Behavior Change Communication For Urban Health A Situation Assessment

Behavior Change Communication for
Urban Health
A Situation Assessment
Health of the Urban Poor (HUP) Program

Behavior Change Communication for Urban Health

A Situation Assessment

Health of the Urban Poor (HUP) Project

The Center for Development and Population Activities (CEDPA)

By Nirupama Sarma

Independent Consultant

September 2011

Behavior Change Communication for Urban Health 1

Table of Contents

Contents Pages

1. Executive Summary – 4

2. Introduction: 9
2.1 The Rise of the Metropolis
2.2. An Over‐Abundance of Media, A Poverty of Knowledge

3. Innovative BCC initiatives for urban health 13
3.1. Low‐cost, need‐based BCC for maternal and neonatal health: Sure Start
3.2. Harnessing entertainment‐education for early childhood development:
Sesame Workshop, India
3.3. Leveraging social marketing for home‐based diarrhea management:
Saathi Bachpan Ke, Abt Associates
3.4. Building community pride and participation: Basti Nizamuddin Project,
the Aga Khan Trust
3.5. Increasing the Accessibility, Acceptability and Use of the IUD in Gujarat,
India, Population council
3.6. Water‐testing kits as a BCC tool. Jal Mitra, AED Pouzn.
3.7. Community‐Led Total Sanitation – Kalyani Municipal Corporation
3.8. A rights‐based approach to community health ‐ SOCHARA
3.9. ICT for health in India

4. Situation Assessment Based on Field Visits 34

5. Review of communication materials for urban health 41

6. Key Findings and Recommendations 47

Acronyms

ANC Antenatal Care
ANM Auxiliary Nurse and Midwife
AWC Anganwadi Centre
BCC Behavior Change Communication
BVM Basti Vikas Manch
CBO Community Based Organization
DUDA District Urban Development Authority
GOI Government of India
HUP Health of the Urban Poor
ICDS Integrated Child Development Services
ICT Information and Communication Technology
IEC Information Education and Communication
JNNURM Jawaharlal Nehru National Urban Renewal Mission
M&E Monitoring & Evaluation
MAS Mahila Aarogya Samiti
MCH Maternal and Child Health
MMR Maternal Mortality Rate
MNCHN Maternal, Neonatal, Child Health and Nutrition
MOHFW Ministry of Health and Family Welfare
NFHS National Family Health Survey
NGO Non Governmental Organization
NRHM National Rural Health Mission
NUHM National Urban Health Mission
PPP Public Private Partnership
RCH Reproductive and Child Health
SJSRY Swarna Jayanti Shahri Rozgar Yojana
SUDA State Urban Development Authority
TA Technical Assistance
TAG Technical Advisory Group
TNA Training Needs Assessment
ULB Urban Local Body
UP Uttar Pradesh
USAID United States Agency for International Development WCC Ward Coordination Committee

Executive Summary

The globalization of urbanization is seen as the hallmark of the 20th Century, and alongside, the rise
of urban poverty. In India, evangelists of urbanization and the free market economy herald
projections that 70 % of the country’s economy will be produced by cities1 – but the story of the
urban poor, the disenfranchised, and the Impact of such unbridled growth on their health is one that
remains untold.

The Health of the Urban Poor (HUP) project supported by USAID and implemented in eight project
states seeks to redress the inequities inflicted on the urban poor, in particular their health. The
project aims to address the health care needs of the urban poor in a “mission” mode by helping
Government of India (GOI) refine the strategies and implementation of the existing Urban Health
component of the National Rural Health Mission and/or proposed National Urban Health Mission
(NUHM). The project lays emphasis on the institutional convergence of various programs and
schemes implemented by various departments such as (namely, but not limited to) Urban
Development, Drinking Water and Sanitation, Women and Child Development, and Health and
Family Welfare

The Role of Strategic Communication
Strategic Communication, involving three complementary and mutually exclusive approaches of
behavior change communication, advocacy and social mobilization, to promote health‐seeking
behaviors of the urban poor, is a critical element of the HUP project. The Center for Development
and Population Activities (CEDPA), a partner in the consortium led by the Population Foundation of
India (PFI) has been mandated with the task of providing Technical Assistance in the areas of
behavior change communication (BCC) advocacy and gender.

In an effort to initiate preliminary steps towards developing an evidence‐based, effective BCC
program that enhances the outcomes of HUP, CEDPA initiated a Situation Assessment of BCC for
urban health.

The Situation Assessment Involved:
1) A brief review of literature on urban health in India, and more specifically on the role of BCC
in promoting urban health. The review identifies gaps and challenges, as well as identifies
good practices where BCC has been creatively and effectively used to enhance urban health
outcomes.
2) Field visits to project states and discussions with a range of stakeholders (HUP state teams,
government and NGO stakeholders) based on key questions to understand the existing
situation, gaps and challenges
3) Desk review of existing communication materials relevant to urban health, with a brief
analysis of their relevance and appropriateness to HUP’s mandate.

1
India’s Urban Awakening: Building Inclusive Cities, sustaining Economic Growth” McKinsey Global Institute. April 2010

Constraints
Due to a host of factors, it was not possible to meet key government stakeholders at the national
level during the time frame for the study. Hence the study is constrained by the absence of a macro,
national perspective.

At the time the assessment was conducted, most HUP state teams had been newly recruited, and
the program overall was in a nascent stage. In some cases, NGO partners had only recently been
selected, hence there were no on‐ground programs for outreach and BCC available for observation
or discussion.
Finally, at the time of writing the report, a few key studies relevant to this documentation are still
underway; the findings from these documents would serve to enrich this situation assessment.

Key Findings and Recommendations
The assessment reveals a very challenging and complex scenario.
1) The multiplicity of media channels, high media access and penetration in cities is juxtaposed
by a poverty of health information and skills among the urban poor. Evidence from a
number of studies point to the inadequate and low‐quality of outreach and BCC services
provided to the urban poor. A study in Dharavi, Mumbai for example, found that more than
56 % of women were married by the age of 18, and only 18 % had been visited by a health
worker during pregnancy. Such evidence is only symptomatic of a larger problem with
overall systems and structures for BCC in urban slums.

2) Pending the launch of the National Urban Health Mission (NUHM), there are few concerted
government programs for enhancing the health of the urban poor, except for the urban
component of the National Rural Health Mission (NRHM). Government health facilities
provide routine immunization, ANC and PNC, but nothing in terms of outreach and BCC.
Signage and posters at district hospitals, and a few ad hoc pamphlets distributed on a
seasonal basis, and loose, uncoordinated street plays conducted by NGOs are the sum total
of BCC for the urban poor.

3) The nodal departments for communication include the IEC Bureau established under the
NRHM, the IEC officers within the Department of Health (DoH), and the Communication and
Capacity Development Unit (CCDU) under the State Water Supply and Sanitation Mission
(SWSSM) in some states, and focuses on, as the name suggests, communication for water
and sanitation. Outside of these departments, there is no designated staff or budgets for
communication, especially at the city or ward levels. The City Municipal Corporations in
most states have limited budgets of about Rs 10 lakhs/year (approximately $22,225) which is
used for wall writings, dissemination of pamphlets based on seasonal illnesses such as
malaria and diarrhea, and sometimes street plays. Most of these efforts are however, ad hoc
with little effort at evaluating impact.

4) Overall, communication ‐ or “IEC” as it is popularly known, is a highly neglected area of
work within health programs, and more so in the urban area. The program is crippled by
poor staffing (some of the project states have staffing which is 6 % of the total posts
sanctioned) and capacity within government systems. Further undermining the program is
the extremely low priority given to this program component, and the perception that it
does not require specific training or skills. Hence in almost all states the role accorded to

communication staff and departments is one of generating “publicity” in the form of
newspaper advertisements and pamphlets for government programs and schemes, rather
than an evidence‐based strategic approach to enhancing health behaviors.

5) Given inadequate outreach and BCC by the state in urban areas, it is critical that NGOs and
community‐based groups be mobilized to conduct outreach and BCC for the urban poor.
Several studies demonstrate the importance of contact with health workers and community
mobilization as key determinants for improving maternal health status2,3, 4

Examples of BCC for Urban Locations
1) The literature review revealed several examples of BCC interventions for urban areas. They
included a variety of approaches: entertainment‐education based on the theory of “social
modeling” for early childhood development; social marketing of ORS and zinc for diarrhea
management, participatory, community mobilization approaches such as Community‐Led
Total Sanitation (CLTS); low‐cost, need‐based BCC for maternal and neonatal health based
on theories of common risk and efficacy models. HUP must review all these varied
approaches and consider those that might be most appropriate for specific states.

2) The assessment found that in most cases frontline workers do not carry health products
relevant to the content of their BCC – for example, IFA, ORS or Point of Use (PoU) water
disinfection – that can support the BCC sessions. In some places, outreach workers indicated
that they distribute condoms and oral pills; however, even in such instances they had no
data on numbers distributed or used. BCC and demand‐generation can be counter‐
productive if not complemented by access to high quality, accessible and affordable health
products/services. The success of efforts combining twin strategies of demand‐generation
with provision of supplies and services is amply demonstrated by the case stories in this
document (Operation Jal Mitra, or Saathi Bachpan Ke). There is huge potential to introduce
social marketing to ensure that these products are available to the community, with in‐built
cash incentives for community‐based depot holders.

3) Where direct provision of products/ services is not possible, it is crucial to leverage existing
government schemes, especially when it comes to sanitation facilities, in the form of
individual toilets or community toilets. In Lucknow, for example, the Swarna Jayanti Shahri
Rozgar Yojana was leveraged to “rehabilitate” slum dwellers by building two‐room
tenements with individual toilets based on a subsidy and cost‐sharing model. In other states
such as Jharkhand, the NGO Nav Bharat Jagruti Kendra (NBJK) renovated existing but defunct
community toilets through government schemes and ensured maintenance through a family
user‐fee of about Rs 50/month; in Raipur, the Municipal Corporation has established a
performance‐based PPP model for waste management. BCC must necessarily integrate
information on such government initiatives/schemes, and reflect social entitlements, to
further strengthen demand‐generation.
2
Increasing Early and Exclusive Breastfeeding in UP: Implications for Behavior Change Communication. Population Council.
2010.
3
Process Documentation, Sure Start, Path, 2010
4
Cluster‐Randomized Controlled Trial of Community Mobilization in Mumbai Slums to Improve Care During Pregnancy,
Delivery, Postpartum and for the Newborn. More et al. 2008.


4) The assessment indicated that most of the communication materials are produced in‐house,
with little evidence for key messages, or pre‐testing. The literature review and BCC
interventions showcased here, clearly demonstrate the criticality of ensuring that BCC
receives significant investments of time and resources , and the execution of critical steps in
the communication cycle: conducting baseline KAP surveys and formative assessments, the
development of evidence‐based communication strategy, hiring professional
communication and research firms for high‐quality communication materials and
software, capacity building, monitoring and evaluation. These are the key features, the
common minimum, for effective BCC campaigns.

5) The assessment revealed that both in government and NGO interventions, rural and urban,
the frontline workers were female, thus neglecting a crucial component of effective BCC –
that of male participation. There has been substantive evidence over several years that
demonstrate the need for male participation in reproductive health as well as water and
sanitation, spheres of behavior in which men are the key decision‐makers. For example,
Path, Sure Start’s community health insurance scheme launched in Nanded, Maharashtra,
which was based on outreach with women, was not very effective and resulted in very low
registration. For the scheme. Recognizing that men were the crucial decision‐makers with
regard to financial matters such as health insurance, the outreach expanded to include men,
resulting in a rapid increase in enrollments into the schemes. When designing
communication interventions for the urban poor, it would be crucial to integrate, through
male outreach workers, the participation of youth and other male‐centered groups to
ensure their support and participation in reproductive health as well as enhancing water and
sanitation issues in the community.

6) The high penetration of media, as well as the dramatically increasing ownership of mobiles
in the country makes a compelling case for integration of ICT into HUP’s BCC. Examples of
integrating ICT in communication interventions include the Baby Care Center’s use of
interactive, two‐way SMS to interact with pregnant women or young mothers, and Sesame
Workshop, India’s interface of a toll‐free number and the internet to provide ongoing
technical support to trained anganwadi workers and their supervisors. Community radio
stations exists in several of the project states, and can be used to facilitate participatory
community‐driven communication, such as training select youth in slums to produce radio
programs featuring issues that confront them so that the larger community – beyond the
slums, including decision‐makers – take cognizance of them.

Project‐Related Findings and Recommendations
1) Within the current staffing structure, HUP state offices do not have a position for a BCC
professional, nor an attendant budget. Even partner NGOs for demonstration projects do
not necessarily have the designated human resources or budget for BCC. It would be crucial
to integrate BCC as an important element in the state program, both in terms of staffing
and budgets.

2) HUP state offices have started to provide TA to state government departments through by
creating common platforms and facilitating horizontal and vertical convergence across state
and city level departments. The same approach can be adopted for providing TA for BCC,

which suffers from an ad hoc, uncoordinated approach and could benefit from strong
management effort to strengthen and synergize the program. The DFID‐supported TMST in
Orissa has set a fine example of such TA through restructuring and establishing the Center of
Excellence (CoE) as a single‐window to undertake any communication work required by
government state departments. Capacity‐building for the well‐staffed CoE has been
conducted by the reputable Mudra Institute of Communications, Ahmedabad, providing
some good benchmarks for others to follow.

Next Steps
In view of the overall situation of BCC for urban health at the national and state levels, the following
steps are strongly recommended for HUP:

1) Conduct a 2‐day national consultation be held to share the findings of this report, as well
as provide a quick overview of BCC for urban health overall, as well as initiate an overall
and state‐specific communication strategy for HUP.

2) There is a dearth of KAP5 data for urban areas, and the little that exists is very dated. It is
strongly recommended that a formative KAP baseline assessment be conducted for urban
locations in the eight states, to be outsourced to a professional research firm. This will serve
multiple objectives: provide information and data for developing an evidence‐based
communication strategy, and providing a baseline against which the project impact can be
assessed. In addition, a Training Needs Assessment must be conducted among key
stakeholders to identify key areas of BCC requiring capacity‐building.

3) In the immediate short term, TA for BCC may be provided through facilitating state‐level
consultations focused specifically on BCC for urban health (experience‐sharing and
material review). This would also identify key areas within BCC requiring TA from HUP.

4) Pilot city demonstration projects with a strong BCC component to ensure the demand‐
generation that must accompany an effective, responsive program. This is possible especially
in states with city demonstration projects, where local NGO partners have been identified,
and can serve as an entry point into the community. Demand generation activities must be
initiated through door‐door individual counseling and BCC, as well as mid‐media
interventions such as community groups, and participatory theater. These can help mobilize
the wider community, especially adult men who are key decision‐makers, to ensure a
change in social norms, a sense of participation, pride and ownership.

In conclusion, the situation assessment of BCC for HUP yields a complex and scenario; yet, in these
complexities and challenges lie immense opportunities – opportunities that HUP can and must
address, and thus leave footprints in the yet relatively unchartered landscape of health for the urban
poor.

5
A common acronym for Knowledge, Attitudes and Practices, a standard framework for addressing behavior change
communication

Chapter 1: Introduction

The Rise of the Metropolis
The globalization of urbanization is seen as one of the most important social changes of the 20th
Century. More than three‐quarters of the population in developed countries live in urban areas. By
2015, more than half of the population in developing countries is projected to live in urban areas

Closer home, India, which ranks second only to China, has among the largest urban populations in
the world. It is predicted that by 2030, 70 % of the county’s GDP will be produced by cities, and that
this will quadruple per capita incomes across the nation.6 The role of the city will become
increasingly important as India’s agrarian economy gives way to an urban landscape that will
generate 70 % of new employment.

But sadly, this bright‐lights‐big‐city phenomenon celebrated by multinational corporations and
market economy evangelists hides a dark underbelly whose story is rarely told. It is the story of the
urban poor, the millions across the world who leave their homes in villages and small towns in
search of a better life, and have been condemned to live beyond the edges of the Great Urban
Dream.

