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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 Millennium
Development 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 districts
1
of Bihar (see map) to address equity issues
related 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

1
Patna, 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.

Parivartans 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 of
the 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
65.6
65.4
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 from
the 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 a community 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, Vitamin
A
BCG, DPT and
Others
Importance of RI
Vaccination
Sites and Dates
VHSND, PHC,
Inform
Community About
RI
Sensitization
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 inform
community about
benefits of routine
immunization and
Motivate the group
members
To facilitate
experiential sharing
within and outside
groups on RI
Session Overview
Importance of RI -
Discussion on
Issues realted to RI
Discussing the
different types of
Vaccination
Stakeholders
Engaged
Women in the SHGs
(Parivartan and
Jeevika SHGs)
directly
Front line workers
(linking to the
SHGs)
Materials
Cards (various
colors), flip chart,
chart papers, board
marker, bold
marker, cello tape,
white board stand,
clips
Presentation
slides/flip chart

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Success Stories: We Musahars could never have got immunization services had we not got together
Saheli, Dhanauji village, Block Pakridayal, East Champaran

Way forward: Parivartan has a plan of collecting RI outcome indicators such as number of fully
immunized children in Ananya districts. These indicators are captured through project MIS on
monthly basis, sample surveys on quarterly basis, and the evaluation studies (Midline and End line).
Further, for sustainability and scalability of processes, PCI has signed a Memorandum of Cooperation
(MOC) with Bihar Rural Livelihoods Promotion Society (BRLPS), for health and sanitation integration
with BRLPS project Jeevika (Bihar Rural Livelihoods Project). Parivartan is focusing on the process
wherein all the Parivartan-promoted community groups will become incorporated into the Jeevika
framework with the retention of the ongoing Health and Sanitation Agenda. The transition process,
initiated in the month of August 2013, would aim to cover all 18,000 community groups by
September 2014. Further, Parivartan has established a Health Technical Group (HTG) within Jeevika
to provide technical assistance to Jeevika to advance the health, nutrition, water and sanitation
agenda within Jeevikas community-based institutions across the state of Bihar.

This village lacks access to good health facilities. There is no Anganwadi center in the village. The
ANM used to conduct routine immunization in the house of a higher caste Rajput family on a
monthly basis and Musahars women were not encouraged to come forth to access her services.
As a result, Musahars children and pregnant women were not vaccinated nor were they receiving
any other services from the ANM. When Parivartan started work in the village, care was taken to
appoint staff and Saheli that belonged to the Musahars community so that they could identify
with them and be viewed as one of them. One day, while discussing Routine Immunization it was
decided that some action must be taken to ensure regular immunization services. The Parivartan
staff met with block officials and due to this, ANM was directed by the Medical Officer to change
the venue for conducting immunization sessions in the village. After eight months hence, all
pregnant women are receiving TT doses and IFA tablets at their doorstep and all Musahar
children are being vaccinated by the ANM regularly.
39
43
53
47
41
54
0
47
47
50
57
51
58
55
63
53
E Champaran
W Champaran
Saharsha
Samastipur
Begusarai
Gopalganj
Khagaria
Overall
Changes in RI
Outcome Indicator Baseline