At the same time, it was working towards universal child immunisation, a joint World Health Organization (WHO)/United Nation's Children's Fund (UNICEF) programme ratified by the United Nations General Assembly in 1985, that aimed to raise immunisation coverage against the five preventable childhood diseases (Diphtheria, Pertussis, Tetanus, Polio and Measles). The sixth preventable childhood disease that formed part of the Universal Child Immunisation Programme, Tuberculosis, already had immunisation coverage of more than 80 per cent in Colombia, so only five preventable diseases required further attention to contribute to the goal of reaching 80 per cent of the world's children below one year old, by 1990.
A decentralisation process was also under way in Colombia that had transferred the responsibility for primary health care services from the central government to the municipal authorities, under the direction of the mayors.
In this context, UNICEF proposed to the Ministry of Health that a communication strategy aimed at mayors and municipal authorities be conducted to stimulate action at the local level towards universal child immunisation and the eradication of polio. The strategy aimed to promote regular and continuous immunisation activities, rather than the concentrated but intermittent drives linked to national vaccination days, which had been the focus for most communication campaigns in Colombia and elsewhere up to that time.
The strategy consisted of converting the national immunisation objectives, for which the responsibility was frequently diluted between a number of institutions, into limited but concrete and important municipal objectives for local authorities to achieve.
With that purpose, activities to mobilise the authorities and communities around childhood vaccinations were developed:
- Individualised printed materials with data concerning the immunisation coverage of children under the age of one in the community, against the five preventable childhood diseases, were delivered to each of the 1,018 municipalities in the country.
- At the same time, proposals were offered to the mayors and their administrations for specific actions they might take, with precise objectives, for the benefit of children within their jurisdiction. The aim was to commit mayors and their administrations throughout the country so that they would assume a role of leadership and responsibility in striving to reach local immunisation targets that reflected the national targets set by the government.
- At the same time, the aim was to sensitise and mobilise local communities concerning the importance of their active participation in mobilising the resources of the community for the immunisation of its children.
Different activities were carried out in order to apply the strategy. The base principle applied was to make public significant information on vaccination coverage in the Colombian municipalities in order to generate positive changes through community pressure and authorities' actions. The key to the strategy, according to the organisers, was the premise that localised information has more impact in bringing change in a community than does more general information. If the information is placed within their particular context, the community can be made to feel responsible for the needed change. In addition, they are able to see more clearly that change can indeed be made to happen if the local services and the general population were to become more proactive.
The following were elements of this campaign:
Delivering of Individualsed Information
The strategy for vaccination materials took into account three different categories of municipalities: those that had already reached 80 per cent immunisation coverage; 370 municipalities with coverage of less than 80 per cent; and the 37 municipalities that in the previous three years had reported cases of polio.
Given these differences, it was thought that giving each municipality figures on overall immunisation coverage would not focus attention on the problem effectively, and it would therefore be important to provide data for each of the antigens (Polio, Measles and DPT) relative to each of the 1,018 municipalities in the country.
In order to obtain these data, the statistical information available in the Ministry of Health's Expanded Immunisation Programme was taken as a base. However, the way the data was organised was not appropriate to the situation. Therefore, it was necessary to design a computer programme that would extract information from the existing statistics classified by antigen, into classifications by municipality and by the three antigens featured in the campaign. This would establish the relationship between the susceptible population of infants of less than one year and those actually vaccinated in 1988 in order to determine the difference and, hence, the numbers of children lacking coverage.
In this way, data on the numbers of children in each municipality who were not covered for each of the antigens, rather than indicating the numbers of children who were vaccinated, were obtained. Additionally, for each municipality, a concrete immunisation objective was set by providing an estimate of the number of children in the community aged less than one year who would need immunisations in the next 12 months.
The Popularisation of Information
The objective of the strategy was not only to put pressure on mayors and their administrations, including the health services, but also to motivate communities to demand the services necessary to reach the immunisation targets. Therefore, it was necessary that the information was known and understood by a wide audience.
