1. COMMUNITIES COMMUNICATING ON TB.
Executive summary, Global Fund’s ‘Advocacy: mobilization of political will’ project (advocacy component of
Round 9 “Stop TB in Ukraine” Program)
Background
In over 50 years of communications and media development work globally the Thomson
Foundation has encountered a wide range of advocacy, communications and social mobility
(ACSM) strategies. In general there is a perceptible trajectory to these communications approaches;
in short the social mobility aspect of ACSM tends to dominate the wider strategic thinking on how
communications support across a range of thematic area delivered. This approach, in essence,
seeks to reach the widest possible audience of stakeholders to encourage behavioral change or
participatory engagement. This tendency is particularly acute in communications support projects
that focus in on public health. This ‘mass’ approach, whilst in many cases laudable, has severe
limitations in terms of actively delivering targeted results. As such a wider definition of ACSM
work, one that includes bespoke communications efforts towards often over looked stakeholder
groups, can be the most effective methodology, moving away from mass communication models
using conventional media approaches towards encouraging advocacy and communications skills
at a smaller, targeted level.
In order to deliver such an approach within the context of Ukrainian public health it was
incumbent on the consortium built to deliver the ACSM framework of the Global Fund’s
‘Advocacy: mobilization of political will’ project (advocacy component of Round 9 “Stop TB in
Ukraine” Program) that we took on board the multiplicity of regional public health delivery
mechanisms and the subsequent problems within each locale.
Fundamentally, therefore, the necessity of having to design local project for local problems, taking
a micro rather than a macro approach, formed the baseline of all we achieved. As a jumping off
point, in all instances, we selected project partners on the simple, non prejudicial, rationale that
whichever civil society actor was best placed to achieve results – regardless of size or
communications experience – we engaged with them.
Ukrainian needs analysis.
A core set of principals, based on empirical analysis of previous public health communications
projects and the wider public perception of public health delivery mechanisms in Ukraine
underpinned the regional analysis work we undertook over a six month period across the life of
the project in 17 oblasts. This analysis work and assessment of project effectiveness and the
viability of project partnerships was an ongoing process within the project, not a one off at the
beginning. In this way a consistent monitoring and evaluation process was undertaken, enabling
us to adapt approaches and partners to maximize delivery. These key principles that underpinned
this consistent assessment were:
- No ‘uniform’ approach would ever work in the country so diverse regionally, and so
disorganized ‘vertically’

2. - The issue of TB is stigmatised as such at national level, with great reluctance even on behalf
of health officials to talk about it
- Issue awareness with the general public is extremely low, with
stereotypes/gossip/misinterpretation dominating public opinion
- ‘Talking’ about public health is a fairly novel idea in Ukraine, as previously it was a purely
‘technical’ issue, belonging to the realm of ‘experts’, i.e. medics.
- There is no tradition of building across the board stakeholders partnerships, crucially
important for tackling public health related issues
- ‘Third sector’ has a distinct ‘image’ problem, as key players (‘usual suspects’) are seen as
grant chasing cynics who rarely care about the issue they’re involved in, and are likely to
take substantial effort to discredit innovative, thoughtful and result driven efforts by ‘non-
usual suspects’
Using these guiding principles the consortia worked through a target identification process to
find those CSO’s best placed to address specific deficiencies in TB care within Ukraine. The
framework covered:
- Initial monitoring visits by project’s experts with preliminary ‘needs assessment’. These
experts brought together a range of skills to enable a fulsome assessment of possible project
partners, with bespoke knowledge of both media, local government, CSO’s and wider
public health services. Their field visits were aimed at identifying potential stakeholders,
which need to be involved in the discussion on region’s key TB related challenges and the
ways of solving them
- On site working round tables, involving the range of local stake holders, aimed at devising
a ‘map of issues’, related to TB control in a specific region. These round tables were not
simple a means of discussion or a learning platform for the consortium, but rather had to
deliver concrete, prioritized set of key issues in any one region, problems that we then
went onto to address through an open call for solutions.
- Hold a ‘tender’ through call for proposals for interested parties, based on the simple
principle that local implementing partners are best placed to deliver solutions to TB control
locally. The widest possible set of community actors, including those not necessarily
directly involved in public health provision such as church groups, prison authorities or
law enforcement agencies, were encouraged to engage in the tender process, helping to
circumvent the widespread lack of developed, TB specific NGO’s.
- A tender committee made up of the funder, independent experts on public health and TB
control alongside those within the project management who had conducted the initial
regional analysis, assessed each proposal, rated them and then provided feedback to those
selected implementing partners on how best to modify their aims and methodologies to
maximize results.

