© 2022 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of the Ministry of National Health Services Regulations and Coordination, Pakistan and the World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Nothing herein shall constitute or be construed or considered to be a limitation upon or waiver of the privileges and immunities of The World Bank, all of which are specifically reserved. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover photo: © Ipopba / Freepik.com. Used with the permission of Ipopba / Freepik.com. Further permission required for reuse. Cover design: Shehryar Khan & Aqib Khilji / Blimp Digital Marketing & PR. Contents Acknowledgements���������������������������������������������������������������������������������������������������������������������������������������������������������� 2 List of Abbreviations������������������������������������������������������������������������������������������������������������������������������������������������������ 3 Executive Summary��������������������������������������������������������������������������������������������������������������������������������������������������������� 4 Section 1: Overview������������������������������������������������������������������������������������������������������������������������������������������ 7 1.1 Context and Need����������������������������������������������������������������������������������������������������������������������������������������������������� 7 1.2 Process of Development������������������������������������������������������������������������������������������������������������������������������������������ 9 1.3 Scope and Objective�������������������������������������������������������������������������������������������������������������������������������������������������� 9 Section 2: Situation Analysis������������������������������������������������������������������������������������������������������������������� 11 2.1 Stakeholders’ Roles and Coordination����������������������������������������������������������������������������������������������������������������� 12 2.2 Message Development�������������������������������������������������������������������������������������������������������������������������������������������� 15 2.3 Dissemination Channels����������������������������������������������������������������������������������������������������������������������������������������� 16 2.4 Dynamic Listening and Rumor Management����������������������������������������������������������������������������������������������������� 18 2.5 Monitoring and Evaluation������������������������������������������������������������������������������������������������������������������������������������ 19 Section 3A: Framework for Preparedness and Institutionalization�������������������������� 20 3A.1 Objective���������������������������������������������������������������������������������������������������������������������������������������������������������������� 20 3A.2 Guiding Principles������������������������������������������������������������������������������������������������������������������������������������������������ 20 3A.3 Step-by-Step Breakdown of Institutionalization Process������������������������������������������������������������������������������ 20 Section 3B: Framework for Activating Campaigns during Emergencies����������� 22 3B.1 Objective���������������������������������������������������������������������������������������������������������������������������������������������������������������� 22 3B.2 Guiding Principles������������������������������������������������������������������������������������������������������������������������������������������������ 22 3B.3 Step-by-Step Breakdown of Response�������������������������������������������������������������������������������������������������������������� 22 Section 4: Way Forward������������������������������������������������������������������������������������������������������������������������������ 24 Annex: List of Stakeholders Consulted���������������������������������������������������������������������������������������������������������������������� 25 Bibliography�������������������������������������������������������������������������������������������������������������������������������������������������������������������� 26 Acknowledgements This document has been prepared by the Ministry of National Health Services, Regulation and Coordination (Ministry of NHSRC), Government of Pakistan in collaboration with the World Bank. The lead author of this framework is Mr. Taha Tariq, who spearheaded the Federal COVID-19 Risk Communication and Community Engagement (RCCE) Task Force and served as the Ministry of NHSRC’s liaison with the National Command and Operation Center (NCOC) on communication. Dr. Sabeen Afzal, Deputy Director Programs/Health Systems at the Ministry of NHSRC, provided technical guidance and led coordination among stakeholders involved. Dr. Ali Saeed Mirza and Dr. Sutayut Osornprasop, Health Specialist and Senior Health Specialist of the World Bank respectively, provided valuable technical guidance and inputs to the report. Financial support for this work was provided by the World Bank – Vital Strategies Strengthening Public Health Capacities Trust Fund. The development of this holistic framework, the first of its kind, could not have been possible without the gradual progress made towards establishing best practices and protocols for risk communication over the years – especially during the COVID-19 pandemic. The multidisciplinary group of experts within the Ministry of NHSRC, provincial health departments and health development organizations who were involved in drafting risk communication guidelines, developing content and coordinating dissemination all contributed by setting up precedents which served as the foundation for this framework. Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 2 List of Abbreviations AI Artificial Intelligence CSOs Community Service Organizations DHOs District Health Offices DMW Digital Media Wing EPI Expanded Program on Immunization GHSA Global Health Security Agenda ICRC International Committee of the Red Cross INGOs International Nongovernmental Organizations JEE Joint External Evaluation KAP Knowledge Attitude and Perception KMS Knowledge Management System Ministry of NHSRC Ministry of National Health Services, Regulations and Coordination ML Machine Learning MoIB Ministry of Information and Broadcasting NCOC National Command and Operation Center NDMA National Disaster Management Authority NEOC National Emergency Operations Center NGOs Nongovernmental Organizations NHEPRN National Health Emergency Preparedness and Response Network NIH National Institute of Health PDMAs Provincial Disaster Management Authorities PEMRA Pakistan Electronic Media Regulatory Authority PTA Pakistan Telecom Authority RCCE Risk Communication and Community Engagement TORs Terms of Reference UNDP United Nations Development Program UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organization Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 3 Executive Summary Pakistan remains susceptible to emergencies caused by since the JEE’s report in 2016 (especially considering a variety of natural hazards. There are two fundamental the unprecedented focus on risk communication reasons for Pakistan’s high vulnerability. efforts during the COVID-19 pandemic), it is crucial to address the gaps identified to ensure Pakistan is The first reason is increasingly high exposure due to prepared for the next public health emergency. rapid changes in the region such as unprecedented population growth, urbanization, deforestation, This document provides the way forward for addressing climate change, and rising human–animal proximity those gaps. It was developed after consulting all the among others. Biological hazards, which take the form relevant stakeholders within the Government and of outbreaks of communicable diseases that may development sector. Provincial departments of health evolve into epidemics or pandemics, continue to affect were not directly consulted during this process and various parts of Pakistan. At the same time, in the past therefore, it is crucial to note that this framework is decade alone, Pakistan suffered from 16 documented only a federal-level document. geophysical and hydro-meteorological disasters including droughts, floods, landslides, earthquakes, and The document has two main components. The first an unprecedented locust infestation. main component of the document is an in-depth situation analysis of the existing risk communication The other reason for Pakistan’s high vulnerability, mechanism. The second is a framework for i) ensuring which is also critical to this particular endeavor, is preparedness through institutionalization, and ii) its insufficient capacity for emergency response. The activating campaigns during emergencies. most recent, comprehensive, and reliable assessment of Pakistan’s capacity was completed in 2016 based The situation analysis is based on the findings of on the Joint External Evaluation (JEE) of IHR Core the aforementioned JEE as well as subsequent Capacities of Pakistan. IHR refers to the International developments during the COVID-19 pandemic, which Health Regulations, which serve as a significant prompted decision-makers to see risk communication international legal treaty that empowers the World as an undeniable necessity. It provides insights into Health Organization (WHO) to act as the main global the day-to-day workings of the existing informal surveillance system to contain and respond to the risk communication infrastructure, focusing on the international spread of diseases. The JEE tool was strengths and weaknesses of five major aspects: developed for the evaluation of national capacities by integrating the core capacities initially identified by 1. Stakeholders’ Roles and Coordination IHR and the areas of assessment highlighted by the 2. Message Development Global Health Security