Equity Case Study: India - Reaching Nomads with Polio Vaccine and Health Services
UNICEF India achieved a milestone in its history: one year without a single confirmed case of polio in January 2012.
By Abhijit Shanker
19 April 2012 - Nomadic populations are among the highest-risk groups for wild poliovirus transmission in India, which was until recently one of the world’s four remaining polio-endemic countries. Regularly on the move, with unpredictable migration patterns, these itinerant groups often exist beyond the reach of even the most basic health services. UNICEF India has embraced the global strategic refocus on equity and intensified national efforts to reach out to every last child to protect them against polio as part of the polio eradication initiative. One of the cornerstones of the Indian polio eradication effort is its strong Social Mobilization Network (SMNet), which began systematic tracking of and outreach to this highest-risk group in 2010.
UNICEF India achieved a milestone in its history: one year without a single confirmed case of polio in January 2012. Clearly, strategic planning to reach out to nomads in Uttar Pradesh - India’s most populous state with more than 200 million people and a traditional reservoir for poliovirus - has ensured that all children under five years old are contacted during polio immunization campaigns. It also provides these vulnerable groups with access to routine immunization services and valuable health messages.
On 25 February 2012, the World Health Organization officially took India off the list of remaining polio-endemic countries after the country succeeded in passing more than a year without recording any cases of wild poliovirus. Now only Afghanistan, Nigeria and Pakistan are considered to have endemic poliovirus transmission, meaning they have never succeeded in stopping the virus within their national borders. All other poliovirus in the world has its origins in these endemic countries, from which it spread to re-infect populations free of the disease. India’s success in stopping transmission of indigenous wild poliovirus is a major milestone, especially for a country with such huge challenges, including high population density, a large birth cohort (in Uttar Pradesh alone than 500,000 children who need to be immunized are born each month), diverse socio-economic, cultural and religious beliefs and high migration and population movement.
One of the key strategies of the polio eradication programme in recent years has been to reach out and provide protection to vulnerable migrant and mobile populations against polio. Millions of Indians are on the move throughout the country each year, packing up their families and following work as agricultural laborers, typically in brick kilns or on construction sites. These populations long posed a key threat to polio eradication because they were hard to reach with polio vaccine, and their travel patterns helped spread the virus as infected children would move from one town to another, transmitting poliovirus throughout the country.
While the polio eradication programme was able to quickly identify migrant laborers at their places of work, the bigger challenge was in locating and being able to provide services to nomadic groups who adhere to a less defined travel schedule. Nomads move frequently from place to place for their livelihood, setting up ramshackle tent homes whenever and wherever they stop. UNICEF and its partners therefore had to devise special strategies to track, mobilize and immunize these susceptible communities in order to reach the tens of thousands of children who until recently had limited or no access to health services.
Strategy & Implementation
By 2009, the polio programme identified that a disproportionate number of polio cases were being reported among migrant populations, or among children living in close proximity to them. As a result, UNICEF introduced a “Migrant and Mobile Strategy,” to identify these groups, map their travel routes and engage their leadership in promoting polio immunization. This strategy has since been expanded to systematically track and engage nomads for polio immunization.
UNICEF’s Social Mobilization Network (SMNet) in the northern Indian state of Uttar Pradesh (UP) is an army of nearly 5,000 paid community mobilizers who go door-to-door in the highest-risk residential blocks to advocate for a variety of health services, including polio and routine immunization, nutrition, water sanitation and hygiene (WASH), exclusive breastfeeding and diarrhea management. By 2010, and owing to its success, the SMNet was given a new task: to identify all nomadic settlements in the high-risk states of UP and Bihar. Nomadic population settlements were mapped for immediate mobilization and polio vaccination, with the community mobilizers approaching the nomadic groups first to share their essential health messages, then followed by a polio vaccination team who delivered oral polio vaccine. While the nomads at some sites immediately agreed to be vaccinated, all too often these communities were suspicious of health workers whom they suspected to be government representatives who would harass them or demand money, so they usually either flatly refused services or moved on before the vaccinators could approach them.
