Role of Social Mobilization (Network) in Polio Eradication in India

"At the core of SMNet lies co-opting the community. The SMNet uses the members of the community to seed networks with change."

How did India - a country that in 2009 contributed over half the global cases of poliomyelitis - come to be certified polio free in March 2014? Hailing from the United Nations Children's Fund (UNICEF), which is one of the organisations that is part of the Global Polio Eradication Initiative (GPEI), the authors of this article contend that one of the major reasons behind the interruption of polio transmission was the deployment of UNICEF's Social Mobilization Network (SMNet). The SMNet targets resistance to polio immunisation through a multipronged approach that includes  interpersonal communication, counseling, mothers' meetings, announcements from religious institutions, and rallies and that engages local religious leaders and community influencers. This review examines social mobilisation efforts for polio eradication in India with the following objectives: to describe social mobilisation strategies and models which have resulted in polio eradication in India; and to acknowledge the role of social and community mobilisers in addressing community resistance and enhancing community participation for improving public health programmes through an enabling environment for immunisation.

The article is based on a review of primary and secondary data sources that include SMNet management information systems (MIS), various evaluations and technical reports, and working papers that document communication efforts for polio eradication in India. National Immunisation Day (NID)/Sub-National NID (SNID) monitoring data was also reviewed and used. Other sources of information analysed include country data presented at India Expert Advisory Group (IEAG) meetings and polio communication reviews. Reports on polio eradication efforts in other countries were also reviewed.

As the authors explain, the decision to set up a social mobilisation network had its origins in the analysis of the epidemiological data of wild poliovirus (WPV) cases. An analysis revealed that over 59% of cases in Uttar Pradesh (UP) belonged to the Muslim community, while according to the 2001 census, Muslims comprise approximately 18% of the population in the state. Data showed that a Muslim child was 5 times more likely not to receive even one dose of oral polio vaccine (OPV). Studies and refusal analysis also revealed that there was deep-rooted mistrust within the community that resulted in misconceptions and refusals of OPV. Caregivers also complained about the lack of trust in the health system and misbehaviour of service providers towards them. Apart from families that refused immunisation, there were other children who lacked access to services. Belonging to mobile, migrant, and hard-to-reach families, these were the missing children that needed to be mapped and brought back into the polio immunisation net.

In that context, SMNet was first established in UP in 2002 and then expanded to Bihar in 2005-06 with the objective of increasing OPV uptake among children under 5 years of age in these states. In West Bengal, following the last polio case in 2011, the SMNet was established for emergency preparedness in response to the WPV case in Howrah. Surveillance data were used to systematically map and identify pockets of underserved and high-risk areas/groups to determine areas for the SMNet operation. The selection of appropriate advocates was based on negotiations and discussions with several implementing partners as well as beneficiaries.

A 3-tiered structure, the 7,300-strong SMNet mobilises communities by spearheading civil society participation at district, block, and community levels. The community mobiliser coordinators (CMCs) of the SMNet belong to the communities they serve. "Deeply respected in the community, the SMNet mobilizers (98 percent of whom are women) are themselves models for gender empowerment." Responsible for 350-500 households, they go house to house to engage families through interpersonal communication and counseling sessions - addressing myths and misconceptions and ensuring correct knowledge about polio. They also mobilise families before every SIA round to ensure that all children below 5 years get OPV. Holding mothers' meetings and religious meetings to advocate for repeated polio immunisation, coordinating temple and mosque announcements, and conducting polio classes in schools, madrasas, and other congregations are just some of the mobilisation activities that a CMC regularly undertakes. In between rounds, they counsel families where children were missed, tracking pregnant women, registering newborns, and tracking them for polio and routine immunisation.

The SMNet also reaches out to community assets to extend their footprint - an army of 31,000 community influencers to build trust and goodwill for the polio programme, while its 26,650 informers help notify migrant communities. In total, UNICEF's SMNet reaches over 2.2 million under 5 children in some 3 million households of UP, Bihar, and West Bengal.

The article reviews SMNet's strategies for delivering results, covering its: underserved strategy; tracking of beneficiaries and high-risk groups; counseling and mobilisation activities; evidence-based planning at block and district level; capacity building and supportive supervision; monitoring and MIS; and strengthening of routine immunisation and convergent health issues.

It next examines SMNet's social impact, in the categories of: empowering women; empowering children (e.g., through its bulawa tolis, establishes the groundwork and consciousness for their future participation in similar programmes); reaching mobile and migrant populations; and broadening the role of religious leaders.

Cited here is an independent assessment of SMNet in 2013, which concluded that it has been "effective and efficient" at achieving its goals of increasing the total number of children immunised against polio and ensuring that those most at risk are protected. Between 2007 and 2015, resistant households declined 77% in Bihar and 86% in UP, where now less than 0.5% of households resist vaccination. Findings and analyses also suggested a high relevance of the network, SMNet design, and interventions are aligned with community needs. The approach has been relevant to achieve the results of the polio eradication programme by reducing resistance to vaccination and reaching the unreached in polio-endemic states of UP and Bihar.

Recognised by the GPEI for its effectiveness, SMNet has been replicated in other Indian states and polio-endemic countries. The SMNet is supporting India's routine immunisation programme and other convergent health issues like diarrhoea, handwashing, and exclusive breastfeeding - areas that converge with its core programming. Other examples are provided.

"[P]ossibly the most important universal take-away from the SMNet programme is that the community trust is critical to the success of any behavior change programs. Externally imposed agencies fail to bring about long term change without the trust of the community and this trust can be built only if the members of the network are integral to the community."