Polio Communication Review Final Report: Phase 1: Bihar, Darbhanga Report

This report details the findings of the consultant team sent to the Darbhanga sub-region of Bihar state in India to review Integrated Child Development Services (ICDS) mobilisation and team performance in relation to polio eradication and newborns identified, missed children, and Xr conversion (a household that remained missed at the end of one round being converted (immunised) in the next round).

Background Information from the Report:

Polio eradication in India requires continued intensive focus on the regions of Uttar Pradesh and Bihar and, more specifically, in addressing underserved populations and communities. The most recent data indicate that there is a strong level of community support in related high-risk areas but that the emphasis now should be on further strengthening and improving performance related to reaching newborns, locating missed children, and ensuring that conversion of refusal households is achieved.

Programmatic areas that have been strengthened in 2008 include the reinforcement and increase in human resources, use of communication in reaching/covering more geographically difficult areas through use of a grid network, and identifying innovative approaches for use both with underserved communities and through further enhancement of partnerships with both media and other civil society organisations.

The ICDS Scheme promotes the use of community-based Anganwadi Centers (AWCs) and Anganwadi workers (AWWs), who become the focal points for mother and child health issues. At present there are 80,211 AWCs which are operational and these facilities provide a convergence between health and social welfare incorporating both health workers and community/ICDS volunteers (Accredited Social Health Activist (ASHA), Auxillary Nurse Midwives (ANMs), Sahayikas/helpers). Services provided through the network include nutritional support for malnourished children and pregnant/lactating mothers, routine immunisation, and pre-school education.

ICDS is now also playing a vital role in polio eradication initiatives in Bihar, where they are contributing as social mobilisers, vaccinators, supervisors, and monitors. AWWs comprise a network of 1:1,000 persons in Bihar and are further strengthened by the fact that they come from local communities and have an intimate knowledge related to social, cultural, and religious contexts. More specifically, they conduct regular mothers' meetings, update information on pregnant women and newborns, and monitor children in the 0–6 age range as well as adolescents within the community. Given this strategic placement and perspective, AWWs are best equipped to respond to and support their own community's needs.

The focus on Bihar stems from the fact that the state tops the list of polio cases at 215 in 2008, followed only by Uttar Pradesh at 145. Except for a few sporadic cases in 8 other states, the remaining part of the country remains polio-free (as of 2008). Thirty districts within the state reported cases, and P1 type polio is primarily sustained in 72 high-risk blocks, which also include both Darbhanga and Madhubani.

At this point in time it is critical to address the challenges that are present in the recurrently infected blocks and surrounding areas, maintain quality operation in polio-free blocks to prevent infections, strategically use vaccines for both P1 and P3 viruses, and accelerate improved routine immunisation. There has also been a paradigm shift related to operational support which prioritises increasing access to access-compromised areas (Kosi Operational Plans) and use of an alternative grid approaching monitoring system.

From a communication perspective, several dimensions require continued attention and support. These include: ensuring that motivation and commitment among partners/stakeholders remain high in order to address the final push towards eradication; and finetuning of both information, education, and communication (IEC) and interpersonal communication (IPC) approaches. Along with this, further enlistment and identification of new influencers and other partners who can expand presence and freshen the approach is required. Continued evolution and use of innovative ideas/approaches that can quickly be adopted for use in order to sustain and generate continued interest - from both health service providers and local communities - is also necessary.

With these challenges in mind, the United Nations Children's Fund (UNICEF) India recruited a number of communication review teams to assess specific aspects related to communication within the existing programme in order to supplement and build upon "best practices" and further complement successful approaches. Recommendations have been developed together with local project partners and aim to be practical, realistic, easy to implement (especially for short-term recommendations), and nuanced with regard to regional situations and contexts.

Key Issues Identified:

Working Well

Overall, the review team felt that the programme is functioning quite well and that both motivation and commitment remain high and are commendable at multiple levels.

The inclusion of various partners (UNICEF, the World Health Organisation (WHO), government officials, Panchayati Raj Institutions (PRI) members, ICDS, and AWWs, in particular) has contributed to an expansive network which functions to implement a complex social mobilisation process that is required to address multiple levels - both within the family and the larger society - in order to eradicate polio in Bihar by achieving full or complete polio coverage.

What is apparent is the immediate benefit of bringing on board ICDS and their cadre of community workers (AWWs) to strengthen community-level understanding and awareness (through the most effective communication channel – IPC) and to ensure that all children/families are included in the process irrespective of caste, creed, economic status, and/or location. Also, because of high levels of local or community-based involvement, transparency is recognised, and impact related to both refusal reduction and number of actual polio cases is also clearly seen.

In addition, the development of tools for micro-planning, use of the house-to-house approach, use of transit teams, monitoring, and data collection have been effective - both for maintaining high quality and in the continued investigation of both "known" and "unknown" community members who should be engaged in the polio programme. Early identification and subsequent immunisation of newborns also helps ensure that new children are efficiently brought into the Expanded Programme on Immunisation (EPI) process/system.

What Needs Improvement

Refusals still remain a key issue (especially urban literate and "bargaining chip refusers") and require enormous amounts of time and effort by staff and stakeholders.

There is also a need to go beyond the usual known numbers of children immunised through house-to-house visits, especially in urban areas. Greater efforts need to be applied to locating children - including these "unknown" or unrecognised children - through attention and interventions applied to cross-border areas and high turnover urban locations. In addition, ensuring coverage in non-traditional locations (such as labour camps, informal dwellings and settlements, and within other transit populations) is required, as is expansion of informal community surveillance and the identification of new partners who can also be recruited into the network (chemists shops, local elderly men and women, medical representatives, and others).

Community ownership of polio eradication is a very limited priority; the programme is still very much seen as a government supply-driven programme, and impacts more on the suppliers than the beneficiaries. As linked to what has been mentioned above, polio seems to take precedence over other development-related needs.

Longevity issues: Because the programme has also gone on for so many years, there is great risk and substantive effort required to maintain current status and to sustain the commitment, motivation, and energy levels of all involved. Additional efforts also need to focus on continued capacity building around IPC for both AWWs and other project stakeholders, (e.g., PRI, community mobilisation coordinators (CMCs), social mobilisation committees (SMCs), and others).

Polio "identity" and/or communication is also limited, and IEC remains primarily focused on announcements and at times seems monotonous. There is a need to create/include a behaviour change communication (BCC) component which is linked to social mobilisation activities and which would also include the development of more proactive, call-to-action slogans or messages. It may also be useful to reposition polio eradication in terms of wider community health in addition to individual benefits (e.g., move from "I" to "We", and through use of a "little finger campaign" that also includes community-to-community (C2C) surveillance!). In addition, continued emphasis needs to be placed on information sharing and messages on the need for multiple rounds to bolster improved levels of community understanding regarding this.

Equipment – including supplies and communication support materials – is limited, and much cold chain equipment needs to be replaced, upgraded, or better maintained in order to instill confidence and raise acceptance within the community. In addition, attractive and easy-to-use support materials could further enhance AWWs' interactions and effectiveness with regard to improved polio messaging and their roles as health educators.

The team made several recommendations after consultation with district- and state-level polio staff and partners, which can be found in the report.

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