Ethiopian Reporter June 16, 2004
Mr. William Ryerson, founder and President of PMC, has a 30-year history of working in the field of reproductive health, including 15 years of experience in adopting the Sabido Methodology for behavior change communication to various cultural settings worldwide. He has also been involved in the design of research to measure the effects of such projects in a number of countries, one of which has led to a series of publications regarding a serialized radio drama in Tanzania and its effects on HIV/AIDS avoidance and family planning use. Mr. Ryerson was recently in Addis Ababa to be present at the second anniversary of the launching of PMC-Ethiopia Entertainment Education Radio serial that dramas that was observed last Saturday. Melese Telahoun of The Reporter who caught up with Mr. Ryerson posed a number of questions to him on PMC’s achievements on the international level in general and in Ethiopia in particular. Excerpts:
With your wide international experience and involvement in the area of population and reproductive health, what is your view on current population worldwide and in developing countries in particular?
I think it is a very serious problem. At current rates of growth, the world population is growing by more that 78 million a year. And most of that is in very poor countries that are unable to sustain their current population with adequate nutrition and so on. It is contributing to poverty. It is contributing to terrible problems in women’s reproductive health. It is contributing to environmental problems of a global nature as well as country-level problems. It is contributing to loss of bio-diversity, loss of wildlife, loss of wilderness areas and, of course, pollution and global warming that are a combination of population numbers and rates of consumption and waste products, particularly greenhouse gasses. These problems, are threatening in this century to cause very serious environmental problems, including not only the rising of ocean levels, but severe drought in some parts of Eastern Africa and other parts of the world, combined with over pumping of underground aquifers for irrigation that is leading to a situation where we are now depending on borrowed water to feed the world’s people. India, for example, is pumping out its underground aquifers at twice the rate of replacement from rainwater. The water table is sinking and sinking and at some point no one would be able to reach the water table for irrigation supplies. As a result, the agricultural system will crash. The same thing is true in China. The same thing is true in much of Africa, Europe, North America and Latin America.
So, in fact, many continents are now losing farmland because we are going from irrigated crops to desert. When that happens on a global basis, the demand for food, particularly grain, will exceed the supply. Agricultural experts predict that this will happen within the next twenty to thirty years, that there will be a huge unmet demand for food and that only those who have the money to pay for it will be able to afford skyrocketing food prices. That means poor countries will face massive starvation. All of this together spells out the potential for political instability and a huge amount of human suffering on a global level.
So doing what we can to change behavior with regard to family size, use of family planning, and of course the HIV/AIDS epidemic that is adding to poverty and human misery to help prevent more infections of that horrible disease are all critical needs and are being addressed by Population Media Center International through its behavior change communication programs.
There have been a plethora of meetings, conferences, panel discussions and what have you on these problems all these years. But hardly anything has been done on the ground. Do you think that there is a viable solution to that?
I would disagree that nothing is being done. In India, for example, twenty- five to thirty years ago, the average fertility rate was six children per woman. It is now somewhat over three. In Ethiopia, there has been little progress in terms of the birth rate coming down. And worldwide family planning services have grown in these years from ten per cent of the married couples in 1960 to about 60 per cent today. So, there has been progress. But there is still a huge number of people, married couples and sexually active people, not using contraception. The forty per cent non-users today outnumber the ninety per cent non-users in 1960 because of population growth.
Most of those people have access to services that have been made widely available. But for reasons related to either misinformation, religious objections, cultural and informational issues, many of those people have decided not to use contraception. And so, there is a huge need for informing people of the relative safety of planning of one’s family as opposed to adhering to childbearing throughout a lifetime. So, indeed there is a major hurdle ahead of us. But we also have discovered through the use of serialized dramas like Yeken Kignit, an Amharic drama, that it is possible to bring about wide-scale understanding and voluntary behavior change in a way that I think can lead to much more rapid stabilization of population size than many people think is possible. So, I remain a guarded optimist. I think there is a lot still to be done. There is no guarantee that it will be done. Some donors have mistakenly concluded that everything that needs to be done has been done and have withdrawn from support for family planning and population activities. There is a huge need now to re-double our efforts in this area and, if that is done, I do think that solutions are possible.
How about briefing us on PMCs primary purposes?