Agenda (GHSA). Pakistan volunteered for a JEE as the first country in the WHO 3. Dissemination Channels Eastern Mediterranean Region, and the fourth globally. The JEE rated Pakistan’s core capacities across 19 4. Dynamic Listening and Rumor Management broad technical areas (and a total of 48 technical subcategories). On a scale of 1 (no capacity) to 5 5. Monitoring and Evaluation (sustainable capacity), the five subareas of Pakistan’s Risk Communication capacity scored an average of Key findings from the situation analysis are as follows: 2. In fact, none of the subareas scored beyond 3 and the foundational tenet— “risk communication systems • Stakeholders’ roles and coordination saw some (plans, mechanism)”—scored 1, that is, no capacity. improvements over the course of COVID-19 risk communication campaigns but not enough to Without disregarding the fact that the status of ensure consistency and institutionalization. There Pakistan’s capacity for risk communication has evolved is a lack of clear ownership within the Government Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 4 at the federal level due to the absence of a dedicated sensitive, life-saving messages to the public health education section at the Ministry of National not just once but repeatedly. Pakistan Telecom Health Services, Regulations and Coordination as Authority (PTA) has the authority to roll out a well as the presence of multiple other bodies (such standard ring back tone (RBT) on all calls made. as the National Disaster Management Authority) with mandates that either overlap or do not cover o The use of social media can play a risk communication. Health development partners significant role in creating awareness and shaping also face similar issues in coordination and often the opinions of people in Pakistan, especially end up duplicating efforts. The establishment those in urban areas. There are two broad ways of the Risk Communication and Community of paid promotion on social media: direct Engagement (RCCE) Task Force for COVID-19 advertisement, and influencer marketing. Over did make progress in developing protocols for the course of the COVID-19 pandemic, the coordination and can be used as a starting point Ministry of NHSRC established strong ties with for further institutionalization. big tech companies which provide advertisement credits free of cost as part of their CSR programs. • Message development remains an ad hoc exercise that begins after a disaster has occurred or as o On-field engagement is most effective a reaction to negatively charged reporting in to target communities with little to no access to the media. Messages should be disseminated social and mass media, either due to a dearth of regardless of whether the threat has escalated to resources or low literacy. Unfortunately, community a full-scale emergency or not – as many disasters activities remain susceptible to duplication more or emergencies in Pakistan are recurring and than most other types of activities because CSOs cyclical. Another issue is the lack of consistency often operate in silos and have little incentive to in the language and terminology used in message collaborate or divide up coverage of areas amongst development, suggesting a dire need for training each other. in Social and Behavior Change Communication (SBCC) in regional languages and contexts. • Dynamic Listening and Rumor Management through machine learning and artificial • Dissemination channels can be categorized intelligence-based tools was piloted by the Ministry into mass media, ring back tone, and social of NHSRC as part of the risk communication media – each of which has its strengths and activities during COVID-19. Keywords pertaining weaknesses in terms of the ease of utilizing to the pandemic and the Government’s latest them and their impact on the target audience. interventions were fed to the tools and data aggregated on a weekly basis was broken down o Mass media has the highest outreach by location. Subsequently, messaging to counter of all the possible channels of dissemination but rumors and address concerns can be deployed. proved to be challenging due to both monetary and nonmonetary reasons. The bottlenecks have o A dedicated telephone helpline has been identified and can be resolved with some an extremely wide reach in terms of the target interventions. Private corporations can also population as it is a simple means of collecting play a very positive role through their corporate information that requires neither literacy skills social responsibility (CSR) programs. During nor access to the internet. The Sehat Tahafuzz the COVID-19 pandemic, several corporations Helpline functioned as the most accessible form supported the Government by paying for the of two-way communication for the public during production and broadcasting of advertisements the COVID-19 pandemic. A messaging App based on the Ministry of NHSRC’s guidelines. chatbot is another effective platform for two-way communication, considering 106 million 3G/4G o The ring back tone remains one subscribers in Pakistan as of October 2021 as of the most efficient ways of spreading time- per PTA. As part of the COVID-19 response, a Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 5 WhatsApp Chatbot was created to answer queries It is impossible to adopt a single fit-all approach for about COVID-19 in seven regional languages risk communication, hence this document provides making Pakistan one of the first countries to do so. an overarching framework for developing sustainable structures and replicable processes necessary to launch • Monitoring and evaluation of risk communication campaigns for multisectoral multihazard emergencies. activities remains inconsistent. There is a reliance It guides stakeholders to evaluate which platform on self-reporting by provincial health departments, would be most productive to utilize for each segment development organizations, and government of the target audience before launching campaigns. programs with little to no additional checks and Thus, this framework encourages decision-makers to balances in place. Evaluating the impact of risk invest resources in dissemination platforms according communication activities on KAP (Knowledge, to the emergency and target audience in question. Attitude and Perception) has been accomplished for mediums that allow two-way communication, for example, social media (through machine learning tools that provide sentiment analysis like Keyhole) and community engagement (through quantitative and qualitative in-person field surveys carried out by companies such as Gallup and IPSOS). This risk communication framework provides guidance on five strategic areas that must be strengthened to establish a reliable infrastructure for risk communication: 1. Establishment of A Formal Risk Communication Body 2. Mapping of Stakeholders’ Mandate and Geographical Presence 3. Capacity Building and Training of Human Resources 4. Acquisition of Tools for Dynamic Listening 5. Creation of a Knowledge Management System (KMS) Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 6 SECTION 1: OVERVIEW 1.1 Context and Need Pakistan remains susceptible to emergencies caused Pakistan has also been in the midst of the COVID-19 by a variety of natural hazards. These large-scale, life- pandemic since February 2020. threatening natural hazards don’t always manifest in the same way because they can be biological as well as At the same time, in the past decade alone, Pakistan geophysical or hydrometeorological. In fact, they often suffered from 16 documented geophysical and begin as the latter and lead to the former. Ultimately, hydro-meteorological disasters including droughts, they all have an adverse effect on public health and floods, landslides, earthquakes, and an unprecedented thus require a comprehensive response including locust infestation.3 These incidents are, of course, risk communication especially in a country with a in addition to the October 2005 earthquake and July vulnerability as high as Pakistan’s. 2010 floods that occurred in the previous decade and remain as some of the largest geophysical and hydro- There are two fundamental reasons for Pakistan’s meteorological disasters in Pakistan’s history. Unlike high vulnerability to natural hazards. The first reason epidemics which are instantly recognized as a threat is increasingly high exposure due to rapid changes in to health, the impact of geophysical disasters on the region such as unprecedented population growth, public health is not always intuitive for all segments urbanization, deforestation, climate change, and rising of society. However, they do inevitably lead to the human–animal proximity among others. outbreak of diseases or malnutrition. For example, floods lead to stagnant water, which creates the ideal Biological hazards, which take the form of outbreaks environment for the spread of water-borne diseases of communicable diseases that may evolve into such as typhoid and cholera, and vector-borne diseases epidemics or pandemics, continue to affect various like malaria. Similarly, locust infestations and droughts parts of Pakistan. Infamously, the threat of HIV directly threaten food supply and drastically increase outbreaks continues to linger with an outbreak in the prevalence of malnutrition. Ratodero district of Larkana, Sindh in 2019 being declared a Grade II emergency by the World Health The other reason for Pakistan’s high vulnerability, Organization (WHO).1 The threat of acute water which is also critical to this particular endeavor, is diarrhea outbreaks remains prevalent and claims the its insufficient capacity for emergency response. The lives of around 53,000 Pakistani children under the age most recent, comprehensive, and reliable assessment of 5.2 The high frequency of diarrhea outbreaks and of Pakistan’s capacity was completed in 2016 based death rates can be attributed primarily to Pakistan’s on the Joint External Evaluation (JEE) of IHR Core vulnerability to earthquakes, floods, droughts, and Capacities of Pakistan. IHR refers to the International internal displacement owing to conflict, which leaves Health Regulations, which were last revised in 2005 hundreds of thousands of affected persons deprived and serve as a significant international legal treaty of clean water. Finally, much like the rest of the world, that empowers the World Health Organization 1 WHO EMRO (June 2019). 