This spring marks the end of the eight-year, $500-million Breakthrough ACTION project, USAID’s flagship social and behavior change initiative.

The list of accomplishments for Breakthrough ACTION is too long to spell out, but some numbers resonate the loudest: reached one billion people with its COVID-19 prevention messages, published more than 30 peer-reviewed manuscripts, cut child marriage rates in half in focused regions in Nepal, doubled the number of people who said they would use family planning in the future through the West Africa Breakthrough ACTION project, helped residents in a small town in Liberia build their first water pump, helped a community in Nigeria build a bridge so they could access the health facility even in the rainy season, and so much more.  

Elizabeth Serlemitsos has led the project since the beginning, following a long career at CCP based in Africa, including steering CCP’s work on the Ebola epidemic from 2014 to 2016. She has been at CCP since 1993. A lifelong learner, she is also a candidate for a DrPH at the Johns Hopkins Bloomberg School of Public Health.  

She sat down recently to discuss the past, present and future of the field with Stephanie Desmon, CCP’s PR and Communications Director.  

Their conversation is condensed and edited for clarity.  

Desmon: The Breakthrough ACTION project was awarded to CCP by USAID in 2017 to use social and behavior change (SBC) to improve the lives of people in what ended up being more than 40 countries. What would you say is the biggest accomplishment of the project?  

 Serlemitsos: Breakthrough ACTION has completely changed the landscape of social and behavior change. In that process, we have built a global capacity with a shared SBC mindset. For example, in Sierra Leone … we really started focusing on behavioral determinants of health and how to change behavior, not just giving people information. In the Sahel region of north-central Africa, as another example, we helped build out national innovations team, which were tasked at looking at challenges such as food security, climate resilience, health and education through an SBC lens. And again, that was really about changing people’s mindset, about thinking about social and behavior change so differently from the way in the past.

People often thought that giving people information was enough to change behavior – the idea that if I tell someone what to do, they will do it. But we know that it is not enough. Interventions like the national innovations teams really transformed that thinking. These teams, created with the help of our partners Save the Children and ideas42, brought innovation into coming up with the solutions to address those challenges.  

Desmon: One of the things that has always struck me is how critical it is to involve communities in developing the interventions needed to help people live healthier lives. It feels like you dialed that up to another level during Breakthrough ACTION.  

Serlemitsos: For CCP and for many of us who’ve been working in this field for a long time, there’s been this evolution to truly embrace what it means to work with a community to identify local problems as well as local solutions.   

 Breakthrough ACTION continued to build and expand on this by ensuring that communities were front and center in the design of any type of activity. This included having a seat at the table or a voice in the design process, embracing that concept of the lived experience being essential to developing a solution that was going to bring about change.  

It isn’t the role of a project like Breakthrough ACTION to just go into a community and tell them how to fix their problems. Our role is to talk to community members to understand what change they deem necessary and how they think it can best be accomplished. We just facilitate that process.  

Desmon: As you said, Breakthrough ACTION completely changed the landscape of social and behavior change. Are there some specific accomplishments you’d like to share?  

Serlemitsos: Credit goes where credit is due. Breakthrough ACTION sat on the shoulders of all the SBC projects that have gone before and wasn’t just coming out of nowhere.   

One example was something we accomplished alongside our sister project Breakthrough RESEARCH [which ended in 2022]. We worked together on what we call a costing analysis.  

This key document gave us the evidence to show that SBC is a cost-effective approach to behavior change. It really gave us an extra tool in our toolbox of making the case for why social and behavior change is so important and worth investing in.   

I’m also extremely proud of Breakthrough ACTION’s work around provider behavior change, which continued to elevate the work CCP started under the Health Communication Capacity Collaborative [the USAID-funded pre-cursor to Breakthrough ACTION which ran from 2012 to 2017]. Some clients had complained that providers judged them for being too young for family planning or for wanting to delay having children or for wanting to slow down if they had only one or two children, which turned them off from the family planning clinic. There needed to be a better interface between clients and providers. Under Breakthrough ACTION, we developed the provider behavior change ecosystem which expanded our understanding of how providers behave, why they behave the way they do, and what can be done to support providers to address their needs and improve their interaction with their clients.  

I also am extremely proud of the capacity strengthening work under Breakthrough ACTION. Again, building on the long tradition of capacity strengthening at CCP, in addition to all the workshops and on-the-job training we provided, we built an online platform, SBC Learning Central, which strengthened SBC knowledge and skills and awarded nearly 6,500 certificates for the courses offered online.   

Another thing that I’m very proud of is the partnership we had with Meta to develop the COVID behaviors dashboard. They put out our knowledge, attitudes and practice survey on the Facebook platform and we were able to collect data from all over the world and provide countries with data to inform their COVID response, their risk communication and community engagement responses. In the countries where there are a lot of Facebook users, there was an extraordinary amount of data. We provided weekly reports for 67 countries, and we ended up even providing weekly briefings to the Prime Minister’s Office in Indonesia and the Philippines.  

Desmon: For those individuals not familiar with social and behavior change, what might surprise them to learn about the role it plays in fighting outbreaks?  