It is this pursuit, this urbanization, that has defined demography in countries across the world and in
India over the past few years. The country’s urban poor have, since 1998, outnumbered the rural
poor. Described as the “2‐3‐4‐5 phenomena,” this demographic trend has seen the overall
population in India grown at an average rate of 2 %, urban areas at 3 %, big cities at 4 %, and the
slum population at 5 %.7 Today, slums remain the fastest growing segment of the urban population,
with almost double the overall growth of the urban population. Sadly, they also rank among the
poorest and most underserved.

Evidence suggests that the living conditions – and therefore the health – of the urban poor are, in
many ways, far worse off than that for their rural counterparts.8 Nowhere is this more evident than
in the slum, the most visible face of urban poverty, microcosms of squalor and deprivation amidst a
sea of plenty.9 High population density coupled with poor environmental conditions makes the
urban poor vulnerable to lung diseases like asthma and tuberculosis, while the inadequate provision
of clean water and sanitation result in vector‐borne diseases (VBDs) and malaria, which are twice as
high among the urban poor compared to other urban dwellers. 10

The Census of India 2011 found that in all the four cities studied, there was a higher concentration in
slums of households belonging to SC/ST communities and female‐headed households (9‐10 in Indore
and Delhi to a high of 18% in Kolkata), high SC/ST populations (high of 26% in Nagpur), as well as low
levels of education. More than three quarters of poor women in Delhi (82 %) Meerut (81 %) and
6
India’s Urban Awakening: Building Inclusive Cities, Sustaining Economic Growth. Mckinsey Global Report. April 2010.
7
Health of the Urban Poor in India: Issues, Challenges and the Way Forward. Urban Health Resource Center, USAID. March
29th, 2007
8
Draft Framework for Implementation. National Urban Health Mission. Urban Health Division, Ministry of Health and
Family Welfare, Government of India. July 2010.
9
A significant proportion of the urban poor also live outside slums, hence critics argue that focusing interventions in slums
alone risks not reaching the whole population
10
Draft Framework for Implementation .NUHM. July 2010.

Kolkata (77 %) with education of women have little or no education, with education acting as a huge
variable in determining the health status of the family. 11

The poor maternal and child health indicators among the urban poor speak for themselves. Mean
age at marriage for slum women is 13.8 and age at consummation of marriage is 16 years. 12 Under‐
5 Mortality Rate (U5MR) among the urban poor at 73 % is significantly higher than the urban
average of 52 %. Malnutrition among the urban poor was slightly higher (54 %) than for children in
rural areas (51 %).13 More than 46 % of urban poor children are underweight and almost 60% of
urban poor children miss total immunization before completing 1 year.14 The health‐seeking
behavior of the urban poor is further corroborated by a study of urban slums which found that only
13 % of newborn infants with symptoms requiring hospitalization were referred to hospitals.

India still loses 0.4 to 0.5 million children under the age of five every year due to diarrhea.15 Even
though ORS was introduced in India in the 1960s, studies indicate that awareness of ORS was only 62
%, with usage at a low of 27 %.16 Absent or inadequate infrastructure for clean water and sanitation
is a key defining feature of slums, and a cause for child morbidity. Between 30 % and 50 % of poor
households in Delhi, Meerut, Indore, and Nagpur practice open defecation. In four cities (Chennai,
Delhi, Mumbai, and Kolkata), not even one out of every four slum households use improved toilet
facilities. Between 35 % and 47 % of poor households in cities such as Meerut, Indore, Nagpur, and
Delhi have no toilet facility at all. In Meerut, while only 14 % of poor households get their drinking
water from private or public taps or standpipes.

Even in Mumbai, a city that lives at the edge of change, urbanization has made little dent into age‐
old traditions among the city’s poor. A study found that 56 % of respondents in Dharavi, one of
Asia’s largest slums, had been married by the age of 18, and a vast majority (63 %) had three or
more children.17 A significant 35 % of the women were illiterate. Registration of pregnancy was high
(95 %), but late, and only 18 % of women had been visited by a health worker during pregnancy.

Ironically, 35 % of women reported eating even less than normal during pregnancy and 60 %
reported no change in the amount of rest they took. Although 91 % of women had delivered in a
health facility, a third had arrived less than an hour before delivery. About one third of infants were
recorded as having low birth weight.

That health indicators for urban women can be much poorer than those for their rural counterparts
is further evidenced in a study which found that “poor urban women had the highest rates and odds
of being anemic”.18

Analyses of data from another study in urban slums of Uttar Pradesh revealed that though 80.4 % of
mothers had received antenatal care,19 more than 60 % of the women had home deliveries

12
Draft Implementation Framework. NUHM. July 2010
13
Urban Health Resource Centre, 2008
14
National Family Health Survey (NFHS) – 3, 2005‐06
15
Draft Implementation Framework. NUHM. July 2010.
16
Process Documentation, Saathi Bachpan Ke, Abt Associates. 2006
17
Cluster‐randomized Controlled Trial of Community Mobilization in Mumbai Slums to Improve Care During Pregnancy,
Delivery, Postpartum and for the Newborn. PubMed. 2008.
18
The Burden of Anemia Among Women in India. ME Bentley1 and PL Griffiths. European Journal of Clinical Nutrition. 2003

conducted by traditional untrained or trained birth attendants. Reasons for preferring home
deliveries were mostly tradition (41.9 %) or related to economics (30.7 %). A total of 56 % of the
deliveries were conducted in the squatting position and in 25 % of the cases, the umbilical cord was
cut using the edge of a broken cup. Although breast‐feeding was universal, inappropriate early
neonatal feeding practices were common. Pre‐lacteal feeds were given to nearly 50 % of the babies,
with several mothers had breastfeeding problems.

Although urban India has a relatively strong health and nutrition infrastructure – with public sector
investments coming from central, state and local bodies, as well as a vast private sector – vulnerable
urban communities continue to be poorly served. This is not only the result of under‐provision;
rather, it is the product of inter‐related factors such as under‐development, inequitable distribution
of primary healthcare services, poor referral systems, inadequate inter‐sectoral linkages, vertical
programming, human resource commitment, attitudinal and management challenges among service
providers, and inefficiency of data management systems. This mesh of influences also includes
socioeconomic and cultural determinants such as caring practices, the status of women, the nature
of livelihoods, food security, migration and mobility.20

An Overabundance of Media; A Poverty of Knowledge
An abundance of media channels, products and programming define the city, selling glossily
packaged aspirations and lifestyles in the service of consumerism and entertainment, and fiercely
competing for the attention of the privileged minority. India today is one of the world’s largest
media markets, thanks to its 1.21 billion population, with urban media penetration figures that are
the envy of any advertiser. 85 % of urban households have a TV, and over 70 % of all households
have access to satellite, cable or DTH services.21 TV‐owning households have been growing at
between 8‐10 %, while growth in Satellite/Cable homes exceeded 15 %, and DTH subscribers grew
28 % over 2009.22 FM radio is estimated to grow at a whopping 32 % annually; from a weekly
listenership of 70 million in 2005, the figure touched 114 million listeners just a year later. FM radio
covers 91 cities in the country – expected 378 radio channels in India (including AIR and FM).

Meanwhile the poor continue to struggle in the long and dark shadows of urbanization, marked by a
history of inequity, depravation, and the absence of information and skills to improve the basic
conditions of their lives. One study examining “IEC”23 services for pregnancy and child care received
by women at an MCH clinic of an urban health centre in Dharavi, Mumbai reveals some alarming
gaps.24

Warning signs of danger was explained to only 10 % of the antenatal and postnatal women. Advice
regarding family planning appeared to be the most frequently covered, but that too, was explained
to less than half of the subjects. Only one third of the women were advised on breast feeding. Only 8
19
Poor Perinatal Care Practices in Urban Slums – Possible Role of Community Mobilization Networks. Zulfia Khan, Saira
Mehnaz, Najam Khalique, Mohd Athar Ansari, and Abdul Razzaque Siddiqui. 34 (2) Indian Journal of Community Medicine.
April 2009.
20
Cluster Randomized Study. More et al. Feb 2008
21
Indian Readership Survey (IRS) 2011
22
TAM Annual Universe Update , India. 2010.
23
Information, Education and Communication – a term used to refer to a generic, loose set of awareness generation
activities as opposed to strategic, evidence‐based behavior change communication. The former term has mostly been
discarded in current discourse
24
IEC for MCH at an Urban Health Centre in Maharashtra. Indian Journal of Community Medicine. May 25th, 2009.

% of the mothers had been told about all issues regarding pregnancy and child care. Only 25 % of
mothers were advised on home management of diarrhea and acute respiratory infections. Very few
mothers were counseled about the growth pattern of the children, and none were shown the
growth chart. Only 12.9 % of the mothers were informed about all issues. Clearly, BCC on maternal
and child care other than feeding practices is a neglected area.
In the case of water and sanitation issues, the gaps are equally disturbing. A study across three cities
in Uttarakhand indicates that awareness of diseases caused by water and unhygienic conditions
ranges from 74‐83 %. Willingness to construct a personal or community toilet ranged from 30‐ 69 %,
pointing to the acute need to strengthen BCC for health in urban slums. 25
These findings should perhaps not be surprising, given that historically, a large part of the country’s
efforts for health have been focused in rural areas. The launch of the National Rural Health Mission
in 2005 provided an impetus for outreach and BCC through the newly‐created cadre of ASHAS as
frontline workers; this, together with the rural focus of several development initiatives, these have
helped establish some semblance of a system for delivering health services and outreach/BCC to
rural populations.

However, despite the intensive inputs provided by the NRHM, management systems for BCC can
often be inadequate. A study conducted of BCC in Uttar Pradesh indicated that only 28 % of ASHAS
reported receiving flipcharts and 6 % receiving leaflets for distribution on breastfeeding.26 58 % of
AWWs and 72 % of ASHAS said they did not have any IPC aid on complementary feeding. Probing
revealed that a training module was being used as a flipchart to conduct household level IPC, and
only 11‐25 % of ASHAS had correct knowledge on the frequency of feeds – demonstrating the
yawning gap between capacity‐building and monitoring.

All in all, there is compelling evidence pointing to the poor health seeking behaviors of the urban
poor, as well as the significant gaps and weaknesses in outreach and BCC. The next section examines
some innovative/effective examples of BCC for urban health.

25
Assessment of Current Status of IEC and Awareness Amongst the General Community Concerning Program Components
in the Municipal Limits of Dehradun, Nainital and Haridwar. Uttarakhand Urban Sector Development Investment Program
(UUSDIP). PRIA. Feb 2011.
26
Shaping Demand and Practices to Improve Family Health Outcomes in Northern India: A framework for Behavior Change
Communication. Population Council. New Delhi. 2011.

Chapter 2: Innovative BCC for Enhancing the Health of the Urban Poor

The urban landscape is defined by an amazing multiplicity of media channels, high‐budget and
sophisticated programming, a range of technologies, formats and possibilities for convergence.
Alongside are examples of low‐cost, traditional communication approaches that may integrate
community participation, but fail to achieve scale. Identifying specific local strategies, while also
achieving high impact and scale, is a challenge for HUP’s work across the 8 project states. The review
outlined below may help stimulate some thinking in this regard.

There has been a wealth of communication interventions for enhancing health in urban slums, both
globally and in India. In Delhi, for example, the theater group Jagran, a theatre group has used mime
extensively in slums to increase awareness of family planning (alongside other issues such as
sanitation, hygiene etc) in slums. The mime was an integral part of a "conscientization" process that
was meant to cut across language barriers to promote the small family norm. Another effort
focused on increasing awareness of TB and driving traffic into DOTS treatment centers; strategies
involved magic shows, role plays, community‐level sensitization meetings and the taking of a pledge
(I will stop TB).

In the Latin American region Peru launched a large campaign based on PPP to promote hand‐
washing with soap, using radio soap operas and talk shows, hand‐washing contests which were
promoted on radio, and a professionally designed hand‐washing promotional campaign on (regional)
TV channels (with a large viewership in economically poor communities). 27 In China, a latrine
revolution was heralded in the province of Hunan which included promotion of and education on
the construction, use, and health benefits of the double urn latrine. Radio and television programs
were designed to both explain and promote the use of the double urn latrine and to encourage
other health promoting habits such as hand washing. Town meetings were held to discuss
communicable and non‐communicable disease prevention techniques.

In the field of sanitation behavior and social change communication is synonymous with the
Community Led Total Sanitation (CLTS), first designed and implemented in Kenya. Based on its
phenomenal success it was rapidly scaled up and replicated across 43 countries globally. CLTS is a
fine example of a participatory and community‐empowerment based approach to end open
defecation in rural areas; some pilot efforts to adapt it to urban slums settings are underway in
India, and have been detailed in this document.
The Sarvodaya Shramadana Movement of Sri Lanka demonstrates the importance of linking
traditional cultural (in this case, Buddhist) principles into a social mobilization effort which became a
movement. The movement focused on basic and minimum physical needs, a respect for natural
surrounding and environment cleanliness, and living in consonance with cultural and spiritual
principles. The state, in this setting, was necessarily mandated with providing citizens with basic
welfare needs, (free education, health, vocational training and housing) and it was this spirit of
welfarism that imbued all stakeholders to make this a robust movement. An analysis of the low
infant and maternal mortality rates and prolonged life expectancy at birth in Sri Lanka includes the
following: "The primary health care model was incorporated early and worked extremely well, with a
27
The La Dirección General de Salud Ambiental (DIGESA), Peruvian Ministry of Health

wide network of grassroots level workers and health clinics providing quality maternal and
childcare.”
While detailed process documentation and impact data have been hard to come by in the cases
cited above, what is evident is that communication can assume different forms based on context,
settings and need. Based on the TOR and discussions, however, this assessment looks mostly at
BCC28 efforts, and less at advocacy and social mobilization components of strategic communication.
Effort has however been made to have an adequate representation of different approaches, hence
after a fairly intensive literature review and discussions with stakeholders, the following case stories
below have been shortlisted for a more detailed description. The choice of case stories was also
based on the availability of process documentation, communication materials and impact evaluation
data.
The Sure Start example highlights the role of low‐cost need based BCC for maternal and neonatal
health; the Sesame Workshop, India case story details the value of using entertainment‐education
approaches with children under 8, thus also finding an effective entry point to reach caregivers. The
PACT‐CRH campaign Saathi Bachpan Ke provides an excellent example of multimedia and social
marketing approaches for home‐based diarrhea management, while Sochara center‐stages a rights‐
based advocacy approach to mobilizing marginalized and disenfranchised urban communities, with
a broader, environmental and community based approach to health empowerment. The Jal Mitra
case description from AED Pouzn highlights an important finding – that sometimes behavior change
does not require a multitude of communication materials and glitzy campaigns but a simple water‐
testing kit can act as the most powerful BCC tool to motivate people to access and drink clean water.
The selection of these case descriptions is by no means exhaustive, but is based on a few criteria
such as:
 Focus on different kinds of health behaviors within the HUP mandate (MCH and water‐
sanitation)
 Use of different approaches (low‐cost IPC and community mobilization, social marketing,
mass media and entertainment‐education)
 The availability of formative research, baseline and impact data. Often an internet‐based
literature review failed to yield complete information such as baseline and end line data, or
strategies and processes on certain promising communication interventions. However, in the
case of India‐based interventions it was possible to access additional and relevant
documentation;
 The potential for replicability (based on similar socio‐cultural settings etc)

28
BCC is defined as a research‐based consultative process of addressing knowledge, attitudes and practices through
identifying, analyzing and segmenting audiences/ program participants by providing them with relevant information and
motivation through well‐defined strategies, using an appropriate mix of interpersonal, group and mass‐media channels,
including participatory methods. Neil Mckee. 2003.

Case Story 1: Sure Start, Path: Low‐cost, Need‐based BCC for Maternal and Neonatal
Health

The Path, Sure Start project (2006‐2011) funded by the Bill & Melinda Gates’ Foundation was
designed to enhance maternal and neonatal health through testing different models in rural Uttar
Pradesh and urban Maharashtra. The project worked with government agencies at the district and
sub‐district levels, as well as NGOs and CBOs.