Our organization is focused on partnering with the mass media to inform and motivate people in a way that will lead towards stabilization of human numbers and bringing numbers into harmony with the ability of the environment and the economy to support people and a quality of life that is reasonable and to lessen the harmful impact of humanity on its environment. That is our overall mission. And our primary activity is the use of mass media strategies that we call the whole society strategy. PMC uses a variety of approaches to reach people from the print media to the broadcast media to the micro media. The centerpiece of our strategy is the use of long- running entertainment-education serialized melodramas in which characters evolve into role models for the audience for positive behavior with regard to reproductive health and status of women issues. In Ethiopia, of course, that includes three serial dramas: Yeken Kignit, Dimbiba, which are both being broadcast on Radio Ethiopia, and Maleda, distributed on cassettes along the route between Addis Ababa and Djibouti.
What is your yardstick for the effect of your global intervention versus the magnitude of the problems of poverty, environment, HIV/AIDS and so on?
The global intervention of PMC is inadequate at the present time to solve the problem in every country in the world. We are a fairly small and fairly new NGO. We were founded six years ago and we are active now in Ethiopia, Sudan, Mali, Cote d’Ivoire, Burkina Faso, Mexico, and Brazil. We have a small project in the United States that is trying to raise awareness of the American public on population issues through a national cartoon competition. We also have a number of other countries in which we are developing projects that are likely to get started this year. We are trying to scale up. Of course, that is dependent on donor resources. That is the major barrier to achieving what we need to achieve at a level that is commensurate with the problem that we are addressing. We really need to be working in fifty of the fastest-growing countries of the world now in need. And so we need a ten-fold increase in our resources in order to do an adequate job on a global basis.
Nevertheless, in the countries where we are working, we are using an evaluation methodology for measuring the effects of our program and for isolating the effects from all the other interventions going on so we can tell what the relative impacts of our intervention have been.
Have you done any such evaluation in Ethiopia?
Here in Ethiopia, for example, we have been doing nationwide monitoring of listenership through both focus groups and listener diaries. We have various reproductive health clinics, 48 of them in Amhara, Oromia and Addis Ababa, interviewing new clients to ask them their reason for coming in. And, indeed, the number who are naming radio information as their primary motivation to receive the services is increasing dramatically, and 96 per cent of those who identified radio as their reason name one of PMC’s programs. So, we know that we are having a huge impact on behavior with regard to seeking reproductive health services. We have also carried out a quantitative random baseline study in the regions we are serving, and we will do a post-intervention survey later this year to measure the effects in the relative change in knowledge, attitude and behavior among listeners and non-listeners in order to see the relative change among those groups.
So, we have an evaluation methodology that allows us to tell very clearly what our impact is, and we hope to take both the strategy of communications and the evaluation methodology to many more countries.
Where do you get your funds for running your projects?
That is always our big question. We have a combination of donors. We started out with a number of individual donors in the USA who helped us get started and who continued to support our work here, including those who give specifically for Ethiopia. We have donors in India, in Thailand and in many other countries. But most of our support is in the United States. We are a US registered charity. We also have attracted foundation support. Our biggest foundation donor and the biggest donor in Ethiopia is Packard Foundation. We also have attracted government support both from the government of Ethiopia through the HIV/AIDS Prevention and Control Office (HAPCO) and the government of the United States which, through USAID, has provided us with a grant in response to a proposal for a project in Francophone West Africa. We have support from a number of UN agencies. The UN Population Fund supported us in doing 14-country project in Africa and Asia. This was not doing serial dramas but training in the Sabido methodology of serial dramas for eight countries in Africa and six countries in Asia. So, we have indeed a variety of donors and donor types. We turn to donors of all types to enable us to do our work.
How much money are we talking about when it comes to donation used for your activities in Ethiopia?
It is much easier to tell you how much our Ethiopia project has received over a four-year period. The Packard Foundation has provided one million dollars for the serial drama project plus another 200 thousand dollars for a multi-media activity, plus 200 thousand dollars, for a project to build capacity of journalists, to cover reproductive health issues and population issues. HAPCO is supporting us at the level of just over 100,000 US dollars a year. The Hughes Memorial Foundation has provided 75,000 dollars in a three-year time frame that will not be renewed this year. This is because they tend to support projects just for a short period of time and then move to other projects. And then there is another 50,000 US dollars contributed by individuals. In addition to that the CDC purchased some airtime. I think it was a 16,000 US dollar block of airtime in which one of the serials was played. Care Ethiopia has provided us 63000 dollars to support our serial drama project and then there is support for other related projects from IPAS and Save the Children- USA.