2 UNICEF (n.d.). 3 The Center for Excellence in Disaster Management and Humanitarian Assistance (June 2021). Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 7 (WHO) to act as the main global surveillance system. Pakistan’s high degree of exposure to natural hazards It is an instrument of international law that aims and the low rating assigned to its risk communication for international collaboration “to prevent, protect infrastructure is a cause of serious concern, considering against, control, and provide a public health response the influential role that successful risk communication to the international spread of disease in ways that are can play in emergency response. While a robust, well- commensurate with and restricted to public health staffed health care delivery infrastructure can play a risks and that avoid unnecessary interference with pivotal role in managing the burden of an influx of international traffic and trade.”4 The JEE tool was a patients during a public health emergency, effective consequence of the Global Health Security Agenda risk communication actually has the potential to limit (GHSA), “a group of more than 70 countries, the influx at the outset through social and behavior international organizations and nongovernment organ- change messaging. WHO’s Strategic Framework for izations, and private sector companies that have come Emergency Preparedness captures the reason behind together to achieve the vision of a world safe and this notion well when it notes that, “community secure from global health threats posed by infectious members are the first responders—and the first diseases.”5 The GHSA was launched in February 2014 victims—of any emergency and, as such, essential as it was clear that, in an increasingly connected world, members of the preparedness process”.7 Robust risk combatting the grave threats to public health could not communication systems play an imperative role in possibly be the responsibility of a single actor. It was containment precisely because they see community necessary to adopt a multistakeholder, multisectoral members as active actors with the power to change the approach to strengthen the overall global capacity course of the catastrophe they have come to face. The for preparedness and management of global health COVID-19 pandemic has revealed beyond a doubt that risks. Therefore, the JEE tool was developed for the the intensity of the emergency has a direct correlation evaluation of national capacities by integrating the core with how aware and convinced people are of taking capacities initially identified by IHR and the areas of actions necessary for their own protection, and the assessment highlighted by the GHSA. overall containment of the emergency. In response to resolution EM/RC62/R.3 of the Without disregarding the fact that the status of Regional Committee WHO Eastern Mediterranean Pakistan’s capacity for risk communication has evolved to assess and monitor the implementation of the since the JEE’s report in 2016 (especially considering IHR (2005), Pakistan volunteered for a Joint External the unprecedented focus on risk communication Evaluation as the first country in the WHO Eastern efforts during the COVID-19 pandemic), it is crucial Mediterranean Region, and the fourth globally. The to address the gaps identified to ensure Pakistan is Joint External Evaluation rated Pakistan’s core prepared for the next public health emergency. Having capacities across 19 broad technical areas (and a total established that any type of disaster inevitably threatens of 48 technical subcategories). It identified several public health, developing a multihazard multisectoral areas of concern that required immediate attention risk communication system is of utmost importance and improvement. On a scale of 1 (no capacity) to 5 in Pakistan. (sustainable capacity), the five subareas of Pakistan’s Risk Communication capacity scored an average of 2. In fact, none of the subareas scored beyond 3 and the foundational tenet— “risk communication systems (plans, mechanism)”—scored 1, that is, no capacity.6 4 World Health Organization Regional Office for the Eastern Mediterranean (n.d.). 5 Global Health Security Agenda (n.d.). 6 World Health Organization (2017). 7 World Health Organization (2016). Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 8 1.2 Process of Development crucial to note that this framework is only a federal- level document. The situation analysis, however, does This document was developed after consulting all the make references to how risk communication has been relevant stakeholders within the Government and approached both at the federal and provincial levels, development sector at the federal level. Stakeholders especially during the COVID-19 pandemic. consulted within the Government include vertical programs of the Ministry of National Health Services, 1.3 Scope and Objective Regulations and Coordination (hereby referred to as Ministry of NHSRC), the National Institute of Health This document comprises two broad components: (which is responsible for ensuring Pakistan complies with commitments made under the International • Situation Analysis of the existing risk communica- Health Regulations), the National Disaster Management tion mechanism, and Authority (NDMA), and other line ministries (such • Framework (based on the situation analysis) for: as Ministry of National Food Security and Research, (a) Ensuring preparedness through and Ministry of Climate Change). Simultaneously, institutionalization health development partners including various United (b) Activating campaigns during emergencies Nations agencies and international nongovernmental organizations (INGOs) were consulted as well. (The The JEE provided an overview of where each aspect of full list of stakeholders consulted has been attached as risk communication stood in reference to the yardstick an annex). established by IHR. However, the situation analysis in this framework provides more nuanced insights into The data on which insights in this report are based the day-to-day workings of the existing informal risk was collected in two ways. A large portion of the data communication units; this will allow the subsequently was gathered organically over the course of nearly a proposed framework to be firmly grounded in year and half; the process began in December 2020 practice rather than theory. With close reference to when the lead author took charge of the Ministry of the developments during the COVID-19 pandemic NHSRC’s COVID-19 risk communication and began (which the JEE does not include), the situation analysis liaising with the National Command and Operation describes strengths and weaknesses of: Center (NCOC) on the Ministry’s behalf. Therefore, conversations between relevant stakeholders during 1. Stakeholders’ Roles and Coordination the COVID-19 pandemic, including analysis of the risk communication interventions they launched, 2. Message Development heavily informs this document. At the same time, 3. Dissemination Channels some critical quantitative and qualitative data was also gathered by formally interviewing concerned 4. Dynamic Listening and Rumor Management stakeholders specifically for the purpose of developing 5. Monitoring and Evaluation this document and/or kickstarting the process of institutionalizing risk communications. For instance, The situation analysis will be able to provide an in-depth insights were also drawn from a two-day consultative context for tapping into the most fruitful resources and conference organized by the National Institute of focusing on the best practices that have proven effective Health from September 29, 2021 to September 30, across the five aforementioned areas. Similarly, it will 2021. In line with COVID-19 SOPs, most formal also provide a way to navigate frequently emerging interviews were conducted online wherever possible, resource constraints by sharing insights on whether especially when Pakistan faced COVID-19 waves and a they can be surmounted or not, and what alternative subsequent spike in cases or hospitalizations. pathways should be explored instead. Provincial departments of health were not directly It is impossible to adopt a single fit-all approach for consulted during this process and therefore, it is risk communication in the face of all disasters. Hence, Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 9 the subsequent framework only seeks to provide an involved, and which body must authorize the final overarching framework for developing sustainable messages, etc. In a similar vein, it does not direct structures and replicable processes necessary to launch stakeholders to utilize a particular platform for campaigns for multisectoral multihazard emergencies. dissemination of messages. It only outlines, based on In laying out guidelines, it remains conscious of going existing evidence, which segments of the population into the granularities only up to the point where the each platform would yield for the highest reach and guidelines are replicable for all emergencies. For engagement. Thus, this framework ultimately leaves it example, the framework does not outline which up to decision-makers in the future to invest resources messages need to be communicated (for they would in dissemination platforms according to the emergency be unique to each scenario and organization) but how and target audience in question. they should be developed: what type of theoretical frameworks must be adopted, what qualifications must be set as prerequisites for the human resources Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 10 SECTION 2: SITUATION ANALYSIS As mentioned above, the Joint External Evaluation of Pakistan’s IHR Core Capacities scored and provided brief qualitative assessments of the country’s risk