Untitled

1
©United Nation Children’s Fund(UNICEF) May 2018
Photo Credits: UNICEF/India/2017
Permission to reproduce any part of the publication is required
Please contact:
United Nations Children’s Fund
UNICEF House, 73 Lodi Estate, New Delhi,
Tel: +91-11-24690401/0409, 40798000
Fax: +91-11-24690410, 246427521
Web: www.unicef.org/india
Permission will be freely granted to educational or non-profit organizations.

Others will be requested a small fee.
2
3
Acknowledgement
This compendium of social and behaviour change communication case
studies from 15 States has been developed for Communication for
Development (C4D) cross-sectoral program of UNICEF India. We begin
by acknowledging the C4D India Chief Siddharth Shrestha for his vision
and direction in finalising the compendium. Our sincere thanks to the true
leaders in State C4D Specialists - Mr. Abhishek Singh, Mr. Bhai Shelly,
Ms. Harsha Mehta Pankaj, Ms. Lopamudra Tripathy, Ms. Manjaree Pant,
Ms. Mona Sinha, Mr. Nasir Ateeq, Mr. Nilesh Nikade, Mr. Sadique Ahmad,
Mr. Sanjay Singh, Ms. Seema Kumar, Ms. Sonali Mukherjee, Ms. Soniya
Menon, Ms. Sukhpal Kaur Marwa, and Ms. Veena Kumari - whose critical
insights and persistent support enabled us to develop these case studies.
We would also like to extend our sincere thanks to the reference network
team of UNICEF, comprising - Ms. Arupa Shukla, Ms. Geeta Sharma,
Ms. Rachana Sharma, Ms. Rania Elessawi, Mr. Sanjay Singh, Ms. Seema
Kumar, Ms. Soniya Menon and Ms. Veena Kumari - whose valuable and
objective critique through three writing workshops helped us raise the
quality of these case studies. Our thanks also to Ms. Alka Malhotra and
Ms. Shalini Prasad for strategic advice and input on relevant case studies.
On behalf of UNICEF, we would like to thank all the State government

officials for supporting and helping to take C4D’s vision to fruition. We
would certainly be remiss to not mention and sincerely thank the partner
organisations and field teams of all States who helped us in understanding
and capturing the soul of these case studies.
Lastly and most importantly, heartfelt thanks and gratitude to our

stakeholders - mothers, fathers, caregivers, adolescents, and children, who
trusted us with their stories and helped us bring them to life.
Gratitude to all for this rewarding, insightful journey in the world of social
and behaviour change communication.
Table of Contents
Gujarat.............................................................8 - 19
Odisha............................................................. 20 - 31
Assam..............................................................32 - 43
Uttar Pradesh...................................................44 - 59
West Bengal.....................................................60 - 75
Telangana........................................................76 - 87
Bihar.................................................................88 - 103
Tamil Nadu.......................................................104 - 115
Madhya Pradesh..............................................116 - 131
Karnataka.........................................................132 - 141
Jharkhand........................................................142 - 157
Chhatisgarh......................................................158 - 169
Andhra Pradesh...............................................170 - 181
Rajasthan.........................................................182 - 193
Maharashtra.....................................................194 - 205
5
Summary Note: Social
and Behaviour Change
Communication (SBCC) Case
Studies Compendium
This compendium of 15 SBCC cases presents results
and learning from the Communication for Development
(C4D) cross-sectoral interventions from 15 states of
India – all implemented during the country programme
2013- 2017. Additionally, a national level C4D Results
Report ‘Resonating Change’ has also been compiled.
The case studies at the state level were selected based
on the following criteria:
1. Level of maturity - High/Medium/Low
2. Level of Research - Well Researched/Moderately

Researched/Not Well Researched
3. Geographical Spread of Implementation - High/

Medium/Low
A CMS team then interacted with respective UNICEF

state teams to understand the on-ground situation,
stakeholders, SBCC initiatives implemented, and
subsequent results. The team ensured a visit and
interaction with community stakeholders, government
officials and other partner agencies – accounting for
2-3 days for each field visit. All of this was completed
between May 2017 and December 2017.
The SMART framework adopted to document the

cases, considered each intervention through the
following lenses:
• Situation – Problem situation that the initiative

intended to address
• Method – Activities initiated to address the situation
• Action – Implementation of aforementioned

activities
• Results – Outcomes of each initiative
• Transformative Change – Larger level impacts

and changes
6
This was a joint effort of C4D UNICEF and CMS. The 10. Karnataka - Supportive Supervision to improve
C4D team invested significantly in reviewing, inputting, demand for RMNCH+A services
and writing the content and shaping the design of each
11. Jharkhand - MAHIMA: Breaking the Taboo Around
document. Each case was reviewed by the respective
Menstruation
state C4D Specialist and then reviewed by the UNICEF
Reference Group, which was specifically constituted for 12. Chhattisgarh - Ek Kilkari: System Strengthening for
the purpose. Pink Lemonade was the design partner for Routine Immunisation
this assignment.
13. Andhra Pradesh - Improving the Lives of
The states and the initiatives documented are: Adolescents in Visakhapatnam district
1. Gujarat - Udaan: An Intervention for Prevention of 14. Rajasthan - Empowering Communities and
Child Marriage Adolescents for Collective Ownership of 'Child
Marriage Free Gram Panchayats' in Rajasthan
2. Odisha - Sishu O Matru Suraksha: A Social and
Behaviour Change Intervention for Child and 15. Maharashtra - Intervention for Improving
Maternal Health Routine Immunization in Underserved Municipal
Corporations of Bhiwandi and Malegaon
3. Assam - Home Based Newborn Care
Voucher System
4. Uttar Pradesh - Suramya: Communication to

Eliminate Open Defecation
5. West Bengal - District SBCC cells: System

Strengthening Through Social and Behaviour
Change Communication in Development
Programmes
6. Telengana - Nudging the Norms through Faith

Based Organization for Promotion and Protection of
Child Rights
7. Bihar - PYARHI: Breaking the Taboo and Culture

of Silence
8. Tamil Nadu - Behaviour Change Communication

through mobile technology Promoting IYCF
practices among caregivers
9. Madhya Pradesh - Mamta Abhiyaan: Sneha,

Suraksha, Samman
7
1
Udaan
An Intervention for
Prevention of Child
Marriage in Gujarat
Udaan is designed to find a community-led solution to the high prevalence of child marriage in Gujarat. The
purpose is to initiate a community dialogue that helps reflect and initiate change that affects the prevailing
social norms around child marriage. UNICEF[1], in partnership with the Gujarat State Child Protection Society
under the Social Justice and Empowerment Department, Department of Education, Government of Gujarat,
and Anarde Foundation (NGO partner), carried out a pilot in 120 administrative blocks of Banaskantha district,
Gujarat. The intervention was initiated with a village mapping exercise to identify barriers. Education of
adolescents was chosen as the introductory intervention to pave the way for more intensive dialogue around
the prevention of child marriage. The intervention resulted in communities engaging in positive dialogue,
skill, and confidence building in adolescents. It also led to successful partnerships with Gujarat University,
leveraging of government resources for SABLA[2], and the strengthening of government and implementing
partner systems in the areas of adolescents’ education, life skill building, and child protection.
8
Theory of Change
Gender norms, poverty and

high cost of marriage, lack
of easy access to schooling,
perceived lack of safety and
remote location of schools,
political patronage leading
to weak enforcement
Promoting adolescents
Engaging with castes
as change agents and
willing to change,
influencers, creating safe
comparing with
spaces for adolescents
progressive castes to
to exercise their agency,
set example
imparting life skills training
Continuing education as a Using Theatre of the

stepping stone to initiate Oppressed to create
dialogue around adolescents, dilemmas, compel
their healthcare, nutrition, life introspection, and take
skills, and marriage decisions to effect change
Adolescent girls and boys

Change in communities'
are confident and speak up
socio-cultural practices,
for their rights, academic
reduction in child
institutions lead in social
marriages, scaling-up of the
change, partners gain
government programmes in
social recognition and build
other districts
their capacity to address
social issues
9
Area of Intervention
Banaskantha
Gujarat
Map not to scale

Intervention State This map does not reflect a position by UNICEF on the legal status
of any country or territory or the delimitation of any frontiers.
Intervention District Source: http://d-maps.com/carte.php?num_car=4183&lang=en
Situation
Worldwide, more than 700 million women alive Gender norms mean girls and women have an inferior
today were married before the age of 18. India alone position in society. Fear of losing family honour in case
accounts for one-third of this global total[3], although of a premarital sexual relationship, and child marriage
only accounting for 18 percent[4] of the world population. as the means to save the family from any possible
India has had a law preventing child marriage since dishonour is grounded in prevalent gender norms
1929, but implementation has proved to be a challenge. around virginity. Even the seemingly poverty-driven act
In turn, child marriage has adverse implications on of marrying off girls in lieu of debt has its roots in gender
health and several other aspects of life; with high norms that privilege men in every aspect and deny any
infant, child, and maternal mortality rates being partly voice to girls.
attributed to child marriage.
Poverty, high wedding costs, and other economic
Instance of child marriage in Gujarat: considerations sometimes drive families to marry
In Banaskantha, 56 percent of married women (aged their children early. Practices such as sibling and cross
20-24) were married before the age of 18. This, in marriages, or Atta Satta – the simultaneous marriage
contrast to the Indian average of 43 percent and the of one set of brother and sister to another set of brother
Gujarat average of 35 percent[5], makes Banaskantha and sister from the same village, tribe, or clan – are a
the district with the highest child marriage prevalence in result of this.
the state[6].
Political patronage weakens enforcement agencies.
Drivers for prevalence of child marriage[7] Communities with formal groups like caste panchayats[8]
form a key voting block, and often have political
Lack of easy access to schooling (mainly due to connections. Enforcement agencies and Frontline
distance), especially at the secondary level, leads Workers (FLWs) find it difficult to go against their
communities to encourage families to marry girls accepted rules and norms.
early – so the onus of protecting her and her chastity,
which is equated to family honour, is transferred to the Due to the above reasons, child marriage is widely
bridegroom's household. The safety and chastity of girls practised. Socially approved sanctions for child
is a major concern for parents. marriage are key contributors to the trend.
10
Discussions at the Anarde outreach programme.
Method
Acknowledging child marriage and the many challenges partner. Anarde has had a long presence in
it poses, UNICEF, in partnership with Gujarat State Banaskantha with experience in water conservation,
Child Protection Society (SCPS)[9], Department of child rights, sanitation, and hygiene behaviour related
Education, and Government of Gujarat initiated the interventions. Other initiatives towards the formation of
Udaan Programme with a pilot in Banaskantha district. women’s Self Help Groups (SHGs) in the district also
Within UNICEF, three internal departments – Education, helped them engage closely with communities.
Child Protection, and Communication for Development
Udaan started with a caste-mapping exercise
– converged for this intervention. The objective of the
across 120 villages in Danta and Kankrej blocks of
Udaan intervention is to bring together caste panchayat
Banaskantha district. This activity involved village-
leaders, who influence the decisions of adolescent girls
level mapping of various castes and communities
and their family members, and initiate a dialogue on the
inhabiting the village, status of adolescents, and other
consequences of underage marriage. This is done to
key issues for the community. Village-level mapping
promote a new social practice that, in due course, could
helped to decipher the community’s perceptions on
have the potential to change the prevailing social norms
education of girls, and age of marriage. It also aided the
around child marriage.
understanding of social and gender norms, and how
To take this intervention to the field, UNICEF selected these dictate their behaviour, caste structures, and the
Anarde Foundation, a local NGO, as the implementing role of caste panchayat leaders.
11
Mapping of 19 castes was done over a period of two
years and categorised into three groups:
Castes that are rigid and resistant to change[10]
Middle-order castes with a strong presence in

the community, but willing to change
Progressive castes, where change has

already started
Given that this was the pilot phase and UNICEF had
little experience in engaging with the community on
the sensitive subject of child marriage, a conscious
descision was taken to work with the middle-order caste
panchayats. The reasons being that these castes have:
• Significant, widespread presence in terms of Thakor Rabari Valmiki

geography and membership
area, with the village mapping exercise highlighting a
• Organised cast structures high prevalence of child marriage. They were considered
to be positive influencers for the middle-order castes, as
• Strong norms, but not staunch or rigid beliefs
elaborated later in the document.
• High prevalence of child marriage
Parallel to the village-mapping exercise, the intervention
Out of the eight middle-order castes identified, the also initiated the formation of organised groups of
Thakor, Rabari, and Valmiki communities were picked to adolescent girls and boys in 120 villages, with the aim
kickstart the intervention. These progressive castes were to provide adolescents with a platform to participate and
the three most populous communities in the intervention express their opinions on issues concerning them.
Hasumati Sarvarkar is a cluster resource

person with Anarde Foundation.
12
Action
Three key components here were:
1. Intensive engagement with the priority castes: 2. Empowering adolescents to act as influencers:
Focus group discussions, one with each of the Using the existing adolescent groups as a
three caste panchayats, were conducted. These platform, UNICEF supported the SABLA Life Skills
discussions aimed to enable the communities to programme of the government. UNICEF aimed to
identify the issues being faced by their adolescents strenghten the SABLA components with specific
reference to life skills. Through this, the government
and youth, posing hurdles in their development.To
and UNICEF sought to:
help them in this reflection, UNICEF also brought
in members from Prajapati (more progressive) • Empower adolescent girls and boys
communities to illustrate how reforming and revising
• Create an enabling environment at the community
social norms has helped their communities progress.
level by sensitising parents and community
The key challenges identified were education,
functionaries
substance abuse, unemployment, and regressive
social practices like child marriage. The initial • Strengthen government service delivery and child
interactions focused on establishing inter-linkages protection mechanisms at various levels
with various government schemes, to help facilitate
• Create safe spaces to ask questions and express
education and employment. This included the concerns
Saraswati Sadhna Yojana[11] that provides bicycles to
girl students, and the SABLA[12] scheme that supports
nutrition, healthcare, and life-skills education for
adolescent girls.
Tejalben Dushuruthbh got a cycle under the

