Manara Policy Series | Part One of Four
The Moment That Makes the Question Urgent
Pakistan is no stranger to public crisis. Over the past two decades, the country has confronted polio, rapid population growth, repeated climate disasters, a global pandemic, recurring heatwaves, and the relentless spread of digital misinformation. In each of these episodes, government institutions, international agencies, and civil society partners have reached for the same essential instrument: public communication designed to shift behavior.This instrument goes by a formal name: Social and Behavior Change Communication, or SBCC. It is defined, broadly, as the strategic use of communication to promote positive health and social outcomes, grounded in theories of behavior change and tailored to the specific social, cultural, and structural conditions of target populations (Wikipedia, 2025). In practice, it encompasses everything from door-to-door community engagement and mass media campaigns to interpersonal counseling, social norms programming, and digital outreach.SBCC is not a peripheral function of public policy. It is central to how states build the social conditions for effective service delivery. A vaccine does not protect a child if a parent refuses it. A nutrition protocol does not reduce stunting if a household cannot access or afford nutritious food, or does not understand why complementary feeding matters. A heat warning system saves no lives if communities do not trust the institutions issuing the warning, or cannot act on the advice being given. Communication is, in this sense, the connective tissue between policy design and population behavior.What makes Pakistan a particularly instructive case is the scale and diversity of its SBCC experience. Over several decades, the country has implemented campaigns across polio eradication, population welfare, family planning, maternal and child health, girls' education, agricultural extension, sanitation and hygiene, nutrition, COVID-19 prevention, and climate-related hazard response. Some of these efforts have been among the most intensive public communication exercises in the region. Yet the lessons from these campaigns remain largely siloed, each documented within its own programme framework, rarely examined together.This article is the first in a series that begins to ask: what does Pakistan's accumulated SBCC experience tell us, taken as a whole, about the relationship between messaging and social change?
What Has Been Built
It would be a mistake to open this inquiry with a deficit framing. Pakistan has developed real institutional capacity in public communication over many decades, and that capacity deserves acknowledgment.The most visible example is the polio eradication infrastructure. Today, approximately 400,000 vaccinators conduct door-to-door campaigns to reach over 45 million children across Pakistan during each immunization round (Global Polio Eradication Initiative, 2025). Roughly 68 percent of frontline workers in the polio programme are women, precisely because female health workers can cross social and cultural barriers that male workers cannot, entering homes and building trust with mothers in ways the programme has recognized as operationally essential (PMC, 2025). The social mobilization architecture behind this effort, coordinated through Emergency Operations Centres at federal and provincial levels, linked to Union Council-level officers, and supported by community health workers and social mobilizers, represents one of the most extensive community engagement systems in the developing world.This infrastructure has also begun to evolve in thoughtful directions. Pakistan's National Emergency Operations Centre surveyed more than 2,600 female frontline workers in the highest-risk districts, then convened 14 in-person workshops across the country to listen to their experiences and co-design solutions (Global Polio Eradication Initiative, 2023). Pakistan was the first country in the Global Polio Eradication Initiative to launch such a co-design programme, a recognition that frontline workers are not simply messengers but a source of knowledge about the communities they serve.Population welfare communication has its own long history in Pakistan. The country's first Family Planning Scheme was launched as part of the Third Five-Year Plan of 1965 to 1970, and mass media became a central vehicle for population messaging from the 1970s onward (Country-Data, n.d.). One of the most cited examples from this era is "Aahat," a six-part prime-time television drama broadcast on Pakistan Television Corporation (PTV) in 1992, produced jointly by the Ministry of Population Welfare and Johns Hopkins University's Population Communication Services. It was, by the accounts of those who documented it at the time, the first instance of modern contraception methods being successfully promoted on Pakistani mass media (comminit.com, n.d.). The drama targeted middle and lower-middle income men and women, aiming to increase awareness of birth spacing, improve husband-wife communication on family planning, and encourage clinic visits. It drew on the entertainment-education model, embedding behavior change messages within narrative storytelling rather than instructional messaging. This approach reflected an awareness, even in the early 1990s, that persuasion requires more than information. It requires emotional resonance.Alongside population welfare, PTV also served as a platform for agricultural extension. From its early years, PTV's stated programming mandate included awareness-raising on agricultural