Maharashtra, with 25 million urban slum dwellers and poverty exceeding 25%, was an appropriate
testing ground for Sure Start’s urban interventions. Different approaches were tested in each of its
seven different locations: a health insurance and financing scheme in Nanded, volunteerism and
SHGs in Solapur, convergence of MNH and HIV in Pune, Public Private Partnerships in Navi Mumbai,
insurance Nagpur, quality of care (client satisfaction norms) in Malegaon, and quality of care in
Greater Mumbai.

Sure Start focused on 42 % of the state’s urban areas— i.e., 1.6 million people in seven urban
slums—through five key strategies:
 Mobilizing the community, creating demand, and facilitating an enabling environment for
individual, household, and community action.
 Promoting household skills and healthy behaviours in essential maternal and newborn care.
 Facilitating access to skilled birth attendants and essential commodities such as safe delivery kits
and antibiotics to manage severe infections.
 Strengthening community‐level networks to promote collective action. For example, the 30
Monitoring of Maternal and Newborn Health Services (MOMS) committees in Pune were
instrumental in creating a bridge between the community and the medical practitioners
 Strengthening linkages between communities, health care systems, and public and private
service providers.
Sure Start used creative methods to convey important information about maternal and newborn
health to communities. In both Uttar Pradesh and Maharashtra, the program uses interactive and
entertaining tools including dance, music, theater, and games to create awareness. On the whole,
Sure Start communications efforts are centered around five key messages: cord care, thermal care of
the newborn, immediate and exclusive breast feeding, birth preparedness, and danger sign
recognition.
BCC was an integral aspect of the project’s community mobilization. Interpersonal communication
(IPC), the main channel used, was executed through home visits by trained health workers from the
community. The presence and promotion of two important government schemes ‐ the Janani
Suraksha Yojana and the Matrutva Anudaan Yojana – helped bolster the communication campaign
credibility, and facilitated the adoption of new behaviors. A professional media advocacy group
helped ensure that the schemes were widely publicized and covered by the news media.


In Pune, Maharashtra, the Monitoring of Maternal and Newborn Health Services committees had a
difficult time when they began work. “People used to think that the health of mothers and newborns
wasn’t any of our business,” says Ms. Shamshad Sheikh, a committee member who also holds a day
job as a social worker. But the committees made it their business, on every level. They approached
doctors and nurses at local hospitals and health care facilities, explaining the Sure Start mission.
Initially, there was a disconnect between health care practitioners and the community. After
repeated visits from committee members, however, a bridge between the two was created.
Community perceptions toward the project also slowly changed. Ms. Sheikh and her colleagues
vividly remember the story of one pregnant woman. “We kept asking her to go for an antenatal
checkup,” Ms. Sheikh says, “but she was averse to the idea.” Step by step, the committee members
chipped away at the resistance of the mother‐to‐be. Finally, she went to a nearby health center.
“The doctors found her to be in dire need of medical attention and blood transfusions, which they
administered,” says Ms. Sheikh. “They narrowly saved her life and the life of her unborn child.”
A key feature of the project was its need‐based BCC. In order to ensure that they were responding
more effectively to the varying and specific needs of every woman, the BCC focused on “providing
need‐specific information and counseling based on behavioral diagnosis”. A checklist was prepared
to identify and diagnose issues related to desired maternal and newborn health (MNH) behaviors.
Based on these behavioral issues and their underlying causes, project workers provided BCC and
counseling in a manner that enabled beneficiaries to overcome challenges and modify their
behavior.
Communication materials were developed and displayed in all the health posts and centers of the
Navi Mumbai Municipal Corporation. A set of flash cards was developed through a participatory
process and pretested (refer annex A for guidelines for the flashcards) for comprehension. The text
and pictorial messages were designed to suit the beneficiaries’ process of absorbing new
information, and the health workers were trained to use these job aids to conduct need‐based BCC.
The outreach protocol is as follows: a pregnant woman is visited thrice during her second and third
trimester. BCC messages during each visit are different, a staggered approach rather than giving the
entire gamut of messages all at once. This is done so that the recipient is able to understand and
mentally retain messages and is able to follow the content. The messages are also communicated to
family members. During subsequent home visits, the behaviors are tracked and recorded.
Challenges, if any, are identified and counseling is offered. The value of need based BCC, a fine
segmentation of audiences and their specific needs, has been corroborated in several studies.29

One of the challenges confronting the BCC was the need to respond to the many different
audiences, languages, customs and cultures typical of a melting pot such as Mumbai. Project sites
were marked by community‐based health workers and a community resource centre.

29
The right message, at the right time, at the right place. Catherine Toth, World Vision India and the United States. 2008

Achievements
In terms of sheer output indicators in Maharashtra, the project has conducted capacity‐building of
35 community health groups in Nagpur, established 20 community groups in Navi Mumbai, recruited
1,634 volunteers in Solapur, established 30 MOMS committees in Pune, and helped 200 families
register for and benefit from community based health insurance in Nanded, with six hospitals
(equally divided between public and private).

Lessons Learned
1) The lessons learned by Sure Start are closely linked to the strategies the project has
adopted. The dearth of government health workers and systems for outreach and BCC was
addressed through community workers who were present and accessible to the
community.
2) The BCC was an integral program component, rather than an ad‐hoc, separate activity
focused on disseminating pamphlets. The communication materials were developed through
a participatory process, and important indicators such as “number of home visits for BCC”
have been effectively integrated into the HMIS system.
3) An important and additional learning was how few BCC materials were required to facilitate
behavior change – in this case, the urban interventions only had one set of flashcards to
support BCC (though there were some IEC materials at health facilities).
4) The use of need‐based BCC – rather than a generic “one‐size‐fits‐all” ensured that the BCC
was relevant and useful, hence adopted by the beneficiary. Studies conducted show that
need‐based BCC is associated with significant increase in knowledge about MNH, demand
for MNH services as well as increase in utilization of MNH services. The project contributed
to a dramatic increase in institutional deliveries in Maharashtra from 78 % in 2005 to 92 % in
2009. ANC check‐ups in Navi Mumbai increased from 36.8 I 2007 to 49.4 % in 2008. This was
possible because of the high‐quality, need‐based and calibrated IPC which was the key
strategy.
5) The project’s efforts to enhance the role of quality, affordable and accessible health care
services, the introduction of community based health insurance and emergency health
funds, and the linkages with existing government health schemes helped bolster the BCC
with credibility and increased the likelihood of behavior change being adopted. This is a
crucial learning which must be adopted by HUP.
6) The project discovered very early that male participation was crucial. When the community
health insurance scheme was launched in Nanded, the initial outreach with women proved
to be futile with very low registration. Realizing that men were the crucial decision‐makers
with regard to financial matters such as health insurance, the outreach expanded to reach
out to men, resulting in a rapid increase in enrollments into the schemes. Men were also
included in the MOMS committees in Pune, with clearly defined gender‐specific roles in
keeping with the social context of the community. For example, while women members
reached out to new and expectant mothers, the men were responsible for logistical details
such as organizing transportation and blood services.

Case Story 2: Sesame Workshop India: Using Entertainment‐Education for Health and
Hygiene

Sesame Workshop, India (SWI) is the country office of the world‐renowned Sesame Workshop
(started in the 1960s as Sesame Street) with a mission to enhance early childhood development
(ECD). The India program, launched in 2007, is more widely recognized by the popular TV show Galli
Galli Sim Sim (GGSS) and its cast of lovable muppets who feature on its on‐air and on‐ground
activities. The organization uses entertainment –education strategy to operationalize its basic
theoretical framework of social modeling for positive behaviors 30

SWI does not work directly on the key focus behaviors of HUP, nor its key target groups. However, in
working with children under the age of 8, it has also found a creative and strategic entry point to
reach its secondary audiences – parents, teachers and other caregivers such as Anganwadi workers
(AWWs).

SWI’s program has three components:
 GGSS aired on Cartoon Network and Pogo
 An on‐ground campaign featuring mobile community viewing (MCV), which includes a
refurbished hand cart that follows a route map in slums, screening GGSS segments and
conducting activities with children and caregivers. These activities entertain and educate young
children, while also equipping them with important life skills and knowledge on health, hygiene
and nutrition.
 In‐school program – SWI produces customized educational content for pre‐school children and
their caregivers. The caregivers are trained through a cascade approach using video training in
the use of materials and in progressive teaching methodologies. A toll‐free number has been
established to support the caregivers in conducting relevant activities, take feedback and collect
response to the kits through a poll.

While the TV program reaches both urban and rural populations, the organization’s other work – the
MCVs and the in‐school education program ‐ is primarily urban focused, and has been implemented
through about 40 NGOs in Chennai, Bangalore, Hyderabad, Kolkata, Delhi, Ahmedabad, Mumbai and
to some extent in Jaipur (with MCVs). Over the past five years, the organization has developed over
14 educational kits which have been provided to 7000 pre‐school centers in the country.

Recognizing the importance of scale, SWI has in recent years expanded to working with the
government, especially with the ICDS program, in order to build the capacity of anganwadi workers.
In Mumbai, for example, SWI works with 5130 anganwadi centers through 29 ICDS projects. 100
master trainers have been created through a TOT process, who will then train AWWs on ECD using
SWI’s communication materials.

30
Social Learning Theory, A Bandura, Englewood Cliffs, NJ. Prentice Hall.


Integrating ICT for Capacity‐Building and Ongoing Technical Support

Recognizing the importance of interactive and ongoing capacity‐building (beyond one‐off
workshops) SWI is moving to video‐based training modules, and has introduced phone‐based
support systems (in Marathi) to facilitate regular technical support to frontline workers. Short (3‐4
minutes each) thematic video‐based training modules have been developed, which provide specific
action points for the AWWs, such as how to make story telling more effective. A curriculum
integration document outlines the activities to be conducted by the AWW each day of the week.
Supplementing the activities in the curriculum integration document is the telephone‐based support
system which has three components:
1. Call out to the AWWs: On the basis of the curriculum integration document, weekly activities
are recorded and uploaded on the Awaz‐de server. The moderator allocates numbers where
the message has to be broadcast and assigns the day when the calls need to go out (every
Monday). Every Monday the system calls out to these numbers and broadcasts the activities
assigned for that day. On completion of the broadcast, the listener has the option of hearing
that/any other activity again.
2. Feedback: The caller has the option of leaving messages/feedback on this system. Awaz‐de
sends a daily digest of the number of calls received (by phone number). SWI team then calls
these numbers to respond to queries or take feedback.
3. Poll: The system also has the facility to call out and conduct polls to understand over‐all user
response to the materials/support provided or vote for their favorite component/activity.
This ensures daily and ongoing feedback, facilitating quality improvement and assurance.

Reach
 GGSS reaches 9 million children (52 % of TV watching children in the 4‐9 age group), and has
an equal viewership of boys and girls.31 The reach is highest in the socio‐economic group
(SEC) B (high middle income) and C (middle, low‐income) for 4 to 9 year olds.
 GGSS educational materials and training are provided to over 6,500 preschools and teachers
in 8 languages in 6 cities in India, reaching about 200,000 children each year.
 Since 2007, Mobile Community Viewing (MCV) activities have reached over 850,000 children
and nearly 300,000 caregivers.

Impact
SWI’s focus is on inter‐generational changes in social norms and behaviors, hence its evaluations
focus more on knowledge and attitude. Independent research conducted in Mumbai and Jaipur
shows that 87 % of all children exposed to the TV show recall show characters’, names and
associated social messaging. Children exposed to the TV show also improved on basic cognitive skills
by about 11 % on average. 32

In Mumbai, as measured by an independent evaluation, at slums with the MCV, the average score
on an assessment of healthy foods increased by 21 %age‐points, compared to a 5 %age‐point
increase among children living in the control area. The study also found that more than twice as
31
Television Audience Measurement (TAM) Media Research. Sesame Workshop, India. 2011.
32
Kadence International 2010

many children in the treatment slum were able to correctly sequence the steps of hand‐washing,
and 26 % more parents in the treatment slum reported that they always tell their children to wash
hands with soap prior to eating, compared to a 1 % drop in parents in the control slum.33

Lessons Learned
1) SWI’s significant reach and impact testifies to the power of entertainment‐education and
social modeling as an approach to promoting behavior and social change. Because of its
huge potential to attract and engage audiences, its use of stories and role models, GGSS has
successfully reach and helped socialize children (as well as their caregivers) on a range of
issues such as decision‐making, conflict resolution and health‐seeking behaviors. The same
has been evidenced by several other EE initiatives both globally and in India (UNICEF’s
teleserial Jeena Usi Ka Naam Hain talks about MCH issues).

2) Crucial too, is the critical role of high‐quality professional programming content and
communication materials that can compete with commercial programs. SWI’s software
and materials have been rigorously pretested and produced in accordance with high quality
benchmarks.

3) SWI has made significant and crucial investments into communications research at all
stages of the project, and ensured that research is effectively integrated into programming
on a timely basis. Research at Sesame Workshop India is of three broad types, i.e., formative
research, process or programmatic research, and summative/endline research. Every
intervention is also evaluated by external third‐party research using international quality
standards of research with widespread dissemination of results.

4) The project has also demonstrated that media programming can be effectively translated
into real‐life advocacy, beyond the immediate interest of communication for ECD. For
example, SWI has created community platforms with the active participation of municipal
corporations in Gurgaon. Issues identified through the phone calls can be translated into
community and public advocacy. Through this forum, the program proposes to form listener
groups in the community content.

5) SWI’s work also points to the challenges of broadcasting on Doordarshan, where it was
aired between 2006 and 2010, thus reaching lower socio‐economic sections of the
population. However the exorbitant costs of airing (higher than market rates) forced them to
withdraw and air on Pogo and Cartoon Network, channels which are owned and produced
by Turner. The experience points to DD’s unresponsiveness towards its role as a public
service broadcaster, an issue that requires intensive and sustained advocacy. In all other
countries – except India and Indonesia – SWI’s flagship program is aired on public service
stations such as PBS (US), SAFD (South Africa) and BTV (BanglaTV).

33
iBGM Policy Innovation, 2010

Case Story 3: Social‐marketing for home‐based diarrhea management. Saathi Bachhpan
Ke, PACT‐CRH

Though India introduced ORS in the 1980s, approximately 500,000 children die annually from
diarrhea‐related dehydration, making it the second largest killer of under‐5 children in India.
Research indicates that 88 % ‐‐386,600 ‐‐ of these deaths are preventable through modifications to
the environment, including availability of clean water, sanitation and hygiene

The Saathi Bachpan Ke (Friends of Childhood) campaign was implemented by the PACT‐CRH project
between 2002 and 2007 to tackle the problem of childhood diarrhea and mortality. The project was
implemented in the urban locations of EAG states and Delhi. The overall goal of the campaign was
to grow the market for ORS, with objectives such as increasing the sales of ORS and increasing use of
ORS as the first line of treatment for childhood diarrhea. At the time the project was launched,
awareness of ORS was moderate at 62 %, and usage was a low of 27 %. Thus the project adopted a
two‐pronged approach: it helped the private sector develop the capacity to supply relevant products
and services; and created public demand for products and services through the use of marketing and
behavior change activities.
The campaign applied an integrated and multi‐pronged marketing approach that included:
 Community outreach and innovation
 Public relations through a well‐known media advocacy firm
 Intensive communication campaign involving several TV, radio spots, mid media activities
and materials
 ORS Day events/celebrity activities
 Policy advocacy
 Retail availability and prescription promotion

The project combined resources of a large number of partners: MCCann HealthCare one of India’s
leading advertising agencies, and Corporate Voice Weber Shandwick (CVWS) a public relations firm
to provide communication, media relations, outreach and event management support for the
campaign. PSP‐One, under the PACT‐CRH program, provided the overall strategic direction and
oversight for the campaign. 34

Impact:
 Awareness of the need for exclusive breastfeeding children upto six months increased from
68 to 73 %.
 Awareness of the need to increase nutritional intake after diarrhea increased from 51 to 64
%.
 Use of ORS among children with diarrhea in the past two weeks increased from 28 to 48 %
 Claimed use of soap for hand‐washing on at least two out of four critical occasions in last 24
hours remained at a high of 93 %
 Sales of ORS increased annually by 10 % against a target of 5 %

34
The project has evolved considerably since 2007, and was re‐launched under the name of Market‐Based Partnerships for
Health (MBPH) in 2010 through funding from USAID. However, because documentation is not yet available for the current
phase, this case description borrows from early documentation of lessons learned through the Pact‐CRH project.