Saraswati Sadhana Yojana, prompting her
parents to continue her education.
13
Aashaben is a volunteer with Anarde,
under the Udaan project.
This programme component follows UNICEF’s The issue-based performances were typically 15 minutes
framework of rights, means, and activities for adolescent long. Actors from within the adolescent group would
empowerment. The child helpline number,1098, was build up a scene – such as the imminent marriage of an
popularised to help register anonymous complaints adolescent girl – and then stop at a critical point in the
related to the abuse of their rights. A suggestion box was story. They would then invite audience participation and
questions, followed by a discussion on the right thing
introduced where adolescent girls and boys could drop
to do and how to do it. The scale-up programme plans
their complaints and queries, which would later be shared
to include mothers and fathers of adolescents as key
with the Village Child Protection Committee (VCPC)[13] for influencers, along with caste or panchayat[15] leaders in
resolution. the child marriage prevention initiative, and make them
change bearers of the process.
3. Communication around child marriage:
After having initiated work on education and life
skills, the next step was to bring together the caste Partnership for Change
panchayats, senior leaders, women, and adolescents
together and trigger communication around child UNICEF partnered with Gujarat University to involve
marriage. A tool was needed that would strategically young college students in awareness campaigns
unfold self-realisation and open conversations around education and child marriage. This was carried
around the sensitive topic of child marriage. ‘Theatre out in March 2017, in collaboration with the Child
Protection and Education department in Banaskantha
of the Oppressed’[14] (TOO) was introduced as the
district in 300 villages – with the involvement of 450
communication tool, and UNICEF conducted a
students from nine colleges in the district. It is a key
five-day capacity building workshop to train team example of how resources can be mobilised and
members of Anarde Foundation, Gujarat State Child partnerships can be built with universities to generate
Protection Society, and District Child Protection momentum for the initiative.
Unit (DCPU).
14
Alkhaji Hajurji Thakor is the caste
leader of the Thakor community.
Results
The capacity- building investment in adolescents has Dr Swarup Rawat, District Child Protection Officer,
resulted in them becoming more confident and speaking Banaskantha, stated that the department received 95
up for their rights[16]. Caste leaders from Thakor Samaj[17] complaints of child marriage immediately after a
acknowledged this change and felt that their children 10-day awareness campaign conducted in March 2017.
could share their newly learnt knowledge with other According to him, the communities now recognise
children. As a community, they felt that they have now the child protection unit and look up to it for help
become more cohesive and have started to reflect on and support on issues related to child rights, child
the factors that deter their communities’ progress. They abuse, exploitation, and violence against children.
now work together to identify the ways and means to Additionally, the state government also recognises the
overcome them. key contribution of UNICEF’s Life Skills component and
The intervention also showcased a successful has decided to replicate this in other districts where
partnership with universities, to leverage resources for Kishori Shakti Yojana[18] (KSY) is being implemented.
social causes. Further, as part of SABLA, $248,000 (INR 1,61,27,787)
in government funds were leveraged in the programme
Rameshbhai, the founder of Anarde Foundation,
implementation plan to enhance social and behaviour
reported that:
change and the life skills component in the nine
• There is an improved confidence in Anarde’s staff SABLA districts.
and delivery of their role because of this intervention
This intervention has also seen a sectoral convergence
• The intervention has improved the social capital in for UNICEF, where it has been able to bring together
the district for Anarde and opened the social space the Education and Social Justice departments to work
for them to work and contribute to their society towards one cause.
15
Transformative Change
UNICEF’s intervention has caused the communities to
reflect and initiate the process of revising opinions on
mass marriage, more specifically on child marriage.
The Thakor community has revised its community
rule-book to include a bylaw that prohibits child
marriage amongst their caste members. This signals
a significant movement forward that would help achieve
the long- term objective of prevention of
child marriage.
The results from this intervention have been

acknowledged by the state and district-level child
protection departments. In Banaskantha district, the
Child Protection Department has already initiated the
process to form a Village Child Protection Committee
(VCPC) in all its 1,255 villages[19]. This transformation
maps back to C4D’s output indicator which aims to
strengthen the state government to implement, monitor,
and evaluate the programmes with social and behaviour
change at its core. Taking the learning from the Udaan The mobile phone camera is a powerful tool
pilot in Danta and Kankrej, UNICEF, along with the for documenting ground-level activities such as
support of DSJE, is now scaling the project to other 'Theatre of the Oppressed' performances.
blocks and eventually other districts.
Caselet
The first time Chetna Viraji Thakor's parents considered getting
her married was in 2014. She was just 13 years old then. Studying
further meant travelling around 6km to the nearest school in Tundia.
Chetna's parents did not think it would be safe for her to travel to the
school alone and on foot.
Kanubhai Prajapathi, the cluster resource person for Anarde

Foundation in Danta block of Banaskantha, counselled Chetna's
parents. He helped get a cycle for Chetna under the government's
Saraswati Sadhana Yojana, resulting in the prospect of her marriage
being averted for the next two years.
The second time Chetna's parents considered her marriage, she was
15 years old. She had, by then, joined her village adolescent girls'
group. Thanks to the training by UNICEF and Anarde Foundation, she
was more aware of the problems associated with early marriage. She
called upon the group for help, and all 14 girls from the group came
over to her house to talk her parents out of the idea of marriage.
Chetna is now 17, and working towards a career in computers;
happily unmarried.
16
In Summary
In 2013, UNICEF launched
its Udaan pilot initiative for
Action
prevention of child marriage
in partnership with Gujarat
State Child Protection Society,
Department of Education, A network of cluster After mapping
Government of Gujarat, and 19 castes in
resource persons and
Anarde Foundation. Here is a Banaskantha, three –
roadmap of the initiative rolled
village volunteers
is developed to Thakor, Valmiki, and
out in 120 villages across the
conduct on-ground Rabari – are selected
Banaskantha district.
interventions. for the intervention.
Communication with Groups for adolescent

communities and girls and boys are Caste leaders of
adolescents on a formed for life skill caste panchayats
common platform to training. Gender are identified as key
help them reflect on sensitisation workshops influencers within the
challenges faced by are conducted for the community.
them is initiated. groups as well.
Results
Theatre of the Adolescent girls There is increased

Oppressed is organised and boys are more awareness about
across villages of these confident and are child protection
three communities. able to speak up in within societies in the
public forums. targeted districts.
Communities now Successful

reflect on practices demonstration of
such as child marriage, partnerships with
and their harmful universities have
effects on children and leveraged resources
their community. for social causes.
17
Communities are in Government

the process of revising departments have
norms on mass marriage been strengthened to
and more specifically, implement and monitor
child marriage. such crucial and
sensitive interventions.
The DCPU has achieved

60 percent (1,255) Mothers of adolescents
completion of the task have been made key
Current Scenario
to develop Village Child influencers in

Protection Committees. decisions regarding
early marriage.
The Udaan initiative is Upscaling includes

now being rolled out in plans to involve fathers
the remaining blocks of adolescents into the
of Banaskantha. conversation as well.
CASELET
18
References
[1]
Within UNICEF C4D, 3 thematic teams are working together for this intervention; education,
child protection, and communication for development
[2]
SABLA is Rajiv Gandhi Scheme for Empowerment of Adolescent Girls. It is an integrated
package of services and includes nutrition provision, IFA tablet provision, health check-up
and referral services, nutrition and health education, counseling and guidance on family
welfare, life skill education, and vocational training for girls aged 16 and above.
[3]
United Nations Children’s Fund, Ending Child Marriage: Progress and Prospects, UNICEF,
New York, 2014
[4]
http://www.worldometers.info/world-population/india-population/
[5]
District Level Household Survey-3 (2007-2008)
[6]
According to the National Family Health Survey-4 (2015-2016)
[7]
United Nations Children’s Fund, Reducing Child Marriage in India: A model to scale up
results, UNICEF, New Delhi, 2015
[8]
Caste panchayats are caste-specific juries of elders of a particular caste for a village or a
higher level in India.
[9]
SCPS is formed under the Social Justice and Empowerment Department (SJED)
[10]
UNICEF has decided that it will work with all the rigid caste members as well in the future
after having built its experience from the pilot in Banaskantha
[11]
SSY can be availed by any Indian girl belonging to scheduled caste, scheduled tribe, or
other backward caste communities.
[12]
SABLA is Rajiv Gandhi Scheme for Empowerment of Adolescent Girls. It is an integrated
package of services and includes nutrition provision, IFA tablet provision, health check-up,
and referral services, nutrition and health education, counseling and guidance on family
welfare, life skill education, and vocational training for girls aged 16 and above.
[13]
VCPC is formed as part of the Integrated Child Protection Scheme of Department of
Women and Child Development and Social Welfare. The objective is to have committees
that can address child rights and protection related issues at the village level itself.
[14]
‘Theatre of the Oppressed’ (TOO) is a communication tool, developed by Brazilian theatre
director Augusto Boal, to encourage discussion about different forms of oppression within
society.
[15]
Panchayat is a smallest geographic administrative unit in India. It acts as a local self-
government organization.
[16]
This is anecdotal and based on inputs from UNICEF’s education and C4D team.
[17]
As shared in an interactive discussion with the caste panchayat leaders.
[18]
The broad objectives of KSY is to improve the nutritional, health, and development status of
adolescent girls.
[19]
As told by Dr Swarup Rawat, DCPO, Banaskantha during an interaction as part of the study
for documenting this case study
19
2
Sishu O Matru Suraksha

A Social and Behaviour Change
Intervention for Child and Maternal
Health in Odisha
Globally, about 800 women die every day of preventable causes related to pregnancy and childbirth – 20
percent of whom are from India[1]. Though the Maternal Mortality Rate (MMR)[2] reduced from 212 in 2007 to
178 in 2012, there remains scope to save more children and mothers.
Underlying reasons for a relatively high MMR and Infant Mortality Rate (IMR) include social norms
relating to health and nutrition, and low demand and access for the same.The intervention led by the
Government of Odisha is supported by UNICEF, and aims at strengthening community-based institutions
through Social and Behaviour Change Communication (SBCC), leading to better access and utilisation of
Reproductive, Maternal, Newborn, Child, and Adolescent health (RMNCH+A) services in the region. Local
Non-Governmental Organisations – My Heart and Parivartan – implemented the programme in extremely
vulnerable sub-centres of Koraput and Malkangiri districts. An enabling environment was created to promote
change by leveraging already existing community institutions and events, and improved interpersonal
communication tools such as Facts for Life (FFL) videos, storytelling, Mother and Child Protection cards – for
adult learning, leading to enhanced knowledge and behaviour change communication skills of key actors. As
a result, there has been an increase in the knowledge and communication skills of community influencers,
inclusion of women and children from hard-to-reach areas, and an increased involvement of community
members for demand and utilisation of health services. Interlinkages between government departments have
been established, and capacities of partners involved in this programme have been developed.
20
Theory of Change
Improved access to preventive and curative RMNCH+A services
for women and children
Able to identify and Guide and counsel Are more sensitive

diagnose medical the community on to local cultures,
conditions and seek health-related matters, beliefs, and practices,
medical help when needed, encourage community to communicate effectively
are not superstitious, and seek medical help when with the community,
do not feel alienated from needed, and work with the work with the traditional
the public system public service providers healers, and provide
quality health services
Orient and sensitise

Train the community on traditional healers, Develop skills of line staff
key health issues, traditional leaders, and on communication, how
components of RMNCH+A, elected representatives to deal with local culture,
social norms, and their on key health issues, belief, and practices,
impact on health, appropriate appropriate RMNCH+A and work with traditional
health-seeking behaviours, behaviour, and healers and leaders
and entitlements entitlements
Traditional healers and

leaders
Community Influence and shape beliefs,
Extreme poverty and hunger, health-seeking behaviours and Services
unique culture and social practices, administer traditional Inaccessible, remote, sparse,
norms, beliefs and practices healing practices like herbs and and of poor quality. Service
influenced by traditional healers spirit worship, do not trust public providers do not have skills to
and leaders, low awareness services, and do not encourage deal with local practices and
of RMNCH+A services and the community to seek medical norms, and are not sensitive to
entitlements, alienation from help in case of need indigenous culture, beliefs and
the public services, and low challenges, and do not recognise
uptake of services the role of the traditional system
21
Odisha
Koraput
Map not to scale

Malkangiri
Situation
Odisha is an Indian state located on the south-eastern coast. It ranks low in the Human Development
Index (HDI) – 17th in 2011[3]. The IMR[4] and the MMR[5] in Koraput and Malkangiri districts are
significantly behind the national average, institutional delivery, and full immunisation coverage.
Table 1: Reproductive and Child Health indicators
Indicator (2013)9 India Odisha Koraput Malkangiri
IMR* 42 53 48 48
MMR** 178 235 245 245
Institutional delivery (%) 78.5 80.8 53.4 52.6
Full immunisation coverage (%) 53.5 68.8 51.6 29.6
Source: Annual Health Survey, 2012-13 *per 1,000 live births