I understand that your media communication approach is research- based and follows the Sabido Methodology. What is Sabido Methodology? And how does it serve your purpose?
This is a very important question. Many people say, ”Well, we have heard that entertainment serial dramas can be used for promoting social change.” But they don’t understand there is quite a complex methodology behind us.
Miguel Sabido was a producer of prime time television serial dramas in Mexico. He developed a methodology based on social science research into what causes people to adopt certain values and related behaviors, and what causes people to change their values and behaviors, including role modeling by parents and peers, creation of modeling among movie actors and characters in entertainment programs. It also includes communications theory, dramatic theory, the theory of the multiple levels of the human brain function (intellectual, emotional and instinctive), theories regarding non-verbal communication and how they work, such as tone of voice and lighting, sound effects and music, theories related to archetypes and stereotypes. All of these have been put together into a theoretical framework by Miguel Sabido for use of serialized dramas with multiple sub-plots and overall plot framework in which at least one of those sub-plots stresses a social issue. And his first application of this methodology was through a serial drama dealing with the problem of illiteracy in Mexico. He was inspired to do this by the Mexican ministry of public education that was carrying out an adult education drive by using public service announcement to try to recruit people into adult education programs. And, in one year’s time, with that strategy, the ministry recruited 99,000 people to sign up into adult education classes. Sabido went on the air the next year with a serial drama on Televisa, which is a big commercial network. And of course he had to have high ratings in order to keep it on the air. So he made it highly entertaining.
But in one of the sub-plots he had these illiterate characters and under the influence of characters who were in favor of adult education and the conflicting influence of negative characters who thought adult education was a waste of time. These identification characters made a gradual transition to finding out about adult education and the infrastructure for it; to thinking perhaps they did have the ability and the brain power to go through such classes, to registering, struggling through the classes, getting their diplomas, and then finding that, because they are independent now, able to read and write, their lives were improving. And he showed all this without giving people messages, just showing the evolution of these role models with which the audience was identifying. In fact, this program was so popular that it had 33 per cent of the nationwide viewership watching every episode. It was on for five nights a week for one year. So a total of 260 episodes.
As these characters started to go into the classes, and then come out, and their lives improved the audience observed that and said, maybe I could do like this man did and go through these classes and my life would improve. Sabido started to run epilogues in which he gave addresses of registration sites for adult education. The first epilogue followed the episode in which his most popular character received his diploma in a very emotional scene. He was an elderly man who had been saving the letters from his granddaughter that he had never been able to read and, now, finally, he could read these letters. Holding his diploma he broke down in tears because he was so happy and so relieved after all this time to be receiving his diploma. And then Sabido ran this epilogue in which he said perhaps you too would like to do what this man did. And he warned the ministry of public education that this episode might generate a crowd. And they said, we like your program very much. But there is no problem because we are set up to handle large numbers. After all, the year before your program started, we signed up 99,000 people.
So Sabido broadcast that episode, and the following day, 250,000 people came to register for adult education, in one day’s time. Before the serial ended a few weeks later, they had signed up 840,000 people, more than eight times the year before. Most of that was as a result of the serial drama and this was a drama that was profitable because it was commercially sponsored and yet did a great deal of good for Mexico.
Sabido then went on to do a program promoting family planning as a way of ensuring family harmony in married life and again caused a huge increase in the number of people seeking family planning in clinics. His application of this methodology through teaching in India, in Kenya, here in Ethiopia and in other countries has led to massive population-wide changes in behaviors with regard to reproductive health issues over and over again when it has been successfully employed.
And we believe the program here in Ethiopia will have a similar result. It is being very well done. And it is very popular and we think that it will contribute a great deal to behavior change.
Your organization has, among others, selected Ethiopia for carrying out its mission. What was its justification?
Two things. I came here first in 1999 to explore interest on the part of the Ethiopian government in having such a program and got a very strong positive response. They said they would like to have such a program, that nothing like this has ever been done in Ethiopia before and they are beneficial.
One of the reasons to come here is Ethiopia is it the second most populous country in Sub-Saharan Africa. And it is, therefore, from a demographic perspective, very important. It is also one of the most impoverished countries, has faced repeated droughts and famines. But these famines and endemic poverty are likely to continue until the population growth rate slows significantly. The situation is different in other countries that have taken measures to effectively control their population sizes. Rather than people spending all of their money on just survival, there is money left over for capital formation, purchasing of electric goods that would stimulate the manufacturing sector and investment in both infrastructure and the building of businesses to improve productivity and in education and all of the things that would lead to enhance productivity and develop the economy. Over and over again when these countries have brought their birth rates down, their economies have taken off. This is true of Brazil. This is now true of China. It is true of all the countries since World War II that the UN has re-classified from developing status to developed status.
