Advocacy has almost become a bad word today because of its association with corporate lobbying and irresponsible blocking.
In public health, positive advocacy is at its best a virtuous thing that helps remove barriers to accessing health, spurs implementation of solutions and strengthens policy. Positive advocacy conveys clear messages, using data, to specific audiences using well-conceived methods.
Neglecting any of these elements makes the advocacy less effective. Message-audience-method-data, therefore, is the mantra.
The message is the very first consideration. Ideally, there should be only one message and it must be crisply articulated. A message is always more effective when it is backed by data to substantiate it. The message must be tailored in terms of its tone or level of detail to the target audience.
There are many methods by which the message can be delivered to the target audience and these include media, influential people, scientific journals and community voice, which is often the most effective way. Enough theory! Let’s look at five public health advocacy examples—the first two from my personal experience—through this lens.
In Avahan, the Gates Foundation’s India HIV-prevention programme, violence from the police themselves was identified as a major problem for female sex workers and was strongly linked to low condom use. The message to the police, the primary audience, was clear: the violence must end.
Sex workers approached the police directly as a community group. They were equipped with hard data about incidence of violence. A report was sent every month, and media— another method—got involved. Concerted efforts and the rich evidence led to a collaborative action by police and sex workers. Incidents of violence came down rapidly.
Rajasthan’s RajSangam programme enables front-line health workers in each village to share data and work as a team using tools such as the village maps they create. The message that this collaboration improves maternal and child health outcomes had to be relayed to the state government before the solution was scaled. Direct feedback from front-line workers, their supervisors and the community reinforced how the solution increases front-line effectiveness and improves service delivery. Even now, after statewide scale-up, extensive monitoring data is being collected to show that the neediest populations such as high-risk pregnant women, malnourished children and newborn babies are indeed being impacted.
A private corporate social responsibility (CSR) report in 2017 estimated the proportion of CSR spending by 300 large firms (accounting for two-thirds of national CSR spending) on health at 17%, compared to 32% for education. The message is that the figure is disproportionately low given India’s abject health outcomes, and the audience, those who decide CSR spending. The voice of leaders of respected NGOs and intermediate channels such as media can highlight the issue to funders. Substantial data on funding requirement and consequent impact on health and economic progress of the country is essential.
The government’s ‘Malnutrition, Quit India’ campaign, launched in 2012, used celebrity Aamir Khan in radio, print and television (methods) to urge people to take adequate action to tackle malnutrition.
But who was the audience? Awareness is most needed for rural communities in remote villages. These citizens don’t exactly settle down each day with the morning newspaper to read what Aamir has to say about leafy vegetables. Quite likely, they haven’t even heard of the star.
What a waste of powerful voice. This type of diffused advocacy generates sympathy among the general population, but rarely translates into action.
Tobacco control is another example of misdirected advocacy. The hyperactive government campaign prints “smoking kills" on the screen even as the hero begins to contemplate lighting a cigarette. Everyone knows that by now—why state the obvious? Has no one told the ministry that it has been established that “fear messaging" never works? Who is the audience?
In any case what works for urban cigarette smokers might be irrelevant for beedi smokers in villages. There is a greater case for advocacy aimed at higher taxes, laws and regulations that deter smoking as a habit.
Advocacy should be thought of as a mantra, with the core elements of message, audience, method and data. Supported by strong data, together they lead to positive advocacy in the best sense of the word. The crux of it all is, whether it triggers action. Awareness creation is not enough.
Ashok Alexander is founder-director of Antara Foundation. His Twitter handle is @alexander_ashok.