**per 1,00,000 live births
Sishu O Matru Suraksha was based on a partnership

between UNICEF, ASHA workers, and local NGOs.
22
The western region of the state in which these districts community-based institutions like Panchayati
are located, is geographically difficult to reach due to Raj Institutions (PRI) [8] and Gaon Kalyan Samiti
underdeveloped infrastructure and Left-Wing Extremist (GKS)[9] lacked adequate understanding
(LWE) groups. These factors make it difficult to deliver about RMNCH+A.
public services like healthcare.
• Cultures, beliefs, and norms guiding health-
seeking behaviours of the population. Institutional
The state government has taken steps to improve
health infrastructure and delivery, and accessibility health workers were not sensitive to the traditional
of healthcare services in the state. It has classified practices related to healthcare. They did not
the government health sub-centres[6] into four recognise the role of traditional healers (known as
categories (V-1, V-2, V-3, V-4)[7] based on degree of desharis) within the community, who are the first
inaccessibility, presence of LWEs, and characteristics point of contact for community members.
of the service area. Other issues specific to the two
• Frontline Workers (FLWs) such as Accredited
districts were:
Social Health Activists (ASHA)[10] and anganwadi
• Low awareness on the need and availability workers[11] come from the same communities they
of RMNCH+A health services among the serve, with similar beliefs and norms influencing
community. Members of local self-governing and their interactions with the community.
Deshari counseling a mother about her child.
23
Deshari carrying out routine
check up for a child.
Method
To address the above challenges, UNICEF • There was low demand from the community due to
Communication for Development (C4D) and their low awareness about need for health services.
Nutrition and Health Department complemented the
efforts of Government of Odisha and implemented The specific objective of the programme was to improve
an intervention on Social and Behaviour Change access to quality health services for women and
Communication (SBCC). It focused on strengthening children by promoting health-seeking behaviour.
service delivery of Maternal and Child Healthcare In particular, it aimed to:
through demand generation. My Heart and Parivartan
• Create awareness within the community on
were the partner organisations (already working with
RMNCH+A related health services, social norms
the government) who implemented the programme
in Koraput (48 V-4 sub-centres) and Malkangiri (40 and their impact on maternal and child health, and
V-4 sub-centres) districts respectively in 2014-15. their health entitlements.
This intervention incorporated learnings from the
• Orientation and training of traditional healers and
implementation of a European Civil Protection and
leaders about RMNCH+A related health services,
Humanitarian Aid Operations (ECHO)[12] funded
behaviours, and entitlements.
humanitarian action project, which aimed at increasing
institutional deliveries, coverage of full immunisation, • Develop interpersonal skills of FLWs to improve
and improving management of childhood illnesses. their service delivery skills.
Learnings from the ECHO project were: The community was mobilised through different
• Frontline Workers (FLWs)[13] require training on participatory methods to build rapport and gain support.
behaviour communication skills for service delivery The programme made use of innovative tools to
and awareness generation for RMNCH+A services. enhance knowledge and behaviour communication
skills of primary stakeholders. These included FFL
• It is important to build capacities of traditional videos[14] projected using Pico Projectors[15] or shared as
healers and members of self-governing institutions Mobisodes[16], and Mother and Child Protection Cards[17]
about preventive and curative maternal and child for interpersonal communication. The community
healthcare services and entitlements. was engaged through focus group discussions on
• Need to use adult learning methods to train the healthcare practices for pregnant and lactating mothers
identified stakeholders. and children.
24
Bimla Bhumia with her son Nabin from
the district of Malkangiri.
Action
UNICEF identified and sensitised community
influencers[18] and tapped them to build upon existing
human capital, rather than create a new community of
workers. Further, panchayats, Gaon Kalyan Samiti, Self
Help Groups, Village Health Nutrition Day (VHNDs),
and Fixed Immunisation Day (FIDs) were utilised as
platforms to facilitate maternal and child health related
activities and develop other programmes for the village
in general.
• More than 4000 traditional healers in Koraput and

Malkangiri districts were trained to mobilise and
promote healthy behaviour among community
members. They were also sensitised to the • More than 3,000 quarterly GKS meetings were
importance of institutional deliveries, routine facilitated as a part of the programme. The
immunisation, and proper nutrition among mothers panchayat encouraged families to attend VHNDs
and children, and encouraged to promote the and FID, and monitored the actions of the
availing of formal medical care during times of community during these events. Further, community
ill health. health workers used the FFL videos to disseminate
health and nutrition related knowledge.
• FFL videos were used to build behaviour change
communication skills in around • GKS and PRI members were sensitised towards
6,500 FLWs across the two their roles and responsibilities related to maternal
districts and train them on and child health. They were provided training
methods to work along with focused on building their skills to update village
desharis and the local culture. health registers and health information boards,
In turn, FLWs also used FFL videos during their schedule and draft village health plans and annual
home visits to increase knowledge of common health reports, and better utilise funds. They were
childhood illnesses, underlying behavioural issues, also asked to encourage community members to
and life-saving practices. seek formal healthcare.
25
24-year-old Dalimba Pujari and her 9-month-old son have
been supported by UNICEF’s MCH programme.
Results
A joint effort by UNICEF C4D and Government Tulabadi Mahanandia, ASHA worker
of Odisha, the programme has been successful
in reaching disadvantaged women, children, key
“Earlier, whenever I used to counsel during
caregivers, and community influencers. Formal and
trainings, no one paid attention to what I said.
informal health service providers have contributed to
Now, they are engaged and there is improved
the creation of an enabling environment to influence
interaction between us because of entertaining
SBCC in health practices[19].
videos educating them about maternal and child
• Increased knowledge and communication skills health. There is better understanding among
of health service providers: The intervention has villagers about it now. We discuss topics like
helped improve knowledge and communication sanitation, diseases like Malaria, facilities like
skills of FLWs and traditional healers. They are now emergency 108 number, etc. Earlier, we used to
able to communicate with their patients effectively work alone, but now others like 'desharis' and
and counsel them on child and maternal health. ward members also support us. 'Desharis' sent
FLWs are able to deliver their services with support us villagers who need help with improving their
from community influencers. In hard-to-reach areas, health. We make plans, conduct regular meetings
traditional healers have started following up with for GKS and maintain cleanliness in the village.
pregnant and lactating mothers and their families, We also give money to people during emergencies
and ensure that they receive appropriate and refer pregnant women to hospitals”.
healthcare facilities.
26
• Building agency of women: With participation in
community activities like GKS and SHG meetings,
awareness among women about health practices
and services has increased. Women are able • Increased community involvement leading
to discuss their health issues with formal health to generation of demand for health services:
service providers, improving health-seeking Institutions like GKS and PRI have started providing
behaviours and increasing the utilisation of formal an interactive platform to the villagers to step
health services among them. forward and ask questions, clarify doubts, and
present the village’s problems. Closer engagement
• Increased knowledge of traditional healers: between GKS, PRIs, and the community has also
The programme has increased knowledge and helped to develop an informal monitoring and
awareness about reproductive, maternal, and child feedback mechanism. These regular reviews and
health issues, and healthcare practices among monitoring have helped establish a system of social
traditional healers. They are also informed of the accountability at the PRI level. There is now an
rights and entitlements of the mother and child, increase in the number of GKS meetings held, from
so that they encourage the community to avail 89 percent to 94 percent in Koraput and from 65
these entitlements. percent to 80 percent in Malkangiri district. Fund
utilisation by GKS has increased from 55 percent
• Capacity development of partners: Partner
to 80 percent in Koraput and 51 percent to 80
organisations have been able to increase their
percent in Malkangiri district, during the programme
understanding of the technical aspects of maternal
cycle 2014-16[21].
and child health. Their communication skills have
become more effective, and they now understand • Referrals to formal institutions and creation
the criticality of SBCC and how to use it to increase of an enabling environment for participants:
programme effectiveness. Traditional healers motivate villagers to seek
help from FLWs who, if needed, refer them to
• Interlinkages between government
Primary Health Centres (PHCs) for treatment.
departments: The programme has leveraged
This has created an enabling environment,
funds, infrastructure, and human resources of
thereby increasing the effectiveness of health
various state departments and central government
workers, leading to fewer casualties in the district.
schemes. This includes Department of Health and
Pregnancies registered have gone up drastically,
Family Welfare, Department of Women & Child
with an increase from 35 percent to 84 percent in
Development, Department of Panchayati Raj
Koraput and 50.5 percent to 73.4 percent
Institutions, and Rural Development Department[20].
in Malkangiri[22].
• Building continuity and consistency into the

system[23]: Ensuring sustainability through transfer
of knowledge and practices to the government, the
project has been successful in mainstreaming the
communication strategy into ongoing government
programmes such as National Rural Health
Mission (NRHM)[24], Integrated Child Development
Services (ICDS)[25], Sarva Shiksha Abhiyaan
(SSA)[26], Swachh Bharat Abhiyan, and actively
involving other implementers at the district level.
Communication tools and strategies developed
by UNICEF C4D such as FFL videos have
been adopted by the government in these
health schemes.
Radhika Pujari has been with the MCH
project for the last three years.
27
28
In Summary
UNICEF C4D, in partnership with the Government of
Odisha and local NGOs, facilitated an intervention in
Koraput and Malkangiri districts of Odisha. This was done
in order to improve the utilisation of RMNCH+A services
in the region. Since then, there has been an increase
in knowledge and communication skills of community
influencers, and greater involvement of community
members for demand and utilisation of health services.
Action
Preparatory meetings were Community influencers were

held between UNICEF sensitised about their roles
C4D, partner NGOs, and responsibilities towards
and the state and district improving child and maternal
functionaries to outline an health issues.
implementation strategy.
Village healers were made

aware of better care practices Formal care providers were
for maternal and child health trained in interpersonal
and encouraged to promote communication skills.
formal care services.
Together, they disseminated

child and maternal health
related behaviour change
communication to other
community members.
29
.......
.......
Healthcare providers
Women are now more
increased their knowledge
participative in GKS and
and communication skills,
SHG meetings, making
enabling them to effectively
them more aware of positive
counsel and communicate
health behaviours.
with their patients.
Results
Interlinkages between NGO partners have been able to

government departments saw comprehend technical aspects
existing schemes, funds, and of child and maternal health and
human resources leveraged communicate effectively through
for behaviour change. engaging mediums.
There has been increased Informal caregivers have

participation by the begun referring formal
community with regard to the institutions, creating an
demand and generation of enabling environment
health services. for participants.
The intervention has

successfully mainstreamed
the communication strategy
into ongoing government
schemes, ensuring the
sustainability of the project.
30
References
[1]
http://unicef.in/Whatwedo/1/Maternal-Health [20]
The Ministry of Rural Development, a branch of the Government of India, is
entrusted with the task of accelerating the socio-economic development of
[2]
the number of maternal deaths per 100,000 live births rural India. Its focus is on health, education, drinking water, housing
and roads.
[3]
http://www.in.undp.org/content/dam/india/docs/orissa_factsheet.pdf
[21]
DPMU Endline Survey Report
[4]
Infant mortality refers to deaths of young children, typically those less than
one year of age. It is measured by the infant mortality rate (IMR), which is [22]
the number of deaths of children under one year of age per 1,000 live births.
[23]
Based on key informant interview with Odisha UNICEF C4D state
[5]
Maternal Mortality Rate (MMR) is defined as the number of maternal deaths representative and programme document.
per 1,00,000 live births due to causes related to pregnancy or within 42 days
of termination of pregnancy, regardless of the site or duration of pregnancy. [24]
NRHM is an initiative undertaken by the government of India to address the
health needs of underserved rural areas.
[6]
In India, Primary Health Centres(PHCs) are the basic first-line units
providing primary health care. Each PHC has five or six sub-centres [25]
Integrated Child Development Services (ICDS) is an programme which
staffed by health workers for outreach services such as immunisation, provides food, preschool education, and primary healthcare to children
basic curative care services, and maternal and child health services and under 6 years of age and their mothers.
preventive services.
[26]
Sarva Shiksha Abhiyan (Education for All Movement), or SSA, is an Indian
[7]
V-1-Less vulnerable, V-2-Moderately vulnerable, V-3-Highly vulnerable and Government programme aimed at the universalisation of elementary
V-4-Extremely vulnerable. education "in a time bound manner", as mandated by the 86th Amendment
to the Constitution of India making free and compulsory education to
[8]
The Panchayati Raj is a South Asian political system found mainly in India, children between the ages of 6 to 14, a fundamental right.
Pakistan, Bangladesh,Sri Lanka,Trinidad and Tobago, and Nepal. It is the
oldest system of local government in the Indian subcontinent and form the
third tier of governance.
[9]
Gaon Kalyan Samiti (GKS) is structured to help the village promote health
activities, improve environmental and sanitation standards, seek support
for emergency healthcare services, conduct social audits, and set up regular
meeting.
[10]
Accredited social health activists (ASHAs) is community health workers
instituted by the government of India's Ministry of Health and Family Welfare
(MoHFW) as part of the National Rural Health Mission (NRHM).
[11]
Anganwadi workers work for rural mother and child care centre in India in
anganwadi centres. They were started by the Indian government in 1975 as
part of the Integrated Child Development Services programme to combat
child hunger and malnutrition..
[12]
Headquartered in Brussels, through ECHO, The European Commission
aims to save and preserve life, prevent and alleviate human suffering
and safeguard the integrity and dignity of populations affected by natural
disasters and manmade crises..
[13]
The first point of contact among formal health service providers in rural India
such as ASHA and ANM.
[14]
Series of Facts For Life videos.
[15]
Portable, hand held projector which helped to conveniently project videos in
remote areas.
[16]
Mobisode is a short episode of Fact For Life videos made specifically for
viewing on the screen of a mobile phone.
[17]
Mother and Child Protection cards are
[18]
This includes traditional healers, traditional leaders and members of the self
governing bodies.
[19]
Based on key informant interviews with stakeholders and programme
documents.
31
3
Home-based Newborn Care

Voucher System in Assam
A community-led supportive
supervision tool to enhance service
delivery by ASHAs
Nearly three-quarters of all neonatal deaths in the world occur in the first week of birth, of which 25-45
percent occur in the first 24 hours[1]. India has a high Neonatal Mortality Rate (NMR) at 25 per 1,000 live
births (SRS, 2015)[2]. Skilled care during pregnancy, childbirth, and in the postnatal period can enable early
detection of ailments and subsequent management of health complications in mothers and newborns.
Assam’s Infant Mortality Rate (IMR) is 41 as opposed to the national figure of 37[3] ﹘ making it a high priority
state for the national government. To address this issue and improve healthcare services, the Government
of Assam and UNICEF partnered to improve Newborn Healthcare Services (NHS). The Home-based
Newborn Care (HBNC) Voucher programme was part of this larger partnership, launched specifically to
strengthen the existing programme in Assam by establishing a community-led monitoring mechanism for
the scheduled home visits by ASHAs. As part of this intervention, Frontline Health Workers (FLWs) called
ASHA[4] used vouchers to engage with the community and provide seven key services essential for neonatal
health. A pilot was carried out in the Golaghat District of Assam, where the vouchers were used to facilitate
service delivery. UNICEF’s programme assessment study on HBNC revealed that the voucher helped
increase the coverage and improve quality of HBNC practices in the district. This was primarily attributed
to enhanced performance motivation among the FLWs, as the vouchers provided validation of their work. It
also significantly enhanced knowledge/awareness and care practices among mothers and caregivers. This
concept of employing HBNC vouchers to strengthen service delivery and community ownership was further
scaled up to all 32 districts in Assam, and its replication is in progress in the state of Rajasthan.
32
Theory of Change
Improved Neonatal Health
Desired Long-term
Change Improved service delivery by ASHAs & empowered
communities for newborn care
Precondition 2 Improved social accountibility among Improved awareness and practice in