communication indicators in 2016:8 Indicator Score Conclusion Risk Communication Systems (plans, 1 No capacity. No formal government risk communication arrangement mechanisms) exists. Internal and Partner Communication and 2 Limited capacity. Some ad hoc communication coordination exists such as Coordination during meetings, with some partners, and/or irregular information sharing. Public Communication 2 Limited capacity. A public communication unit or team exists; government spokesperson identified and trained; and, procedures for public communication are in place. Communication Engagement with Affected 2 Limited capacity. A community level engagement system is semiformed Communities with mapping of existing processes, programmed, partners and stakeholders/ social mobilization, behavior change communication, and community engagement included in the national risk communication strategy in the context of health emergencies. Some key stakeholders in this domain identified at the national and immediate (provincial/regional) level. Dynamic Listening and Rumor 3 Developed capacity. Routine and event-based systems for listening Management and rumor management exist or an ongoing system with limited or unpredictable influence on response. The JEE report is a valuable starting point for dedicate resources to risk communication— albeit in an identifying strengths and weaknesses of the current ad hoc manner. Thus, the following situation analysis risk communication infrastructure. However, it leaves fills these gaps by commenting on five aspects of the certain gaps that must be filled in order to move country’s risk communication landscape that cut across forward with the development of a comprehensive the indicators identified by JEE—all informed by (but framework. Firstly, it does not delve into the reasons not limited to) recent developments triggered by the behind the status quo of each of the indicators to COVID-19 pandemic. Most importantly, it provides reveal why exactly these five risk communication critical insights on both existing processes of achieving indicators stand where they do. This, in turn, makes certain goals irrespective of their functionality, as well it extremely challenging to tackle individual parts as their overall utility or potential. For example, the acting as the bottlenecks to success. Secondly, the analysis delves both into the different pathways for risk communication landscape across the country has rolling out campaigns for risk communication and the certainly evolved over the course of the COVID-19 impact on different segments of society. pandemic that reached Pakistan in February 2020 and unprecedentedly forced various stakeholders to 8 World Health Organization (2017). Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 11 2.1 Stakeholders’ Roles and during emergencies. The NDMA has historically done a commendable job of fulfilling these responsibilities; Coordination it has rescued affected persons, restored transport networks, and delivered necessities during disasters. In order to formulate a robust framework that can be However, these interventions are largely logistical and used in the future, it is imperative to identify the existing NDMA’s mandate does not include risk communication. stakeholders, analyze their recent contributions, and review their capacity for coordination. At the provincial level, provincial health departments have the mandate to utilize their funding and other Postdevolution Federal and Provincial resources for executing risk communication activities. However, due to devolution, provincial health Roles and Responsibilities departments have no obligation to replicate efforts of At the federal level, the defunct Ministry of Health had an the federal Ministry of NHSRC—a fact that makes extensive “Health Education” section which supported close cooperation across the health sections all the the communication endeavors of the Ministry of Health more important in ensuring consistency of messaging. and attached and subordinate departments. After the As of now, provincial health departments develop their 18th Amendment to the Constitution of Pakistan, the own key messages for risk communication as per their concurrent list was abolished and the subject of health requirement and need. Such independent initiatives was devolved to the provinces. The Ministry of Health, result in messages that are discordant, influenced by along with its constituent wings, which included the the respective provincial context and not in line with Health Education section, were thus also abolished. international best practices. Since then, the Health Education section is yet to be Much like the structure at the federal level, the revived. As a result, individual vertical programs under Provincial Disaster Management Authorities (PDMAs) the Ministry of NHSRC have budgetary provisions also operate in parallel with the provincial health for risk communication activities but these activities departments and act as the lead agencies for disaster are conducted in isolation and not coordinated with management at large (that is, management of aspects the wider health system in line with international best outside of public health, which does not lie in their practices. Irrespective of these inconsistencies, the purview). The Center for Excellence in Disaster Ministry of NHSRC and National Institute of Health Management notes that “many smaller-scale disasters (being responsible for IHR reporting), are working in remain within the remit of their respective district conjunction with provinces to ensure compliance. or provincial authorities as they do not rise to the In the case of emergencies, the National Health level of requiring federal or international attention”9, Emergency Preparedness and Response Network and therefore the PDMA takes the lead as opposed (NHEPRN) is the attached body of the Ministry of to the NDMA. As is the case with the NDMA, the NHSRC that has the mandate to review threats to PDMAs are yet to consistently take ownership of risk public health and strategize a response. At the same communication during emergencies, prompting other time and at the same (federal) level, the National stakeholders to intervene on an ad hoc basis. Disaster Management Authority (NDMA) is the lead agency for disaster management at large excluding the Partner Organizations health aspect. The National Disaster Management Act of 2010 mandates that NDMA draft guidelines, arrange There are three categories of partner organizations resources, and provide support to affected areas as that support the Government’s service delivery across the federal or provincial authorities may determine all federating units: 9 The Center for Excellence in Disaster Management and Humanitarian Assistance (June 2021). Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 12 1. International Financial Institutions and Health be targeted with awareness campaigns, and highlight Development Partners, for example, World Bank, any gaps in coverage. Moreover, when operational Asian Development Bank, Bill & Melinda Gates plans are developed by the Government, roles and Foundation, United States Agency for International responsibilities as well as funding requirements are Development, Foreign Commonwealth & not clearly defined. As a result, there is duplication of Development Office, etc. efforts and resources. Thus, certain communities are not targeted at all while others receive an overload of 2. United Nations’ agencies, for example, World messages (that may actually trigger resistance instead Health Organization (WHO), United Nations of acceptance). Such leakages and some of the steps Children’s Fund (UNICEF), United Nations taken to mitigate them successfully and unsuccessfully Development Program (UNDP), United Nations are summarized in the case study below. Population Fund (UNFPA), etc. Case Study: Coordination for Risk 3. Community service organizations (CSOs) including local nongovernmental organizations Communication during COVID-19 (NGOs) concentrating on smaller communities In the absence of a robust emergency risk in specific regions on particular areas of human communication system that assigns clear leadership and development, and international nongovernmental ownership, and in the face of the most unprecedented organizations (INGOs) with broader agendas. threat to public health, the Ministry of NHSRC reacted Across all categories and federating units, there by notifying a Risk Communication and Community is a serious lack of coordination between partner Engagement (RCCE) Task Force on March 6, 2020. organizations, at least as far as activities pertaining The purpose of the task force was to create awareness to risk communication are concerned. This results regarding the spread of COVID-19 based on the from the lack of a uniform unit or structure at federal latest findings, which, of course, kept evolving over and provincial levels. For instance, till date, there is the course of the pandemic; it sought to coordinate no repository that identifies all active partners, their efforts from message development to dissemination. scope of work, and maps out their presence across The following TORs were announced in the official the country. The availability of such a repository notification of the task force issued by the Director would constitute a valuable database that could General Health’s office: provide a bird’s eye view of which communities can Role of the Risk Communication Taskforce Convene and Coordinate Convene weekly/ad hoc meetings to coordinate risk communication initiatives from planning, strategy development, capacity building, implementation, and monitoring for synchronization of activities in line with the National Action/Response Plan developed for COVID-19. Strategic Communication Preparedness Oversight in development of a preparedness plan that guides the work of the Ministry. Plan Resources and Tools Support and guide the development of risk and preventive communication and health education resources/tools for public outreach that can be adapted at provincial/area level. Support in Implementation Guide the provincial teams in implementation, monitoring, and reporting of communication interventions. Knowledge Management Oversee and guide on available data sources and share with all stakeholders. Provide technical support in knowledge management on COVID-19 for Pakistan and other countries having a similar context. Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 13 The task force comprised representatives from the • United Nation’s Children Fund (UNICEF) following Government entities and health development partners at the federal level: • United Nations Development Program (UNDP) • Ministry of NHSRC • International Committee of the Red Cross (ICRC) • Expanded Program on Immunization (EPI) The membership of the task force remained fluid and more partners joined in as responding to COVID-19 • National Emergency Operations Center (NEOC) became a priority, even though they were not formally notified initially. Similar RCCE Task Forces were • National Institute of Health (NIH) established at the provincial level with the intention that they would liaise with the federal RCCE Task • World Health Organization (WHO) Force. SWOT Analysis of COVID-19 RCCE Task Force Strengths Weaknesses ● Monetary support for interventions on urgent basis ● Poor monitoring and evaluation ● Consensus on technical guidance ● Lack of accountability and ownership ● Multiplatform dynamic listening ● Poor leadership and coordination ● One government approach ● Insufficient representation of stakeholders ● Poor understanding of Government rules of business Opportunities Threats ● Formalization of a multihazard multisectoral risk ● Vast range of unengaged risk communication stakeholders in communication unit the country (private sector) ● Mapping of all stakeholders’ presence and mandate ● Unmonitored media, especially social media ● Allocation and institutionalization of risk ● Disregard for the importance of risk communication across communication budget non health stakeholders The task force saw some success in the first few Emergency Operation Center’s Sehat Tahafuzz 1166 months of its notification. Members contributed Helpline (discussed below) to include communication enthusiastically by utilizing the funds available to regarding COVID-19. Simultaneously, member develop content based o n messaging mutually agreed organizations also kickstarted dynamic listening upon by WHO, the Ministry of NHSRC, and the through social media sentiment analysis as well as National Command and Operation Center (NCOC), Knowledge, Attitude and Practice (KAP) surveys in the which was established solely to coordinate the national field, which provided valuable insights on the evolution response to the COVID-19 pandemic. (or lack thereof) of peoples’ behavior. Development agencies supported the production and Gradually, the RCCE Task Force became far less dissemination of advertisements on television, radio, functional and productive, succumbing to the same and social media, which incorporated public service fate as other ad hoc efforts at organization. Firstly, messages by celebrities as well as jingles that appealed even when partners were actively contributing to to children. They also funded the development of a the COVID-19 awareness campaign, there was little WhatsApp chatbot and the expansion of the National attention devoted to tracking the progress made by Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 14 each partner in terms of disseminating the messages Electronic Media Regulatory Authority (PEMRA) are and covering communities across Islamabad Capital some of the bodies dedicated to communication at Territory, let alone across Pakistan. As discussed large that must have a seat at the table where decisions earlier, this lack of a bird’s eye view can be attributed regarding emergency risk communication are made. to the absence of a repository that maps out the Moreover, associations of health care workers, such presence of development partners across the country, as Pakistan Medical Association, and Pakistan Nursing and utilizing it to track activities conducted. Another Association, must also be involved to ensure that reason contributing to the lack of insight on progress messages trickle down to the grassroots level through made was a loose, merely symbolic affiliation with the health care workers who are at the forefront of provincial stakeholders leading risk communication in interacting with communities affected by disasters. their respective regions. Secondly, there were no strict commitments regarding 2.2 Message Development duration of membership, and this allowed many The development of messages for risk communication partner organizations to exit the task force with little has so far remained an ad hoc exercise that only to no accountability. Some partners exited the task begins after a disaster has occurred or as a reaction to force or became passive members when their budgets negatively charged reporting in the media. However, dedicated to COVID-19 risk communication activities the majority of disasters or emergencies in Pakistan were used up or priorities changed. are recurring and cyclical, for example, floods, dengue outbreaks and smog, etc., and are therefore predictable Thirdly, there was a dearth of consistent leadership enough for the Government to plan in advance. For and ownership of the task force by the Government, instance, there have been dengue fever outbreaks of specifically the Ministry of NHSRC, which launched varying degrees in several parts of the country during the task force in the first place. The glaringly obvious the same season over the last decade. Yet, there is no reason was that there was no dedicated and permanent evidence of consistent risk communication from the human resource at the Ministry of NHSRC that had Government prior to the onset of the season when any expertise in health communications. The task force the risk of the outbreak begins increasing. Awareness was being supervised by a health communications drives are launched only after an outbreak has been expert who served on a donor-funded contractual declared and the health care system is already under position shared between the Ministry of NHSRC and pressure. Instead, messages should be disseminated EPI. regardless of whether the threat has escalated to a full- scale emergency or not. Institutions such as schools Finally, it also became apparent that the representation and workplaces as well as mass media platforms ought of Government entities was insufficient in the RCCE to reinforce habits that improve safety round the year. Task Force. COVID-19 certainly began as a public health crisis but ultimately adversely affected all aspects Another glaring issue is that of lack of consistency in of life including movement and livelihood —a fact that the language and terminology used in the development is often true for almost all emergencies and disasters. of messages. This is due to the fact that message Therefore, a plethora of Government entities were development is supported by and based on the work involved in the response, and even represented at the of development partners, the vast amount of public National Command and Operation Center (NCOC) health literature that exists in English, and messages but they were not taken in the loop as far as risk that are primarily prepared in English. Such messages communication activities were concerned. Such an reach and resonate with a relatively small segment exclusion during the COVID-19 risk communication of the population compared to messages in Urdu response was a symptom and continuation of a or other regional languages. Studies have shown that problem that occurred in nearly all other emergencies messages in national or local languages outperform in the past as well. The Ministry of Information and those in English in terms of engagement and retention Broadcasting (MoIB), Digital Media Wing (DMW), by the community. Furthermore, it is also a fact that Pakistan Telecom Authority (PTA), and Pakistan messages for print and electronic media are usually Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 15 developed in English and subsequently translated into prevents them from executing projects efficiently. national or local languages, which often leads to key messages being lost in translation. Language is not only The issue described below in detail illustrates how the influenced by but also reflects sociocultural practices four aforementioned factors have complicated the and beliefs. Hence, a lot of the messages which tend process of rolling out engaging television campaigns to encapsulate Western values remain somewhat and how those bottlenecks can possibly be resolved. devoid of the nuances of the local culture. Therefore, there is a dire need for training in Social and Behavior Many Government authorized agencies are adept at Change Communication (SBCC) in Urdu and regional developing advertisements for private corporations and languages that are rooted in the local context of brands with little to no expertise in social and behavior different communities prone to disaster. change communication for public health emergencies. The messaging or media campaigns they develop do not serve the purpose well and end up merely dictating 2.3 Dissemination Channels guidelines as opposed to truly addressing the concerns of the public or influencing levers that determine Mass Media: Television, Print behavior. Hence, there is a need to revisit Government and Radio regulations and advocate for special stipulations in the case of risk communication during emergencies. Mass media has the highest outreach of all the possible Furthermore, the modalities to engage area-specific channels of dissemination; and within mass media, media firms have to be devised. radio has the highest reach in Pakistan while print has the lowest in comparison. Using Government funds to Bearing these challenges in mind, an alternative roll out engaging, behavior-change inducing campaigns method available was the provision in the PEMRA via mass media is challenging due to four reasons. law stipulating private television