A more effective strategy was required that not only identified settlements, but also included information on their social and cultural affiliations and travel routes. From the available information collected by the community mobilizers, a detailed analysis was carried out, identifying and classifying all nomadic groups that visit the state in order to create a more focused approach. Several main groups were acknowledged: Kanjars, an endogamous group of mainly artisans and entertainers; Gadia Lohars, who originate from the adjoining state of Rajasthan and who travel from place to place on bullock carts in which they live; Nats, performers who ply their trade on the streets or at religious and social congregations; Gandhileys, a complex group with no specific religion or culture, often involved in poaching, prostitution and begging; Banjaras, who buy goods in bulk and go door-to-door to sell them; and, traditional faith healers, another complex group with no specific religion, who make their living by selling herbs.
In view of the complexities and challenges characterizing these groups, the SMNet instituted a network of “informers” - comprising either members of the nomadic groups themselves or locals who live or work close to known nomadic camping sites - to share information about the arrival or departure of the nomads. As of January 2012, there are 5,837 informers throughout UP who provide information on nomadic group locations and help connect social mobilizers and health workers to local leaders and families. This network has proven invaluable to mobilizers and vaccinators, not just as sharers of information, but also as intercessors able to approach nomadic groups on the polio programme’s behalf, easing mistrust of polio eradication workers.
Status of informers in Utta Pradesh, January 2012
Progress & Results
As a result of the persistent effort to track nomadic groups, there has been a steady increase in the number of highest-risk group (HRG) sites identified and mapped in polio immunization micro-plans. In January 2011, there were 11,309 sites identified in 45 districts of UP covered by the SMNet. This year, there are 15,576 identified sites. The total number of families mobilized for polio immunization has increased from 146,316 in January 2011 to 196,340 in January 2012, with 156,175 children under five identified for polio immunization activities, as outlined in the following table:
|| Total number of sites identified
|| Total number of families
|| Total number of children under five |
|| 145,868 |
|| 147302 |
|| 155836 |
|| 154696 |
|| 166053 |
|| 109264 |
|| 102879 |
|| 117425 |
|| 120249 |
|| 151058 |
|| 154775 |
|| 156175 |
Trust has increased over time as the nomadic populations have been able to see the altruistic intent of the polio workers. As a result, the social mobilizers witnessed a dramatic increase in the willingness of nomadic parents and caregivers to act on essential health messages. Today, SMNet community mobilizers are readily accepted into nomadic settlements to share messages promoting polio immunization and describing the underlying causes of poliovirus transmission, the six essential times for hand washing, the use of oral rehydration salts (ORS) and zinc to manage diarrheal episodes, sanitation, exclusive breastfeeding up to six months of age, and the benefits of routine immunization to guard against the six vaccine-preventable childhood diseases.
Despite progress, tracking and mobilizing nomadic families remains a challenge, with each group requiring a specific approach in consideration of their diverse socio-religious backgrounds in order to persuade them to accept available health services.
Some groups, such as the traditional healers, remain resistant toward modern medicine. Many groups stop over at the identified sites only for a few hours before they move on, meaning mobilizers and vaccinators often arrive to find camps empty.
The challenges highlight the benefits of a focused strategy tailored to each group in order to maximize the contacts made with nomadic families, as well as the need to maintain local contacts who can bridge the gap between a marginalized group and a centralized health or development service. The tracking and mapping of the nomadic sites for polio eradication has proved a boon for the health sector, enabling it to reach out to these evasive populations with routine immunization services. The following map of the Daurala block in the Meerut district in western UP shows the location and number of nomadic settlements and brick kiln and construction sites, enabling accurately targeted routine immunization interventions.
The most difficult aspect of working with nomadic families is to keep track of them. Successful tracking and mapping of nomadic groups offers real potential for providing a range of other services, potentially even allowing for the offering of limited education and the provision of nutrition, water and sanitation services.
The mechanism developed for tracking of nomads can be further expanded and institutionalized in the state. It can also be emulated elsewhere in the country to reach out to the most vulnerable populations. Furthermore, the information gathered on these highest risk groups can be used to substantially boost routine immunization coverage and reduce their vulnerability.