Lessons learned
1) Consumer research played an integral role in campaign planning, and was used to develop,
test and monitor all key interventions, creative advertising items, merchandising, training,
retailing and contact programs and to track knowledge and attitudes among providers,
contraceptive use shifts and sales tracking for ORS. The tracking data provided timely
information which was used to facilitate mid‐course corrections, and respond effectively
to changing realities and needs in the larger environment, as well as strengthen policy
advocacy.

2) A significant mass media component, with media plan developed by professional firm
using highly sophisticated tools, helped increase the reach and visibility of the campaign.
This was complemented by strategic and professional news media advocacy, which helped
increase the visibility and salience of the issue overall and of the campaign in particular.

3) The project had extensive negotiations with media channels to ensure free airtime was
provided to the campaign spots. The project achieved a visibility‐to‐spend ratio of almost
200 %, i.e., for every paid spot, there was one that was aired free. This is significant,
considering that the media cost accounted for more than 60 % of the annual campaign
budget. Further, 10 and 20 second cuts of the ads served as “force multipliers,” increasing
the Opportunities to See (OTS) and Gross Rating Points (GRPs), making the media plan more
efficient.

4) A highly laudable element of the project was its high‐level advocacy and close interaction
with producers and script writers of popular tele‐serials to weave in messages on diarrhea
management and ORS into their storylines. This not only increased visibility of the issue, but
also lent high credibility, and message recall levels which were higher than that for regular
television commercials. This leveraged significant benefits in terms of pro bono coverage
and higher exposure levels for the messages. Examples of such entertainment‐education
integration include: a two‐minute capsule into one of India’s most popular serials “Kyonki
Saas Bhi Kabhi Bahu Thi”; an interview on “Kaun Banega Crorepati” with Smriti Irani (the
campaign ambassador for the WHO‐ORS and Amitabh Bachchan the host; an exclusive and
complete in‐serial piece on CHDM on Star Plus’ Kahani Ghar Ghar Ki; “Sanjeevani” which
featured a story on managing diarrhea at home; and an exclusive on CHDM on “Tandurusti
Hazaar Nemat” on ETV Urdu, a highly watched channel among SEC D and E in Uttar Pradesh
and Bihar.

5) The project’s direct contact component featured a robustly designed and implemented
‘Nukkad Natak” intervention which provided an interface between the consumers and
those delivering CDHM. This was especially useful in media dark areas, crossed barriers of
illiteracy, involved all stakeholders and addressed local factors/myths. In all, 540 shows were
conducted in 27 towns. The evaluation indicates that the shows reached more than one
third of the target audience, and KAP Indicators were significantly higher for the intervention
sites compared to the non‐intervention sites. For example, caregivers who gave ORS or
home‐made remedies at the onset of diarrhea (88 % and 52 %), gave more or same amount
of fluid (90 % and 77 %).

Case Story 4: Building Community Pride and Participation: The Basti Nizamuddin Project,
The Aga Khan Trust35

Please Note: This case story has been included because of its holistic approach to building
community pride and participation in their habitats and surroundings. Though not explicitly focused
on BCC – which is to start in 2012 through NGO outreach into the communities – the case story
yields valuable lessons in using broader social change approaches involving the whole community,
and focus on improving multiple dimensions of life in the slum – education, vocational training,
sanitation and infrastructure, building community pride

Despite being located in the heart of plush South Delhi, the Basti Nizamuddin area is one of the most
congested, most under‐developed, most poorly‐served ghettos in this otherwise prosperous part of
the capital. Roadside eateries jostle for space with beggars and milling crowds. Infested by drug
lords, its narrow lanes have bred petty criminals and wasted youth who have had little or no options
for education, recreation or employment.

In this dismal scenario, the Aga Khan Trust (AKT) stepped in to forge a public‐private partnership
propelled on the twin engines of cultural revival and urban renewal. The AKT and a slew of
government agencies have taken the Basti Nizamuddin area under their wing and initiated a
remarkable series of small changes, each of which will, hopefully, in the years to come snowball into
something meaningful and lasting. What is more, it will hopefully also hold out a template for similar
projects in cloistered communities, communities that wear their backwardness like an impenetrable
cloak of defeat and nihilism.

The people of the Basti Nizamuddin area were initially wary of any deviation from a time‐honored
way of life. Despite their disenchantment with elected representatives to provide even basic
amenities such as schools, dispensaries, parks, libraries, night shelters and livelihood options, the
local population was initially skeptical, to say the least. The skepticism faded somewhat when people
realized the AKT was not in the business of throwing away money; it simply wanted to combine
conservation, urban improvements and socio‐economic development initiatives to achieve the UN
Millennium development goals.

Every component of the urban renewal project was conceived to give something back to the people
of the community, that even in straightforward conservation, the attempt was to involve the local
population, train volunteers from the community, provide market linkages so that the benefits
would remain even after the project would be completed.

Broadly speaking, the projects undertaken focused on the areas of literacy, livelihood, health,
women’s empowerment and environmental sustainability. In simpler words, these took the form of
customized projects keeping in mind the peculiar needs of this pocket of urban squalor and neglect
in a sea of prosperity and upward mobility. For instance, 400 youths and adults were involved in a
program that included adult education, career counseling, vocational training, and skill
enhancement. With a focus on women, this included embroidery and dress design and, through the
Insha Crafts Centre set up in August 2010, fostering group savings and group enterprise.

35
Hindustani Awaaz Literature Culture and Society, BlogRakshananda Jalil. June 2011

Another 500 families were targeted to reach roughly 1000 children in an Early Childhood Care and
Development (ECCD) program where an existing, poorly‐run, ill‐attended municipality school was
‘taken over’ and transformed into a model school with state‐of‐the‐art classrooms, trained staff and
a whole new approach to imparting education. An English access micro‐scholarship program funded
by the US Embassy helps to improve English language skills among 14‐16 year‐old. A Career
Development Centre, operating from four rooms in the School, aims to equip young people with
computer skills that will help them enter the formal sector through jobs in retail or the burgeoning
BPO industry. A Life Skills module covers those areas usually neglected in formal, structured
education such as self‐awareness, communication skills, team building, creative thinking, critical
thinking, problem solving, decision making and coping with stress and emotions.

A community health program addresses the most pressing needs of a local population that has long
lived in abysmal conditions. To make the program truly broad‐based, while there is a well‐equipped
dispensary and diagnostic centre there is also a focus on improving the standards of hygiene by
imparting education on unhealthy living conditions, poor sanitation, and waste disposal systems. As
in the school, an existing, poorly‐run municipality clinic was transformed into a polyclinic with a
bustling gynae‐OPD and increased visits by specialist doctors. An outreach program, to be launched
in 2012, will enhance the capacity of community health workers and train health volunteers who can
go into the community and speak about pressing issues such as water‐borne diseases, the spread of
malaria and dengue (rampant in such areas) as well as AIDS/HIV awareness.

With infrastructure being the first casualty of an over‐crowded and densely‐populated area, the AKT
identified a slew of urban improvement interventions. This included a master plan for the entire
area, repair and upgrading of sewage lines and hygienic access to sanitation facilities. Signage,
improved street lights, recharge pits and water harvesting systems, open spaces for cricket matches,
even an Apni Basti Mela, community toilet complexes and gymnasium, and a string of cultural events
have revitalized the stagnant pool that the basti had become. Groups of trained volunteers take
visitors on heritage walks, further instilling a sense of pride and ownership. The first Jashn‐e‐Khusro
program last year showcased the basti’s rich cultural life – film screenings, exhibitions, qawwalis,
academic discussions, poetry readings,

Lessons Learned
1) Though this particular slum has an additional and unique advantage of being a historical site,
it provides valuable lessons on an integrated, holistic approach to enhancing lives in urban
slums. In particular, its emphasis on community mobilization, building a sense of pride,
ownership and responsibility in the community for their neighborhood is critical given the
overpowering sense of disenfranchisement among slum dwellers.
2) Equally important is the fact that the project has facilitated concrete benefits for the
community such as conducting Life Skills Education, vocational training, and providing some
health services.

Case story 5: Increasing the Accessibility, Acceptability and Use of the IUD in Gujarat,
India. Frontiers, Population Council36
This operations research study was carried out to explore the strategy of using behavior change
communication (BCC) to increase use of the Intra Uterine Device (IUD) in rural and urban areas in
Vadodara District in the state of Gujarat, India.
The specific hypothesis being tested was that, by improving the demand for the IUD and
simultaneously strengthening the technical competencies and counseling skills of the providers, IUD
use would increase. The study was carried out by the United States Agency for International
Development (USAID)‐funded FRONTIERS Program of the Population Council, in collaboration with
the Department of Health and Family Welfare, Government of Gujarat, and the Center for
Operations Research and Training, Vadodara.
These collaborators were motivated by the observation that, although the IUD is a highly effective
(and relatively inexpensive) contraceptive method, it is unpopular worldwide; India is no exception,
with less than 2 % of women adopting this family planning method.
In order to test their hypothesis, researchers first engaged in a diagnostic and preparatory phase
that involved formative research designed to understand the users' perspectives about the IUD and
its use, as well as prevailing myths and misperceptions about the contraceptive. Similarly, informal
discussions and focus group discussions (FGDs) with providers helped in understanding providers'
perspectives and their problems in promoting the IUD and personal biases against the IUD, if any.
The findings were used for preparing BCC materials and counseling aids, which were then field‐
tested for language, clarity, and acceptability of the messages and then modified, if required. These
materials included:
 A client leaflet containing information about the IUD, how it works, who can use it,
advantages, side effects, and myths associated with IUD use. This leaflet was used for
awareness raising in the community by distributing it widely through health workers as well
as anganwadi workers.
 A provider leaflet designed to help providers remember the steps of IUD insertion and
removal.
 An IUD chart featuring a graphical representation of the steps of the "no‐touch" IUD
insertion and removal technique.
 An IUD flip chart containing information designed to help providers in counseling. The size of
the booklet was small so that the providers could easily carry it in their purse during field
visits.
 Two posters imparting key messages about the IUD that were displayed at the sub‐centers
(SCs), primary health centers (PHCs), Vadodara municipal corporation clinics (VMCs), and
anganwadi centers (government‐sponsored child‐care and mother‐care centers).
Following the development of a training curriculum, staff members from 41 facilities (5 PHCs, 30
sub‐centers, and 6 VMCs) were trained, including 10 medical officers and 67 paramedical workers.
All the paramedics that participated in the study were trained in IUD insertion and removal and were
36
Increasing the Accessibility, Acceptability and Use of the IUD in Gujarat, India. ME Khan et al. Frontiers, Population
Council May 1, 2008.

regularly providing the device. Hence, the training was largely a refresher course in terms of
technical skills; however, more comprehensive training on counseling skills and use of job aids for
effective communication with clients was incorporated into the capacity‐building sessions.
Drawing on the fact that one anganwadi worker is assigned per 1,000 people, and she usually resides
within the community, anganwadi workers were asked to participate in disseminating information
regarding the IUD. The anganwadi worker conducts one meeting every month with pregnant
women, lactating mothers, and newly married women to counsel them about nutrition, safe delivery
practices, and family planning; as part of the study, a total of 300 group meetings were conducted
each month in the study area with emphasis on the IUD. Male workers were asked to conduct group
meetings with husbands and educate them about the IUD.
In order to create a positive programmatic environment where contraceptive choice is emphasized
and valued, the Medical Officers in Charge (MOICs) of the clinics were asked to signal to workers
during monthly meetings that there is a commitment to provide all methods ‐ including the IUD ‐ not
just sterilization. Project staff regularly visited the clinics and reviewed the monthly service statistics
to assess the method mix of the clinic.
The impact of the intervention was evaluated 9 months after introduction of the interventions. The
methodology involved a pre‐ and post‐intervention design with no control group. The key dependent
variable considered for the study was use of the IUD among clients. However, given the short
intervention period available and the fact that behavior change is a continuous process that passes
through a series of stages, a major increase in the adoption of the IUD was not expected. Instead,
researchers anticipated changes in process variables, such as increased positive perception and
knowledge of the IUD at the community level and a decrease in myths about the device.
Impact
1) Researchers found that knowledge of providers on the critical steps for providing IUD
services increased significantly, from 5 % to 40 %, and the proportion of women having poor
knowledge decreased significantly from 81 % to 47 %. Though the proportion believing in
myths decreased significantly from the baseline, the prevalence of these myths was still high
at end line.
2) The proportion of IUD users who reported the quality of IUD services received to be good
increased from 26 % to 73 %.
3) A majority (92 %) of providers used the IEC materials developed during the project when
counseling clients, and 95 % of them stated that their performance improved because of the
IEC materials.
4) Due to continuous monitoring and supportive supervision by the medical officers, over‐
reporting of IUD cases decreased significantly from 42 % to 2 %. Comparison of month‐wise
IUD insertion rates during the intervention period (2007), compared with 2006 showed
significant improvement after adjusting for over‐reporting.
5) Specifically, the state government is considering printing the information, education, and
communication (IEC) materials and counseling aids for the entire state. The IEC Division of
the Ministry of Health and Family Welfare (MOHFW) has accepted a revised version of these
IEC materials and has sent the CD to all the state governments with the request that they get
it translated into local languages and then use it for dissemination of knowledge and as a
counseling aid.

Lessons Learned
1) Researchers found that demand generation activities and provision of good‐quality IUD
services, together with a supportive programmatic environment ‐ when carried out
simultaneously ‐ showed increased acceptance of the IUD.
2) They contend that "The intervention could be easily integrated into the existing
system....[T]he IEC and counseling aids developed for the study have been well accepted by
health care providers, clients and national and state government officials."
Case Story 6: Water‐Testing Kits as a BCC Tool. Jal Mitra, AED Pouzn.
The AED Pouzn project was a 5‐year project implemented in India, Indonesia and Tanzania between
2005 and 2010 to tackle diarrhea, which accounts for approximately 5 lakh deaths every year.

In India, the project titled Operation Jal Mitra was implemented in Uttar Pradesh, in Kanpur,
Lucknow and Allahabad cities, and the villages of Basti, Faizabad, Ambedkar Nagar and Sultanpur
districts. The project aimed at increasing awareness of contamination of drinking water, promoting
usage of point of use (POU) water disinfection, and integrating zinc treatment with ORS for
treatment of diarrhea.

The project objectives were to:

• Increase use of POU methods/products among urban and rural poor by promoting their:
• awareness,
• acceptance,
• availability
• affordability
• Increase awareness on multi‐point water contamination and to ensure safe drinking water at
POU
• Test program models to produce scalable, sustainable and cost‐effective strategies for
increasing use of POU water‐purification methods and devices amongst the poor

Through a substantive partnership‐building process, the project was able to ensure the availability of
low‐cost POUs and their promotion within the slum communities.

Major Partners included:
• Suppliers of POU products (liquid chlorine, chlorine tablets)
• Commercial filter manufacturers
• NGOs with ongoing activities in urban and rural areas

Private sector partners
• Population Services International (PSI) Safewat (Chlorine liquid)
• Medentech Aquatabs (Chlorine Tablet)
• Hindustan Unilever Ltd (HUL) Pureit Water Filter

NGO Partners
• Urban : Pratinidhi Samiti
• Rural : PANI and Partners of the SATHI network

The four solutions/behaviors being promoted were boiling water, chlorination, sodis, water filters.
The project worked through local NGOs whose community workers conducted intensive door‐door
outreach using simple pamphlets, and importantly, water testing kits which proved to be perhaps
the centerpiece of the BCC.

The project’s strategies included regular meetings /follow‐ups with community, innovative use of IEC
material and promotional events such as having stalls at village ‘haats’, product‐training for project
staff and community demonstrations by private sector partners. The project’s PPP ensured that
Point of Use (PoU) products for decontamination of water was available to the community at a cost‐
effective price (NGOs would buy it from the private sector for Rs. 15 for 30 tablets, and sell it to the
community at Rs. 30/ ‐ which would be the average cost per month per family).