channels to dedicate a certain duration of airtime to public service First, there is a lack of coordination between various messages. Accordingly, messages of good quality government stakeholders who can be engaged for risk (in terms of relevance to social and behavior change communication and community engagement such as communication) were developed with the support of Ministry of Information and Broadcasting (MoIB), health development partners. These advertisements Pakistan Telecom Authority (PTA), Pakistan Electronic were aired free of cost on multiple private television Media Regulatory Authority, public hospitals, and channels. Although it was a welcome development, it public academic institutions. is important to be cognizant of the fact that private television channels have no incentive to air these free- Second, there is a severe lack of funding allocated to of-cost public service messages on prime time and media campaigns in all ministries as they are deemed so, their reach remained extremely limited. However, too expensive and considered a waste of resources—a Government funding can only be utilized for prime result of an overall misunderstanding of the potential time airing by paying those agencies which are already of well-structured and compelling advertisements that on the Government roster. Thus, any material produced seek social and behavioral change. by agencies not suitably registered cannot be aired using Government funding. Therefore, in future, it is crucial Third, even when funding is allocated for risk that any health development partner that commits communication, as was the case during the COVID-19 to paying for the production of advertisements also pandemic, stringent governmental rules and regulations allocates funding for broadcasting them in order to make it difficult to utilize the funding efficiently and ensure the best utilization of resources. achieve the best possible return on investment. Private corporations can also play a very positive role Fourth, stakeholders’ limited understanding of the through their corporate social responsibility (CSR) pertinent rules and regulations of departments other programs that allocate resources specifically for the than those that they themselves are a part of also Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 16 good of the public. The mechanism for engaging Social Media private sector CSR platforms for supplementing and enhancing communication is a useful adjunct to the The use of social media can play a significant role in Government’s own communication plans. However, creating awareness and shaping the opinions of people this would require a well-structured approach to in Pakistan, especially those in urban areas. This is engage a number of line ministries to incentivize because of the high potential for virality on social and institutionalize such a mechanism. During the media platforms and current evidence that suggests COVID-19 pandemic, several corporations ranging that the origin of most sensational, fake news can be from telecom companies to fast-moving consumer traced back to social media. Moreover, the growth rate goods companies supported the Government by paying of social media users in Pakistan is very high, which for the production and broadcasting of advertisements implies that the segment of population that can be based on the Ministry of NHSRC’s guidelines. targeted through such platforms would continue to expand over the years. According to DataReportal, Ring Back Tone (RBT) there were 46 million social media users in Pakistan in January 2021, which is equal to about 20 percent of The ring back tone remains one of the most efficient the population, and indicated a 24 percent increase in ways of spreading time-sensitive, life-saving messages number since 2020.11 Other estimates fall within this to the public not just once but repeatedly. This can be a ballpark and hence, confirm the rapid pace at which useful modality not only for responding to nationwide social media is gaining influence. emergencies but also for a number of different population level communication activities even when There are two broad ways of paid promotion on social there is no emergency (for example, breast cancer media: direct advertisement, and influencer marketing. awareness). At the time of writing this report, Government funding could not be used for advertisement on social media Pakistan Telecom Authority (PTA) has the authority as there were no laws in place by MoIB for regulating to roll out a standard ring back tone (RBT) on all the practice. Therefore, only funding from partner calls made. The efficiency of this mechanism can be organizations was used to purchase advertisement judged by the fact that it reaches a hundred percent credits or pay influencers. of the target audience. According to PTA, there are 187 million cellular subscribers in Pakistan as of Over the course of the COVID-19 pandemic, the October 2021 which amounts to about 82 percent of Ministry of NHSRC established strong ties with big the total population of the country.10 Departments tech companies such as Facebook and Google which of the Government can formally request PTA to roll provide advertisement credits free of cost as part of out a ring back tone and are mandated to pay for the their CSR programs. For example, Facebook provided service. However, by-laws of PTA include a stipulation advertisement credits to the Ministry of NHSRC and for disseminating public service messages via ring back the Digital Media Wing (Ministry of Information and tones free of cost during times of emergency. For Broadcasting) for several Facebook and Instagram example, at least 12 unique ring back tones have been advertisement campaigns pertaining to the COVID-19 rolled out since the start of the COVID-19 pandemic vaccination drive in Pakistan. Facebook also waived upon the request of the Ministry of NHSRC. off the fee for setting up a WhatsApp chatbot that answered queries regarding COVID-19 (the “COVID-19 WhatsApp Chatbot”). 10 Pakistan Telecom Authority (n.d.). 11 Kemp, S. K. (February 2021). Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 17 Community Engagement (on-field) opinions on current affairs. This makes social media platforms extremely rich sources of data on the On-field engagement is most effective to target public’s knowledge, attitude and perception (KAP)— communities with little to no access to social and access to which can inform Government interventions. mass media, either due to a dearth of resources or low Machine learning and artificial intelligence-based tools literacy. The key stakeholders that make the highest make it possible to categorize and interpret the vast levels of impact in this domain are District Health amount of data extrapolated from social media, which Offices (DHOs), community health workers, and is impossible to do manually. community service organizations (CSOs). Community activities remain susceptible to duplication more than The use of such tools was piloted by the Ministry of most other types of activities because CSOs often NHSRC as part of the risk communication activities operate in silos and have little incentive to collaborate during COVID-19. Keywords pertaining to the or divide up coverage of areas amongst each other. As pandemic and the Government’s latest interventions mentioned above, in the case of partners, there is no can be fed to the tool and data aggregated on a weekly repository that maps the presence of CSOs by district basis, broken down by location. Such practices would and mandate; building one would be a game changer allow ministries to flag fake news as well as legitimate not just for planning at the federal level but also for concerns of the public immediately. Subsequently, coordination by the DHO at the union or tehsil level messaging to counter rumors and address concerns in the provinces. can be deployed. These tools are offered by the corporate sector and 2.4 Dynamic Listening and Rumor private companies and therefore, funds would need to Management be allocated for utilizing this modality. Reliance on Analog Methods for Mass Dedicated Helplines for Two-way Media Monitoring Communication The mechanism for monitoring mass media and A dedicated telephone helpline has an extremely wide compiling reports is still manual in Government reach in terms of the target population as it is a simple departments. This practice is far from time-efficient but means of collecting information that requires neither nonetheless allows stakeholders to get a pulse on the literacy skills nor access to the internet. reporting on ongoing emergencies and even reach out to specific media outlets to clarify any misinformation. The Sehat Tahafuzz Helpline functioned as the most It is certainly not effective for acquiring data on accessible form of two-way communication for the viewership trends by type of audience that could public during the COVID-19 pandemic. It was initially be analyzed and used for developing more targeted launched by the National Emergency Operation Center campaigns. (NEOC) for the Polio Eradication Program to address queries regarding Polio immunization and other routine childhood immunizations. This helpline then Use of Artificial Intelligence (AI) and underwent significant capacity enhancement to begin Machine Learning (ML) for Social addressing queries regarding the novel coronavirus in Media Monitoring February 2020. The Ministry of NHSRC and NEOC, with the support of partners, expanded the staff As described above, the number of social media users and trained them specifically to assuage the public’s in Pakistan is growing at a rapid rate and information concerns regarding COVID-19. In fact, owing to the posted on social media platforms is susceptible to frequently evolving information about COVID-19, the virality. Social media platforms not only incorporate staff are regularly retrained till date; the most extensive digital news outlets but also create an equal opportunity additional training was completed prior to the launch and conducive environment for the public to share its of Pakistan’s