Japan, Hong Kong, Singapore, Taiwan, South Korea, Barbados, the Bahamas, all of those have been classified as developed. And the way their economies took off was first, they brought their birth rate down. People had money left over that they weren’t spending on just food, housing and clothing for children. It made more capital available, allowed for economic growth, and the economies took off and per capita income went up rapidly. And, of course, we are saying this now and some of the Asian tigers, particularly China, that has used a strategy for bringing its birth rate down that I don’t think has been as effective as just persuasion would have been. China is starting to switch from coercion to persuasion thankfully. But, indeed, their economy is now one of the fastest growing in the world. And it relates directly to the demographic change that has occurred.
So, from our perspective, Ethiopia is one of the most important countries in Africa and in the world to address problems of poverty and population growth and we are very happy to be working here.
The United Nations Fund for Population Activities (UNFPA) and a number of other organizations, including the Family Guidance Association of Ethiopia (FGAE), have been operating in Ethiopia for quite sometime now. But in spite of that, the population explosion in the country still continues. What do you think of that?
It is quite simple. Contraceptive services alone are not sufficient to bring down the birth rate. Certainly they would contribute to the reduction of the birth rate because, by providing services such as FGAE does, you provide what some people have been looking for. You meet the unmet demand for family planning services and a lot of those who want to limit or space childbearing. But, as I said, increasingly, among the non-users of contraception, you find people who are not persuaded that they should plan their families or who want very large family size, and changing desired family size through information and motivational communications and role modeling to achieving that second step of getting the non-users to access the services that have been made available. So, indeed, Population Media Center is filling one of the important missing ingredients for stabilizing population by providing the communication and motivation to people to access the services that groups like the UNFPA and FGAE have been providing.
We have learnt from reports that the PMC Ethiopia media communication program is following a Sabido methodology research based approach. Has it made any progress?
Yes. It is doing well on that. Sabido and some people trained in Kenya and other places came here as part of the training for the writers and the producers here. And, they have followed very carefully the qualitative research step to look at what the people think, other major issues and to build those issues into the program, to look at the official policies of the government with regard to the issues that are going to be addressed so that the values that are being promoted are based on the polices of the country, and then to create characters who represent the positive values or the negative values with regard to those issues as well as ambivalent characters who make a transition from the norm of society to the positive values.
The negative characters oppose the official policies of the country just like you find in real life. And yet, ultimately, the consequences of their behavior are what audience observes affecting them.
So characters, who, for example, oppose family planning and don’t use family planning will ultimately suffer from the poverty that results from unplanned parenthood. Characters who are not in favor of the preventive steps that are necessary to avoid HIV/AIDS infection will expose themselves to infection by the virus, and they will suffer from that.
The audience will observe the negative consequences of the negative characters’ behavior and the positive consequences of the positive characters’ behavior. They will observe how the transitional characters manage to bring about change in their own lives despite all the obstacles that one faces in changing their behavior. And those characters will show the audience the way to a new social norm. So, that is basically what we are doing here.
Do you have any message to get across to donors?
I think that the critical thing for donors to think about is, when they are thinking about how to invest their available resources in projects to assist the development of Ethiopia, they need to ask two important questions. One is what is the track record of the strategy that is being proposed by any organization to show the effectiveness of their strategy as it has been applied in other countries. Do they have that track record? PMC of course has experience in many countries with the Sabido methodology and has a lot of data that, country-by-country, describes the results of this strategy. The second question that donors need an answer to is: What is the cost per person of the strategy that is being proposed? And, therefore, can it be scaled up to serve the people of the entire country at a reasonable cost? Some people propose smaller projects that reach a small number of people. But if you were to try to reach 70 million people with the strategy, it will be far too expensive.
We were able to demonstrate in an experiment in Tanzania that we were able to save lives by getting people to change behavior to avoid HIV/AIDS infection at eight US cents per person and to adopt family planning at a cost of a new adopter of 80 US cents. So it is very cost effective – more than any other known strategy in the field of HIV/AIDS prevention. It is, therefore, less important to know what the total cost of a project is than what the cost per person affected is through such an intervention.