The communication strategy involved a set of simple, clear and actionable messages which were
reflected across a range of communication materials, which were to be carried in smart, attractive
bags for the community workers. The primary messages included: drinking unclean water can be
fatal; thousands of children die every year due to diarrhea and dehydration from unsafe water;
water can be made clean and safe to drink through four key solutions (boiling, sodis, POU products)
with details on the solutions.

Stickers for use in homes proudly proudly declared “our family drinks clean water, our health is
safe,” thus conferring a degree of status as well on those who had changed their behaviors, and
reflecting the diffusion of innovations ad social modeling approaches defining many successful
campaigns. 37A flipchart helped community workers conduct IPC sessions, while a range of calendars,
posters, playing cards and brochures for service providers detailed important messages on ORS and
zinc combination treatment for diarrhea and dehydration.

In 2010, the project’s endline survey indicates impressive gains:

Indicators Endline Base line
Awareness on need to treat drinking water 99% 96%
Awareness about at least 1 treatment method 97% 47%
‐ knowledge about boiling water 70% 20%
‐ knowledge about liquid medicine 72% 1%
‐ knowledge about tablet medicine 53% 1%
‐ knowledge about water filters 62% 1%
Ever user of chlorine products
Chlorine liquid 60% Nil
Chlorine tab 17% Nil
Total ever users of chlorine products 76% Nil
37
Diffusion of Innovations, Everett Rogers 1995.

Consistent user of chlorine products
Chlorine liquid 30% Nil
Chlorine tab 2% Nil
Total consistent user of chlorine users 32% Nil
% consistent chlorine user among HHs surveyed 32% Nil
% consistent chlorine users among ever users 42% Nil

Lessons Learned
1) One of the most important learnings from the project is that BCC must be accompanied by
relevant products/services that are affordable, available and accessible. By working
simultaneously on generating demand and ensuring supply (of chorine liquid/tablets)
through community‐based health workers, the project was able to achieve significant impact
and behavior change.

2) Converting people to using POU devices/methods takes time. Multiple sessions are needed
to bring about behavior change, and home visits are more useful.

3) A strong BCC tool can help reach the tipping point in just 15 minutes. H2S testing kits are a
powerful behavior change tool, and the project quickly discovered that a solution (in the
form of chlorine) should be offered immediately after highlighting the problem.

4) “Haat” or market based activity can be an effective promotion tool in creating awareness
about water treatment. To attract the attention of visitors, the stall needs to be well‐
designed.

5) Program related learnings include that NGOs can be trained to become effective product
demonstrators and micro‐distributors ; the poor too appreciate being given multiple
options. Penetration increased dramatically after chlorine tabs and liquids were introduced
during the Pilot

The use of ICT to support health and health‐seeking behavior 38
Brief case descriptions of the numerous applications of ICT within the field of health
That ICT can play a useful role through a broad range of applications across development and health
programs is well‐evidenced both in India and globally. India has the largest number of mobile
subscribers, second only to China. It is predicted that ownership of mobiles will surpass that for TV
and radio by 2010. Similarly, the reach of internet in India is expected to grow exponentially
between 2010 and 2015 due to efforts by GOI. According to TRAI, the annual growth rate for mobile
subscriptions is 50 %. Recognizing the potential of these new media, the Eleventh Five Year Plan
2007‐12 aims to enhance, evaluate and scale up the role of ICTs in health care and governance.
Further, GOI has allocated 3 % of the budget of every ministry, including that for health and family
38
Role of Information and Communication Technologies in Accelerating the Adoption of Healthy Behaviors, Atanu Garai
and Ramakrishnan Ganesan.. Journal of Family Welfare, Vol 56, Special Issue. 2010.

welfare, to ICTs. The NRHM also proposes to optimally utilize ICT to strengthen health
infrastructure, and service outreach, including utilization by beneficiaries.

Overall, there are five ways in which ICT can be integrated in health care:

1) Data collection by frontline workers
The integration of ICT at the frontline worker level facilitates faster data reporting, has also been
demonstrated to improve the quality of the data itself, as well as faster monitoring and supervision,
which improves the performance of providers and service delivery quality. Pilot projects in a few
states have started integrating HMIS with mobile devices such as mobile phones, netbooks and
electronic health records. – in Tamil Nadu, for example, net books given to 15 village health nurses
for uploading beneficiary health data directly to the HMIS database.

RapidSMS was used in Ethiopia, as well as the Child Count project in Kenya ‐ in both cases improving
faster and better management, as well as monitoring and coverage. The Uganda Health Information
Network (UHIN) showed that the use of personal digital assistants in data collection resulted in 24%
more benefit per unit of spending. However, feedback on the usability of such technology is mixed –
in the case of frontline workers with the Catholic Relief Services in Uttar Pradesh, due to low literacy
and lack of familiarity, only 35% of ASHAS were able to use SMS without assistance.

2) Community feedback systems
Evaluations of traditional feedback systems such as the Citizens Report Card (CRC) an initiative of the
Public Affairs Centre (PAC) in Bangalore demonstrated the impact of using community feedback for
improving public services.

Another example is that of Lokavani – an e‐governance initiative launched in 2004 in Sitapur district,
Uttar Pradesh by the district administration and NIC. This had an online grievance redressal system,
in which all complaints are registered on the website and reach the office of the District Magistrate.
With the support of six officers, he personally monitors each complaint, and the website is updated
once action has been taken. As of June 2008, 115 Lokvani kiosks were operational in Sitapur district.
By June 2008, there were a total of 117,179 registered complaints, 97 % of them addressed. This
model has a high degree of relevance and replicability for urban health.

3) Changing the behaviors of end users
Bulk SMSing can help increase overall knowledge and awareness of an issue among beneficiaries,
serve as reminders, and provide information regarding service referral points. Within this category
there can be:
‐ Single interaction systems, for example to notify people on national/sub‐national
immunization days as in the case of the Pulse Polio Initiative, or
‐ Multiple interaction systems such as those used by weight loss programs (with reminders,
calls, tips etc), or that used by IFFCO Kissan Sanchar Limited (KSL). Launched in November
2007, the latter allows farmers to buy a special “Green Sim” for which they receive 5 pre‐
recorded voice calls on weather, market prices, government schemes, crops and animal
husbandry advisories, fertilizer availability electricity timings. By October 2009, the service
had 3 million subscribers. Such applications can quite easily be translated to the field of
health

Another innovative use of ICT for strengthening health seeking behavior is demonstrated in the
BabyCenter interactive network targeting pregnant and new mothers. It provides personalized,
stage‐based email and SMS messages (tied to gestation / baby's age) addressing a wide range of
topics relevant to pregnant women and new mothers.

In India, the BabyCenter website had 3.5 million users in December 2009 and received 2,000
discussion posts a day. The site provides expert‐vetted content and parent‐to‐parent advice.
BabyCenter India has launched a phone‐based platform, combining daily SMS and prerecorded voice
content, accessed through an Interactive Voice Response system. Users receive customized emails
from pregnancy till the child is 3 years of age. Messages focus on maternal and child health issues
such as nutrition, iron folic acid tablets and danger signs during pregnancy. The BabyCenter seeks to
adapt this platform in the long term to cover a significant proportion of the Indian market, including
rural, low literacy women, poorly trained frontline health workers, and consumers seeking reliable
information on health. Given the high levels of mobile ownership especially in urban areas, this
approach certainly has potential for replication under HUP.

4) Education and skills development of frontline workers/service providers
E‐learning and mobile learning is effective in imparting knowledge and skills. In several studies e‐
learning was proven to be as effective as classroom learning , and has been consistently associated
with increased motivation, independent learning and control, and recall. Successful e‐learning
initiatives can be used to train frontline workers on fixed days and fixed sites at PHCs/CHCs

5) Telemedicine and ICT for decision making
While telemedicine is more relevant to rural settings where there is limited access to health care, ICT
has also been harnessed to improve the performance of frontline workers conducting BCC through
Decision Support Systems (DSS) which have an indirect effect on strategies by providing managers
with data for informed decision making and improving the productivity of frontline workers, as well
as their timeliness and quality of their interactions.

Case Story 8 : Community‐Led Total Sanitation, Kalyani City Municipal Corporation
Today it is widely accepted that Community Led Total Sanitation (CLTS) is one of the most effective
and successful approaches to achieving open defecation free (ODF) communities. Pioneered in
Bangladesh in 2000 by Dr. Kamal Kar, the approach is now being implemented in 43 countries in
Asia, Africa and Latin America, with at least five countries having adopted CLTS in their respective
national sanitation policies.

In essence, CLTS involves participatory community mobilization exercises, such as Transect Walks
where community groups are facilitated through neighborhood walks to observe the consequences
of open defecation. The hands‐off facilitation and participatory analysis of a community’s sanitation
profile “trigger” feelings of disgust, shame, fear and finally self‐respect, prompting a self‐realization
of the negative consequences on health, environment and economy such as chronic illness, poor
drinking water quality, workdays lost, medical expenses and consequent impact on livelihood. This in
turn prompts individuals and the community to take collective local action. One of the major
contributions of CLTS has been to illustrate that externally‐imposed ‘hardware’‐driven prescriptions
do not work – unless the community is motivated from within.

In India, more than 1.1 billion people lack access to toilets. CLTS in the country is mostly used within
the framework of Government of India’s Total Sanitation Campaign (TSC), which was launched in
1999 and is rural focused. CLTS is reportedly in use now in 16 of 35 states in India. In Himachal
Pradesh and Haryana where CLTS has been used in all the districts of the state, results have been
remarkably better with around 60‐70% increase in sanitation coverage over a period of 4‐5 years
during 2006‐2010.

In recent years CLTS has been used in three urban centers as well: Kalyani near Kolkata in west
Bengal (2005‐07); Raigad near Mumbai in Maharashtra (2008); and Nanded in North‐Western
Maharashtra (2011‐on‐going).
Kalyani, a township near Kolkata, has a population of 0.1 billion and a total of 52 slums. Many of the
slums’ inhabitants are migrants from Pakistan, Bangladesh etc. Whilst some of the slums are more
recent, some are as old as 50 or 60 years. Most homes have no toilet facilities, and even the ones
that do, practice open defecation.
Despite huge expenditures over many years, by various players – the Kolkata Urban Services for the
Poor (KUSP, the Refugee Rehabilitation Department, and the MDP –sanitation goals were not
achieved. Free or subsidized toilets provided through government schemes were often not used, and
other slums were also waiting to receive these handouts rather than take their own initiative.
In 2006, the idea of CLTS was introduced to the councilors of Kalyani and they were persuaded to
start a pilot project in 5 slums. The major objectives of this pilot was to explore the possibilities of
introducing community led development initiatives with special reference to public health such as
environmental sanitation, elimination of open defecation, solid waste disposal and other public
health issues.
The pilot project in five slums started with sensitizing and introducing CLTS to elected municipal
councilors and all department heads of the municipality, local NGOs/CBOs, health workers, and
community leaders. It was made clear that increasing the number of toilets, and various toilet
models was not the goal; rather, it was behavior change and achieving ODF status. In the case of
NGOs/CBOs, hands‐on CLTS was organized, followed by post‐triggering and development of field
facilitators. PRA tools were used extensively, and it was made clear that there would be no external
subsidies.

The concept of sanitary toilets costing a mere Rs 300/‐ was introduced to the residents. "The main
motivation for us, besides the low cost was the fact that it promised to reduce medical expenditure
if everybody used it," says one community representative. The project cost was just Rs 2.50 lakh. The
transformation was amazing. Once our neighbors saw the disease rates falling and started feeling
proud of having their own toilets, using and maintaining them, they even started to spend more to
get better pans, concrete walls and good doors for them."
Deepak, a community leader, recalls how an aged man resisted building a toilet till the last. Finally,
the slum children took to whistling at him whenever he attempted open defecation. "He was
embarrassed and shamed into getting his own toilet," he says. Other slum dwellers became
interested when Harijan Para won an Inter Slum Cleanliness Competition.

Kalyani was declared an open defecation free (ODF) city in 2008. But this was not enough. Mass
awareness to sustain the 100% sanitation was required. The toilets were up. Using them and
maintaining them became a priority. It was then that the idea of creating a folk theatre group for
advocacy emerged. Some enthusiastic community members, including four talented women, formed
the Harijan Para Slum Folk Theatre Group that stages street plays and stage shows to spread
awareness on the benefits of sanitation, relief from diseases and ending open defecation.

Impact
‐ Kalyani was declared ODF in November 2008; however, to maintain this progress additional
incentives have been provided to the slum dwellers such as giving ODF slums priority for
other development work such as building roads, water pumps, drains, and so on, and
installing solar street lamps. Community leaders from Kalyani have also been taken on
exposure visits to some of the more progressive Mumbai slums.
‐ The Kalyani University which owned the land where the Harijan Para had come up illegally,
donated the land to them in acknowledgement of their efforts for ODF status and keeping
the area clean.
‐ The immediate impact was in terms of disease rates, with gastro‐intestinal rates falling
sharply ‐ from 347 cases in 2005‐06 to 124 cases in 2007‐08. It has fallen further in the last
two years. "The incidence of anemia in adolescents has gone down considerably, as found
through a school monitoring program, which has been attributed to improved sanitation in
the township.
‐ A CLTS team consisting of 8 women health workers meets every Sunday to discuss ongoing
problems and finding solutions – new toilets have been constructed in the township based
on their suggestions, and to ensure that new houses coming up have inbuilt toilets.
Sustaining and maintaining its ODF status is a key thrust

Lessons Learned
1) At the heart of CLTS lies the recognition that merely providing toilets does not guarantee
their use, nor result in improved sanitation and hygiene. Earlier approaches to sanitation
prescribed high initial standards and offered subsidies as an incentive. But this often led to
uneven adoption, problems with long‐term sustainability and only partial use. It also created
a culture of dependence on subsidies.
2) In contrast, CLTS focuses on the behavioral change needed to ensure real and sustainable
improvements – investing in community mobilization instead of hardware, and shifting the
focus from toilet construction for individual households to the creation of “open defecation‐
free neighborhoods.” By raising awareness that as long as even a minority continues to
defecate in the open, everyone is at risk of disease, CLTS triggers the community’s desire for
change, propels them into action and encourages innovation, mutual support and
appropriate local solutions, thus leading to greater ownership and sustainability.
3) CLTS also helped identify natural leaders in the community who have been further mobilized
for other broader development initiatives. This also contribution to the introduction of adult
non formal learning initiatives, as well as the banning of country liquor in the community
4) CLTS has a great potential for contributing towards meeting the MDG goals, both directly on
water and sanitation (goal 7) and indirectly through the knock‐on impacts of improved
sanitation on combating major diseases, particularly diarrhea (goal 6), improving maternal
health (goal 5) and reducing child mortality (goal 4).

5) Some of the challenges faced include: initial resistance among slums with tribal populations,
low levels of social solidarity in some migrant communities with floating population.
Working in un‐authorized slum with no legal entities, local political leaders who act as gate‐
keepers, and the dependence on subsidies.
Case Story 8: A Rights‐Based Advocacy Approach to Community Health: SOCHARA
Please Note: This case story has been included because of its broad‐based participatory approach to
promoting social change for urban health, even though it is not explicitly focussed on BCC in the
conventional sense.

The Society for Community Health, Awareness, Research and Action (SOCHARA), with branches in
Bangalore and Bhopal, is well known for its leading role in the areas of research, advocacy and
practice for a holistic, community‐based, pro‐poor approach to health. Since its establishment in the
early 1980s, when it started working on health in the slums of Bangalore, SOCHARA has played a
lead role in the Health for All movement, and the People’s Health Assembly.

Disturbed by the negative challenges evolving in globalizing India and its cities, SOCHARA evolved a
new paradigm of health action ‐ one that moves beyond the biomedical, mystifying model to a more
social, community‐oriented model; one that promotes the overall well‐being and participation of
individuals, families and communities. This necessarily includes demystifying health, community
empowerment and action on the social determinants of health, and mobilizing their demand for
affordable and quality health care. The organisation acts as a catalyst by working through several
civil society networks representing marginalised populations such as women slum dwellers, street
children and the differently abled, thus demonstrating the strength of collective bargaining power.

