a simple strategy designed to trigger a once-in-a-lifetime behaviour, such as immunisation, would be adequate for changing and maintaining complex, life-long behaviours, such as consistent condom use.
- There is a nearly exclusive focus on condom promotion to the exclusion of the need to address the importance and centrality of social contexts, including government policy, socio-economic status, culture, gender relations and spirituality.
Another important reference is one of the latest works signed by Everett Rogers and Arvind Singhal, two leading academics and communication experts with deep knowledge of the development world. Their book on communication and AIDS (6) reviews numerous strategies and approaches in the world, and basically concludes that communication strategies have to be designed locally, and be the result of a participatory process, in order to be successful. Communities of people living with AIDS need to be included in the planning and decision-making process to achieve sustainability. Among all the numerous examples portrayed, the authors highlight the successes of strategies that are inclusive, horizontal and community driven.
There is much evidence in the above reports, about what doesnt work and what works. One wonders why things continue to be done in the old fashion way, in spite of the mounting evidence. UNAIDS, the very agency that is supposed to coordinate the efforts of all other UN agencies releases a major document on communication strategies for HIV/AIDS, but nothing seems to follow. For most of the programmes that are vertically directed from Geneva or New York, nothing changes.
It is not enough to know what is wrong in communication for HIV/AIDS, but imperative to change the approaches from the top management layers. The whole decision-making process is in question. No need to do more studies and expensive meetings. There is clarity about the way to go forward, but there is enormous resistance from cooperation agencies to introduce changes in their modus operandi.
Changes needed in management culture
Current communication strategies seem to be copied from one country to the next. Actually, one would think that the same strategy papers and documents are photocopied, and that the only change that is done is in the name of the country. Ive even seen documents by mercenary consultants that forget to change the name of the country in every page of the document!
Im being generous referring to these strategies as communication strategies. Most of them are really information & dissemination strategies. Well, Im still being too generous here, most of them are not even strategies, but a list of activities and products that repeat endlessly: television and radio jingles highlighting a declaration of a top official or a well known entertainer, thousands of T-shirts and posters (usually they never get distributed on time), catchy slogans and billboards with smiling faces. More of the same. Lack of creativity. Inability to look critically at 20 years of mistakes.
How can you have a communication strategy if you dont call in professionals that are capable of developing it? Actually, it occurs to me that these international and national organisations, do not want to have a different strategy. Maybe they are happy doing the same things every year. This could be the explanation, otherwise I cannot understand why they leave the responsibility of the communication strategy in the hands of a doctor, a nurse, or an administrative officer, or in the hands of a journalist, which knows so little about communication for development as of quantum mechanics. Dumping the responsibility of the communication strategy on the shoulders of doctors and nurses is exactly like asking a communication specialist to perform by-pass heart surgery to a patient. Some will argue that it doesnt show the same way. It may seem that the analogy is unfair, however, this is exactly what is happening: if I perform heart surgery, the patient will certainly die, because I am not a specialist. Well, millions of people in the world continue getting infected and dying because non-specialists and improvised communicators are designing the strategies that are aimed to prevent more cases.
There is a key issue here that we should try to stuff deep into the brains of decision-makers: communication for development is a specialised field, it is a discipline in its own, as serious as engineering, economics or medicine can be. They need to learn that it is wrong to pretend that improvised staff can design communication strategies.
We have mentioned the lack of strategies and the lack of specialised staff to design and implement these communication strategies. There is a third element that prevents communication to be an essential tool in the fight against HIV/AIDS: it is not part of the real agenda. Yes we hear a lot about communication and every single cooperation agency will acknowledge that communication is crucial in health education and promotion, and in particular in relation to HIV/AIDS, however
If we take a close look at the budgets, communication is absent or reduced to peanuts. First, no allocations for highly qualified communication specialists. Available posts are of third or fourth level (P2 or P3 in the UN jargon), and, as said before, are often occupied by people that do not have a clue about communication for development. No funds either for research, training, planning and development of communication strategies; they only allocate resources to pay the advertising agencies or the television networks.
