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Routine Immunization in Bihar PARIVARTAN

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    Strengthening Routine Immunization through

    Community Mobilisation: Parivartan Project in

    Bihar

    Background: Bihar is one of Indias largest and poorest

    states with over 100 million people. Poor nutrition and

    poor health, particularly for women and children, lead to

    early deaths and generational cycles of lost potential. The

    state has one of the countrys highest rates of maternal,

    neonatal and infant mortality. Underlying factors that

    contribute to these negative health outcomes primarily

    include extreme poverty, gender and social inequality

    among many others. Recent trends in routine immunization

    outcomes in a high-burden state like Bihar is critical to

    India achieving its goals and contributing to MillenniumDevelopment Goals (MDG) 4 and 5.

    Despite recent gains and commitments from the Government of Bihar (GOB) and active leadership of key

    stakeholders to improve routine immunization outcomes, deep-rooted problems limit the governments

    ability to affect lasting change. Persistent barriers include poor quality and availability of frontline staffs,

    limited access to services by neglected and marginalized populations, lack of accurate data, lack of

    effective program management, weak training systems, of supervision in health facilities. To this end, the

    Bill and Melinda Gates Foundation (BMGF) is currently funding the Ananya Initiative, in partnership with

    the Government of Bihar (GOB), to accelerate improvements in a broad range of priority health outcomes:

    reproductive, maternal, neonatal and child health, nutrition, key infectious diseases, and sanitation and

    hygiene. Within Ananya, Project Concern International (PCI), in partnership with PATH and the

    Foundation for Research in Health Systems (FRHS), is implementing a community mobilization and social

    accountability grant, referred to as Parivartan, which provides a platform to empower communities to

    engage in processes that catalyze support networks and enable shifts in behavior and social norms,

    contributing to improved and sustainable health and sanitation outcomes in Bihar. Parivartans overall

    objective is to increase the adoption of key maternal, new-born, child health, and sanitation (MNCHS)

    behaviour among women of reproductive age in the Most Marginalized communities of scheduled castes,

    scheduled tribes, and backward Muslims. Parivartans theory of change proposes to overcome the

    barriers to driving health and sanitation outcomes among most marginalized communities in Bihar by

    organizing women into Self Help Groups (SHGs), sensitizing them to be influencers on health & sanitation

    and empowering them to lead their communities to improved family health behaviour, as well as greater

    accountability and equity of services.

    Parivartan Reach Out:Parivartan works in 55 blocks in

    8 districts1of Bihar (see map) to address equity issuesrelated to caste, gender and other social variables which

    influence health and sanitation outcomes. At the

    grassroots, the project reaches approximately 275,000

    women in the reproductive age group in the most

    marginalized communities through 18,000+ SHGs created

    by Parivartan, with each group typically having 12-15

    1Patna, Begusarai, Samastipur, East Champaran, West Champaran, Gopalganj, Khagaria, and Saharsa

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    women. In addition, Parivartan reaches out to approximately 150,000+ women belonging to 10,000+

    Jeevika SHGs in two districts of Khagaria and Saharsa. Through these SHGs, Parivartan mobilizes

    communities with a focus on: a) strengthening their ability to shape social norms and promote behavior

    change and drive demand for services critical to MNCHS; and b) strengthening accountability and

    monitoring mechanisms through community structures for MNCHS services and related schemes to

    advance equity and service access. Each community group is supported by a Saheli, a village volunteer,

    who initiates and facilitates the discussions on MNCHS, leading to behavior change.

    arivartans

    Focus on Routine Immunization (RI):

    The vaccination of children against six serious

    but preventable diseases (tuberculosis,

    diphtheria, pertussis, tetanus, poliomyelitis, and

    measles) has been a cornerstone of the child

    health care system in India. The proportion of

    children fully immunized has remained at 67.5%

    in Bihar (AHS, 2011). According to Parivartan

    Baseline Report (2014), 47% of children in the

    targeted districts are fully immunized.