ASHAs with regard to neonatal care community with respect to neonatal care
Timely Enhanced
Effective Enhanced access
disbursement demand for
Precondition 1 monitoring of
of incentives to quality HBNC
of community to
HBNC visits primary health
ASHAs for HBNC services from
by ASHA care functionaries
visits made community
Voucher designed Print communication

Capacity building of
with multiple pages campaign for
Activities ANMs/ASHAs on HBNC
and key messages community awareness
HBNC VOUCHER INITIATIVE
33
Logical Framework
IMPACT
RISKS: Confounding
Improved neonatal factors for IMR
health and better service
ASSUMPTIONS:
delivery by FLWs
Improved HBNC =
Reduction in NMR
OUTCOME
RISKS: Social distance
Improved social between community
accountibility among and FLW
ASHAs and better
awareness and practice ASSUMPTIONS:
in community Desired reach = Desired
impact
GOAL-SETTING UPWARDS
PLANNING DOWNWARDS
OUTPUTS
Vouchers distributed RISKS: Disparity in

across SCs, 8,000 distribution
FLWs trained, and
print campaign rolled ASSUMPTIONS:
out across Golaghat Smooth implementation
ACTIVITIES
Voucher designing,
RISKS: Initiative dislike
Capacity building of FLWs, by FLWs
and print campaign for
community awareness
ASSUMPTIONS:
Desired reach
INPUTS
Concept building, advocacy

with government, HR,
consensus building among
stakeholders
34
Assam
Map not to scale

Golaghat
Situation
In India, and around the world, the Infant Mortality of work presented on field. On the demand side,
Rates have decreased over the last two decades. correct and consistent infant healthcare practices in the
Between 1990 and 2015, IMR in India had reduced community were noted to be inadequate (NFHS-4).
from 87 to 37. However, in the same period, the share Based on opinions from health system experts,
of neonatal deaths were high and had, in fact, increased challenges in the existing neonatal care service delivery
from 46 percent to 58%[5] for deaths under the 5-year model in Assam were as below:
category. Three major causes of neonatal death are
infections, asphyxia, and preterm birth – accounting for
nearly 80 percent of all neonatal deaths[1]. Apart from 1. Irregular HBNC home visits and inconsistent
disparity in available healthcare facilities, poor health- newborn care advice by ASHA pointed
seeking behaviours and unscientific practices followed towards the paucity of quality monitoring and
by the community due to prevalent maleficent social supportive supervision mechanism.
norms and customs create further challenges. Their
demand for health services is limited or absent, making
2. Missed opportunities of Interpersonal
the situation more complex for interventions targeting
Communication (IPC) on newborn care
healthcare improvement.
create a void in the sphere of health
communication and promotion activities.
Assam has a high IMR at 48 per 1000 live births[6].
According to the National Family Health Survey
(NFHS), Assam’s health indicators have improved
between NFHS-3 and NFHS-4. However, there is 3. Limited demand from community for
substantial scope to prevent infant deaths through a essential HBNC for their infants.
targeted focus on neonatal health. One of the gaps
identified by various expert reviews and anecdotal
evidence was the inadequacy in quality supportive The HBNC voucher initiative provides a window of
supervision of ASHAs. They are trained on maternal opportunity for quality counseling during HBNC home
and infant care, but their capacity to effectively visits. It is a Communication for Development (C4D)
communicate, engage, and involve the communities approach strategically aimed at harnessing behaviour
warranted continued strengthening. Further, an output- change; both at the service delivery as well as
driven supervision system often undermined the quality
community levels.
35
Method
In 2013-2014, the Government of Assam (GoA) • The back cover and photographs depicting the
in partnership with UNICEF launched the HBNC ASHA activities were finalised
voucher as a pilot initiative through the National Health
Mission[7] (NHM). Within UNICEF, health units and • The number of counterfoils per leaflet were
C4D converged their efforts for this intervention which increased from two to three; one for the mother, one
was rolled out in 88 health centres in the Golaghat for the ASHA worker, and one for submission to the
district. The Community Medicine department from peripheral health centre
Assam Medical College Hospital (AMCH), Dibrugarh Step 3
was brought on board for its technical expertise and Communication material development and display
assistance in designing the HBNC voucher. in health institutions as well as at Village Health
It involved the following steps: and Nutrition Day (VHND): As an endeavour to
promote social equity within the scope of this initiative,
Step 1 the communications team prioritised the need to have
Planning and evaluation: Continuous interactions different versions of the voucher and posters to suit
were carried out between NHM and UNICEF C4D to the needs and expectations of different marginalised
plan this pilot initiative. The groups also discussed communities in the state. It was envisaged that
the evaluation design which would be conducted maintaining an equity focus would amplify the adoption
simultaneously to assess the potential of and acceptance of the voucher among different distinct
the initiative. communities residing in Assam.
Step 2 Step 4
Design, pre-test, and printing of HBNC vouchers Rollout of the pilot: UNICEF undertook the Voucher
and sensitisation of health workers: As part of pre- and Communication approach, apart from capacity-
testing, UNICEF C4D presented the voucher to the building and supportive supervision of FLWs who
community and service providers before the actual implemented the initiative.
rollout of the intervention. Based on findings from the
pre-testing (based on community feedback):
An ASHA worker during

a home visit.
36
The process of the visit and use of HBNC was designed
as follows:
• On each visit, the ASHA is expected to perform the

activities listed on the voucher.
• At the end, if satisfied with the services, the mother

hands over one signed counterfoil to the ASHA and
retains a copy.
• Upon completion of all visits, the ASHA submits all

leaflets at the block health centre and is paid `250
per child as an incentive for her work.
• The ASHA is mandated to make home visits as part

of HBNC on the following days:
Dipali Phukan, a primary healthcare worker,
hands the HBNC voucher to a patient.
- 1st, 3rd, 7th, 14th, 21st, 28th, and 42nd day of
childbirth for children born at home
- 3rd, 7th, 14th, 21st, 28th, and 42nd day of

childbirth for children born in an institutional
Action facility
The pilot was initiated in 2014 and implemented for Communication material included posters with details
six months in Golaghat, Assam – one of the six High about the voucher and healthcare practices for infants,
Priority Districts (HPD)[8] identified in the state. UNICEF which were developed and displayed in the health sub-
conducted Capacity Building (CB) of FLWs on home- centres. The HBNC voucher has additional Information,
based counseling for HBNC where they were trained on Education, and Communication (IEC) material which
the use of vouchers and how to, in turn, train mothers includes photographs that highlight entitlements and
about the same. scheduled visits.
As part of the HBNC voucher programme, an FLW This is an empowering instrument to both the ASHA
is mandated to visit a newborn six to seven times in as well as the mother ﹘ ASHA can validate the home
the first 42 days post-delivery (six times in case of visits conducted and the mother can identify what to
institutional delivery and seven times for home delivery) expect during home visits and keep track of stipulated
and provide the following services: weigh the child, visits. The intent of the voucher is to improve the
measure the temperature, counsel the mother on accountability of ASHAs towards service delivery
breastfeeding, kangaroo-mother care, immunisation, and enable them to communicate more effectively
and handwashing. If needed, she issues referral slips with mothers and caregivers. This promotes better
for the child, mother, or both for their treatment in the community knowledge and awareness in newborn care,
block hospital. stimulating increase in demand. It also helps create a
sense of shared responsibility between the ASHA and
The voucher contains seven[9] leaflets, each of which is
mother/caregiver of the newborn.
triple perforated and corresponds to ASHA visits during
the first 42 days. Information on the different activities
to be performed by ASHA, different government
schemes[10], facilities available, entitlements under
RMNCH+A (Reproductive, Maternal, Neonatal, Child,
and Adolescent Health) scheme, and essential newborn
care are detailed in the communication material.
Mothers delivering at hospitals are oriented about
newborn care services provided by ASHAs through
HBNC vouchers.
37
Results
UNICEF, in partnership with Assam Medical College Change in mothers and caregivers
and Hospital, Dibrugarh, conducted a programme
• Statistically significant[12] improvement in knowledge
assessment study to understand the effectiveness
among mothers and caregivers regarding various
of the voucher initiative. Prior to the rollout of
government schemes and the available services for
intervention, a baseline study was carried out in 88
newborn care.
selected health sub-centres of the district. Within each
health sub-centre, a cluster of seven infants less than • Significant improvement in knowledge regarding
two months of age were selected. The mother and availability and importance of Iron Folic Acid (IFA)
ASHA of each of these infants were interviewed at the tablets, deworming, postnatal checkups, birth
time of the baseline study, and the findings of registrations, vaccinations, and weighing of
this baseline survey were compared and analysed the child.
with the results drawn from the post-intervention
evaluation study. • Improvement in knowledge of the ASHAs' visit
schedule for home-based newborn care
Key changes observed as a result of this intervention improved after the implementation of the HBNC
among mothers/caregivers, ASHAs, and the voucher system.
government system ﹘ when compared to the
baseline ﹘ were as follows:
Table 1: Knowledge-change results from programme assessment study
Description of Indicator Baseline Endline Mothers were encouraged

to use institutional facility
Knowledge about services to be for childbirth.
66.7% 99.2%
received from ASHA
Availability and importance of

IFA tablets 78.7% 98.6%
Importance of postnatal
checkup 46.6% 93.1%
Information on vaccination 66% 97.1%
Exclusive breastfeeding 89.3% 97.4%
Weighing of the child 73.5% 94.9%
Change in ASHAs
Description of Indicator Baseline Endline
Approximately 8,000 FLWs
Birth preparedness 18.4% 84.1%
were trained on home-based
counselling about newborn care.
Infant feeding practices 20.1% 91.8%
As per the study, the knowledge
level of ASHAs showed statistically
Infant feeding practices 40.2% 96.7%
significant improvement following
the implementation of the voucher
Care of young infants 10.9% 85.7%
system.
Table 2: Knowledge change results in ASHAs from programme assessment study
38
health, associated complications, care-giving practices,
Mothers and caregivers are entitlements from the public schemes and access
now more aware of government to healthcare.
schemes and their entitlements.
The Government of Assam has acknowledged the
positive outcomes of this pilot intervention and scaled
it to all 32 districts of the state, with subsequent
inclusion of the initiative into the State Programme
Implementation Plan (PIP) 2015-2016. The HBNC
voucher has been included as a standard monitoring
format for the supervision of FLWs to ensure provision
of quality home-based care services for newborns.
The HBNC voucher innovation from Assam found a

place among the 60 innovations and good practices
included in the 'Good Practices across the Globe'
document released at the Call to Action summit in 2015.
Following the success and acceptance of the initiative

in Assam, the Government of Rajasthan[13] has also
The strong focus on communication skills has helped recognised the utility of vouchers in monitoring service
strengthen the IPC skills of FLWs. This has, in turn, delivery and improving accountability of FLWs, and has
helped them: decided to replicate the HBNC voucher system.
• Communicate effectively with mothers about

newborn care with the help of communication
materials to ensure continuum of care.
• Build trust in mothers and community members

about their capacities through effective and quality
service delivery.
Change in government health system
• Schedule of actual HBNC home visits conducted

by ASHA was streamlined to a considerable extent.
• There’s an increase in institutional deliveries

“The Home-based Newborn Care voucher
and decrease in home deliveries, which could be
is a simple yet powerful communication
attributed to the improved level of knowledge and
tool which empowers both the community
awareness among mothers and families
and the Frontline Workers (FLW). It helps
regarding various government schemes listed on
engage and involve the community more in
the voucher.
newborn healthcare. It helps FLWs execute
Transformative Change their role better, and know of the earnings

they are entitled to. The HBNC programme
The initiative has been able to establish an osmotic was appreciated by the government, and it
relationship between supply and demand ﹘ it has now been scaled across all districts in
empowered FLWs with communication aids to Assam. UNICEF C4D has yet again brought
report and substantiate their work, as well as an innovative solution that helps us improve
interact and engage better with the communities the health scenario in our district.”
and rigorously follow up on visits. Mothers and Mrs. Laya Madduri
caregivers have also been empowered through Deputy Commissioner, Dibrugarh district, Assam
the initiative with improved knowledge on neonatal
39
In Summary
Action
The Government of Assam, in
partnership with UNICEF, initiated
Home-based Newborn Care (HBNC)
to address the issue of high NMR
and IMR rates in Assam. It aimed to
strengthen the existing programme
by establishing a community-led
monitoring mechanism for the Capacity Building on
scheduled home visits by ASHAs. home-based counseling
Here’s a blueprint of how the was conducted for FLWs,
intervention was rolled out in 2014 where UNICEF trained
for six months in the district them on the use of HBNC
of Golaghat. vouchers and delivering
the same to mothers.
An FLW was mandated to

Through the voucher, FLWs visit a newborn six to seven
counseled mothers on times in the first 42 days
various care practices like post-delivery ﹘ six times
breastfeeding, kangaroo-mother in case of an institutional
care, immunisation, etc. delivery, and seven if
home-based.
At the end of every visit, the

mother handed over a signed Communication and
counterfoil to the ASHA which awareness on the intervention
was then submitted at the was done through posters
block health centre. As an detailing the voucher and
incentive, the ASHA was paid healthcare practices, placed
`250 per child for her efforts. in health sub-centres.
40
Results
Change in mothers and
caregivers: There’s a significant
improvement in the knowledge
among mothers and caregivers on
the available government schemes
and services for newborn care. They
are now also better informed about
the ASHA visit schedule.
Change in ASHAs: About 8,000

FLWs were trained, as a result
of which their knowledge level
showed statistical improvement.
They communicated effectively
and built trust about their
capacities through effective and
quality service delivery.
Change in government health

system: Through the intervention,
the ASHAs’ HBNC home visit
schedule was better streamlined.
Institutional deliveries also saw an
increase ﹘ a change that can be
attributed to improved knowledge.
41
The positive outcomes of the

