Author: Roma Solomon, May 21 2015 - "What are you doing now that polio has gone? You and your team must be out of a job!" Well, these are easier questions to answer than those we faced when we started working on polio eradication. "You think you can get rid of polio - no way?" And then down the line, it became, "Your Polio programme has destroyed the Routine Immunisation programme, eating up all the resources and being completely vertical".
No, there was no satisfying everyone, but these were questions we had to have the answers to - not only for others but for ourselves as well.
India was declared polio-free, along with the entire South East Asia region, in March 2014, and the country celebrated the success of one of the longest public health initiatives ever. The fight against polio makes for a fascinating story that carries some very important lessons for all health and development professionals.
'National Immunisation Days' began in 1995, and women lined up at fixed booths to get their children vaccinated against polio. There was a festive air, making it seem like a 'People's programme'. However, it soon became clear that children were being missed in large numbers. This led the government in 1999 to take the bold step of sending the vaccinators to each house, tracking all children below five years of age and giving them OPV (Oral Polio Vaccine).
Slowly, a very positive activity transformed into a seemingly coercive one, with parents' enthusiasm turning into reluctance in some states and then into hard core resistance. What went wrong makes for a lesson in community mobilisation that must never be forgotten.
Why were house visits started without any explanation? Can unfamiliar health workers enter houses asking for small children to be brought out, vaccinating them, marking their fingers and houses without permission? Naturally, these vaccinators were treated like intruders, and hostilities increased when parents found that only polio vaccine was being offered or, rather, thrust upon them.
Rumours sprang up overnight - maybe it was a contraceptive dose (two drops meant only two children) or an AIDS-causing drug targeting a particular section of society. Boy children specially were locked up, hidden, or sent away, fearing they would become impotent. The teams were manhandled in many cases, and religious leaders circulated fatwas, leaving no room for negotiation.
Of course, the whole country did not respond this way. In states that had strong health systems, the situation was different, and communities were more accepting and less doubting. But in Uttar Pradesh (U.P), there was maximum opposition to the programme.
Something had to be done and quickly. The government looked around for support, and it came from many sources. One was the CORE Group of NGOs (a consortium of international and national non-governmental organisations (NGOs) funded by USAID in the year 2000) that had been mobilising families in many states of the country through a gamut of mobilisers ranging from school children to teachers to local influencers.
UNICEF and CORE hired young volunteers to accompany the vaccinator teams but they, too, were met with fierce resistance and threatened with physical violence. The two agencies then approached the U.P government in 2003 proposing what came to be known as the Social Mobilization Network or SM Net. This joint effort would consolidate resources and allocate work areas while the volunteers - now known as CMCs (Community Mobilisation Coordinators) would be recruited from the same communities they would work in. They would be trained in interpersonal and other communication strategies and would visit each of their allocated households to explain to parents the importance of OPV and other vaccinations.
It was still not easy to get doors to open, especially when the vaccinators would turn up every month. Help was sought from other community members, ranging from religious leaders, teachers, unlicensed medical practitioners, and even barbers - the latter having fathers as captive clients on their chairs with whom they could discuss the advantages of vaccinations!
Special discussions were held with these influencers, and their questions and concerns were addressed in a very transparent fashion. These people gave of their time and services voluntarily and would accompany the CMCs to the hostile houses and convince parents that OPV would protect their children.
Small 'gangs' of child mobilisers were roped in on booth days to inform mothers to bring their children for polio drops. CMCs organised regular meetings for mothers and fathers where games and other tools were used to convince them of the necessity of their children being vaccinated. Parents were encouraged to talk about their fears, as well as their other health priorities and problems. The mobilisers connected them with government frontline workers so that a direct linkage would be formed with responsibilities on both sides - keep demand high and match it with adequate quality services.
Communities, however, looked for more health services, not just polio immunisation. And that led to health camps being planned just before the polio round. The government would provide doctors, nurses, and drugs, as well as the SM Net, tents, publicity, etc. These camps were visited by lots of patients and are continuing, especially attracting antenatal cases - the ideal takeoff for giving information about tetanus toxoid and other types of child immunisation. Since families expected more interventions from the CMCs, it was too good an opportunity to miss not to provide routine immunisation (RI), especially informing them on the advantages of timely and complete immunisation. During summer months, pouches of oral rehydration solution (ORS) were given, and other topical health issues were discussed.
India's huge migrant population, including brick kiln workers, was tracked down to the last family with the help of local informers like barbers, ration shop owners, etc. Children in these families are the most likely to have missed out on their vaccinations, so each was registered. Pictorial messages were used to create awareness in this group.
The most detailed micro-plans were made, giving locations of booths and vaccinator teams’ routes, including names of vaccinators and mobilisers. These helped in monitoring the workers, and 'supportive' was added to the unfriendly word, 'supervision' so that missing a child became difficult. These same polio micro-plans transitioned into synchronised plans for RI sessions.
India’s superstar, Amitabh Bachchan, opened more closed doors than any other single person with his now famous ‘’Two drops of life”. There was perhaps no communication channel or strategy that was missed and, in fact, the radio, television, walls, all were flooded with information on polio campaigns. And in time, families came around and stopped resisting. However, success did not come easily and failure kept appearing in the form of the poliovirus that was able to track each vulnerable child better than us.
The very first lesson that stared us in the face was our presumption that communities would willingly take any service given by the government. Yes, they would have if they were receiving health services they were supposed to. But, long deprived of what they knew to be their right, they took out all their frustrations on the program and the vaccinators.
Since this was a vertical program, it would have only worked in an environment of mutual respect and trust even if technically it lacked nothing. What it did lack, however, was strategies for 'demand generation'. It was taken for granted that mothers would happily accept the vaccine at their doorstep. But there was a wide gap between the government frontline health workers and families. The former had to quickly learn how to listen and talk to the latter, minding their body language, answering questions truthfully, and spending time to explain why children needed OPV twenty to thirty times. This was not easy, especially when faced with hostile and resisting parents. The SM Net mobilisers were then requested by the government to train their staff, especially vaccinators, on interpersonal communication.
The media, too, needed orientation, as they can make or break things - and nothing spreads faster than bad news! Local contacts were made by the mobilisers, and positive stories and coverage began to appear.
Data played a very critical part, and it was freely shared among partners. It was amazing to see real-time data from all vaccination points at the evening feedback meetings (held during campaigns and chaired by the district administrators) being analysed. Immediate decisions were taken to solve problems and improve coverage the next day. But this was done through a fresh approach like support and mentoring.
In the field, there was a changing scenario each day - ranging from a local issue to a general boycott of the campaign by villagers who demanded better infrastructure such as electricity, roads, etc. Newer ways of tackling these issues meant newer messages and innovative ways of delivering them.
Special persons had to be hired by the SM Net to access religious places where they would dialogue with very learned priests and provide references in the holy books about the importance of protecting children from diseases like polio.
The overriding gap that the polio programme identified was that there was very low immunity in children because of poor RI coverage, attributed to not only parents' ignorance but absence of a robust and regular programme. This is the time that RI must follow as a natural corollary - otherwise, the doors will close again. Task forces for polio at the state and district levels are being replicated, and the rich treasury of information, education, and communication (IEC) material is also being delved into for RI.
Seamless partnership between the government, development agencies, and civil society was the main factor that turned the program around from an unwanted one to a people's movement, and this needs to be a launch pad for other initiatives, especially RI.