    This is important to address, given Bihars low routine

    immunization rates, as evidenced by the fact that nearly half ofthe children belonging to Parivartan groups are not fully

    immunized. For addressing this issues Parivartan is making

    efforts to increase awareness among marginalized on the

    benefits of RI. This is being done through an integrated

    approach, with messages on RI, specifically those on

    immunization integrated with other MNCHS messages. The

    Parivartan compendium consists of 13 modules, one of which

    focuses entirely on the issues related to RI (See snapshot of the

    module on the right).

    The module on RI specifically focused and informed the

    community members on:

    About importance of routine immunization

    Inform community about the vaccination date and

    vaccination site (VHSND, PHC, Sub-Center and

    Community Health Centre) and importance of the different doses

    Sensitization and Awareness creation of group members on collective actions and also

    Support ASHA and ANM in immunization process

    65.665.4

    67.5

    Total Rural Urban

    Children Fully Immunized ( ) - AHS 2011

    48

    39

    43

    53

    47

    41

    54

    0

    47

    0

    20

    40

    60

    Patna E Champaran W

    Champaran

    Saharsha Samastipur Begusarai Gopalganj Khagaria Overall

    Immunization Baseline

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    At the grassroots, Sahelis conduct group meetings,

    during which modules are rolled out. In these meeting,

    Sahelis engage in discussions using informational

    materials such as flash cards, games, and stories fromthe modules. These discussions lead to increased

    levels of participation which, over time, evolves from

    the low end of passive listening to the high end of

    collective action that ultimately results in adoption of

    MNCHS behaviors at the individual level. Sahelis help

    SHG women to understand that RI is not only a

    personal issues, its more acommunity development

    issue. They encourage debate and foster acceptance on

    RI, which are described in detail in the module.

    Further, emphasis is also placed on diffusion, through

    the group members, to other eligible women within

    their household, and in their neighboring areas. In

    addition, Parivartan focuses on creating linkages with the front line workers (FLWs) such as ASHAs

    and Anganwadi Workers (AWWs) through their participation in group meetings. Parivartan initiated

    roll out of the RI module in the month of December-January 2014, and all 18,000 SHGs already

    covered. Till date 2265 Sahelis had been trained for rolling out the module on RI. These trained

    Sahelis have trained all the community groups across Parivartan Districts.

    Different Doses

    - OPV, VitaminA

    BCG, DPT andOthers

    Importance of RI

    VaccinationSites and Dates

    VHSND, PHC,

    InformCommunity About

    RISensitization

    Awareness

    Collective Actions

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    For addressing the issues related with routine immunization, the Sahelis undertake a variety of

    strategically related social mobilization activities in their assigned areas and also participate in

    training sessions to improve their skills:

    -

    The Sahelis meet with womens groups to share information on routine immunization and enlist

    their support in spreading the word. The Sahelis organize daytime gatherings of mothers to

    encourage them to immunize their children. Even the Sahelis also visit homes to educate

    caregivers of unimmunized children about OPV and engage them to fully immunize their

    children. Sahelis first target families furthest from routine immunization points and where a

    newborn resides and then secondarily any home behind schedule on routine immunization, and

    finally households fully up-to-date on vaccination.

    Through this process, the Sahelis basically help the community members to take collective actions.

    Though, it will take some time to capture outcome and impact level indicators on RI issues from these

    groups, but the outcome level indicators showed a huge change in the group level due to the roll out

    of the RI module:

    Sahelis Family Level Group Level

    Influencing the Community

    Groups

    Influencing

    Individuals

    Learning Objectives

    To informcommunity aboutbenefits of routineimmunization andMotivate the groupmembers

    To facilitateexperiential sharingwithin and outsidegroups on RI

    Session Overview

    Importance of RI -Discussion onIssues realted to RI

    Discussing thedifferent types ofVaccination

    Stakeholders

    Engaged

    Women in the SHGs(Parivartan andJeevika SHGs)directly

    Front line workers(linking to theSHGs)

    Ma

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