3. Results
The deep localization of the project methodology overall meant that continued assessment of
selected implementers was essential. In many cases the ACSM projects were covering totally new
ground, involving participation from groups with little or no experience of advocacy and, in many
cases, confronting engrained resistance by established authorities with responsibility for dealing
with TB control. The building up of confidence, maintenance of project relationships and
consistent involvement of the project team, from analysis through to delivery, was an essential
aspect of the project. As mentioned, moving beyond conventional, macro ‘social mobilization’
approaches meant long term design and monitoring engagement in a vast range of regions dealing
with a disparate range of structural and social problems effecting TB control mechanisms. For
example working with a church group in prisons in several regions meant continual guidance.
As a result of the advocacy efforts a number of stakeholders, previously unaware of the relevance
of TB control issues were not only addressed, but eventually involved in working alongside public
health workers on the sustainable basis. Namely, representatives of social services, sanitary-
epidemiological services, penitentiary services, religious authorities, education workers, small
businesses, regional business monoliths, regional media etc. were engaged during the project.
Some key highlights include:
Priests in prison.
Established means of advocacy engagement in health issues in Ukrainian prisons have proved of
limited use when dealing with TB control. The question was simply, who is best placed to engage
within the prison population in certain oblasts? And to whom should they be talking to about TB
control? The answer was unconventional. Having looked the issue of TB in prisons as a key
problem to be addressed in Dnipropetrovsk oblast, a solution came from the Ukrainian Othordox
church. Priests came forward to suggest that they may be able to interact with trust and legitimacy
to prisoners who carry authority and influence, getting them to be the leaders in TB control in their
prisons, encouraging prevention, maintaining treatment regimes and developing consistent
sanitary practices. With project help individual priests were given tool kits and training on
effective methods of communicating and interacting with this critical target group, and these
practices were distributed across several oblasts.
Dentists and diaspora.
One critical problem with TB control in Western Ukraine in particular is the often migratory nature
of regional employment patters. How to reach these groups of workers, often returning from
Western Europe only occasionally, how to screen them for TB and how to help enforce treatment
regimes? The answer came from, once more, an unusual source, one not previously used to ACSM
work in TB prevention – dentists. With many returning migrants accessing cheaper dental work in
Ukraine, indeed seeing dentists as their only and principal engagement with any health sector
professional, dentists soon emerged as a critical, primary access point for ACSM activities on TB
control.
Doctors and regional hospitals.

4. The TB issue is still not a high priority for the primary health care system in Ukraine, with the
perception remaining that marginal groups are still the only ones principally affected. As such it
rapidly became apparent that this first line of defense within TB control is often inefficient and
underactive, leaning on regional hospitals to deliver TB control. More than this these two sections
of the healthcare system rarely talk to each other on TB issues. Our job? Bring them together,
advocate best practice to the primary health care practitioners and demonstrate the needs and
management requirements expected of them by the regional health care authorities in a non
confrontational, mediated way.
Social workers dealing with at risk groups.
The new crop of recently hired social workers across the country represented a unique opportunity
to refocus a wider advocacy agenda on TB control. We took this opportunity with both hands
across the country, with social working authorities coming forward to access ACSM models on TB
tailored by the consortium for their regional needs. This engendered a degree of persuasive
leverage, with one regional social worker authority asking to replicate TB ACSM best practice they
had heard of us delivering it elsewhere in the country.
Recommendations.
The role of ACSM
In many ways ACSM activity remains amorphous, little explained and when applied at all in
public health in Ukraine it is done only as an after thought, reacting to events rather than being
instrumental in managing them. As such detailing the practical aspects of advocacy,
communication and its attendant social mobilization progress, in all its applications, needs to
emphasized from the very beginning in any TB control project.
Go regional
The general approach to any TB ACSM project must be bespoke, tailored for individual regional
issues which are in no way uniform in Ukraine. As such opening up cooperation and interactivity
with as diverse a range of actors is crucial. In the end those best placed to deliver solutions to TB
control, who know who to talk to and how to talk to them to bring about change are often not the
usual suspects – those tasked with the formal, structural authority to handle these issues have
proved inadequate so far. Going beyond the formal state mechanisms, within a regionalized
framework, simply allows for those who can work well as advocates, but yet have not previously
thought of themselves as having this role, to take up the challenge. The key to taking this approach
has to be nurturing and maintaining these new relationships consistently throughout the life of the
project.
Assessment before authority.
Continually assessing individual participants ACSM effectiveness at a regional level provides the
leverage and legitimacy to then go to regional authorities with recommendations, alongside giving
these authorities solutions, not simply a list of criticism they are then expected to correct.