development, covering themes ranging from crop management to the proper use of pesticides and fertilizers (ArchivePK, 2016). For a largely rural population with low literacy rates, broadcast television and radio functioned as primary channels for practical agricultural knowledge, including guidance on the timing of pesticide application and input management, information that for many farming households arrived through no other route. Research on television viewing habits among Pakistani farmers has confirmed that for rural communities, broadcast media represented the most accessible and trusted source of agricultural guidance, particularly in areas where extension services were weak or absent (ResearchGate, 2012).The Meena Communication Initiative is another reference point that deserves recognition in Pakistan's SBCC history. Developed by UNICEF and first broadcast in the early 1990s, the animated series featured a nine-year-old South Asian girl navigating issues of education, health, gender equity, and child rights. In Pakistan, Meena and her brother Raju were designated Ambassadors for Children's Rights, and the initiative was systematically integrated as a communication resource across education, health, and girl-child rights programming (Tribal Cultural Heritage in India, n.d.). The series was broadcast in Urdu and adapted with country-specific cultural sensitivities, including modifications to character depictions based on Pakistani social norms (OnlineKhabar, 2021). The Meena initiative addressed one of the most structurally entrenched challenges in South Asian development: the social normalization of girls' exclusion from education. It did so not through instruction but through identification, giving girls, and their families, a figure to relate to and aspire toward.The COVID-19 response offers a more recent institutional reference point. At the height of the pandemic, a Communication Cell was established within the Ministry of Health, supported by UNICEF and the Bill and Melinda Gates Foundation, staffed by communication specialists tasked with monitoring and countering misinformation across social, print, and electronic media, coordinating messaging across government departments, and providing regular briefings to the National Command and Operations Centre (PMC, 2024). The cell operated as a real-time communication management function, something few comparable contexts had put in place systematically.In family planning, the Lady Health Worker programme remains a foundational channel for community-level communication on reproductive health, nutrition, and maternal care, reaching populations that neither formal health facilities nor mass media campaigns consistently reach. In WASH programming, UNICEF-supported behavioural determinant studies have generated substantive evidence on what drives sanitation and hygiene behaviors at the household level. In nutrition, social and behavior change components have been integrated into programs combining cash transfers with complementary feeding support, with cluster randomized trials offering evidence on their effectiveness (Soofi et al., 2022).This body of work reflects genuine investment in SBCC. It is not a history of inattention.
What Has Remained Structurally Constrained
And yet, across most of these domains, a set of recurring structural tensions can be observed, even from the existing sectoral literature.The first is the gap between messaging and the structural conditions that make behavior change possible. UNICEF's own guidance on SBCC acknowledges that the field has too often been reduced to information dissemination, used to encourage compliance without addressing the underlying barriers that stand in the way of the desired behavior (UNICEF SBC Guidance, 2025). In Pakistan, this pattern is visible across multiple sectors. Sanitation campaigns are harder to sustain when households lack water connections. Nutrition messaging has limited impact when food insecurity is structural rather than informational. Heat action warnings are less effective when populations have no access to cooling, electricity, or shade. Behavior change that is not supported by structural change tends to remain thin and reversible.Pakistan's population welfare experience makes the same point in a different register. As one senior government advisor documented in the 1990s, low uptake of contraception in Pakistan was less a product of ideology or religious objection and more a product of access and poverty: people could not make use of family planning services they could not reach or afford (PubMed, 1992). Decades of public communication campaigns did not fully resolve this, because the communication was outpacing the service infrastructure it was meant to support. The agricultural extension case mirrors this: broadcast messaging about proper pesticide timing and application reached farmers who lacked access to quality inputs, affordable credit, or trusted extension officers to guide implementation, limiting the translation of knowledge into practice (ScienceDirect, 2007).The second tension is fragmentation. Pakistan's SBCC landscape has developed largely through project-based financing, with separate programmes in each sector operating on their own timelines, communication architectures, and institutional logics. The Lady Health Worker network, the polio social mobilization system, the COVID communication cell, the WASH behaviour change programme, and the heat action plan in Karachi have each developed in relative isolation from one another. There is no shared national framework defining common standards for formative