Public Health Advocacy in Low Income Settings: Views and Experiences on Effective Strategies and Evaluation of Health Advocates in Malawi IFGH Conference: January 2012 Enida Friel MD, MPH, DTM&H, DRH

Background The evidence base in the peer-reviewed literature on effective strategies of PH advocacy is limited; comes mostly from high income settings Only a few frameworks to evaluate PH advocacy available in the peer-reviewed literature, all coming from high income settings

Research Aim Gain an understanding of effective strategies and ways to evaluate public health advocacy in low income settings by exploring the views and experiences of health advocates in Malawi

Research Methodology Semi-structured phone interviews with a purposeful sample of health advocates representing 12 organizations involved in PH advocacy in Malawi. Open-ended questions adapted from an on-line survey conducted with US-based advocacy organizations. Interviews were recorded and responses were analyzed according to emerging themes.

Profile of organizations interviewed

Effective strategies% of respondents Research67% Community organizing/mobilizing 67% Policy advocacy50% Legislative advocacy42% Media advocacy42% Capacity building25% Networking17%

Effective strategies Example 1: importance of research, community mobilizing and policy advocacy ‘Research findings on TB services were presented to communities and local chiefs who then identified local structures where sputum samples could be collected locally for testing…. Gradually this practice became national policy, and as result Malawians in remote rural areas no longer walk distances for TB testing’

Effective strategies Example 2: importance of research, community mobilizing and policy advocacy ‘Communities and health authorities were involved from the beginning on research on CTC (community-based therapeutic care for malnutrition). Findings were presented and reviewed regularly with them and in the end CTC became part of primary health care services in Malawi’

Evaluation practices All the participants had evaluated their work. Evaluations were internal and external with a slight weighting towards internal evaluations. Conducted by professional evaluators and/or staff within the organization. Because advocacy was often part of what they did, advocacy was also often evaluated as part of other programmes.

Benefits of evaluations Improving programme effectiveness (programme analysis, strategies, activities, resources, M&E, sustainability) Capacity building of staff and partners Getting people’s views on the programme and the organization

Evaluation challenges% of respondents Lack of resources/ time67% Difficulties with defining success58% Lack of experience /tools, frameworks / capacity to evaluate advocacy 50% Preference for quantitative methodologies/ indicators 33% Resistance from communities/ partners / staff33% Issues with attributing success25% Low dissemination / implementation of results17%

Interim measures of success% of respondents Improved capacity to advocate33% Increased understanding/ interest on the issue; improved relationship with decision makers/ communities 33% Improved access to services/living, working conditions33% Recognition of the organization; organization growing in resources, capacities, scope 33% Increased media coverage25% Increased allocated resources for the issue8% Increased attendance of events8%

Discussion and recommendations The themes emerging from the Malawi research are similar to the US study even if prioritization differs. Despite the level of income, experiences and views are shared across advocates therefore lessons, tools, frameworks could be shared among different settings. A framework to evaluate PH advocacy in Malawi was developed Research, community mobilizing, policy, legislative, media advocacy, capacity building and networking worth investing upon

Discussion and recommendations Evaluation is important so worth invested upon Frameworks evaluating PH advocacy in Malawi should: 1) assess success at outcome and input, process level 2) use a combination of research qualitative and quantitative methods 3) seek to demonstrate contribution rather than be concerned with proving attribution 4) assist with improving programme implementation and understanding of factors influencing it 5) in the absence of achievement of long-term goals use interim measures of success