The fourth element within these cooperation agencies and development organisations involved in HIV/AIDS is where they place communication in the decision-making process, and I would argue: very low. They place it very low, so low that communication people never participate in the decision-making process on communication. The decisions come from above, and the third-level information officers or campaign officers seem to be around only to do the small tasks.
If somebody on top of a development organisation thinks that community participation and strategic communication are important, he or she might have to start implementing in-house changes:
1. Hire people that are specialised in communication for development, not journalists, not nurses, not doctors. Everybody now agrees that HIV/AIDS is not a medical issue, but a social issue; however, doctors and bureaucrats seem to be still holding on power.
2. Re-define the communication posts with a vision of strategy. End with the campaign officer syndrome, and define the terms of reference with the help of competent communication for development specialists. Elevate the hierarchy of communication posts, so to involve communication specialists in the decision-making process.
3. Allocate funds for the communication process (research, training, evaluation, planning, implementation) and not just for information and dissemination activism that is only good for institutional visibility towards donors.
4. Involve communication strategists from the inception of a new programme or project, not just half-half way or when the programme is already in shambles.
Will managers listen? I am convinced that bureaucrats are very hard to change. They work in the middle of a culture of self-sufficiency and compromises, which ensures their promotion and their pension at the end of their career, without making any waves for social change. Ive seen in the past 15 years dreadful changes in the world of international cooperation. The noble ideals that animated world-class leaders such as James Grant or Federico Mayor Zaragoza, when they were at the top of UNICEF and UNESCO respectively, are now gone. This is a time for accountants and bankers, not for big humanistic ideas.
Even when decision-makers in development agencies have a better understanding of communication as a process of participation and dialogue, they shy away from this approach, they prefer the easy vertical way of doing business as usual. The idea of process and the idea of participation are associated with trouble, to all hierarchical organisations. People having the possibility of making decisions on their own lives, is not something appealing for organisations and donors that have their agendas fixed in advance in New York, Paris or Geneva. This is why they prefer to spend the funds in private advertising companies and mass media campaigns: they get institutional visibility, which is good both for annual reports and their individual promotions, and they avoid getting into long-term dialogue-driven processes. This is where my latest experience with UNICEF comes in.
Mozambique: a case story of fiasco
Ive been a UNICEF staff member for seven years, working in Nigeria and Haiti during the nineties. As a communication for development specialist I had also worked as a consultant in many other countries, and designed national communication strategies on behalf of both bilateral cooperation agencies and UN organisations. Whatever I have learned in my career, it has been exposing my ideas and experience to the various cultures and societies I was fortunate to work and live in.
Which is why I gladly accepted the challenge to develop a communication strategy to combat HIV/AIDS in Mozambique early in 2003. UNAIDS contacted me first, then UNICEF, on behalf of the National AIDS Council of Mozambique. When I was first asked (by email) what were the ideas I had for the communication strategy, I immediately replied: I have no idea, I will have to travel to Mozambique first and talk with people. Ive never been the type of consultant that carries all around the world the same diskette with the model strategy he or she has already sold to several partners. I usually start from the scratch, through a bottom-up approach.
They did accept my initial reaction and once in Maputo, after field visits and dialogue with key partners, I offered UNAIDS and the CNCS(7)to lead and facilitate a participatory process that would involve all local organisations working on HIV/AIDS including NGOs, government ministries, international cooperation agencies, local associations of people living with AIDS, and organisations based in the provinces. Under the leadership of Janet Mondlane the CNCS was enthusiastic about trying this new approach, far from the conventional catalogue of media interventions with little or no impact at all, considering that television, journals and also radio in some degree, have little influence outside of Maputo and a few main cities in the provinces.
The process that I lead included field visits to provinces, meetings with all partners, who were already associated in SAIDAS, a network of organisations working for HIV/AIDS. I was under UNICEF contract, although reporting directly to the CNCS, which was for me the ideal situation. The process went on during most of 2003. My visits were limited to the key decision-making seminars, since I wanted local organisations to take the process in their hands. More than forty organisations participated in the various stages that lead to the design and validation of the communication strategy.