Through the voucher and
intervention have led to it being
communication aids, FLWs
scaled to all the 32 districts
are now better empowered to
of Assam, and included in
interact and engage with the
the state PIP. The voucher
communities, as well as report
innovation has also found a
and substantiate their work
place among the 60 innovations
apart from following up on
included in the Good Practices
their visits.
Across the Globe document.
Mothers and caregivers have

also been empowered ﹘
with improved knowledge on
neonatal health and relevant
practices. They’re also aware
of the public schemes and
access to healthcare that are
at their disposal.
Caselet
Lakshmi Medha, aged 22, is mother to two boys. The hospital. Ayush underwent blood transfusion at the
younger one, Ayush, is a healthy 3-month-old infant. government hospital and, following proper treatment,
When he was just 7 days old, Shanta Kurmi – the had a speedy recovered. Lakshmi believes that her
ASHA of the village – visited Lakshmi to check on ASHA visited Ayush on the 7th day after his birth
the infant. She identified signs of jaundice, mobilised because of the voucher's reminder, as a result of
an ambulance, and quickly referred her to the which her child's life was saved.
42
References
[1]
http://www.who.int/mediacentre/factsheets/fs333/en/
[2]
http://apps.who.int/gho/data/node.sdg.3-2-viz-3?lang=en
[3]
Per 1,000 live births; Sample Registration System (SRS) Survey, 2015
[4]
Accredited Social Health Activist (ASHA)is the health activist(s) in the community who
create awareness on health and its social determinants and mobilise the community
towards local health planning and increased utilisation and accountability of the existing
health services.
[5]
https://www.unicef.org/publications/files/APR_2015_9_Sep_15.pdf
[6]
National Family Health Survey-4 (NFHS-4)
[7]
NHM is the flagship programme of the Ministry of Health and Family Welfare’s (MoHFW),
Government of India.
[8]
To ensure equitable healthcare and to bring about sharper improvements in health
outcomes, the bottom 25 percent of the districts in every state according to the ranking of
districts based on composite health index have been identified as High Priority Districts
(HPDs). This health index is developed by Ministry of Health and Family Welfare.
[9]
For babies born in an institutional facility, only six leaflets are relevant and used.
[10]
Schemes included were Janani Surakshya Yogana (JSY), through which ASHA escorts
a pregnant woman to facility, provision for getting cash incentives, financial assistance
scheme for mother (Mamoni) and girl child (Majoni), knowledge about JSSK (Janani
Swasthya Surakshya Karyakram) and ADORONI scheme for providing free services for
transportation from home to facility and back to home, including free medicines etc.
[11]
Mahanta TG, et al. Effectiveness of introducing home-based newborn care (HBNC) voucher
system in Golaghat District of Assam, Clin Epidemiol Glob Health. (2015), http://dx.doi.
org/10.1016/j.cegh.2015.08.002
[12]
The P value, or calculated probability, is the probability of finding the observed, or more
extreme, results when the null hypothesis (H 0) of a study question is true. A p-value of less
than 0.05 indicates a strong evidence for null hypothesis indicating a statistical significance.
[13]
http://www.dnaindia.com/jaipur/report-rajasthan-to-adopt-assam-model-to-curb-
neonatalmortality-rate-2492375
43
4
Suramya
Communication to Eliminate Open
Defecation in Uttar Pradesh
Government of India initiated Swachh Bharat Mission[1] (SBM) (Clean India Mission) in 2014 with the key
objective of eliminating open defecation in the country by 2 October, 2019. Information, Education, and
Communication (IEC) was identified as a key component of the programme, to bridge the gap between the
construction of toilets and their sustained use. Around 5 percent of the state funds under SBM have been
allocated for this purpose. However, the utilisation of IEC funds was slow. Key district officials of the SBM
team lacked the capacity to plan, implement, and monitor communication activities which were initiated
in an ad hoc manner. Moreover, officials focused more on IEC rather than Social and Behaviour Change
Communication (SBCC) to motivate healthy sanitation behaviour, which was not sustainable in the long run.
There was also the lack of an SBCC-dedicated and capacitated human resource working on sanitation at
ground level. As part of the UNICEF Communication for Development (C4D) initiative in the state of Uttar
Pradesh and its technical support to SBM, the development of SBCC plans and calendars was proposed
in 25 districts to efficiently allocate resources and utilise the IEC component. The district SBM team was
intensely engaged in the process of formulating an SBCC plan and annual implementation calendar during
a three-day workshop, along with key line departments and local stakeholders – religious institutions, non-
government organisations, and corporate groups. Different communication strategies such as advocacy,
Interpersonal Communication (IPC), entertainment education, mass media, and social mobilisation were
incorporated in the SBCC plan which encouraged active participation from the community. As a result, SBCC
plans and calendars have been formulated in 25 districts and there is an improvement in utilisation of IEC
funds. A positive shift can be seen towards the use of SBCC approach to influence the sanitation behaviour
of communities to achieve an Open Defecation Free (ODF) status in Uttar Pradesh.
44
Theory of Change
1. Improvement in utilisation of IEC component under SBM
2. Shift from IEC to SBCC approach; more importance given to communication activities
3. Convergence of line departments to achieve results for SBM
4. Availability of human resource trained in SBCC at ground level
5. Synchronised demand and supply for construction of toilets and its sustained use
District SBCC plan and calendar made with intense engagement

from SBM team, line departments, and other stakeholders
Priority given to Lack in convergence Lack of strategic

construction of toilets, of efforts by line implementation of
and not SBCC to departments to achieve communication activities
influence behaviour results for SBM
Lack of capacity in key

Lack of SBCC skills
IEC approach rather district officials to plan,
in existing human
than SBCC approach implement, and monitor
resources at ground level
SBCC activities
Slow and inefficient progress in utilisation of IEC component under

Swachh Bharat Mission (Rural)
45
Map not to scale

Uttar Pradesh
Intervention State
This map does not reflect a position by UNICEF on the legal status
Source: http://d-maps.com/carte.php?num_car=4183&lang=en
Situation
Government of India launched Swachh Bharat strategy. Additionally, they had limited capacities
Mission (SBM) in 2014 to focus on sanitation, and to plan and implement interventions to influence
accelerate efforts to achieve universal sanitation sanitation behaviour. Hence, utilisation of state
coverage in the country. SBM in rural areas intends funds as per SBM (rural) guidelines made slow
to improve cleanliness and make gram panchayats[2] progress.
Open Defecation Free (ODF). The programme
2. Communication strategies and activities were
emphasises on community-wide behaviour change
based on IEC approach, rather than a more
to trigger demand for sanitary facilities to achieve its
comprehensive SBCC approach. IEC is more
objectives. Guidelines for SBM (rural) have specified
of a short-term awareness building exercise
the formulation of state and district IEC plans focusing
targeted at individuals and communities, which is
on a long-term strategy for communicating key
not effective in the long run. Knowledge is not a
messages on sanitation to the community. In all Indian
necessary and sufficient condition for behaviour
states, 5 percent of the total SBM allocation is for IEC,
change. For sustained use of toilets in households,
communication activities, and capacity building in
healthy sanitation behaviours must be sought at
rural areas.
individual, community, and institution levels through
The Government of Uttar Pradesh (GoUP) has set a multi-pronged mobilisation and communication
target to achieve an Open Defecation Free status by strategies. SBCC involves analysing personal,
2 October, 2018. Out of the 75 districts in the state, societal, cultural, and environmental factors for
30 aim to achieve it by the end of 2017. To achieve sustainable change.
ODF status, over 21 million USD is allocated for IEC
3. IEC component under SBM lacked strategic
activities under SBM in Uttar Pradesh.
planning, implementation, and appropriate
Challenges in achieving the behaviour change goals budgetary allocations.
of SBM:
4. For human resources available at the ground level
1. Government functionaries lacked the understanding under SBM, there is no systematic process of
of the need to engage in a holistic Social and capacity building on community mobilisation and
Behaviour Change Communication (SBCC) interpersonal communication.
46
1. SBM was mostly hardware driven, with more focus comprehensive district SBCC plans. SBCC encourages
given to implementing core programmatic aspects. healthy behaviour change, and increases commitment
Communication activities were not given priority. and investment from individuals, communities, and
institutions to eliminate open defecation. Additionally,
2. There was lack of convergence of key departments
SBCC helps to improve knowledge and increase
for the implementation of IEC activities to achieve
demand from the community for the construction and
results of SBM.
use of toilets by creating an enabling environment. It
These systemic-level challenges could be overcome motivates individuals and communities to accept the
through intensive engagement in the formulation of use of toilets as the new social norm.
Toilets built by the Pradhan in a local

school in Mirzapur District.
Method
The Swachh Bharat Mission (rural) has strongly Objectives of district SBCC plan and calendar
promoted the Community-led Total Sanitation
In the next phase, UNICEF supported the Government
(CLTS)[3] approach in Uttar Pradesh, which focuses
of Uttar Pradesh in 25 districts to establish SBCC
on triggering behaviour change for adoption of good
plans at district levels. This aimed to address systemic
sanitary practices by communities. UNICEF provided challenges and create an enabling environment that
technical support to SBM in Uttar Pradesh for capacity helped improve the efficiency of SBM roll-out. The
development of officials and communities on CLTS and specific objectives of the district-level SBCC plans
SBCC. This helped key functionaries of SBM, primarily were to:
the Mission Director of Uttar Pradesh, to understand the
• Build and enhance knowledge and interest, and
importance of SBCC in achieving ODF status. Support
spur the demand for construction and use of toilets
from the state SBM team ensured participation of key
stakeholders, especially government line departments • Promote, reinforce, and sustain practices of safe
at district and block levels. sanitation and hygiene behaviours
47
• Increase knowledge about sanitation and community’s interest while educating them on key
hygiene-related products and services issues using locally popular mediums.
• Provide knowledge and clarifications related • Mass media for mass awareness and mobilisation
to SBM around key issues.
For effective and sustained impact, the SBCC plan • Social marketing for pooling resources in the most
needed to have a strategic implementation timeline (i.e., cost-effective manner by integrating marketing
allocating an appropriate time, at the appropriate place, strategies and interventions to influence behaviour
with appropriate resources) in the form of an annual change regarding open defecation.
calendar.
• Advocacy to engage with opinion leaders such as
UNICEF’s support to district SBM team elected representatives, local popular persons from
arts and culture, and religious and
UNICEF's C4D programme provided technical community leaders.
assistance to the district administration for the
systematic planning and integration of SBCC in the
programme delivery of SBM in rural areas. As part of its
technical support, UNICEF C4D’s role was to:
• Facilitate the district SBM team in preparing an

SBCC plan and annual calendar for strategic
implementation
• Identify resources for SBCC activities in the context

of SBM
• Conduct a dissemination workshop at district level

A register maintained by the head of gram
to share the SBCC plan with different stakeholders panchayat to record communication activities and
achieve ODF status in Mirzapur district.
SBCC approach and strategies
For a sustained behaviour change, SBCC recognises

Mapping of partners and pooling of resources
change at individual, community, and institutional level.
The SBCC approach follows a socio-ecological model[4] To ensure that human resources available at the ground
which helps understand and remove bottlenecks level under SBM have effective SBCC skills, they
within the system by designing complex multi-level were first mapped at district and block levels. Existing
interventions. It acknowledges interdependency of number of human resource across each village, block,
individuals with policies, interventions, and processes and district from government departments such as
to maximise influence at all levels. Thus, the SBCC Panchayati Raj, Health, Education, Rural Development,
strategy focuses on addressing barriers towards Uttar Pradesh State Rural Livelihood Mission, were
demand generation. Recognising this, different identified. Non-government organisations, religious
communication strategies were used for different institutions, youth clubs, corporate organisations, and
stakeholders. These included: self-help groups who work in the field of sanitation
were also mapped. In addition to human resources,
• Social mobilisation to engage government line potential platforms, events, and places of mass
departments and local institutions such as Frontline gathering were identified where ODF messages could
Workers, community-based organisations, and self- be communicated. This was the first step to encourage
help groups. convergence of departments to achieve the results
• Interpersonal Communication (IPC) for of SBM.
sustainable behaviour change in the community via
increasing knowledge on the issue. Capacity development of the identified human resource
at the ground level was done through CLTS training
• Entertainment education to capture the in SBM.
48
Action
1. Formulation of District SBCC Plans
1.1. The pre-planning stage: This stage provided an

opportunity for the district SBCC team to look at the
situation of open defecation in a holistic manner. It
prepared the team with the information required to
make district SBCC plans.
• District Analysis: A month before the formulation

of the SBCC plan, UNICEF shared a template with
the district SBM team to record the information
required for formulation of the district SBCC plan
such as:
• Existing institutional arrangements for sanitation

and hygiene
• Number of human resources related to sanitation

and hygiene within the district
• Roles and responsibilities of identified human

resources
The District Panchayati Raj Officer (DPRO) or District

Programme Coordinator (DPC) from the district SBM
team led the collection of information needed for district
analysis.
• Situation Analysis: An assessment was carried

out to understand existing open defecation
practices in communities, factors associated with it,
and community requirements to achieve ODF. For
this, the SBM team carried out field visits as well
as interactions with individual, family, community,
and institutional-level stakeholders. The information
from the situation analysis was presented on a
Pradhan of one of the villages in
given template by the district SBM team and shared Mirzapur district talking about how
with UNICEF C4D. it achieved ODF status.
• Strength, Weakness, Opportunity, and Threat