On‐ground work involves participatory processes to enable communities to exercise their
responsibility to health and demand health care as a right. SOCHARA’S participatory work spans four
key areas:
• community‐health action and campaigns
• community‐based training strategies
• community‐based action research; and
• information exchange and advocacy.

In 2003 Sochara introduced a Community Health Fellowship Scheme which trains young graduates
(from any discipline – medicine, nursing through management and engineering) to understand the
idea of community health as a fundamental right and responsibility. Through the fellowship young
health professionals tackle community health problems in urban slums by organizing people to
demand health as a right, explore community action and evolve community responses to tackle the
deeper roots of illness ‐ poverty, malnutrition, illiteracy, and poor sanitation. Often times this will
also mean planning, campaigns or evolving tactics of engagement that include monitoring, dialogue,
even confrontation with policy makers. The Right to Information has often been used to demand
public sector services.

This new paradigm involves building the community’s capacity in a variety of ways ‐ building social
entrepreneurial skills among urban slum youth, working on a campaign on the right to water and
prevention of privatization of the water, working on community action plans to tackle the menace of

vector borne diseases, organizing employment and recreation for unemployed youth as a counter to
potential addictions, life skills education for school drop‐outs and street children to enhance their
coping skills. A number of communication activities such as street plays and role plays, inter‐slum
competitions and games for adolescents are conducted. In all these instances, SOCHARA acts as a
catalyst, ensuring that its approach influences the on‐ground work of its wide network of partner
organizations.

In more recent years SOCHARA has focused more on advocacy with policy groups to ensure that the
voices of the marginalised reached policy‐making fora and think tanks, helping decision‐makers
understand the real and inter‐related dimensions of the problems confronting the urban poor.
Through such forums, SOCHARA has advocated for improving the poor living in conditions that were
the result of the iniquitous and unsustainable development plans followed by the state and the city.
The most important difference between SOCHARA and other think tanks is its ability to be actively
involved with community action in various ways.

Communication By and For the Urban Poor: the Slum Jagathu Newspaper

Over ten years ago, Lingarajpura, one of the 778 slums that mark the high‐tech city of Bangalore,
witnessed the birth of Slum Jagathu (Slum Awareness), a newspaper by and for the thousands of
slum dwellers in the city who lie beyond its reaches of wealth and technology. The paper , the only
one of its kind in the country, was started by Isaac Arul Selva, a Class IV dropout.

Frustrated by the innumerable problems confronting life in the slums, government apathy, and the
mainstream media’s neglect of these issues, Selva decided to produce his own newspaper. "We
mainly do investigation reports on different issues, slum problems, misappropriation of funds by
officials and politicians and politics‐related issues," says Selva. Slum Jagatthu is a magazine
specifically for slum dwellers, to express themselves, and organize themselves.

Human rights and social entitlements is the key focus of the paper, with priority being given to three
key areas of urban governance: notifying/legalizing all slums; ensuring that the urban budget is
clear, transparent and has the necessary allocations for slum development, and that these plans are
fully discussed with slum dwellers and receive their consensus.
The paper has acquired significant credibility over the years – so much so that policy issues raised by
them are quoted in mainstream newspapers and by government officials. With a modest circulation
of 2000, the paper is distributed to over 180 slums, as well as city corporators, ministers and other
government officials directly concerned with slum development.

By seizing the tools of communication, and making the voices of slum dwellers heard in a broader
public domain, Selva has clearly blazed a trail for the empowerment of a marginalized segment of
the population. Slowly every slum dweller must recognize and have the confidence to say, “This is
my city. I have full rights here. I will utilize my rights fully.”

Chapter 3: Situation Assessment based on Field Visits

Field visits were an important component of the study, and were conducted in July 2011. All the
project states – with the exception of Bihar and Madhya Pradesh (which were not ready for the visit)
were visited for approximately 1‐2 days, with some key questions being shared ahead of the visits.
Discussions were held with key stakeholders identified by the state HUP office. This included
government representatives working in water‐sanitation, maternal and child health and focal points
for IEC/BCC; as well as other development partners working in the state. In some cases, discussions
were held with local NGOs working in urban slums. Some of the key findings relevant to the BCC
component are highlighted within this document.

The complexity and preponderance of government bodies mandated with health and urban
development is both complex and challenging. With some state‐level variations, overall, the broad
structure for the range of government stakeholders includes the Department of Health (DoH), the
State Urban Development Authority (SUDA), the Public Health Engineering Department (PHED), and
the centrally‐driven Jawahar Lal Nehru Urban Renewal Mission (JNNURM) launched by the Ministry
of Urban Development and Poverty Alleviation (MOHUPA). However, there are state level variations
– for example, UP does not have a PHED; instead they have a Jal Nigam at the state level which is
mandated with water and sanitation. Similarly, while Urban RCH is the urban component of the
NRHM in Orissa, in Uttar Pradesh urban health work is done through the Urban Health Cell.

Structures for Urban Health
While rural health has the advantage of clearly defined systems, both for primary and tertiary care,
as well as an established system under the NRHM for outreach and frontline workers – and
supervisory and support systems, this is especially lacking in the urban areas.

The urban RCH program is the urban component of the NRHM in most states. There are a range of
state and city‐level health facilities in urban areas. Some of these facilities, especially the District
Hospitals, have “IEC” in the form of several posters and signage on various health issues –
breastfeeding, immunization etc. How effective they are in conveying important information to the
beneficiaries is unclear, and merits further investigation.

While ANMs, vaccinators, Lady Supervisors exist at most of these facilities, their “outreach” consists
mostly of going into designated areas on a fixed‐day, fixed‐site basis for routine immunization and
ANC/PNC. They have few, if any, communication materials. But beyond these frontline workers,
there are no supportive supervision systems such as health educators etc. that is prevalent in the
rural system. District and Block Health Educators, or Media Extension and Information Officers
(MEIOs), (nomenclature varies across the states) who are intended to provide supportive supervision
and conduct BCC activities and events are completely missing within the urban landscape.

NGOs contracted under the urban RCH program have an allocation of approximately Rs. 50,000/‐ to
conduct BCC work which takes the form of street plays, posters and brochures; again, a more
detailed investigation is required to understand their reach and effectiveness. Discussions suggest
that they are mostly ad hoc and lacking in program rigor.

The Structure for BCC
With the exception of the DoH, none of the other departments at the state or city level have
designated focal points for “IEC.” At the state level, the DoH has an IEC officer, and in states such as
Jharkhand a designated Joint Director for IEC. In some states, the IEC Bureau under the NRHM is
responsible for most of the BCC work; in Jharkhand, however, instead there is a BCC cell, established
by UNICEF to substitute for the IEC Bureau. Similarly, in Orissa, the Centre of Excellence (CoE)
replaces the IEC Bureau and the SIHFW, the latter being a nodal agency in most states for capacity‐
building in different program areas, but especially for BCC.

The state IEC Bureau in most states under the NRHM, is almost without exception, poorly staffed
and capacitated. Most of the Bureaus have 2‐3 staff, who could benefit from intensive capacity‐
building. However, more problematic is the mandate of the bureau – which appears to be to
publicize government schemes and programs, hence the excessive reliance on generic posters and
brochures rather than an evidence‐based BCC.

In addition, the Communication and Capacity Development Unit, established under the State Water
Supply and Sanitation Mission (SWSSM) in most states, appears to be, as its name suggests, the
nodal point for communication for water and sanitation issues. However, the field visits revealed
that barring one exception, the CCDUs in most states, where they exist, have limited staff and
capacity for strategic BCC. Much of their work seems focused on state‐level media relations,
producing generic IEC materials to publicize state programs.

Among the Urban Local Bodies, in general, there is no sense of ownership with regard to urban
health. In some states (such as Maharashtra) the city Municipal Corporation has an average annual
budget of Rs. 9‐10 lakhs, which is used to produce some low‐cost pamphlets on seasonal illnesses
such as diarrhea and malaria (monsoon), and in some cases some street plays. Program rigor
appears to be missing in most of these cases.

Overall, BCC is a highly neglected program area, and its management emerges as a key issue when
analyzing systems for outreach and BCC, whether urban or rural. A UNICEF study on management
systems for BCC across 8 project states (which overlap with HUP project states) indicates yawning
gaps and challenges in institutional and management systems.39

Poor staffing of communication staff at the state, district and block levels is a key issue, with state‐
level Joint Directors/ officers for IEC, District Health Educators/Media Extension Information Officers
(MEIOs) (nomenclature varies across the states) (MEIOs) or block extension/education officers
(BEEs). State‐level staffing ranged from a meager 22 % (Uttar Pradesh) and 37 % (Bihar) to 75 %
(Orissa), with only one state having 100 % of its sanctioned posts (Rajasthan). At the district level
staffing ranged from a meager 6 % of sanctioned posts (Chattisgarh) through a high of 50 % (Madhya
Pradesh), while at the block level staffing ranged from a low of 6 % (Rajasthan) to a high of 82 % in
Orissa. Needless to say, none of these posts are allocated for urban areas in most states.

Given the extremely poor staffing, understandably the BCC program itself is seriously
compromised. Reasons for the low staffing levels are the recruitment rules, low priority given to
Departmental Promotion Committee meetings as well as the perception of communication not
39
IEC Report, MSG, UNICEF, May 2007.

requiring staff with specific skills. While specific data is not available for urban posts, one IEC officer
said rather eloquently, “ No staff, so no program.”

In the absence of adequate staffing and capacity for outsourcing technical assistance, the quality of
the communication programs in these institutions also suffers. There is a dearth of any formative
assessments to influence the development of an evidence‐based communication strategy. Hence
annual activities are based entirely on budget considerations or priorities determined by others
higher in the hierarchy, with “IEC” occupying the lowest rung of the ladder.

All in all, BCC was a singularly weak element of the health programs in most states. The following are
some select, state‐specific and discrete findings from the state visits.

Lucknow, Uttar Pradesh
Uttar Pradesh is perhaps one of the few EAG states to have a comprehensive and evidence‐based
communication strategy, thanks to the technical assistance provided by ITAP.40 The strategy,
developed through a rigorous and consultative process, has been approved and cleared by the
government, but due to a number of factors has not moved into an implementation phase.

DUDA: Their work in urban slums consists of identifying about 20 women volunteers, 2 from each
from slum, and training them to be change agents through SHGs. The volunteers Identify eligible
couples, and conduct referral for women to services. DUDA supposed to support infrastructure and
maintenance issues. They have Community Development Societies (CDS) (about 1‐55 in Lucknow
alone). These conduct awareness programs, mobilization, ration cards, marriage rights, vocational
training programs – identify eligible couples and pregnant women and conduct referral to hospitals,
copper‐T use etc.

Under the JNNURM, there are two schemes that can be leveraged: Basic Services for the Urban Poor
(BSUP) and the Rajiv Gandhi Avaaz Yojana (RAY), both of which have potential for leveraging to
facilitate the development of sanitation within urban slums. Lucknow has already leveraged some of
these central/state schemes to “rehabilitate” slum dwellers in the same location through 2‐room
tenements with individual toilets.

Development Partners
Uttar Pradesh is unique among the other project states in the sense that it has had a somewhat long
history of several development partners working in the area of health. These include UNICEF, CARE,
as well as the IFPS (Phase 1 and 2) project with its large consortium of partners such as Futures,
CEDPA and JHU/CCP. However, only a few of them have worked in urban areas, namely Abt
Associates (Market Based Partnerships for Health), the Futures Group (ITAP), and more recently, the
Urban Health Initiative funded by the Bill & Melinda Gates Foundation with a range of partners such
as FHI and JHU/CCP. Regular meetings and committees exist to coordinate inputs and the working
of development partners. – the state Technical Advisory Group meets every month to discuss
projects relating to delaying age of marriage, nutrition, contraception, MMR/IMR, immunization, etc.
A Development Partners’ Meeting, and the UP Health Partners Forum meets every two months.

40
Behavior Change Communication Strategy for NRHM in Uttar Pradesh. Dept. of Health and Family Welfare. Government
of Uttar Pradesh. ITAP, Futures. November 2008

ITAP, Futures: Has provided TA for developing NRHM mass media and other communication
materials. The project has conducted capacity‐building in BCC and management through SIHFW for
district and block level health educators/ media. Street theatre and half‐hour radio programs with
call‐ins have been used extensively.

UNICEF does not work on urban health (except for the Pulse Polio Initiative, a vertical program
covering both urban and rural areas) but has conducted capacity‐building for BCC under NRHM,
especially for ASHAS, modules which may be useful for ANMs and anganwadi workers as well. They
have developed some communication materials and software that may be relevant for HUP
(included in the matrix in the next section).

The UHI works in 11 districts of the state, but its initial communication interventions are being
launched in 4 cities – Alligarh, Agra, Allahabad, Gorakhpur. The UHI is focused mainly on family
planning, and has completed a formative communication research study, and developed a detailed
communication strategy for its urban interventions. A multi‐media campaign is currently being
developed. The print materials, already developed, feature large‐size folded pamphlets on
contraceptive choices.

Bhubaneswar, Orissa
By far the most distinctive feature of Orissa in terms of its health communication is the TMST‐
supported Centre of Excellence (CoE), which integrates the SIHFW and the IEC Bureau, creating a
single window and operational convergence for all government IEC. Established in early 2011 after a
long process of consultation and reviews, the CoE has been established to, on the basis of MoUs
with other government departments, undertake turnkey IEC projects. The centre is fully staffed with
all expertise for IEC including design, media planning, research, documentation etc. The Centre has
district‐level units as well, and receives technical support from the State Project Management Unit
(SPMU) funded by the DFID.

In what is clearly a move towards quality assurance, the SPMU has partnered with the renowned
Mudra Institute of Communication, Ahmedabad to conduct capacity‐building of the CoE and
district/block communication functionaries. The state‐level TOT has been completed and the 30
Master trainers will train DMEIOs and BEEs. Field level groups such as PRIs and SHGs have been
sensitized using satellite communication.

Pune, Maharashtra
The State IEC Bureau is unusual in that it receives a high level of funding (Rs. 12‐13 crore/annum)
and has produced fairly high volumes of material, information‐heavy and not pre‐tested. But some
of these materials can possibly be used with some adaptation for HUP. However, staffing and
capacity within the bureau is almost non‐existent.

The HUP Pune office has contracted CASP as a partner for their city demonstration project. The
communication materials used by CASP for other projects are low cost, but could benefit from
additional TA and quality. Unfortunately, even the grants awarded to local NGOs don’t have a
budget for BCC. CASP will form Mahila Arogya Samitis (MAS) with 10‐15 members each, covering 100
households. MAS will function like SHGs, and receive seed money from the project. As part of their
duties, MAS members will oversee the maintenance of community toilets (built by PMC) by safai

karmacharis and mukkadams. CASP has expressed an interest in doing street theatre, but is
constrained by the absence of a budget. They would like to focus their BCC on social entitlements.

The discussion with the Pune Municipal Corporation revealed that in the absence of designated and
qualified staff, they have little capacity to conduct any strategic and sustained BCC. The modest Rs 9
lakh annual budget is mostly used for wall writings and some other signage. Their role with regard to
BCC consists mostly of disseminating materials (pamphlets) produced by the IEC Bureau, in response
to seasonal health risks (such as malaria or diarrhea in the monsoon). Their outreach workers don’t
carry any communication materials, nor is there any interest in doing anything creative/strategic to
trigger behavior change within the community.

Raipur, Chhattisgarh
The HUP office focuses their TA on facilitating greater convergence, and creating platforms for
planning, monitoring and execution of programs by state, district, ward, block/ward level
government stakeholders.

The State IEC Bureau functions like that in most states; on a meager budget (Rs 10 lakh) staffing and
capacity. They see their role as providing “publicity” for government programs rather than any
strategic BCC for enhancing health outcomes, hence the preponderance of posters and brochures.
The State Health Resource Center, under the DoH, provides technical training to NGOs. The State
Institute for Health and Family Welfare (SIHFW) which in some states functions as a key resource
centre for BCC training, is defunct.

