The northern state of Bihar is one of the most populous states in India, with some of the poorest development indicators in the country. More than half the population lives on less than 50 US cents a day, according to the UN Development Programme. Many people are subsistence farmers living in remote villages, connected to the capital Patna by pot-holed roads and cut off from regional service centres by wide rivers that change course and rise and fall with the seasons. It is common for villages to have no electricity, no running water, no flushing toilets and no medically trained doctor. The state’s population is highly transient, with manual labourers moving with the seasons to find work, and taking their children with them. Each year, the Kosi River drastically changes the landscape, flooding the homes of millions of people who are forced to find higher ground and rebuild their homes on new ground. With so many children in Bihar geographically isolated or on the move, it is extremely challenging to access or to map every child. It is no surprise the state was one of the last and most persistent sanctuaries for the poliovirus in India (see Kosi River Intensification).

Social Mobilization

The Social Mobilization Network (SMNet) started in Bihar in 2006, and now has around 1,400 members at all levels. There are around 1,000 Community Mobilization Coordinators (CMCs), the foot soldiers of the network, mostly located in the isolated Kosi River Region of the state. They are local men and women who regularly visit up to 500 households in their communities, taking note of all children under five in their area and counselling parents to have them vaccinated. The CMC makes sure children under five receive the oral polio vaccine every time it is offered in a polio immunization round, and that babies under the age of one are taken to local routine immunization sessions. The immunization status of the children is systematically tracked in the CMC's field book. The CMC promotes a package of measures, including routine immunization, exclusive breastfeeding and colostrum feeding, hand washing with soap at critical times and the use of zinc and oral rehydration salts to tackle diarrheal episodes. More than half the CMCs in Bihar are now women. Because the CMCs live in the villages they work in, the problem of reaching remote flood-prone areas is overcome. In Bihar, there is no booth day - instead, children are vaccinated against polio during house-to-house visits, conducted over five days. The CMC accompanies a government vaccination team, sharing vital information about the whereabouts of children under five. If parents refuse to vaccinate their children, the CMCs and other SMNet coordinators work with local government members - elected members of the Panchayat Raj Institute (PRIs) - to try to change their behaviour. PRIs take on the role of promoting the polio immunization rounds, building ‘polio gates’ in their communities using banners provided by UNICEF.

The coordinators of the Social Mobilization Network work hard supervising the CMCs, making sure the programme is highly visible with the use of communication materials, and to train other frontline workers such as vaccinators and health workers on social mobilization and interpersonal communication. The coordinators forge relationships with locally elected leaders, religious leaders and civil society groups.

Kosi River Intensification

A plan intensifying the focus in the difficult-to-access Kosi River flood plain was drawn up in 2008 by UNICEF and WHO-NPSP, under the leadership of the state government. A grid system was used to identify villages being neglected because they were far from service centres or cut off by the often changing course of the Kosi River and its seven tributaries. Areas being overlooked received extra attention and resources, with the SMNet considerably bolstering its presence in the region, and the polio programme, led by NPSP, establishing hundreds of overnight stay points and satellite offices to help vaccinators to stay in the area for longer and reach remote destinations on time. 

Reaching Children on the Move

In Bihar, more than 10% of children who are vaccinated in each polio immunization round are on the move, receiving the OPV at a train stations, bus stands, markets or from transit teams at large festivals and gatherings. With so much of Bihar’s population moving between different locations for work, mobile vaccinators visit brick kilns and construction sites, vaccinating the children of seasonal labourers. There are more than 7,000 brick kilns in Bihar, operating in the drier months. Bihar shares a porous border with Nepal. Of the 81 vaccination posts along the Indo/Nepal border, 53 are in Bihar. Nepali women work for the polio programme at the transit points during immunization rounds, speaking the same language and understanding the culture of the children being vaccinated and their parents.

Capacity Building

In Bihar, the UNICEF programme has a special emphasis on providing training about the facts of polio and counselling techniques to government health workers, including more than 50,000 Anganwadis (child nutrition workers) and ASHAs (Accredited Social Health Activists). Local Block Mobilization Coordinators organise training and materials to guide the government vaccination teams. Local government representatives, or PRIs, are given orientation sessions after being elected, so that they become well-informed advocates for polio vaccination. Because the mobile and migrant strategy is a major part of the polio programme in Bihar, orientation sessions are also held for Government workers who could provide help during vaccination rounds, including border guards, traffic wardens, police and junior cadets.

Routine Immunization & Convergence

The polio programme in Bihar has broadened its focus to include routine immunization, hand washing, colostrum and exclusive breastfeeding until six months, managing diarrhea with zinc and oral rehydration salts, and water and sanitation. For example, social mobilizers draw up ‘due lists’ of children for routine immunization, arrange with the health officials to hold routine immunization sessions at work sites such as brick kilns and then counsel parents to have their children immunized. Routine immunization rates have more than tripled in Bihar in the past seven years, according to a range of government and partner agency surveys. From a low of less than 20% in 2005, the rate has risen to more than 70%. 

Toilets are being built at work sites, hand washing promoted through an established, safe water supply, and with the assistance of UNICEF advocacy, more than a third of mothers in Bihar breastfeed their babies until at least six months, up from 12% in 2010.

Partnership

Strong partnership has been a key to success of the polio eradication programme in Bihar. UNICEF has worked closely with the state government and non-government agencies including the ICDS (Integrated Child Development Services) Department, the Panchayat Raj (local government) Department, the National Cadet Corp, the Indian Medical Association, the Indian Academy of Paediatrics, Indian Railways, the state diary cooperative COMFED, religious leaders and others. UNICEF has also partnered with media organisations to address fears, myths and rumours about the polio programme. Media workshops have been held to ensure local journalists are well informed. In Bihar 80% of media reports are now considered by UNICEF to be positive for the programme, with the remaining 20% neutral. In each of the 38 districts of the state, three contacts have been identified to cover the Hindi, Urdu and English press.  These media people are focal points, to be contacted when there is new information to be shared about the polio programme.