(SWOT) analysis: This was carried out jointly by 1.2. Planning stage
the UNICEF C4D and SBM team at the district
Day 1: Consultation and planning with stakeholders
level. Based on the district and situation analysis,
the key strengths to be utilised and the weaknesses • A key objective of the intervention was to plan
that need to be minimised were identified. social mobilisation activities rooted in the idea of
convergence of different stakeholders to achieve
Subsequently, a three-day workshop was conducted by the results of SBM. Few models of convergence
the district SBM team and UNICEF C4D to develop an existed at district, block, or village level before the
SBCC plan and annual implementation calendar. SBCC plan.
49
50
• A consultation process was held at the district 3. Monitor the impact of the measures adopted in
level in the DPRO office with representatives of the communities
District Rural Development Agency, Department of
Education, Health, Women and Child Development, Capacity and resources were mapped for the
Uttar Pradesh State Rural Livelihood Mission, stakeholders present during this session.
Civil Society Organisations/Non-Governmental
Organisations, Faith-Based Organisations, • Based on consultations with various stakeholders,
and corporate organisations that implement the C4D team with DPRO, DPCs, Swachhata
development initiatives. The District Magistrate Preraks, and Block Preraks finalised the district
officially invited the above stakeholders to SBCC plan for one year. Only those activities were
participate in the consultation workshop which included in the plan, which the departments found
ensured their participation and provided a platform easy to implement within their routine programme.
for them to understand different activities being
carried out by various stakeholders. Senior officials • Next, the Standardised Operational Procedure
from these organisations were requested to attend, (SOP) for each activity was prepared. SBM
who then took responsibility for the implementation functionaries planned behaviour change activities
of activities suggested during the meeting.
for their gram panchayat and blocks.
• The workshop started with an orientation by
Day 2: Finalisation of district SBCC plan and calendar
UNICEF C4D team on the importance of SBCC in
sustaining toilet usage, and the importance of key • UNICEF C4D team, with district SBM team,
stakeholders to join hands and integrate the ODF
finalised the district SBCC plan with stakeholders
agenda into their programmes and field activities.
which included resource mapping, an annual
• A list of existing IEC activities by different implementation calendar, and a monitoring
departments and organisations in the district was framework. The monitoring framework accounted
made. A brainstorming session was then conducted for Monthly Review Meetings held by DPRO with
with participants, to come up with innovative and key stakeholders, district-level Monthly Reports,
locally relevant ideas to:
and setting up of SBCC cell in War Rooms.
1. Improve knowledge on benefits of toilet use
• Resource allocation including funds, identification
2. Motivate communities to eliminate open of staff, vehicle, equipment, and IEC material was
defecation, and adopt and sustain toilet usage done for each activity.
DPRO and ADO explaining the process • The SOP outlined different steps involved in the
of SBCC plan formulation and the annual
implementation calendar. implementation of each activity with its timeline.
The means of verification for the activities being
designed was decided with a monitoring and
evaluation tool for each.
Day 3: Dissemination
• The District Magistrate approved the SBCC plan

and monitoring framework in the presence of other
government and non-government stakeholders
such as DPRO, DPCs, Swachhata Prerak, District
Education Officer, Chief Medical Officer, Civil
Surgeon, Departments of Education, Health, and
Women and Child Development, Uttar Pradesh
State Rural Livelihood Mission, Civil Society
Organisations/Non-Governmental Organisations,
Faith-Based Organisations, corporate organisations
implementing development initiatives, and
Mahila Samakhya .
51
Pradhan explaining the importance of
using toilets to villagers and encouraging
its sustained use.
2. Strategic implementation of SBCC activities 2.2. Interpersonal communication and capacity

development
Activities planned and implemented under different
heads of the SBCC plan were: • CLTS approach was adopted to train identified
human resources and communities to understand
2.1. IEC implementation, monitoring, and the situation of open defecation in their village, and
management form and implement village-level plans for sustained
toilet usage by all. A five-day CLTS training
• District and block-level War Rooms were module, developed by SBM with UNICEF – before
established by SBM in rural areas. The War Room SBCC plans were made – incorporated detailed
was conceptualised as a 24X7 communication SBCC training and encouraged participation
from communities. This was aimed at generating
mechanism to enable interaction between the demand for sanitary facilities and changing
district, block, and village-level stakeholders to sanitation behaviours rather than just
eliminate open defecation. It provides for concurrent constructing toilets.
monitoring of field-level activities from the ODF
• Training was conducted by technical and SBCC
process. experts for the participants of CLTS training, such
as the head of the gram panchayat, Frontline
• Physical verification was carried out for gram Workers (FLWs), teachers, and religious leaders on
panchayats which declared themselves ODF by an social mobilisation, interpersonal skills, and the
independent District Level Appraisal Committee. CLTS approach.
• Monthly Review Meetings were conducted to review • Masons were trained at the district level on the
construction of leach pit toilets. Discussions and
physical and financial progress like the construction
demonstrations were held with communities on the
of toilets, updating information systems, and benefits of leach pit toilets and its maintenance in
progress of SBCC activities. the long run.
52
2.3. Social Mobilisation romantic-comedy movie ‘Toilet- Ek Prem Katha
• Exposure visits were carried out for the heads of (a love story)’ was organised. Akshay Kumar was
gram panchayats and other change agents in the made the SBM (rural) brand ambassador for
village to share best practices from other districts Uttar Pradesh.
and influence positive sanitation behaviours.
• In Mirzapur and Bhadohi districts, a 'Brother
• Gram panchayats which achieved ODF status Number 1' competition was announced, where
celebrated and felicitated the change agents to male members of the village were encouraged
motivate sustained toilet usage by all villagers. to build a toilet for their sisters during the Indian
Change agents took a torch to the villages which festival of Rakhshabandhan. The quality of toilets
had declared themselves ODF. built for this competition was verified, and the
participants were honoured and rewarded to
• Men, women, and children formed separate encourage positive sanitation behaviours. The
surveillance committees (locally known as the 'Brother Number 1' competition helped male
Nigrani Samiti). The surveillance committees members of the society understand the need for
worked as a monitoring mechanism within the private space for women.
village, as they identified people defecating in the
open and stopped them from doing so, peacefully, 2.4. Convergence with different stakeholders
without threats or punishments. Merchandise such
Education department: Parents of school children were
as a whistle, jacket, and a cap was provided to the
encouraged to discuss construction of toilets, its use, and
committee members for use during surveillance.
benefits. Students talked about their success in motivating
• Street plays and magic shows were carried out by villagers for the construction of toilet, use of the toilet, or
local artists, and a video van was used to spread any behaviour change related to sanitation. Events on
messages about sanitation and hygiene to the the theme of sanitation were held on Independence Day,
villagers. Republic Day, and Gandhi Jayanti.
• To create mass awareness, International Hand Health Department: The Health Department used
Wash Day and World Toilet Day were observed. Frontline Workers to motivate women to construct and
Special Screenings of the Akshay Kumar-starrer use toilets. Hoardings and banners were installed in
front of healthcare centres. SBM messages and slogans
were printed on all OPD (Out Patient Department)
prescription slips. During home visits, FLWs counselled
the adult members of the family about the construction
of toilets, its use, and benefits. In community meetings,
public health experts discussed health risks of open
defecation, describing contamination of food and water.
Department of Women and Child Development: The

department held discussions on construction of toilets,
its use and benefits, and personal hygiene using flip
charts, calendars, or pamphlets.
GARIMA girls: As part of GARIMA, a menstrual

hygiene strengthening programme implemented by
UNICEF, adolescent girls were mobilised to discuss
menstrual health and hygiene, and advocate the
importance of using toilets in their villages through
engagement with peers, FLWs, and the community.
The girls also discussed the need for toilets with their
Toilet gifted to a sister under the
'Brother Number 1' competition. parents before harnessing resources of the gram
panchayat to demand for toilets.
53
2.5. Mass Media
• Posters were put up in all government offices, schools, • Walkathons and marathons were organised
health centres, and prominent places. Pamphlets and where all heads of panchayats and local youth
flyers were distributed by FLWs through different participated to spread knowledge on sanitation and
methods like home visits and village health events. use of toilets.
• To create an enabling environment, success stories • A video van, street and folk theatre, and audio-
and events related to ODF or SBM were shared video materials were used in local languages in
with communities to raise awareness and improve media-dark, hard-to-reach areas.
knowledge.
Children who were part of Nigrani Samiti.
Results
1. UNICEF C4D advocated with the district 2. UNICEF C4D provided technical assistance to
administration to ensure equal focus on SBCC develop the structured district SBCC plan to ensure
along with construction of toilets through SBM, and systematic engagement of stakeholders, and their
developed SBCC plans and annual implementation capacity building. It resulted in acceleration of IEC
calendars for 25 districts. The first SBCC plan was fund utilisation and strategic implementation of
developed for Mirzapur district, and eventually communication activities. There is an increase in
followed by 24 other districts. These plans and expenditure from 7.2 percent in September 2017
activity calendars were reviewed and approved to 11.28 percent in November 2017, out of the
by the District Sanitation Committee (DSC) in 20 total allocated amount of over 21 million USD for
districts, where implementation has started. A implementation of the SBCC activities.
review of the SBCC plan is set up with the DSC for
other districts.
54
Transformative Change them. There were a few innovations along the
way, supported by UNICEF, like the ‘Brother
The following transformative changes were observed Number 1’ competition where male members of
since formulation and implementation of the SBCC plans: the community were encouraged to gift toilets to
At the system level: their sisters. The SBCC plan helped in converging
efforts of different departments. A district SBCC
1. With motivation from UNICEF C4D, senior state calendar was also formed with activities scheduled
and district SBM officials were intensely engaged block-wise and day-wise, which guided us on how
in the formulation of the SBCC plans. A positive to roll out the training. It helped us systematically
change was seen in government officials as they cover the entire district. We did not coerce people
moved from a simple IEC approach for improved into using toilets; instead, we communicated the
knowledge to a more comprehensive and layered risks associated with open defecation. We have
SBCC approach. They understand the importance realised the importance of Social and Behavioural
of SBCC in motivating positive sanitation behaviours Change Communication in convincing people to
in communities. change their sanitation behaviour.
There is now a demand from people to build

2. Key departments and stakeholders converged toilets. They are ready to pitch in their own money
to formulate the SBCC plans and annual for the same as they have realised its importance.
implementation calendar. They allocated resources Not only the rich, but the poor are also ready
for SBCC activities, interpersonal communication, to construct toilets. With the help of an SBCC
community mobilisation, and advocacy. plan and calendar, Mirzapur has been nationally
3. Existing human resources available at the ground recognised for its efforts in eliminating open
level for sanitation services are skilled in community defecation.”
mobilisation, interpersonal communication, Arvind Kumar Singh
and SBCC. District Panchayat Raj Officer, Mirzapur
(Excerpt from the interview)
“We realised the need for Social and Behaviour
Change Communication to influence the use of
toilets, and UNICEF facilitated the formation of
plans to do it. To meet the deadline to achieve the
ODF status in blocks of Mirzapur, we planned the
activities along with UNICEF at the district level in
June 2017. Some representatives were present
from each block, both from the government
and non-government organisations, who were
motivated to be involved in the formulation of
SBCC plans. UNICEF was the partner sanctioned
by the state government. We made concrete
plans and fixed targets to achieve ODF status
in the given time. After the workshop, various
activities including the Community-led Total
Sanitation (CLTS) training began, and it was
scaled up across the entire district. We built
capacities of the head of panchayat who could
convey our messages to the villagers. Earlier,
without the participation of the villagers, we
could construct toilets; but nobody would use
55
Adolescent girls mobilised by UNICEF to talk about
menstrual health and hygiene, and to advocate the
use of toilets.
At the community level:
1. SBM has reached out to certain remote areas with Various government departments and non-government
the help of SBCC plans. organisations are working in tandem to integrate the
issue of open defecation into their programmes. This
2. People are building toilets with support from
reflects the success of SBCC plans in reaching out to
the government and with their own contribution,
the community at scale and across various sectors.
irrespective of their economic background. In
addition, sustained usage of toilets has also been
observed in villages, especially by women.
56
In Summary
Action
UNICEF C4D, in providing
technical support to Swachh
Bharat Mission (SBM), developed
and implemented an SBCC-
centred intervention in Uttar
Pradesh to motivate healthy
sanitation behaviour. Here is a The district SBCC team
blueprint of how the intervention analysed the situation of open
was rolled out in 25 districts. defecation through district,
situation, and SWOT analysis.
A plan was formulated after
consultation with stakeholders,
and relevant resources were
allocated for dissemination.
CLTS was used to train resources District and block-level War

and communities to understand Rooms were established
the situation of open defecation as a 24X7 communication
and implement plans for sustained mechanism for interaction
toilet use. The five-day CLTS among stakeholders to
training was used to impart SBCC eliminate open defecation.
training and encourage community Monthly review meetings were
participation. conducted to monitor progress.
Street plays and magic shows

UNICEF converged with various
were performed by local
stakeholders such as Education
artists to create awareness
Department, Health Department,
on sanitation and hygiene.
Department of Women and
Exposure visits for change
Child Development, as well as
agents were carried out, along
adolescent girls to discuss and
with movie screenings and
promote the use of toilets.
contests for villagers.
Street and folk theatre, posters,

pamphlets, walkathons,
marathons, and a video
van were used to spread
awareness and knowledge
on the importance of hygiene,
sanitation, and use of toilets.
57
Results
SBM ODF's SBCC plans and IEC fund utilisation and strategic
activities have been approved by implementation has accelerated
the District Sanitation Committee since systematic engagement and
(DSC), and implemented in 20 capacity building of stakeholders
districts. Equal importance is on SBCC was done. There is an
given by SBM to SBCC, with the increase in expenditure from 7.2
focus being the construction and percent in September 2017 to
use of toilets. A review of the plan 11.28 percent in November 2017,
has been set up with the DSC for of the total allocated amount of
other districts. over 21 million USD.
Government officials have moved Irrespective of their economic