The NGOs working in urban slums includes CINI, which focuses on malnutrition among children in
the 9 months ‐5 years age group, hence works very closely with mothers and AWWs. Another
project focuses on Vitamin A and Routine Immunization, and is implemented through 8‐10 local NGO
partners. The BCC occurs mostly in the form of monthly mothers’ meetings. CINI conducts training
for its outreach workers and develops communication materials, in addition to supporting some
nutrition rehabilitation centers.

Similarly, Worldvision works in 30 slums of Raipur to address malnutrition. This is done through
mothers’ meetings at the anganwadi centre. Link workers conduct house‐house visits, provide
counseling and BCC on nutrition and encourage mothers to adopt new behaviors. Their
communication materials consist mostly of print materials.

The NGO Sankalp has been working in urban slums over the last 30 years using street theatre, and
conducts group meetings with adolescent girls’ groups, women, and men. They also run mobile
health clinics, and are currently attempting a partnership with a private builder to build community
toilets, where the Rs 2 lakh material costs are shared by the NGO and the Municipal Corporation,
with construction charges being offered pro bono. They intend the local slum SHGs to maintain the
toilets for a nominal cost from users. They have developed some print communication materials,
and have undertaken a KAP study which will be ready in a few months.

A meeting with the Deputy Commissioner Mr. SK Sundarani, Raipur Municipal Corporation, who also
oversees the JNNURM component, was valuable for its programmatic components.

Interesting examples of RMC’s work includes an interesting PPP initiative for solid waste
management, in which private contractors’ remuneration is contingent on performance (as indicated
by citizen feedback). The effort to mobilize citizen participation for social change is clearly a laudable
effort. RMC has also started to leverage central/state government existing schemes (such as RAY) to
ensure sanitation facilities for the poor, as well as a GOI initiative under the SJSRY for slum‐free cities
which addresses social determinants by providing livelihood training and education.

These examples are important because they demonstrate the importance of leveraging government
schemes/entitlements and thus ensuring the availability of products/services to support behavior
change. The BCC activities and materials must necessarily reflect these social entitlements and be
supported by them.

Jaipur, Rajasthan
The state office has been conducting several stakeholder consultations and partnership‐building
exercises, and in this context has expressed an urgent need for advocacy materials that can be used
to facilitate the same. They believe these materials should be produced centrally in Delhi by the
PMU for quality assurance, and have state‐specific adaptations

The state CCDU is one of the first few to be established anywhere in the country. Its work involves
mostly involves state‐ level IEC in the form of electronic media, print materials and the creation of a
website. Interestingly, the CCDU does not have any communication materials; the prototypes are
uploaded onto the website and districts are expected to manage the actual printing and
dissemination; how effective a strategy this may be remains further inquiry. They do not conduct
any BCC training, hence had no modules/workshop reports to share.

Dehra Dun, Uttarakhand
As in other states, the state HUP office is trying to facilitate convergence among its stakeholders,
chief among them the DoH and Municipal Corporation. HUP is planning one urban slum model,
focusing on Watsan (JNNURM) and health and hygiene (Municipal Corporation). The slum model will
include community discussions (including ward members and corporators) and community
meetings.

Development agencies include ITAP, JHPIEGO, Engender Health and IPAS; all these agencies work on
family planning promotion. In the absence of an SIHFW, the state has two regional training centers.

The state CCDU was started in 2006 to focus on demand‐generation for toilets; and awareness‐
generation among Panchayati Raj Institutions. Relative to other states, this state CCDU seems to
have a stronger grasp on BCC. They have produced documentaries, radio and TV spots (production
is outsourced, but media planning is done internally). They have an annual budget of Rs. 4 crore, of
which 57 lakhs is for IEC. A Communication Needs Assessment is currently underway, to be
completed in a month. This was funded by ADB, under the Uttarakhand Urban Sector Development
Investment Program (UUSDIP). They have community development specialists and community
facilitators, who at the gram panchayat level, are mostly female.

An important finding was that the CCDU has developed and used a SARAR toolkit to facilitate
interactive IPC and community mobilization, based on PRA techniques. The toolkit has 5‐6 games
focused on changing attitudes and behaviors relating to water and sanitation. The kit includes 3 pile

sorting cards, story with a gap, transmission of diseases and gender analysis. This – or an adaptation
of it ‐‐ can be considered for use by HUP across all project states (costs Rs. 3000/ a package in its
current form).

The state IEC Officer, Department of Health, indicated that ITAP had developed a benchmarking
study last year on Routine Immunization and institutional delivery. DoH ran a Rs. 3‐crore 3‐month
campaign in 2010‐11 using these communication materials (TV/radio spots, posters, bus panels,
brochures). The department has 11 empanelled agencies for media planning, buying, production etc.
They’ve commissioned a baseline and impact assessment strategy for IEC/BCC Activities. Because of
the huge volume of vacancies there is no real program. The DoH has recently sanctioned Rs 20 lakhs
for doing IEC for urban RCH work for 2011‐12.

Ranchi, Jharkhand
Unlike other states, Jharkhand does not have an IEC Bureau; rather, it has a BCC Cell established in
2009 by UNICEF in response to a request from the Mission Director, NRHM to strengthen the BCC
capacity in the state. The cell is staffed by professionally qualified staff and consultants, with
impressive skills and knowledge on BCC, and supported by UNICEF, New Delhi.

The cell has conducted 2‐day residential training for ANMs, AWWs, ASHAS (Sahiyyas) to equip them
with the knowledge and skills to be the “ideal worker.” They have also strengthened the Village
Health and Nutrition Day in 7 blocks in 7 districts. There are also district level BCC cells with a district
program coordinator. Only 20 % of the block level positions for BEEs are filled, and 4/28 district
positions among the government cadre of health educators. The state BCC cell provides tech
support, and uses materials developed by UNICEF, Delhi.

The state currently does not have any substantive BCC for urban health, though there are some
examples of hoardings, pamphlets on Janani Suraksha Yojana (JSY), health melas and signage at
urban health posts. An electronic warehouse for communication materials to be developed by ITAP
is on the cards.

There was also a six‐district campaign for maternal and neonatal health which involved household
visits and video screenings once a week as well as hoardings. Community group meetings, street
plays and screening of documentary films have been conducted. In particular, the UNICEF enter‐
educate video capsules titled Ammaji Kehthi Hain (based on the popular teleserial Jeena Isi Ka Naam
Hain) have been used extensively to facilitate IPC sessions. AKH can definitely be tested in urban
slums and if successful can be used across all HUP states.

The state HUP is considering partnering with a local NGO – the Nav Bharat Jagriti Kendra (NBJK) –
which has substantive experience working in urban slums. NBJK has been working since 1972 in 9
districts using a community participation, rights‐based approach. In urban areas their focus is
Watsan and microfinance. Their urban work in water and sanitation has been funded by Wateraid
since 2005.

With regard to sanitation NBJK a has a two‐fold strategy:
1) Individual toilets for BPL families under the BSUP (JNNURM, four phases, to be completed by
2012).

2) Renovating existing but defunct toilets (under the Municipal Corporation) and having a
monthly user card system for the family ranging from Rs 50‐100/. These are managed by the
Basti Vikas Samitis formed by NBJK. Five of their 20 slum project areas have community
toilets.

They have used street plays and slum motivators (female) for their outreach and communication
work. They have a wealth of communication materials, developed mostly in‐house, covering a wide
range of MCH and Watsan. Though some of them are creative, discussions revealed that they had
not been pretested, and could benefit from technical support. However, clearly, the quality of the
materials has been more than compensated for by a strong program and good frontline workers.

Chapter 4: Communication Materials Review

As part of the study HUP state offices were requested to gather all relevant communication
materials already available in the state pertaining to maternal, child health, nutrition and Watsan.
They categorized the materials based on a template shared with them. The matrix and materials
were reviewed during the field visit and on the basis of discussions regarding their potential for use
under HUP further shortlisted to a maximum of ten per state.

Some of the criteria used to shortlist the materials were:
1) Content – relevance to HUP”s mandate (a number of materials on water conservation, waste
management were excluded since they were too technical for use by the community as BCC
materials)
2) Presentation of content: simple language, visual illustrations for attractiveness and ease of
comprehension, a simple and clear “call to action”
3) Representation across different media formats and channels (Print, audio, and audio‐visual)

Table 1 provides a snapshot of these materials.

Constraints to the Material Review
1) Many of the materials were, as is appropriate and relevant, in local state languages;
however, this therefore meant they were less accessible to a national‐level desk review.

2) The value of a communication material lies almost depends in equal measure on its
dissemination and usage. However, because this was only a desk review, it was not possible
to assess the material’s dissemination, usage and feedback from the intended audiences –
for e.g., from a frontline worker in the case of a flipchart, a woman in the community
receiving a pamphlet, or in the case of posters meant for display in a health facility

3) The collection of materials is by no means exhaustive or representative of all the
communication materials available in the state. Understandably, there were logistical
difficulties in accessing some of the materials

4) Finally, none of the materials listed can be used as is; all of them would require the
necessary permissions for adaptation and use under HUP, in addition to specific project
based branding and positioning.

In general, there is a wealth of communication materials in most project states; most of them are
print materials in the form of posters, brochures and fliers/pamphlets, though examples exist of
interactive videos to facilitate IPC, job aids such as flipcharts and brochures on social entitlements
for frontline workers, TV and radio spots.

Among the materials detailed below are 4 materials on family planning, 10 on maternal child health
including immunization and diarrhea, and 8 on WASH including ORS. Of these three are toolkits (the
Sarar Toolkit, Jaadu ka pitara box on family planning, and the flipchart on Facts for Life), two are CDs
with films/TV spots, and 5 are radio spots/jingles + Meena.

*All materials recommended for use as is or with modification must obtain permission from the original producers

Sl # Material name/media format Content and Language Producers Comments
Audio‐visuals –TV spots, documentaries
1. TV and radio spots A concerted communication campaign with TV, radio Government of Himachal Can possibly be used in
spots and flipcharts on sanitation and ending open Pradesh, Water and Uttarakhand – but look of
defecation. Was designed for rural Himachal Pradesh Sanitation Program – campaign is rural
by a professional communications firm South Asia
2. Ammaji kehti hain A series of 43 15‐minute video clippings based on Though designed for rural
UNICEF’s TV education‐entertainment series Kyunki populations have a high potential
Jeena Isi Ka Naam Hain (currently aired by for use with women’s groups in
Doordarshan). The videos are designed for use by urban slums. Must be tested in an
AWWs, ANMs or ASHAS for community level group urban slum
discussions, and can also be used during trainings for
IPC
3. Taking Life Seriously – Advocacy/sensitization film on maternal mortality etc. UNICEF, Orissa Very specific to Orissa and
documentary film in Mayurbhanj, Orissa Mayurbhanj. Needs to be tested
for possible use in slums.
4. TV spots Series of 5 excellent TV spots which take off on UNICEF, New Delhi Strongly recommended for use
segments from the popular film Sholay on (on air, and for community level
handwashing. Produced by UNICEF. events) in all the states.
Radio – spots, jingles, short programs
5. Meena episode 15 mt – 15 mt Facts for Life; adapted from the TV series UNICEF Needs to be tested for use
Meena

6 Hand‐washing campaign 2.22 mts – in 8 languages (Hindi, Oriya, Marathi among Wateraid ‐ Very appealing but quite long for
song the ones that are relevant to HUP) airing (hence will drive up airtime
costs). Doesn’t emphasize use of
soap enough. Can be used for
community level events

Job aids for frontline workers – flipcharts, interactive materials
7. “Jaadu ka pitara – upay A nicely designed a job aid for frontline workers for FP. Ranchi, ITAP. The This one communication material
anek, chuno ek” The box has different contraceptive methods, with two government is can be used for all family planning
small brochures on when, how they can be used. considering replicating communication – but needs to be
- this for the state program complemented with materials on
more permanent methods

8. Facts for Life Flipchart Large, well designed flipchart on UNICEF’s flagship Produced by NRHM and In its current form probably too
program. Comprehensive coverage of child health UNICEF. bulky for urban populations.
issues. Topics covered: timing and # of pregnancies, safe Based on detailed pretesting, it
motherhood, early childhood development and can possibly be adapted for use
nutrition, immunization, ORS, vitamin A, water and into a set of flashcards to be used
sanitation, health and hygiene and clean environment, with community based groups
malaria, HIV prevention. such as mahila arogya samitis etc.
or for door‐door IPC.
9. Flash cards for need‐ Though we have not been able to access a copy of this, it Sure Start, Maharashtra Strongly recommended that we
based BCC for urban should be very useful for BCC and outreach in urban urban project access and confirm its potential
populations slums. Guidelines for usage and provided for usage under HUP

10. SARAR toolkit A toolkit based on PRA techniques, this contains a set of CCDU, Uttarakhand Must procure and review to
7 or 8 community/group‐based participatory exercises confirm its potential for usage
for triggering behavior change with regard to water and under HUP
sanitation
11. Snakes and ladders A template for an interactive game on water and CCDU Rasjathan A template for the board game is
game sanitation available; can be replicated based
on review and potential for usage
under HUP, with due permissions
and acknowledgements
12. Who is responsible for For use by development workers to trigger community Recommended for usage, with
this? participation and problem solving for day‐day problems. some visual illustrations to make it
Useful compendium on social entitlements related to more attractive
HUP mandate


13. Pamphlet - On the role and duties of Asha, and the services Can possibly serve as a template
she provides for designing something similar for
- urban NGO community health
workers
14. Set of 3 one‐side Advocacy content on the extent of the problem globally Wateraid For use by development workers.
pamphlets/posters and in india (on access to clean water, open defecation, Good materials that can be used
diarrhea deaths); when and how to wash your hands by HUP
correctly; ORS can save lives – signs of dehydration,
preparation of ORS
Display materials – posters
15. An IEC catalogue on 15 posters on various aspects of water such as water CCDU, SWSM, Rajasthan The posters are not of very good
water Rajasthan. conservation, harvesting, water‐intensive vs non‐ quality and not very relevant to
intensive crops etc. It also has a template for a snakes HUP’s mandate, except for a few.
and ladder board game relating to water and its The snakes and ladder game can
conservation. possibly be used after modifying it
to HUP’s mandate.
Distribution materials – pamphlets (single pagers) and brochures (folded) Please note: there were innumerable pamphlets and brochures, almost all of
them requiring some degree of modification, hence only some have been selected for review. Materials on common themes, and by the same
producer, have been clubbed together
16 Safe Motherhood – to Outlines causes for maternal mortality and morbidity, National Rural Health Can be used but with adaptation
end maternal and pregnancy‐related care such as ANC and PNC, Mission, Rajasthan. and inclusion of content for IFA
mortality. 2‐sided immunization, nutrition, institutional delivery or TBA. etc.
pamphlet
17. Pamphlet s on Family Planning – temporary and permanent methods.
male vasectomy, anti‐female feticide, one on
contraceptive choices condoms, OCPs, Copper T,
exclusive breastfeeding and complementary feeding for
baby
18. Swach Basti, Swasthya Set of 2 attractive 2‐fold brochures, visually illustrated. Vigyan Foundation with Comprehensive and simple. Can
Basti/Bacche The first one diarrhea, prevalence, signs and symptoms, support from Water‐ be used for HUP.
brochures and treatment ; ORS – how to make it (4 simple steps) aid.Uttar Pradesh
plus need for other rehydration solutions – juice,

buttermilk; conditions under which to use ORS (storage,
use within 24 hours); if ORS fails, go to health facility.