The process had three particularly important moments and events:
A) A first seminar, Communication Strategy Workshop, was organised, where 33 organisations got together to analyse current communication activities, identified the problems and suggested the direction for the future strategy. Juan Diaz Bordenave, a leading communication specialist was invited to contribute from his wide experience in Latin America;
B) Three regional workshops took place, covering the three zones of the country, involving all major organisations of civil society, international programmes and government agencies that were active at the provincial level;
C) A Strategy Validation Workshop gathered again all partner organisations and members of SAIDAS to review the strategy paper that I had drafted, based on the recommendations from the first national seminar and the three regional workshops. The result of the validation seminar was the final communication strategy, which had to be integrated in the National Strategic Plan of the CNCS(8).
For the first time in Mozambique and maybe for the first time all over, a one-year long participatory process had been conducted to design a national communication strategy for HIV/AIDS that was the result of in-country dialogue and not of any top-down donor decision. In spite of internal conflicts and jealousies between UN sister agencies and between the CNCS and the Ministry of Health, the enabling environment was conducive to propose changes.
However, things didnt turn as expected. There was a change of leadership at the CNCS. Janet Mondlane left and Joanna Mangueira, an ambitious politician, took her place. Changes also in UNICEF, as the young Brazilian who headed the communication section left for another country and only a low level local officer remained in charge. But the main problem was the UNICEF Representative, one of Carol Bellamys personal appointees, a French woman by the name of Marie-Pierre Poirier(9), also very ambitious and already looking at her promotion to Brazil(10). She didnt like the result of the participatory process that we had previously agreed upon. Both UNICEF and the CNCS were mainly interested in institutional visibility in the short term, not in a long-term locally-driven process.
In spite of having been validated by key local organisations, and also by the representatives of several UN agencies, the brand new national communication strategy was rejected and the whole process halted. UNICEF presented no technical explanation of any substance. Since then, I have been asking for a panel of international communication experts to be invited to analyse the process I conducted of designing and validating the strategy, but that of course this has not been accepted by UNICEF Mozambique. They wont enter into a technical discussion because they do not have the experience and capacity to do so.
My personal experience shows that whatever we do to increase the local capacity to deal with communication issues, and whatever efforts we do to establish democratic and participatory processes, based on dialogue and respect for the local cultures, we still have to face the power of bureaucrats in donor and cooperation agencies.
Conclusion
There is sufficient evidence and clarity about the need to have new approaches to communication for HIV/AIDS that are based on a communication for social change approach. Communities need to be involved in the decision-making process. New communication tools, such as ICTs, have to be used in symbiosis with community radio and other grass-root experiences. We need development communication specialists at a higher level in cooperation agencies, to effectively contribute to the decision-making process. A redistribution of funds is necessary to balance the fabulous expenses in mass media, with the needs of research, training and support of communication initiatives with a sense of ownership by communities. But, above all, we need to influence decision-makers in the higher places, who know little about communication but continue supporting approaches that have failed during the past 20 years.
End Notes
Read my opinion on international days here: http://www.comminit.com/drum_beat_238.html
2 See case story in my book Making Waves: Participatory Communication for Social Change, The Rockefeller Foundation, 2001. Full text available at: http://www.communicationforsocialchange.org/publications-resources.php?id=103
3 Missing the Message: 20 years of learning from HIV/AIDS, PANOS, London, 2003.
4Communication for Development Roundtable Report, PANOS & UNFPA, New York, 2002. The PDF file can be downloaded at: http://www.panos.org.uk/files/UNFPAONLINEREPORT2.pdf
5 A Communications Framedwork for HIV/AIDS: A New Direction, UNAIDS & Penn State University, 1999. PDF file available at: http://www.unaids.org/html/pub/publications/irc-pub01/jc335-commframew_en_pdf.pdf
6 Combating AIDS: Communication Strategies in Action, by Everett Rogers and Arvind Singhal, New Delhi, 2003.
7 Conselho Nacional de Combate ao SIDA
8 Plano Estrategico Nacional (PEN).
9 Names are important, because new changes in leadership could also mean changes in the direction of communication approaches.
10 She got it, of course.
Note:The author Alfonso Gumucio-Dagron specialises in communication for social change.
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