from a simple IEC approach background, the community
for improved knowledge to displays enhanced demand
a more comprehensive and for SBM toilets, and there are
layered SBCC approach. Human frequent cases of people building
resources at ground level for toilets from their own resources
sanitation services are skilled with support from the government.
in community mobilisation, Sustained use of toilets is now
Interpersonal Communication, a common feature, especially
and other SBCC activities. among women.
58
References
[1]
Swachh Bharat Mission (SBM) (Clean India Mission), contains two [12]
Chief Medical Officer (CMO) in India is the senior government
sub-missions: Swachh Bharat Abhiyan ("Gramin" or rural), which official designated head of medical services at the national
operates under the Ministry of Drinking Water and Sanitation; level. The post is held by a physician who serves to advise
and Swachh Bharat Abhiyan (Urban), which operates under the and lead a team of medical experts on matters of public health
Ministry of Housing and Urban Affairs. Run by the Government importance.
of India, the mission aims to achieve an Open-Defecation Free
(ODF) India by 2 October 2019, the 150th anniversary of the birth
[13]
A civil surgeon is a senior designated post in the government
of Mahatma Gandhi, by constructing 12 million toilets in rural India medical and health service.
at a projected cost of ₹1.96 lakh crore (US$30 billion). [14]
The Mahila Samakhya Programme (Education for Women's
[2]
A gram panchayat (village council) is the grassroots-level Equality) that started in 1989 is a concrete programme for the
institution of Panchayati Raj (formalised local self-governance education and empowerment of women in rural areas, particularly
system in India at the village or small-town level) and has a those from socially and economically marginalised groups.
sarpanch as its [15]
Developed by UNICEF Water, Sanitation, and Hygiene
elected head.
programme, where C4D pitched in with the SBCC session.
[3]
Community-Led Total Sanitation (CLTS) is a community-wide [16]
A type of toilet that collects human faeces in a hole in the ground.
behaviour change approach that mobilises communities to
They use either no water or one to three liters per flush with pour-
undertake their own appraisal and analysis of sanitation issues
flush pit latrines. When properly built and maintained they can
and take their own actions to become open defecation free (ODF).
decrease the spread of disease by reducing the amount of human
[4]
https://www.unicef.org/cbsc/files/Module_1_SEM-C4D.docx feces in the environment from open defecation.
[5]
Uttar Pradesh Rural Livelihood Mission is a poverty alleviation
[17]
Akshay Kumar is an Indian actor, producer, martial artist,
project implemented by Government of Uttar Pradesh. stuntman and television personality. In a career spanning more
This scheme is focused on promoting self-employment and than twenty five years, Kumar has appeared in over a hundred
organisation of rural poor. The basic idea behind this programme Hindi films and has won several awards.
is to organise the poor into SHG (Self Help Groups) groups and [18]
Rakhi or Rakshabandhan is a Hindu festival as part of which
make them capable for self-employment.
sisters tie a decorative thread on the wrist of their brother as a
[6]
Coordinates work of the local governance system at the district symbol of love and brothers promise to protect them all their life.
level. The festival involves exchange of gifts, usually by the brother to
the sister.
[7]
District Planning Committee (DPC) is the committee created
as per the Constitution of India at the district level for planning
[19]
Responsible for implementing SBM in India, they look after the
at the district and below. The Committee in each district should overall policy, planning, funding and coordination of programmes
consolidate the plans prepared by the Panchayats and the of drinking water and sanitation.
Municipalities in the district and prepare a draft development plan [20]
These changes have been observed within a small timeframe.
for the district.
[8]
DRDA has traditionally been the principal organ at the district level
to oversee the implementation of anti-poverty programmes of the
Ministry of Rural Development in India.
[9]
Uttar Pradesh State Rural Livelihood Mission (UPSRLM)
is a society formed under the aegis of Department of Rural
Development to promote and improve livelihoods of the
disadvantaged sections of the rural population of the state.
UPSRLM is registered under the Societies Registration Act of
1860.
[10]
Swachhata Preraks and Block Preraks are the catalysts of the
programme at the district level, facilitating Gram Panchayats to
achieve the 100 percent Open Defecation Free status. To achieve
the ODF status, Swachhata Preraks will spearhead the activities
of SBM by planning, coordinating, monitoring, and executing
the annual implementation plan for sanitation in their respective
districts.
[11]
District Education Officer is responsible for monitoring Educational,
Administrative and Legal activities for schools in District under the
Department of Education, Government of India.
59
5
District SBCC Cells

System Strengthening for
Improved Capacity in Social
and Behaviour Change
Communication in West Bengal
The Government of West Bengal implements various flagship programmes to protect and promote the rights
of children. These include Integrated Child Protection Scheme[1], Sarva Shiksha Abhiyan[2], Integrated Child
Development Scheme[3], National Health Mission[4], Mission Nirmal Bangla[5] for development of children,
adolescents, and women. These programmes approached communication from a knowledge and education
lens, and included an Information, Education, and Communication (IEC) component rather than the broader
perspective of Social and Behaviour Change Communication (SBCC), which includes dialogical processes
to bring in individual, societal, cultural, and environmental changes for desired norms and choices. Different
government departments implementing the programmes did not have a strategic and structured approach to
behaviour change communication, and had limited human resources and the lack of skill to deal with SBCC.
The district administration of Purulia, Murshidabad, South 24-Parganas, and Malda established district SBCC
cells with support from UNICEF’s Communication for Development (C4D) programme in West Bengal. It
aimed to integrate planning and implementation of SBCC to achieve the goals of flagship programmes.
In order to develop a critical mass of grassroots personnel capacitated on concepts and processes of
SBCC, human resources were identified within the system at district, block, and gram panchayat level, and
training was cascaded for capacity building. Various communication approaches such as Interpersonal
Communication (IPC), mid-media, folk media, and mass media were used to positively influence behaviour
at the individual and community level. Influencers such as religious leaders and gram panchayat members
were mobilised and involved in the process. As a result, key functionaries adopted the SBCC approach, and
a pool of skilled human resources with improved communication, planning, implementation, and monitoring
skills is now built within the system. The programmes communicate with people living in remote areas in a
more effective and systematic manner, creating more demand for services and better adoption of desired
behaviours.
UNICEF C4D
60
Theory of Change
1. Shift to SBCC approach
2. Building of a pool of human resource skilled in SBCC
3. Strategic planning, implementation, and monitoring of SBCC component
4. More stakeholders demand for services and adopt the desired behaviours
1. Structuring of three-tiered district SBCC cells

2. Mapping and identification of human resources at district, block, and gram panchayat level
Lack of structure
Lack of human Priority given to
IEC approach rather and planning for
resource trained in implementaton,
than SBCC approch SBCC component
SBCC within the SBCC not considered
under development
programmes government important
61
Malda
Murshidabad
Purulia West
Bengal
South 24-Parganas
Map not to scale

Situation
In West Bengal, an eastern state of India, various environmental level, and uses a host of strategies
programmes are implemented by the government to and communication approaches.
address poor development indicators such as low
institutional delivery, high school dropout rates, high 2. Communication interventions were not evidence-
incidence of anaemia in children, and low immunisation based and lacked proper planning and structure.
coverage. The flagship development programmes Hence, communication activities were carried out in
include Integrated Child Protection Scheme, Sarva an ad hoc manner.
Shiksha Abhiyan, Mission Nirmal Bangla (MNB),
Integrated Child Development Scheme, and National 3. The core implementation of development
Health Mission among others. These programmes programmes was given more importance. SBCC
strongly contribute to the survival, development, was considered a soft skill and not given priority
protection, and empowerment of children, adolescents, by officials.
and women, especially those belonging to poor and
4. Officials at district, block, and gram panchayat
remote communities.
level had limited skills to plan, implement, and
Information, Education, and Communication (IEC) monitor communication activities. Available human
is a component of these programmes, with existing resources who had SBCC skills to carry out social
budgetary allocations and guidelines for its utilisation and behaviour change communication at the
and planning. Key challenges identified in utilising ground level were also very limited.
the IEC component to achieve the results of flagship
programmes were[6] that: UNICEF West Bengal’s C4D programme is helping the
district administration of Purulia, Murshidabad, South
1. IEC only focuses on conveying messages and 24-Parganas, and Malda to improve communication of
improving the knowledge of participants to flagship programmes by establishing and strengthening
accelerate results of the programmes. There was the district SBCC cell. Mapping of human resources
a need for key functionaries to shift to a more is one of the key activities undertaken by the
comprehensive SBCC approach, as it includes district SBCC cell to improve child survival, growth
change at individual, societal, cultural, and development, and protection.
62
The SBCC cell Account
Assistant cum Data Entry
Operator operating from
the SBCC cell room in
Malda district.
Method
The district administration established an SBCC cell 5. Build Interpersonal Communication (IPC) skills of
for evidence-based change communication to achieve the Frontline Workers (FLWs).
the results of flagship programmes and schemes. It
coordinates with various line departments and their 6. Strategically engage with youth, adolescents,
flagship programmes for the systematic planning and village volunteers, self-help groups, non-
review of SBCC activities. UNICEF West Bengal’s government organisations, and religious leaders.
C4D programme provides technical knowledge to the 7. Periodically review the progress and challenges of
government for system strengthening and capacity the SBCC activities of different programmes.
development. UNICEF intends to utilise the learnings
from this programme to demonstrate the impact of the For this purpose, human resources were identified
SBCC cell. These learnings would be used to replicate within the government at the district, block, and the
and scale up the programmes in other districts. gram panchayat[7] level and trained for systematic
community mobilisation.
The objectives of the SBCC cell are to:
1. Identify the scope and plan of social mobilisation

activities to increase demand for services under
various flagship programmes, especially those
related to children, women, and adolescents.
2. Provide technical support to the programmes to

plan and implement SBCC activities.
3. Coordinate with different government

departments at district, block, and
community levels.
District Nodal Officer of Malda
4. Develop field-tested messages to influence critical district's SBCC cell.
behaviour and social norms.
63
Table 1: Human Resources identified at each level within the government
District level Key Resource Persons (KRPS)
Representatives of line departments such as Health and Family Welfare,

Women and Child Development, Education, and Rural Development.
Block level Master Trainers (MTs)
Representatives of line departments such as Health and Family Welfare,

Women and Child Development, Education, and Rural Development.
Gram panchayat level Critical Mass of SBCC Volunteers
Frontline workers such as Accredited Social Health Activist (ASHA)[8], Auxiliary Nurse
Midwife[9], anganwadi workers[10], self-help groups, adolescent peer educators, and other
resource persons from government programmes working at grassroots level.
Key Resource person from Child

Protection Unit, Malda district.
At the gram panchayat level, human resources were on health. Further, to plan the SBCC component in
identified to directly engage with the community at regular the programmes, the SBCC cell used multi-pronged
intervals, with many of them even belonging to the communication approaches, which included:
community. Training is cascaded at various levels rather
• Interpersonal communication: Facts For Life
than at one go. Key Resource Persons (KRPs) at the
(FFL) videos[12], IEC materials, flip charts, posters,
district level were trained on SBCC and, on qualification,
and focus-group discussions on different platforms
they became trainers for Master Trainers (MTs) at the
block level[11]. This is repeated to train a critical mass of • Community mobilisation: Mid-media, folk media,
SBCC volunteers at the gram panchayat level. local performances, drama, and popular traditional
media like puppet and magic shows
They are trained with the help of TARANG SBCC
training package, which was essentially developed • Information and Communications Technology:
by UNICEF’s C4D programme for health system Mobile-based messages and WhatsApp
strengthening. UNICEF West Bengal’s C4D programme
• Outdoor media: Hoardings and wall paintings
adapted and expanded the module to cover capacity
development and system strengthening of other • Mass media: Audio-video spots on television,
flagship programmes, in addition to programmes radio, and print media
64
UNICEF West Bengal’s C4D programme supported the Malda
UNICEF West Bengal’s C4D programme supported the Malda
district administration in developing a mascot for SBCC activities,
district administration in developing a mascot for SBCC activities,
and popularised Fazlee Babu as an innovative strategy for effective
and popularised Fazlee Babu as an innovative strategy for effective
communication. Fazlee is a famous local variety of mango, which
communication. Fazlee is a famous local variety of mango, which
people identify with easily. Malda uses Fazlee Babu as the district
people identify with easily. Malda uses Fazlee Babu as the district
communication mascot to promote different flagship programmes.
communication mascot to promote different flagship programmes.
The Fazlee Babu communication package consisted of audio,
The Fazlee Babu communication package consisted of audio,
animations, hoardings, kiosks, banners, posters, flyers, brochures,
animations, hoardings, kiosks, banners, posters, flyers, brochures,
stickers, batches, and head/wristbands. Repository of the available
stickers, batches, and head/wristbands. Repository of the available HoardingofofFazlee
Hoarding FazleeBabu.
Babu.
SBCC material under different programmes was also revised and used.
SBCC material under different programmes was also revised and used.
Action
Structuring SBCC cell
Three-tier SBCC cell structure
Integrated Child Development

Health KRP
Services KRP
Education KRP District SBCC Cell Social Affairs KRP

District Nodal Officer
Panchayati and Rural District Officer Minority

Develoment KRP Affairs KRP
Block Nodal Officer

converging efforts by Master
Trainers at block level
Frontline Workers at
gram panchayat level
Communities
65
Frontline worker from
Bhutni, trained in SBCC
66
• The district administration assigned a senior • At the gram panchayat-level, a Critical Mass or
official of the rank of Deputy District Magistrate social capital of human resource was identified
as the District SBCC Nodal Officer under the from within the government system through a
aegis of the District Magistrate[13] and Additional Human Resource Mapping format designed by
District Magistrate (General)[14]. The District Nodal UNICEF West Bengal’s C4D programme. They
Officer leads the district SBCC cell and converges are responsible for communicating with women,
efforts of line departments such as Health and children, and adolescents to share information about
Family Welfare, Women and Child Development, numerous services available for health, protection,
Education, Panchayat and Rural Development education, development, and protection.
(P&RD).
Capacity Development through Cascade approach
• The District Nodal Officer coordinates with all line
• SBCC experts from the district administration and
departments to systematically map out SBCC
UNICEF train KRPs in a three-day workshop to
provisions of each department, and then chalks out
develop their communication skills, interpersonal
a convergent plan for SBCC activities so that an
communication, understanding of SBCC, planning,
effective and convergent plan can be made.
implementation, monitoring, and documentation for
• UNICEF oriented the district SBCC cells on: SBCC activities.
(i) SBCC component of flagship programmes;
• The KRPs train the MTs, which helps them
(ii) the importance of SBCC for development;
understand planning, monitoring, and evaluation of
(iii) behaviour change process; (iv) planning and
SBCC activities in different flagship programmes.
monitoring of SBCC activities; and, (v) the roles
They are trained to develop SBCC plans for
and responsibilities of district and block-level nodal
implementation at the block level.
officers. UNICEF supports the district SBCC cell in
coordinating with the line departments. • The MTs train the Critical Mass at gram panchayat-
level to provide a clear view of the importance
• A Key Resource Person (KRP) was nominated
of SBCC and to develop village action plans for
from select line departments implementing the
delivering the key messages to communities.
flagship programmes at the district level based on
his/her technical knowledge, communication skills, • Community influencers work in tandem with the
and interest to participate in the SBCC activities. government to positively influence behaviour
They are responsible for coordinating with the change. Self-help groups, gram panchayat
SBCC cell regarding their department’s SBCC members, folk artists, teachers, youth groups,
activities, utilisation of SBCC funds as per annual members of various committees, and local
implementation plan, and monitoring of the SBCC Non-Government Organisations are sensitised
activities. They shared their SBCC plan with the separately. They are motivated to foster
district SBCC cell for effective coordination. communication and social mobilisation activities
such as organising community meetings, SBCC
• At the block level, a senior official was identified as
activities, and monitoring at the village level.
Block Nodal Officer (BNO) who led all the activities
at the block level. The BNO supports the District
Nodal Officer in the functioning of the block SBCC
cell and converges inputs from the line departments
at the block level.
• Master Trainers (MTs) nominated from line

departments implemented the block’s SBCC
activities and coordinated SBCC's fund utilisation
with BNO. MTs developed an SBCC plan for the
blocks, and the same was shared with the district
SBCC cell for effective coordination.
67
Master Trainer training the
Front Line Workers
Results
UNICEF has successfully facilitated the formation Grassroots-level human resources were identified
of district SBCC cells in the four districts. It was through systematic mapping and trained on SBCC. This
established in Purulia in 2006, South 24-Parganas in was done through the cascading method so that, as key
July 2014, Murshidabad in July 2014, and Malda in agents, they could bring in social and behaviour change
September 2015. in their respective areas.
Details of human resources mapped in four districts are given in the table below:
South 24-
Human Resource Malda Purulia Murshidabad
Parganas
Key Resource 25 27 24 22
Persons
Master Trainers 452 361 06 347
Critical Mass of 45,982 8,255 50 8,000