19. Several Pamphlets - kinds of toilet options (2) and benefits of UPSACS, Water aid, Can be adapted for urban slum
individual household toilets. Create settings. Nicely illustrated
- Subsidies available (rural – villages ) and place to
contact for more info.
- Sanitation and hand‐washing; maintaining a
toilet
- When, why and how to wash your
- hands – 8 steps and visuals
- Practicing hygiene – different examples
- Preparation of ORS
20. Pamphlets - Iodine – value, benefits,
- Shahri vikaas vibagh – nirmal nagar puraskar
yojana

21 Pamphlets - adolescent girls health including nutrition, HIV, I am not sure how important a
pregnancy, menstrual hygiene component this is for HUP.
-
- Copper T – benefits, usage etc.
- Also promotes institutional delivery)

Chapter 5: Overall Findings and Lessons Learned

1) The multiplicity of media channels, high media access and penetration in cities is juxtaposed
by a poverty of health information and skills among the urban poor. Evidence from a
number of studies point to the inadequate and low‐quality of outreach and BCC services
provided to the urban poor. A study in Dharavi, Mumbai for example, found that more than
56% of women were married by the age of 18, and only 18% had been visited by a health
worker during pregnancy. Such evidence is only symptomatic of a larger problem with
overall systems and structures for BCC in urban slums.

2) Pending the launch of the NUHM, there are few concerted government programs for
enhancing the health of the urban poor, except for the urban component of the NRHM.
Government health facilities provide routine immunization, ANC and PNC, but nothing in
terms of outreach and BCC.

3) The role of BCC is even further compromised given that it is overall a neglected program
area, and more so within urban settings. Signage and posters at district hospitals, and a few
ad hoc pamphlets distributed on a seasonal basis, and loose, uncoordinated street plays
conducted by NGOs are the sum total of BCC for the urban poor.

4) The nodal departments for communication include the IEC Bureau established under the
NRHM, the IEC officers within the Department of Health (DoH), and the Communication and
Capacity Development Unit (CCDU) under the State Water Supply and Sanitation Mission
(SWSSM) in some states, and focuses on, as the name suggests, communication for water
and sanitation. Outside of these departments, there is no designated staff or budgets for
communication, especially at the city or ward levels. The City Municipal Corporations in
most states have limited budgets of about Rs 10 lakhs/year which is used for wall writings,
dissemination of pamphlets based on seasonal illnesses such as malaria and diarrhea, and
sometimes street plays. Most of these efforts are however, ad hoc with little effort at
evaluating impact.

5) Overall, communication ‐ or “IEC” as it is popularly known, is a highly neglected area of
work within health programs, and more so in the urban area. The program is crippled by
poor staffing (many of the project states have staffing which is in single digits of the total
posts sanctioned) and capacity. Further undermining the program is the extremely low
priority given to this program component, and the perception that it does not require
specific training or skills. Hence in almost all states the role accorded to communication staff
and departments is one of generating “publicity” in the form of newspaper advertisements
and pamphlets for government programs and schemes, rather than an evidence‐based
strategic approach to enhancing health behaviors.

6) In the absence of government frontline workers in urban areas, it is critical that NGOs and
community‐based groups be mobilized to conduct outreach and BCC for the urban poor.

Several studies demonstrate the importance of contact with health workers and community
mobilization as key determinants for improving maternal and child health status41,42, 43

Examples of BCC for Urban Slums
7) The literature review revealed several examples of BCC interventions for urban areas. They
included a variety of approaches: mass and mid‐media entertainment‐education approaches
for early childhood development; social marketing of ORS and zinc for home‐based
management of diarrhea, participatory, community‐based approaches such as Community‐
Led Total Sanitation (CLTS); low‐cost and need‐based BCC for maternal and neonatal health.
HUP must review all these varied approaches and consider those that might be most
appropriate for specific states.

8) The assessment found that in none of the states did government/ NGO frontline workers
carry anything that was relevant to the content of their BCC – for example, IFA or ORS. At
most in some places outreach workers indicated that they distribute condoms and oral pills;
however, even in such instances they had no data on numbers distributed or used. If the
BCC program is to be effective it is critical that the program ensures access to relevant
products and services that are affordable, available and accessible. The success of efforts
combining twin strategies of demand‐generation with provision of supplies and services is
amply demonstrated by the case stories in this document (Operation Jal Mitra, or Saathi
Bachpan Ke). There is huge potential to introduce social marketing to ensure that these
products are available to the community, with in‐built cash incentives for community based
depot holders. BCC, however effective, can be counter‐productive if not bolstered by high
quality, accessible and affordable health products/services.

9) If direct provision of products/ services is not possible, it is crucial to leverage existing
government schemes, especially when it comes to sanitation facilities, in the form of
individual toilets or community toilets. In Lucknow, for example, the slum‐free city
campaign involved building two‐room tenements for slum dwellers with individual toilets,
which were paid for through the SJSRY. In other states such as Jharkhand, NBJK renovated
existing but defunct community toilets through existing government schemes, and ensured
maintenance through a family user‐fee of about Rs 50/month; in Raipur, the Municipal
Corporation has established a performance‐based PPP model for waste management. BCC
must necessarily integrate information on such government initiatives/schemes, and
reflect social entitlements, to further strengthen demand generation.

10) The assessment indicated that most of the communication materials are produced in‐house,
with little evidence for key messages, or pre‐testing . The literature review and BCC
interventions showcased here, clearly demonstrate the criticality of ensuring that BCC
41
Shaping Demand and Practices to Improve Family Health Outcomes in Northern India: A Framework for Behavior
Change Communication. Population Council. 2011.
42
Process Documentation, Sure Start, Path, 2010
43
Cluster randomized controlled trial of community mobilization in Mumbai slums to improve care during pregnancy,
delivery, postpartum and for the newborn. Neena Shah More,1 Ujwala Bapat,1 Sushmita Das,1 Sarita Patil,1 Maya Porel,1
Leena Vaidya,1 Bhaveshree Koriya,1 Sarah Barnett,2 Anthony Costello,2 Armida Fernandez,1 and David Osrin Pub Med. Feb
2008

receives significant investments of time and resources , and the execution of critical steps in
the communication cycle: conducting baseline KAP surveys and formative assessments, the
development of evidence‐based communication strategy, hiring professional
communication and research firms for high‐quality communication materials and
software, capacity building, monitoring and evaluation. These are the key features, the
common minimum, for effective BCC campaigns.

11) The assessment revealed that both in government and NGO interventions, rural and urban,
the frontline workers were female, thus neglecting a crucial component of effective BCC –
that of male participation. Several analyses of health interventions indicate that this is a
much needed dimension for outreach, since men are almost always the key decision‐makers
for behaviors such as contraceptive use and broader reproductive health, as well as
construction of sanitation facilities. As demonstrated very early in the Sure Start project, the
community health insurance scheme launched in Nanded, based on the outreach with
women, proved to be futile with very low registration. Realizing that men were the crucial
decision‐makers with regard to financial matters such as health insurance, the outreach
expanded to include men, resulting in a rapid increase in enrollments into the schemes.
When designing communication interventions for the urban poor, it would be crucial to
initiate or integrate youth and other male‐centered groups to ensure male participation in
reproductive health as well as Watsan.

12) The high penetration of media, as well as the dramatically increasing ownership of mobiles
in the country makes a compelling case for integration of ICT into HUP’s BCC. Examples of
integrating ICT in communication interventions include the Baby Care Center’s use of
interactive, two‐way SMS to interact with pregnant women or young mothers, and Sesame
Workshop, India’s interface of a toll‐free number and the internet to provide ongoing
technical support to trained anganwadi workers and their supervisors. Community radio
stations exists in several of the project states, and can be used to facilitate participatory
community‐driven communication, such as training select youth in slums to produce radio
programs featuring issues that confront them so that the larger community – beyond the
slums, including decision‐makers – take cognizance of them.

Project‐Related Findings and Recommendations
3) Within the current staffing structure, HUP state offices do not have a position for a BCC
professional, nor an attendant budget. Even NGOs contracted for demonstration projects do
not necessarily have the required expertise or budget for BCC. It would be crucial to
integrate BCC as an important element in the state program, both in terms of staffing and
budgets.

4) HUP state offices have started to provide TA to state government departments through by
creating common platforms and facilitating horizontal and vertical convergence across state
and city level departments. The same approach can be adopted for providing TA for BCC,
which suffers from an ad hoc, uncoordinated approach and could benefit from strong
management effort to strengthen and synergize the program. The DFID‐supported TMST in
Orissa has set a fine example of such TA through restructuring and establishing the Center of
Excellence (CoE) as a single‐window to undertake any communication work required by
government state departments. Capacity‐building for the well‐staffed CoE has been

conducted by the reputable Mudra Institute of Communications, Ahmedabad, providing
some good benchmarks for others to follow.

Communication interventions
1) An evaluation of Phase 2 of the communication campaign for NRHM, which included urban
and rural locations in 11 high focus states, indicates that television has a far greater reach
than radio in all locations.44 TV spots appealed to most of the respondents who were
exposed to them (70‐95 %) followed by radio (73‐90 %). Though the campaign was done in
Hindi, language was not a barrier to comprehension and appeal in most of the states
(except those where it was not a major language). In the absence of strong robust systems
for health communication, especially in terms of household‐level IPC, it is strongly
recommended that mass media, combined with IPC be deployed.

Next Steps
1) Conduct a 2‐day national consultation be held to share the findings of this report, as well
as provide a quick overview of BCC overall, as well as initiate an overall and state‐specific
communication strategy for HUP.

2) There is a dearth of KAP data for urban areas; it is strongly recommended that a formative
baseline KAP assessment be conducted for urban locations in the eight states, to be
outsourced to a professional research firm. This will serve multiple objectives: provide
information and data for developing an evidence‐based communication strategy, as well as
provides a much‐needed baseline for key behaviors being addressed by HUP. In addition a
Training Needs Assessment must be conducted among key stakeholders for urban health
communication to identify key areas of BCC requiring capacity‐building.

3) In the immediate short term, TA for BCC may be provided through facilitating state‐level
consultations focused specifically on BCC for urban health (experience‐sharing and
material review). This would also identify key areas within BCC requiring TA from HUP.

4) Pilot city demonstration projects with a strong BCC component to ensure demand
generation that must accompany an effective, responsive program integrating the supply of
quality health products/services. Door‐door BCC sessions and group‐based discussions with
women (through groups such as mahila swasthya sanghas) must be complemented by an en
equally strong outreach with men in the community, who are the key decision‐makers with
regard to sanitation and contraception.

5) In addition to the focus on changing individual behaviors through BCC efforts must be must
be complemented with a strong mid‐media, “community activation” interventions to reach
the wider community and change social norms which can take the form of regular
meetings of community groups (including men and women) with BCC components such as
video screenings, or participatory theatre such as Magnet Theater, a methodology has been
successfully used in India by Path under the Avahan Phase One program. 45
44
A Concurrent Evaluation of Phase 11 of the NRHM BCC Campaign, MCH Star‐USAID. September 2009.
45
MT involves an adaptation of the Forum Theatre methodology, with the inclusion of a fixed day, time and venue for the
performances. MT performances are organic in nature, and draw from real life issues confronting the community, and
freeze with a dilemma confronting the protagonist. Thereupon, the facilitator invites possible “solutions” to the issue and


6) The BCC strategies for HUP must necessarily integrate the following activities and materials

a. An overall branding and positioning for the HUP project which must be reflected in all its
communication materials and activities, and include social recognition of good
community workers, leaders
b. IPC through community health workers using a set of flash cards/flipchart with a clearly
defined outreach cycle
c. Job aids/ready‐reckoners for frontline workers – such as a booklet on all available
central and state government schemes for MCHN and Water‐Sanitation
d. Health‐facility based IEC such as rights of patients, available schemes to support MCHN
and Watsan.
e. Mass media programming featuring TV spots, infotainment, FM radio. The media plan
should ideally be developed through a professional firm
f. A mid‐media, community driven approach such as participatory theater

Ensure the provision of BCC complemented by health care products and services to support behavior
change – the case of chlorine tablets or solutions for clean drinking water, zinc treatment for
diarrhea management, community/individual toilets to make slums open defecation free (ODF). HUP
must invest seriously in facilitating partnerships ….

7) Partnerships with urban citizens’ forums such as Rotary, Lions Club, and well established
private stakeholders for sanitation such as Sulabh International or Nirmal Shouchalay for
specific inputs into slum health interventions.

their enactment, in the process triggering critical problem solving and decision making skills within the community.
Subsequent performances are based on new and related “key issues” identified based on the community responses and
discussions

Bibliography

Shaping Demand and Practices to Improve Family Health Outcomes in Northern India: A framework
for Behavior Change Communication. Population Council, 2011.

A Concurrent Evaluation of Phase II of the NRHM BCC Campaign. Population Foundation of India,
MCH‐Star and USAID. 2009.

The USAID/India Urban Health Program: An Evaluation of Activities to Date and Recommendations
for the Future – October 2005.

Poor Perinatal Care Practices in Urban Slums: Possible Role of Social Mobilization Networks Zulfia
Khan, Saira Mehnaz, Najam Khalique, Mohd Athar Ansari, and Abdul Razzaque Siddiqui

Powerpoint presentation, Sure Start, June 2011.

Assessment of Current Status of IEC and Awareness Amongst the General Community Concerning
Program Components in the Municipal Limits of Dehradun, Nainital and Haridwar. Uttarakhand
Urban Sector Development Investment Program (UUSDIP), PRIA.

Urban Health Initiative (UHI) Communication Strategy: Creating Confident Contraceptive Users:
Communication and Demand Generation Roadmap for Family Planning. Johns Hopkins Bloomberg
School of Public Health, Centre for Communication Programs. October 2010.

Uttar Pradesh Formative Assessment Study. Urban Health Initiative. 2010.

Sure Start Initiation Process: A Compendium

Sure Start Process Documentation

Assessment of IEC Activities in Maharashtra State. Study Report by Pune Health Care Management
and Research Centre. State Health IEC Bureau. 2011

Concept Note: Meeting the Challenges of Urban Population especially for the Urban Poor (With
Special Focus on Urban Slums). National Urban Health Mission, Urban Health Division, Ministry of
Health and Family Welfare, GO. July 2010.

Draft Framework for Implementation, NUHM, Urban Health Division, Ministry of Health and Family
Welfare, July 2010.

Consultation Report: Stakeholder’s Consultation on Health of Urban Poor (HUP) Program. Challenges
and Initiatives. Plan India, Pune. June 2nd, 2011.

National Rural Health Mission BCC Strategy Uttar Pradesh, November 2008, Department of Health
and Family Welfare, Uttar Pradesh.

USAID Evaluation of Urban Health, 2005.

EU –SSP Communication Strategy – Feb. 2011.

Vision
A responsive, functional, and sustainable health system that provides need based, affordable and
accessible quality health care, improved water, sanitation and hygiene for urban poor in eight states.
Goal
To improve the health status of the urban poor by adopting effective, efficient and sustainable
strategic intervention approaches, adopting the principle of convergence of the various development
programs.
Delhi
HUP Demonstration Cities
Agra
Jaipur
Bhubaneswar
Pune
The Centre for Development

and Population Activities
For more information please contact:
Health of the Urban Poor (HUP) Program

Population Foundation of India
B-28, Qutab Institutional Area, New Delhi-110016, Tel: 91-11-43894166, Fax: 91-11-43894199
E-mail: info_hup@populationfoundation.in, www.populationfoundation.in
This document is made possible by the support of the American people through the United States Agency for International Development (USAID). The
contents are the responsibility of the Population Foundation of India and do not necessarily reflect the views of USAID or the United States Government

Behavior Change Communication For Urban Health A Situation Assessment

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Behavior Change Communication for

Health of the Urban Poor (HUP) Program

Awareness on need to treat drinking water 99% 96%

Awareness about at least 1 treatment method 97% 47%

‐ knowledge about boiling water 70% 20%

‐ knowledge about liquid medicine 72% 1%

‐ knowledge about tablet medicine 53% 1%

‐ knowledge about water filters 62% 1%

Chlorine liquid 60% Nil

Chlorine tab 17% Nil

Total ever users of chlorine products 76% Nil

Chlorine liquid 30% Nil

Chlorine tab 2% Nil

Total consistent user of chlorine users 32% Nil

% consistent chlorine user among HHs surveyed 32% Nil

% consistent chlorine users among ever users 42% Nil

The Centre for Development

For more information please contact:

Health of the Urban Poor (HUP) Program

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