Taking into account that some mayors and most populations of small communities had a relatively low level of education and, in addition, were unfamiliar with health issues, it was thought necessary to popularise the information in a creative way in order to avoid confusion in the interpretation of the data. With this purpose, the percentages of coverage of each antigen for each municipality were converted into ratings (good, fair and low), concepts that could be easily understood by any type of audience. The ratings based on the following table:
|From 60% to 79%||Fair|
|DPT3 and Measles||Over 70%||Good|
|From 50 to 69%||Fair|
Once the information about each municipality was ready, the next step was to make it public. The immunisation posters were the chosen channel for carrying out the diffusion phase.
As designed, the poster pointed out the vaccination situation in each municipality: the number of children under one year that were not vaccinated in 1988 with the Polio, DPT and Measles vaccines and the rating (Good, Fair or Low) of the municipality for each antigen (Polio, Measles and DPT). The poster also informed about the number of children below one year that were in each municipality in 1989.
The master poster contained information that was applicable to the whole country, but leaving blank spaces that could be overprinted with the name of the municipality, the statistical information on immunisation coverage and the ratings specific to each municipality. In this way, 1,018 different posters, one for each municipality were designed, with print-runs that varied from a minimum of 50 copies to a maximum of 3,000 according to the population of the municipality. A grand total of 110,000 copies was produced.
The poster reproduced the final part of Juanita's letter to the mayor with its punch line - "I cannot give you my support yet, but you yes, you can give me yours" - as a means of reminding local administrations and making the link with the earlier campaign. The poster was illustrated by the faces of three girls and three boys, all less than a year old, each representing a different region of the country.
In the lower part of the poster was the campaign slogan, a call to action: "Mr. Mayor, let no child remain without immunisation at the end of your term office". And below this appeared the logos of the five institutions participating in the campaign: the Ministry of Health, UNICEF, PAHO/WHO, Rotary International Foundation and Procomún.
Explanation for the Mayors
As a complement to the posters, an explanatory leaflet was produced for the mayors, with the title, "What immunisation rating did your municipality receive?" The leaflet contained material aimed at motivating mayors in the performance of their new functions with regard to child health, explaining the significance of the ratings for immunisation coverage given to the municipalities, and inviting the mayors to use the data in the poster for their municipality as a departure point for reaching the objective expressed by the campaign slogan: "Let no child remain without immunisation at the end of your term of office."
The leaflet also presented ideas the mayor could easily put into practice. These included suggestions to: persuade their Committees for Community Participation in Health to give priority to immunisation; provide such services on a daily basis and the hours preferred by the community; locate the areas of the municipality where most of the unvaccinated children were concentrated and intensify actions there; keep their immunisation coverage statistics up to date; facilitate the training of vaccinators, the creation of immunisation posts and the distribution of vaccines; and promote the mobilisation of human, institutional and community resources in favour of immunisation. The leaflet also included information on types of vaccine, number of doses and the ages at which children should be immunised.
The top management in Colombia of the Ministry of Health, the Corporation for the Promotion of Municipal Communities (PROCOMÚN), UNICEF, Pan American Health Organization (PAHO)/WHO and the Rotary International Foundation signed a letter of introduction and support addressed to mayors, and this letter was sent with the posters and the leaflets. The letter explained the commitment of Colombia to the global aim of universal child immunisation and the eradication of polio and motivated mayors to commit themselves to this goal.
Democratisation of Information
Since the objective of the campaign was not limited to reaching mayors and their administrations, but also to reaching the whole community with information that would stimulate demand for services, it was clear that the posters should be given the widest possible distribution.
In order to guarantee this level of diffusion, both among the authorities and the community, and also to ensure that even in municipalities with only fair or low ratings the information would be properly disseminated, a broad distribution plan was designed. In addition to the mayor and the health services, the materials were sent to members of the municipal council, community action groups, Catholic priests, the offices of Telecom, the Caja Agraria (agricultural bank), Rotary Clubs, Governors of Departments, the Red Cross, the Colombian Institute for Family Welfare (Instituto Colombiano de Bienestar Familiar), the communication media and others.