PMC Ethiopia started operating in Ethiopia some four years back. What do you believe are its major achievements so far?
Certainly, the research that we have carried out has been an achievement in itself. We have provided information to the government and to NGOs and stakeholder agencies, such as the UN agencies, through the research we have carried out that is unique. We have both qualitative and quantitative research with regard to reproductive health issues among the general population. We carried out a media consumption analysis and analysis of other media strategies that have been used over the last decade or more, an analysis of the health service infrastructure, and all of that information been proved valuable. In fact, among the 41 publications that we have, some of these documents, including our baseline survey, have been made into official government documents, and the baseline survey was adopted by the Ministry of Health as an official Ministry of Health publication. So the research has been valuable.
But beyond that now, the three serial dramas, the two on radio and the one on audiocassettes, are already clearly causing huge amounts of behavior change as well as changes in attitudes among the population. We have documented that in the reports that have been presented in our review meetings. On top of that, we have other activities – training of journalists, traveling stage plays and national competitions for creative writing dealing with reproductive health issues – that has resulted in two books are being freely distributed to schools, and youth clubs and documentaries that we are preparing on population issues on video for distribution throughout the country. There is a wide variety of projects and activities, that we have carried out in Ethiopia that have been making contributions to the country’s development. The two radio serial dramas are now being listened to by about half of the new clients seeking reproductive health services in clinics. Beyond just the behavior change of people seeking services, whether it is family planning or testing for HIV/AIDS or treatment for HIV/AIDS, or in the case of men coming in to seek condoms at family planning clinics or to seek treatments for sexually remitted diseases (STD’s), there is a huge amount of behavior change that we can demonstrate as attributable to these serial dramas. So, that is a major achievement to date. On top of that, the data that we have so far collected from listener group diaries and from focus groups that have been carried out quarterly shows that, among those people, there is a lot of self-reported behavior change going on.
The quantitative report on how much behavior change has occurred throughout Amhara and Oromia regions will be known after we do the survey that is scheduled for November. So, I can’t give you a lot of quantitative information. But it is clear from what we have been getting from clinic sites that there is a lot of behavior change going on.
Have the achievements scored so far by PMC- Ethiopia surpassed your initial expectations?
No. They haven’t surpassed our expectations. I am quite pleased with them. But because I have been working with the Sabido Methodology now for two decades, I have seen over and over the kinds of accomplishments that are made in various countries. I guess I would have to say I am not surprised by the accomplishments here. But I am very pleased and very proud of the great job that the PMC staff in Ethiopia, the Country Director Dr. Negussie Teffera, the writers, the actors, actresses are all making a huge contribution to the future of this country. It is meeting my expectations. But I had very high expectations at the outset.
Could you give us an idea of your future short-term plans in Ethiopia if any?
That is a difficult question to answer. Certainly we are planning the next four-year phase of our work in Ethiopia, and we have still a lot which we want to do in this country. Our intervention, one or two serial dramas, are not going to solve all the problems in this country. But, we believe, based on the experience PMC personnel have had in a number of countries, we can bring about rapid change and that it will lead to improvement on the quality of life in Ethiopia. Whether on a country or on a global level, to be an optimist or a pessimist about the human situation is something that is hard to decide. There are lots of things going against us which I talked about earlier: the problem humanity is facing, some of the environmental, economic, political and other issues that we have as a global society. And in a country like Ethiopia, there is no shortage of problems that the people are struggling against. But on the other hand, we know what is needed to be done. We have learned a great deal over the past twenty-five years through the application of the Sabido Methodology in various countries. And so, we really know what to do as long as we can mobilize the resources to make it happen, we can make progress and improve peoples’ lives.
We are planning an intensification of our broadcast program in Ethiopia within the next four years. We have been doing two episodes a week in the Amharic program and one episode a week in the Oromiffa program. We are hopping to move to do additional episodes in the coming four years for even greater impact on attitudes and behavior as well as the various other types of interventions that I have described that we will carry on.
Have you faced any challenges in the process of making efforts to realize your mission?
The biggest challenge is resources, and yet money is available. There are institutions receiving funds that have not been able to spend all the funds that have been made available to Ethiopia. But getting through the bottleneck and getting those funds to support the work that we are doing is a critical issue and can be a barrier to our progress. Clearly from our perspective, providing resources to enable the project to move forward at an intense level with very clear and transparent expense budgets that are understood by all partners is an urgent need.