Serlemitsos: With the Ebola outbreak in West Africa, from 2014 to 2016, the U.S. started paying a lot more attention to global health security (GHS) and the role our work could play to stem the spread of disease. As a result, we saw a dramatic increase in investment in helping countries to be better prepared for and better able to detect and respond to emerging infectious disease threats.   

Breakthrough ACTION was in the right place at the right time, so to speak. As this portfolio of global health security (GHS) work was growing, Breakthrough ACTION started to build up internal expertise in Risk Communication and Community Engagement (RCCE), an approach that helps individuals and communities adopt the necessary behaviors to respond to an emerging infectious disease or an outbreak or a spillover event.    

So, prior to the COVID-19 pandemic, Breakthrough ACTION was already working in 10 or so countries on global health security, and that included setting up the coordination mechanisms and technical working groups to develop strategies to help them respond to emerging risks.

By the time COVID-19 first started appearing in the news in late January 2020, Breakthrough ACTION was already supporting those countries to respond. In places like Guinea and Sierra Leone, they were already mounting a response before the U.S. was even talking about it. So, when everything shut down in the U.S. in March 2020, Breakthrough ACTION was able to immediately pivot in the rest of the countries to mount a COVID-19 response. What Breakthrough ACTION did during the COVID-19 pandemic was extraordinary. We were positioned in the countries even before the U.S. government recognized it as the threat it became because of those early investments in RCCE and GHS. USAID invested a lot of resources in us as we tackled the pandemic.

Desmon: Because of the way USAID was dismantled so quickly, large-scale integrated projects around the world like Breakthrough ACTION will no longer exist and some of the gains will be lost. What happens if the U.S. stays out of foreign aid and development forever? What could happen in the next pandemic?  

Serlemitsos: The countries where Breakthrough ACTION has worked are already better organized and equipped and will be able to mount a better response to a future outbreak of a new disease. But it’s extremely hard to do when the money is not there. And while I have no doubt that those national governments will step up to the extent that they’re able and will support whatever comes up, certainly the U.S. government’s contribution was remarkable during COVID-19, and I think very much appreciated and had demonstrated impact in reversing the threat.  

Desmon: What will stick with you about the work Breakthrough ACTION has accomplished?   

Serlemitsos: There’s are so many things, so let me give a broad answer, which is the people, because the project was made up of an extraordinary group of people. The level of dedication, commitment and expertise that the 700-plus staff who worked on Breakthrough ACTION was just exceptional. It’s hard to imagine replicating that anywhere, anytime.  

One of the foundations of Breakthrough ACTION has been innovation, and we were constantly seeking to find new ways of doing things that would be more cost effective, more impactful, to really find those breakthroughs that would move the needle. If you look at our website, we have our Breakthroughs Gallery, which illustrates many, many of the breakthroughs that we made. It’s an important thing to think about.  

On the opposite end of that spectrum, a very specific thing that I think is also remarkable is what we were able to accomplish in Tanzania with antimicrobial resistance work. The work that we did ended up being so influential that it not only changed national policy on antimicrobial resistance in Tanzania, but the Tanzanian government went on to take a leadership role in changing policy for the entire east and southern African community.   

In Nigeria, meanwhile, there was an identified challenge with service providers over prescribing malaria treatment which can lead to drug resistance. The team went through the whole process of looking at what that challenge was and identifying all the behaviors around it. And they were able to identify a relatively easy solution, which was that any child who presented with a fever at a health facility was to be tested for malaria before they saw the service provider. So that when they saw the service provider, the provider already knew whether the child had malaria and didn’t just assume they did, which leads to overprescribing.  

That was instrumental in terms of changing the way children are treated for fever. It was one of those relatively simple tweaks that that made a huge difference.  

Desmon: What else do we need to know about Breakthrough ACTION as it winds down?  

Serlemitsos: We were able to demonstrate the effectiveness of social and behavior change to things well beyond health. We had funding in agriculture, in democracy and governance, in the education sector.  

We had to really be able to convince non health sector people of the value of social and behavior change. If you think about the history of CCP, which started this work focused on family planning, and it was through the demonstrated success with family planning that we opened people’s eyes to applying it to maternal and child health, applying it to malaria, to HIV. It was really in that process of demonstrating success that we helped others to see how it could be applied in their fields as well. Because at the end of the day, all those things – child marriage, agriculture, nutrition, democracy and governance, addressing harmful social norms – it’s all behavioral.  

 Desmon: My last question is about legacy. A lot of those who worked for Breakthrough ACTION have been doing this type of work for a very long time and grown up with it. And you know, this is your life’s work, and there might not be options for people to continue in this kind of work. How does that hit you?  

Serlemitsos: Well, it’s obviously a very personal question, because it affects each and every one of us very differently. We have been just one part of a whole system that has been dismantled. I mean, it’s devastating.   

But we are walking away with a skill set that can be applied to anything. I think every one of us will continue to carry our mindset and our toolbox wherever we go.   

I can’t imagine that there’s a way in which we as individuals and as a center won’t continue to have a positive impact on the lives of the people with whom we are engaging, in whatever capacity that is.   

As we think about the longer term and the bigger picture, and what people may do next, I think about the global climate crisis that our planet is facing. I think there’s an extraordinary opportunity for all of us. And whether it’s in a professional capacity or a personal one, I hope we will apply everything that we know about effective social and behavior change to the climate crisis for the good of the planet.