For each of these recipients at the municipal level, separate rolled packages were made up with quantities of posters that ranged from 5 to 40 copies, with 3 copies of the leaflet, and a copy of the covering letter. The National Postal Administration distributed the 7,000 individualised packages free of charge.
In the case of the managers of the 870 local branches of the Caja Agraria, of the parish priests, and of the 135 presidents of Rotary Clubs in the country, cover letters from administrators at the middle and upper levels of their organisations were sent with the materials. These letters reminded recipients of the need for commitment to children and requested their special support for the campaign, in particular by displaying the posters in places of public access.
As a complement to the printed material, a 30-second television spot and radio spot were produced. Their purpose was to help sensitise the mayors and municipal authorities, and to create public awareness of the importance of their participation in the immunisation campaign and the need to mobilise local resources for it.
To obtain air time, just as in the earlier case of the "Juanita" spots, the cooperation of Inravision (the National Radio and Television Institute), of private television programmers and radio networks was sought. This resulted in ample free-charge broadcasting of the spots.
Launching of the Campaign for Public Opinion
The Ministry of Health, jointly with the top local management of UNICEF, PAHO/WHO, Rotary International Foundation and PROCOMÚN, launched the campaign in the presence of high-level public functionaries, representatives of governmental and non-governmental organisations, and of the media. In his speech, the Minister of Health appealed to the mayors and the media to participate in the effort to reach national immunisaton objectives.
To attract the attention of the guests to this ceremonial launch, a special invitation card was designed with the following text on the outside: "Do you know what immunisation rating your municipality was given?". When opened, the invitation displayed the message: "Make yourself aware of it and commit to ensuring that, in the municipality where you were born, no child remains unvaccinated."
Upon arrival at the site of the launch, each guest was given a copy of a poster with vaccination figures for the municipality of his or her origin. The intention was to obtain their commitment, whatever his or her field of activity, to support the immunisation targets set for their municipalities.
Immunisation and Vaccines, Children, Health.
The funding for the immunisation poster campaign was obtained from PAHO/WHO, Rotary International Foundation, and UNICEF. The funding covered production costs of the printed and audiovisual materials and preparation of the materials for dispatch. The radio and television broadcast time was given without charge and the distribution of the packages was also cost-free.
According to the organisers, the alliances created between the three funding agencies and the two national agencies to implement the strategy helped consolidate a model for inter-institutional cooperation around the expanded programme on immunisation, that still works today.
The application of this strategy also transformed national level data on immunisaton into local figures that seemed to be meaningful to the community. At the same time, it revealed the local reality, which national figures do not always reflect, and may even hide.
The accomplishment of this objective implied the mobilisation of different sectors of the society for the creation of an alliance in favour of child health, that counted on the support of politic authorities at the highest level and had its roots in the municipal communities.
According to the organisers, this was the first time that information about vaccination coverage was not only interpreted and delivered locally, but also was presented in the form of how many children were still missing immunisation, thus creating a precise target for every municipality.
Interestingly, according to the organisers, members of some smaller communities took such responsibility for immunising the children within the community that they set out to find the missing children and have their parents bring them in. Whereas the initial idea was mainly to create pressure on the local authorities (mayors, health personnel, etc.), it also had the effect in many communities of stimulating the community in general to put pressure on the parents of individual children.
United Nations Children's Fund (UNICEF), Pan American Health Organisation (PAHO), World Health Organisation (WHO), National Federation of Coffee Growers, Corporation for the Promotion of Municipal Communities (PROCOMÚN).
Fraser, Colin and Sonia Restrepo-Estrada, "Juanita: Putting children in the electoral arena. A case-study of advocacy and social mobilisation for children linked to decentralisation and elections in Colombia" UNICEF, 1994. ("Juanita: La ni