research, message development, channel selection, or impact evaluation across sectors. The institutional knowledge generated within each programme tends to remain within that programme.The third constraint is the funding cycle. Many SBCC interventions in Pakistan have been financed by project-bound donor funding with fixed durations. Community trust, which is the foundation on which behavior change communication actually works, takes time to build and is quickly eroded when programmes close, staff change, or messaging cycles end. The polio programme's experience with vaccine refusal in high-risk union councils points directly to this: in communities that have experienced repeated campaign visits without accompanying improvements in health services or living conditions, communication fatigue and distrust have grown alongside campaign intensity (Ahmed et al., 2025). Research documents the tension clearly: in some contexts, focusing on OPV education and mobilization alone, in the absence of authentic dialogue and responsive service integration, may not increase vaccine coverage in the most resistant communities (Independent Monitoring Board of the GPEI, 2019, cited in Ahmed et al., 2025).The fourth tension concerns the digital environment. During the COVID-19 period, Pakistan experienced what researchers documented as a sharp rise in health-related disinformation in 2020, with false messages circulating across WhatsApp, Twitter, and YouTube, including fabricated government health alerts, conspiracy theories about vaccine contents, and misinformation about treatment (Friedrich Naumann Foundation, 2021, cited in Media Support International, 2023). Analysis of COVID-related messages across 227 public WhatsApp groups in Pakistan found that while misinformation represented approximately 14 percent of COVID-related content, misinformation messages had the longest circulation lifetime of all content categories, remaining in circulation longer than news, religious information, or verified public health content (Javed et al., 2022, cited in Media Support International, 2023). This dynamic is not unique to COVID; fake anti-vaccine videos targeting Pakistan's polio campaign in 2019 led to the suspension of vaccination drives in parts of the country and left over two million children temporarily unvaccinated (Media Support International, 2023).The point here is not that communication failed. It is that the communication environment has shifted in ways that make traditional SBCC models increasingly insufficient on their own.
A Changing Risk Context
The structural challenges described above have existed in various forms for years. What makes this moment distinct is that Pakistan's risk environment has changed in ways that raise the stakes considerably.Climate change is no longer a future concern for Pakistan. It is a present operational reality. The 2015 heatwave in Karachi affected 65,000 people in less than ten days, treated 40,000 in hospitals, and resulted in approximately 1,200 deaths (Karachi Heatwave Management Plan, 2017). That event, while devastating, also catalyzed institutional action: Karachi developed a Heat Action Plan, the first in Pakistan, drawing on technical assistance and lessons from Ahmedabad's experience in India (Karachi Heatwave Management Plan, 2017). But heatwave mortality and morbidity remain a recurring challenge, with research from tertiary care emergency departments in Karachi documenting continued pressure on health systems during subsequent heat events (JPMA, 2025).Pakistan ranks among the countries most exposed to climate-related health risk, despite contributing considerably less than one percent of global greenhouse gas emissions (PMC, 2023). Floods, droughts, vector-borne disease expansion, urban heat stress, and food insecurity will increasingly interact with Pakistan's existing social vulnerabilities: gender inequality, low literacy in rural areas, inadequate housing in urban peripheries, and fragile health system capacity. Each of these conditions changes the behavioral terrain within which communication campaigns must operate. Climate stress also creates compounding communication challenges: populations managing acute food insecurity, displacement, or heat-related illness are harder to reach with preventive messaging, and harder to persuade toward behaviors whose benefits are deferred.At the same time, the digital information environment continues to shift rapidly. Smartphone penetration is rising. Social media platforms have become primary information sources for large portions of the urban population. And the speed at which health-related misinformation travels through encrypted messaging platforms has outpaced most institutional communication responses. Pakistan's experience during COVID-19 illustrated both the possibilities and the limits of a centralized communication management model when the information environment is distributed and often unmonitorable.Trust, finally, is not a fixed resource. It is earned and lost through repeated interactions between communities and institutions. Where public agencies have delivered on promises, brought vaccines, services, and responsive communication, trust has in many cases been sustained. Where campaigns have been persistent in messaging but unresponsive to community needs and grievances, trust has eroded. The existing literature from Pakistan's polio programme suggests that in some of the most resistant communities, what residents object to is not just a specific vaccine but a broader pattern of being communicated at rather than engaged with (Ahmed et al., 2025).