COVID-19 vaccination drive. Thus, the Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 18 human resource available is comfortable with and communication because it also aggregated data that has the capacity for absorbing new information in a revealed the most frequently asked questions (albeit short span of time and communicating it to the public in not as much qualitative detail as the helpline can), during an emergency. This type of infrastructure allowing the Government to integrate answers to those and human resource makes helplines such as Sehat concerns across all avenues of communication (press Tahafuzz valuable assets that could be utilized for releases, press briefings, flyers, etc.). other disasters as well as health communication outside of emergencies. However, the COVID-19 WhatsApp Chatbot abruptly stopped working in October 2020, seven months after Since the Sehat Tahaffuz Helpline records complaints its launch, precisely because it had been launched made by callers and also collects information such as in haste without ensuring its financial sustainability gender, age, and location, it aggregates and analyzes data and relying on the temporary, gratis support offered to reveal the most pressing concerns or misconceptions by Facebook and the Business Service Provider in across various demographics. This data contributed question. immensely to the Ministry of NHSRC’s dynamic listening and informed both risk communication as At the time of writing this report, efforts are well as policy making. underway to relaunch the WhatsApp Chatbot in a manner that ensures longevity and adaptability to risk While such an accessible two-way mechanism of communication in the face of other disasters. communication can have an immensely positive impact on risk communication and the overall management of 2.5 Monitoring and Evaluation a disaster, it comes at a hefty monetary cost. So far, the entire Sehat Tahafuzz Helpline infrastructure is funded Monitoring refers to tracking the progress of the by the coalition of donors that support the NEOC risk communication activities agreed upon and being and Pakistan Polio Eradication Program with a limit conducted by different stakeholders. As of now, on the time duration for which donors can continue there is a reliance on self-reporting by provincial to support it. Thus, it is of utmost importance to health departments, development organizations, and assess the Government’s options for retaining the government programs with little to no additional infrastructure in a sustainable manner and allocating checks and balances in place. Moreover, reporting is even more funding to allow for the helpline to be used restricted to district/city level but the aforementioned for communication. mapping of stakeholders can enhance its application to tehsil level or union council. Messaging App Chatbots for Multisectoral Multihazard Utilization Evaluation refers to both the impact of risk communication activities on the behavior or perception A messaging App chatbot has immense potential for of the target audience itself, and on the metrics that creating awareness quickly and managing rumors, measure the scale of the emergency at large. especially considering that there are already 106 million 3G/4G subscribers in Pakistan as of October 2021 Evaluating the impact of risk communication activities as per PTA. Messages can be sent and received by on KAP (Knowledge, Attitude and Perception) is subscribers at no additional cost (other than the data possible and has been accomplished for mediums that subscription). allow two-way communication, for example, social media (through machine learning tools that provide As part of the COVID-19 response, the Ministry of sentiment analysis like Keyhole), and community NHSRC launched the COVID-19 WhatsApp Chatbot engagement (through quantitative and qualitative in- to answer queries about COVID-19 in seven languages person field surveys carried out by companies such as (English, Urdu, Punjabi, Pashto, Sindhi, Balochi, and Gallup and IPSOS). Kashmiri), making Pakistan one of the first countries to do so. It was another effective platform for two-way Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 19 SECTION 3A: FRAMEWORK FOR PREPAREDNESS AND INSTITUTIONALIZATION 3A.1 Objective safe. Most importantly, it sets out to establish a sustainable mechanism that will eradicate the • The objective is to share information with culture of ad hoc, reactionary measures and also affected communities in a timely manner so make sure that Pakistan meets its international they can understand and act upon it to protect commitments. themselves. Thus, they may minimize harm not only to themselves but others as well by adopting 3A.2 Guiding Principles behavioral change enabled through effective communication within their sociocultural contexts. The following principles guide the approach to establishing a robust, sustainable risk communication • The first five steps in the overall twelve-prong infrastructure in Pakistan: framework pertain to laying the infrastructure for sustainable risk communication units. They provide • Risk communication requires immediate support guidance on how such units can be equipped with from and prioritization by the highest authorities the necessary technical, financial, and human within the Government. resources, as well as on how critical partnerships and baseline operational modalities can be established. • Risk communication must be strategized on a These interventions are designed to be undertaken national level and implemented at a local level. as soon as possible regardless of whether there is an ongoing emergency or not. Ideally, these actions • Risk communication must be spearheaded by should be taken in “peace time” so resources can the Government but involve global development be allocated towards enacting sustainable change in partners, private corporations, media, and a timely manner as opposed to responding to the communities. needs of the emergency with knee-jerk reactions. • Risk communication requires listening and • The framework stems from a people centric constant iteration. approach. It seeks to ensure equitable access to • Risk communication requires capacity building as information and resources that can protect people well as monitoring and evaluation. from threats to public health so that even the most vulnerable, marginalized communities remain 3A.3 Step-by-Step Breakdown of Institutionalization Process Steps Action Establish a Formal Risk Communication A. Identify relevant Government bodies (including provinces), donor organizations, Body and Development Intergovernmental Organizations for inclusion into a federal-level Risk Communication and Community Engagement Unit B. Develop and notify a federal-level Risk Communication and Community Engagement Unit with defined terms of reference (TORs) C. Estimate annual baseline monetary requirements and allocation of resources Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 20 Steps Action Map Stakeholders’ Mandate and A. Map out the geographical presence of all health development partners, CSOs, Geographical Presence NGOs, and INGOs across Pakistan B. Identify the target audience, and summarize the mandate and capacity of each of these stakeholders Conduct Capacity Building and Training of A. Allocate a budget and create sanctioned positions to recruit a dedicated team Human Resources of risk communication experts with the required skill sets within the Ministry and departments of health B. Organize capacity building programs for key members of the federal-level Risk Communication and Community Engagement Unit enabling them to develop campaigns based on Social and Behavior Change Communication (SBCC) principles in line with global best practices but rooted in the sociocultural context of Pakistan C. Develop a pool of master trainers in the country who can transfer skills and principles for campaign development to the key stakeholders at the federal and provincial level D. Develop hazard-specific manuals and SOPs for various tiers of health care workers on community engagement Acquire Tools for Dynamic Listening A. Allocate resources for the purchase of subscriptions to machine learning-based tools for social and digital media sentiment analysis (such as Keyhole) B. Strengthen existing partnerships with big tech corporations behind the most popular social media platforms to secure free-of-cost advertisement credits that can promote critical messages round the year, and establish mechanisms for flagging and removing (where possible) misinformation regarding public health C. Allocate resources for the expansion of existing helplines and their sustainability (including hiring additional staff, covering overheads of the headquarters, and ensuring capacity building) D. Launch a financially viable messaging App (chatbot) for risk communication that can send push notifications and address queries regarding at least two major threats to public health in at least seven languages (English, Urdu, Punjabi, Pashto, Sindhi, Balochi, and Kashmiri). Incorporate information regarding other frequently occurring disasters and prolonged threats to public health in subsequent phases Create a Knowledge Management System A. Design a user-friendly knowledge management system (KMS) that can (KMS) accommodate and act as a repository for: I. Message boards (technical guidelines and copy for campaigns) II. Finalized content (infographics, DVCs, TVCs, flyers, etc.) III. Stakeholder mapping (by geographical presence and mandate) B. Develop protocols that outline the process of submitting, vetting, and approving material before it can be uploaded to the KMS along with protocols to dictate how material available there can be used by stakeholders C. Allocate resources to ensure that the KMS can be hosted on a Government- approved server with sufficient space on the cloud for storing all data D. Launch KMS and make it completely accessible for relevant federal-, provincial-, and district -level authorities so they can utilize existing content in the face of an emergency as per the protocols for use mentioned above (in “B”); provide public access to “message boards” so citizens can benefit from the guidelines and any other external partners, such as private corporations with CSR programs, may use the message boards to develop new content for various platforms without violating any copyrights Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 21 SECTION 3B: FRAMEWORK FOR ACTIVATING CAMPAIGNS DURING EMERGENCIES 3B.1 Objective 3B.2 Guiding Principles This section describes in detail steps that should be The following principles guide the approach to taken in response to or in anticipation of an emergency. responding to a particular disaster with comprehensive The following steps certainly cannot be implemented risk communication: in isolation and should be reviewed in tandem with the five strategic areas described earlier that need to • Risk communication must be tailor-made for be built upon for the institutionalization of a risk specific audiences as opposed to being executed communication mechanism. This will create the with a one-size-fits-all approach financial, legal and administrative conditions necessary for launching structured, evidence-based and trackable • Risk communication is multifaceted and requires risk communication campaigns tailored to the next several stakeholders to take ownership of different emergency in a timely and cost-efficient manner. aspects Thus, the following steps are meant to be followed • Risk communication for any threat must be based each time any region in the country is faced with a on Social and Behavior Change Communication public health emergency in order to launch a unique, theories context-specific risk communication response. 3B.3 Step-by-Step Breakdown of Response Steps Action Identify Nature of Risk and Target Audience A. Assess the nature of the threat and its potential for expansion over time by seeking guidance from the body leading the overall emergency response B. Identify the segment of the population affected by or at risk of being affected by the emergency, and note the salient features of this demographic (geographic presence, age, gender, ethnicity, etc.) Convene Stakeholders and Delegate A. Convene a meeting of all members of the federal level Risk Communication and Responsibilities Community Engagement Unit B. Brief all stakeholders on the nature, potential, and those affected of the emergency, and share the goals of the body leading the overall emergency response C. Brainstorm and agree on specific targets for risk communication which are in line with the larger goals of the overall emergency response D. Develop an operational plan with a list of various types of interventions and the baseline funding required to execute them E. Delegate the execution of activities to specific stakeholders by utilizing the existing database that maps out stakeholders by mandate, capacity, and geographical presence F. Reach a consensus on intervals and mechanism for reviewing progress of interventions agreed upon in the operational plan Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 22 Steps Action Develop and Disseminate Messages A. Develop messages based on Social and Behavior Change Communication (SBCC) theories under the leadership of human resource trained in the methodology, ensuring that all four levels of influence recognized by the Social Ecological Model are considered: ○ Individual ○ Relationships ○ Community ○ Society B. Share key messages with master trainers at the federal and provincial level who can then further train health care workers and key opinion leaders (KOLs) at the grassroots level who interact with affected persons on a regular basis C. Determine which mediums (for example, on-ground community engagement, vs. broadcast media) and type of content (for example, audio-visual vs. text-heavy, or Urdu vs. Pashto) would be most efficient for influencing the target audience’s behavior D. Produce and disseminate engaging content that integrates the finalized key messages in a format deemed most efficient for influencing the target audience’s behavior Monitor Progress of Stakeholders A. Conduct progress reviews for all interventions and stakeholders involved at regular intervals as per the mechanism agreed upon B. Solve any bottlenecks by making changes to the planned intervention that may help adapt with the reality on the ground. Initiate Dynamic Listening A. Gather data on ongoing conversations and/or feedback from the public regarding the emergency by monitoring mass media, social media, and queries on two-way feedback mechanisms such as helplines and chatbots B. Take notice of any misconceptions or concerns arising due to lack of awareness or the prevalence of fake news C. Convene all stakeholders involved to develop and disseminate messaging that addresses those misconceptions; ensure the messaging is integrated with all content developed in the future as well Evaluate Impact on KAP and Overall Scale A. Design and execute surveys through community engagement, social media and/or of Emergency telephone to evaluate the impact of interventions on KAP B. Collect baseline data on metrics used to gauge the overall scale of the emergency (for example, number of infections, hospitalizations, or fatalities) before certain risk communication interventions and compare them with data aggregated after those interventions C. Account for the factors that could not be kept consistent over the course of the emergency, as multilayered interventions (related or unrelated to risk communication) D. Document the evaluation and extrapolate learnings that could be used to improve the operational plan going forward Collate Content and Key Findings A. Collate all content produced and disseminated as part of the risk communication interventions during the emergency B. Draft assessments of the performance of various content utilizing relevant findings from dynamic listening tools and the evaluation exercise C. Upload all content along with their assessments to the Knowledge Management System (as per protocols established earlier), and notify all stakeholders at the federal and provincial levels that the material is available for use whenever the need arises Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 23 SECTION 4: WAY FORWARD Ultimately, Pakistan’s emergency preparedness Finally, all stakeholders must make it a priority to advocate infrastructure requires a national level framework for for investment of resources in risk communication. risk communication developed with the consensus They must help establish strong relationships between of stakeholders in the provinces and other federating risk communication units and public health emergency units as well. This federal level framework should serve response centers such that the former is indispensable as the basis for a provincial consultation in order to to the latter. Stakeholders should use their insights develop that national framework. and existing evidence to convince leaders at all levels of governance that risk communication is not a mere At the same time, costed risk communication exercise in “advertisement” or “marketing”. It is, in operational plans customized to the ground realities fact, an endeavor that has the potential to safeguard of the region should be developed by provincial arguably the most precious, irreplaceable asset in this governments as well. It is critical that they integrate a world: life. multisectoral approach, which is the backbone of this federal level document as well. Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 24 ANNEX LIST OF STAKEHOLDERS CONSULTED The full list of Government stakeholders consulted for The full list of nongovernment stakeholders (health the development of this framework is as follows: development partners) consulted for the development of this framework is as follows: • Central Health Establishment • Foreign, Commonwealth and Development Office • Directorate of Malaria Control • Japan International Cooperation Agency • Expanded Program for Immunization • Kreditanstalt für Wiederaufbau • Maternal, Newborn and Child Health Program • United Nations Children’s Fund • Ministry of Climate Change • United Nations Development Program • Ministry of Health Services, Regulations and Coordination • United Nations Population Fund • Ministry of National Food Security and Research • World Bank • National AIDS Control Program • World Health Organization • National Disaster Management Authority • National Emergency Operations Center • National Health Emergency Preparedness and Response Network • National Institute of Health • National TB Control Program • Polio Eradication Program Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 25 BIBLIOGRAPHY Global Health Security Agenda (n.d.). A Partnership Against Global Health Threats. /ghsagenda.org/ https:/ Kemp, S. K. (February 2021). Digital 2021: Pakistan. DataReportal. Pakistan Telecom Authority (n.d.). Telecom Indicators. Retrieved December 1, 2021 from /www.pta.gov.pk/en/telecom-indicators https:/ The Center for Excellence in Disaster Management and Humanitarian Assistance (June 2021). Pakistan Disaster Management Reference Handbook. /reliefweb.int/sites/reliefweb.int/files/resources/CFE-DM-DMRH-PAKISTAN2021.pdf https:/ UNICEF (n.d.). WASH: Water, Sanitation and Hygiene. UNICEF Pakistan. /www.unicef.org/pakistan/wash-water-sanitation-and-hygiene-0 https:/ WHO EMRO (June 2019). Donor Update: HIV Outbreak in Sindh Province. World Health Organization. /www.emro.who.int/images/stories/pakistan/documents/who_donor_alert_pakistan_13_june_2019.pdf ?ua=1 https:/ World Health Organization Regional Office for the Eastern Mediterranean (n.d.). International Health Regulations. http:/ /www.emro.who.int/health-topics/international-health-regulations/index.html World Health Organization (2016). A Strategic Framework for Emergency Preparedness. Geneva. Licence: CC BY-NC-SA 3.0 IGO. World Health Organization (2017). Joint External Evaluation of IHR Core Capacities of the Islamic Republic of Pakistan. Geneva. Licence: CC BY-NC-SA 3.0 IGO. Multihazard Multisectoral Risk Communication Framework for Pakistan, 2021 26