Why a Systems-Level Reflection Is Now Necessary
Pakistan's SBCC experience has generated genuine knowledge. The polio programme's social mobilization system, the community health worker infrastructure, the COVID communication cell, the Karachi Heat Action Plan, the population welfare television campaigns of the 1990s, and the body of behavior change research attached to maternal health, nutrition, girls' education, and WASH programming collectively represent one of the most substantive repositories of applied communication practice in the region.What that experience lacks is a coherent systems-level analysis that cuts across sectors, asks comparative questions, and draws structural conclusions. The existing evaluations are sector-specific and programme-bound. They describe what worked within a particular programme at a particular time, but they do not ask what Pakistan's accumulated SBCC experience reveals about the conditions under which behavior change communication succeeds or fails as a function of governance, financing, institutional design, and community trust.That kind of analysis matters more now than it did ten years ago, because Pakistan is entering a period in which the frequency, severity, and complexity of public health and climate-related challenges is increasing. Heatwaves will recur with greater intensity. Infectious disease risks will multiply in climate-stressed environments. Digital misinformation will continue to complicate public health communication. And the populations most exposed to these risks are precisely those who are hardest to reach through conventional communication channels.A systems-level review of SBCC in Pakistan would need to do several things that no existing document does: synthesize lessons across major campaign domains; examine how governance structures and financing cycles shape communication design; assess how Pakistan's evolving risk environment changes the behavior change landscape; benchmark Pakistan's experience against international frameworks for social norms programming and Communication for Development; and propose a forward-looking model for SBCC in an era defined by climate-health convergence.
Introducing the Forthcoming Inquiry
This article is the first in a series that Manara is publishing as part of a broader analytical initiative. The series will examine what Pakistan's SBCC experience, taken as a whole, can tell policymakers, donors, and development practitioners about the design of more resilient, systems-aware communication programs.The forthcoming Manara white paper, Messaging, Meaning & Social Resilience: A Systems Review of SBCC in Pakistan, will undertake a structured desk review and comparative systems analysis, drawing on the existing body of programme evaluations, academic research, and international frameworks. It will not replicate what the sector-specific literature has already done. It will attempt, for the first time, to connect the dots across those evaluations and ask what the pattern suggests.The argument behind this inquiry is simple. Pakistan has done more in the field of SBCC than the analytical literature has yet captured. It has also entered a moment in which the adequacy of its existing communication systems will be tested in new and demanding ways. Understanding what has been built, where the structural constraints lie, and what a renewed systems approach might look like is not a technical exercise. It is a strategic imperative for a country navigating compounding risks with limited institutional bandwidth.Between messaging and meaning lies a significant gap. Closing that gap, carefully and on the basis of evidence, is the work this series begins.
This article is the first in Manara's four-part policy series on Social and Behavior Change Communication in Pakistan. It accompanies the forthcoming white paper, Messaging, Meaning & Social Resilience: A Systems Review of SBCC in Pakistan.
References
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