SBCC volunteers
68
Frontline Worker from Bhutni to influence behaviour change at community
trained on SBCC. level. We have invited community influencers
such as doctors and religious leaders to
interact with the community. A key strategy
of the SBCC cell in South 24-Parganas is to
communicate with community members regularly
on pressing issues to improve institutional
delivery, encourage breastfeeding, and improve
knowledge on dengue.”
Mahua Das, District Nodal Officer,

South 24-Parganas
Transformative Change[16]
The following transformative change can be observed
at the system and community level:
At the systems level
1. Key functionaries have moved from IEC to a more

holistic SBCC approach which encompasses
evidence-based communication strategies
at individual and community level. Various
government departments now understand and
appreciate community-led behaviour change, and
have prioritised the SBCC component in flagship
programmes for effective implementation to achieve
their results.
“The district SBCC cell in South 24-Parganas

Master Trainer from one of
has helped plan and implement communication the blocks in Malda district.
activities of different programmes more efficiently,
and achieve better results. Earlier we had an
IEC approach to communication activities, 2. Communication activities under flagship
where we used to convey messages through programmes of different departments are better
posters and pamphlets. Now, we have shifted planned and structured. Officials recognise
to a comprehensive SBCC approach which their role in influencing behaviour change, and
is much more than just distribution of posters integrating their efforts to convey key messages in
and putting up hoardings. It is more interactive a comprehensive way. The SBCC cells are effective
and involves the community in all activities in encouraging integrated planning of SBCC
activities in the district.
69
"Due to gaps in the implementation of the ownership to improve their
Sarva Siksha Abhiyan, we haven't been able own situation. There is also an
to reach 100 percent enrolment of students in increase in demand for these
schools. There are other factors at play such
services. We are continuously
as child marriage, trafficking, and labour due to
which children don’t go to school. The district trying to strengthen the SBCC
administration focuses not only on improving cell so it will run without support
education but also controlling these factors. from UNICEF, and only then can
We need to mobilise the community, for which we call it successful.”
we need to trigger people through SBCC.
We achieved mobilisation systematically and
Sulak Kumar Pramanik
developed SBCC plans at district, block, and
village level. We organised SBCC activities District Nodal Officer, SBCC cell, Malda
which included folk artists and religious leaders.
The Department of Health, Women and Child 4. Implementation of SBCC activities has contributed
Development, and Education are working to the increase in institutional delivery, decrease in
together to reach 100 percent enrolment. Earlier,
school dropouts, child marriage, and elimination of
we didn’t know what other
departments were doing, but open defecation.
now we are working together
and delivering better.”
"There are various government
Anjan Mishra, programmes like the Swachh
Key Resource Person Bharat Mission and Sarva
District Planning Co- Siksha Abhiyan, as part of
ordinator, Sarva Siksha
which we sought to eliminate
Abhiyan, Malda
open defecation and decrease
school drop out rates. However,
3. A large pool of human resources within the the situation was such that
government is available who are trained in SBCC, toilets were constructed but not
systematic planning, and implementation of used. In the education sector,
communication activities to achieve results of teachers weren't delivering to their true potential
flagship programmes. despite adequate infrastructure in schools, and
students failed because of poor education.
“All line departments under the district District-level workshops were held to assess
administration have development programmes the situation and come up with SBCC strategies
with a separate IEC component. However, we to be incorporated in the flagship programmes.
now have a more comprehensive Social and Through the SBCC cell, we conducted
Behaviour Change Communication strategy programmes to influence change in communities.
to convey messages and influence behaviour We organised folk songs and encouraged
change at individual and community level. We community influencers such as Imams and
built a team of trained Key Resource Persons, Purohits to talk to the community about the
Master Trainers, and Frontline Workers who plan benefits of ODF and continuing school education.
and implement the SBCC activities at district,
A lot of work has been done by all government
block, and gram panchayat level. FLWs were
departments, as evident by the ODF status
deployed at the grassroots-level to reach out to
achieved by many villages in the district, and the
people to influence critical behaviours and norms.
decrease in the school drop out rate."
We have learned that community-led change is
sustainable and community motivation is the key Debotosh Mondal,
component. We have provided the community Additional District Magistrate,
with services, and now the community has taken Land Reforms Malda
70
“The Anandi programme is run by the government “The Child Protection Unit has trained SBCC
to address low institutional delivery in the district, volunteers such as Frontline Workers and
which was 58% in 2014-15. In August 2016, school teachers in 10 blocks of the district on
district-wide sensitisation was held to spread SBCC, and its importance in achieving results
messages about the importance of institutional of child protection programmes. We focused on
delivery. The situ ation improved slowly and, improving immunisation, and decreasing child
currently, institutional delivery has reached 90% marriage and child labour in the district. We
in the district. This improvement was because provided community members with information
of the use of various communication strategies. on behaviours for child growth, development,
We invested our resources to develop need- protection, and empowerment. We organised talk
based communication materials. We put up shows by community influencers, showed videos,
hoardings at three strategic places in every block, and initiated participatory activities. Due to all the
and wall messages on houses. A local mascot, efforts, we have seen a decrease in the prevalence
Fazlee Babu (the local mango), was used to of child marriage in the district. Earlier, girls were
popularise the messages. The messages were not able to complete their education and married
well researched and sensitive to the local cultural before the age of 16. Now, due to improved
context. We sensitised different stakeholders knowledge of the effect of child marriage on the
such as panchayat members and self-help health of adolescents, especially girls, parents
groups on immunisation. On a marry them only after they cross 18 years of age.”
scale of 1 to 10, I can say that
our communication skill has Sonali Das,
improved from 2 to 7.” Key Resource Person, SBCC cell
District Child Protection Unit, Purulia
Dr. Mrinal Kanti Das Deputy
II Chief Medical Officer,
Malda At the community level
1. Through the effective communication material and

cascade approach of training, the government
SHG member being
trained by Master Trainer. has been able to reach out to remote areas in
large numbers through the critical mass of SBCC
volunteers.
"The concept of SBCC cell came to Malda in

2015. SBCC cells at district and block levels
have identified Key Resource Persons and
Master Trainers, and trained them on the SBCC
component and how to use it to implement the
flagship programmes. It has helped different
departments converge their efforts and implement
their programmes more efficiently. Through the
cascade method, we have been able to reach out
to people at the grassroots level who require help
from the government. Communication strategies
such as community radio, magic shows, quizzes,
and folk songs attract the attention of people and
help reach media-dark communities where the
government was unable to reach out earlier. These
communication activities made it easier to explain
key messages to many stakeholders.”
Hemadri Sarkar
Department of Self Help Group and Self
Employment, Malda district
71
2. Community influencers such as SHG members, to carry out SBCC activities to positively influence the
religious leaders, folk artists, and gram behaviour of communities.
panchayat members are mobilised and trained
“I have been associated with the district administration’s developent work for the last 6 years, and with
the SBCC cell since the last 2 years. Earlier, the administration used to ask me and my team to perform
Gombhira, the local folk art, on an ad hoc basis whenever required. After the formation of the SBCC cell,
our activities are more systematic and planned. Plans are formed by the government and our activities
are incorporated in those plans. We were first given training on the topics we needed to communicate. We
were given detailed information on the effects of open defecation and benefits of breastfeeding. We wrote
songs and dramas on these topics. Officials reviewed our script and songs before we performed it for
better delivery. Frontline Workers mobilise the community and invite them to our performance. The dramas
are interactive and educational for the viewers. People do not pay attention if an outsider merely lectures
them. We belong to the same community and speak to them in the local language, so people like to listen
to us. They learn and enjoy at the same time. After we finish our performance, we ask questions, interact
with the villagers, and guage how much of the content they have actually absorbed. We give out prizes if
they answer correctly – which motivates them to pay attention."
Ashok Chakraborty, Folk Artist, Malda
With support from UNICEF West Bengal's C4D the government, and encourage the adoption of healthy
programme, SBCC cells were established. They behaviours and practices at individual and community
facilitate sustained improvements in the provision, levels.
utilisation, quality, and efficiency of services through
SHG members interacting with each other

after a session on SBCC.
72
In Summary
UNICEF initiated an intervention to
strengthen the implementation of flagship
programmes through an SBCC approach,
as opposed to the commonly followed
Information, Education, and Communication
(IEC) route. It supported administrations A three-tier SBCC cell was structured,
Action
in establishing SBCC cells, and mapping consisting of a district and block SBCC
Nodal Officer each, who coordinates
and identifying grassroots-level human
with line departments. A Key Resource
resources to capacitate them on the
Person (KRP) was nominated at the
components and processes of SBCC. district level, and Master Trainers (MTs) at
Here’s a blueprint of how the intervention block level from the line departments. At
was rolled out in four districts of West the gram panchayat-level, a Critical Mass
Bengal, namely Purulia, Murshidabad, or a social capital of human resource was
South 24-Parganas, and Malda. identified for the same purpose.
SBCC experts from the district

administration and UNICEF trained
KRPs on SBCC and various related
areas. The KRPs trained MTs, who
in turn trained the Critical Mass.
Community influencers, self-help
groups, folk artists, teachers, and
various other stakeholders were then
sensitised separately and motivated
to foster SBCC activities.
SBCC cells have successfully

Results
been facilitated in the four

districts ﹘ Purulia in 2006,
South 24-Parganas in July 2014,
Murshidabad in July 2014, and
Malda in September 2015.
Through the cascade

method, many human
resources were identified and
trained to become a social
capital for change.
73
At the system level:
Key functionaries have moved on from
IEC to a more holistic SBCC approach.
Activities under flagship programmes
are better planned and structured, and
a large pool of SBCC-skilled human
resources is available. There has been
an increase in institutional delivery,
a decrease in school dropout, child
marriage, and open defecation.
At the community level:

The cascade approach of training
has helped the government reach out
to remote areas in large numbers.
Community influencers like self-help
groups, religious leaders, folk artists,
and gram panchayat members
also positively influence community
behaviour through the training.
74
References
http://www.wcd.nic.in/schemes/integrated-child-protection-scheme-icps
[1]
[2]
http://www.wbsed.gov.in/wbsed/home_public_pbssm.php?stake_code=19-14
[3]
http://icds-wcd.nic.in/icds/icds.aspx
[4]
http://nhm.gov.in/
[5]
http://www.missionnirmalbangla.in/
[6]
Based on Key Informant Interview with West Bengal UNICEF Communication for
Development (C4D) team.
[7]
Gram Panchayat (village council) is the grassroots-level of Panchayati Raj formalised local
self-governance system in India at the village or small-town level, and has a sarpanch as
its elected head.
[8]
Accredited social health activists (ASHAs) is community health workers instituted by the
government of India's Ministry of Health and Family Welfare (MoHFW) as part of the
National Rural Health Mission (NRHM).
[9]
Auxiliary nurse midwife, commonly known as ANM, is a village-level female health
worker in India who is known as the first contact person between the community and the
health services. ANMs are regarded as the grassroots workers in the health organisation
pyramid.
[10]
Anganwadi workers work at the rural mother and child care center in India. They were
started by the Indian government in 1975 as part of the Integrated Child Development
Services programme to combat child hunger and malnutrition.
[11]
http://jespnet.com/journals/Vol_3_No_2_June_2016/12.pdf
[12]
Facts for Life videos, published by UNICEF, contains essential information that families
and communities need to know to raise healthy children.
[13]
A District Collector, often abbreviated to Collector, is an Indian Administrative Service (IAS)
officer in charge of revenue collection and administration of a district in India.
[14]
Assists a District Magistrate in carrying out day-to-day work in various fields.
[15]
Based on programme documents.
[16]
Based on Key Informant Interview with the District and Block SBCC cell and line
departments.
District SBCC cell, Malda district: http://www.sbccmalda.org/
75
6
Nudging Norms through Faith

Based Organisations for the
Promotion and Protection of
Child Rights in Telangana
Child marriage, child labour, child trafficking, and violence against children are common place in the
Khammam and Mahabubnagar districts of Telangana. To tackle these issues, UNICEF collaborated with
the Centre for World Solidarity[1] and Faith Based Organisations (FBOs) to implement an initiative to
secure child rights in the two districts, in January 2017. UNICEF developed a sustainable and systematic
model of collaboration with FBOs ﹘ they were identified, mobilised, and given capacity building on Social
and Behaviour Change Communication (SBCC), child protection, child rights, and their violation. FBOs
influence and shape beliefs, norms, and behaviour as they frequently interact with the community and
are highly respected. Based on a successful previous collaboration on polio vaccination facilitated by the
FBOs, UNICEF partnered with them in the Mahabubnagar and Khammam district of Telangana to address
high child marriage rates and other child protection issues in these areas. Facts for Life (FFL) videos and
SBCC materials were used for the capacity development of these FBOs. They actively participated in social
and religious events to engage with the community and influence them to effect change in social norms.
Moreover, FBOs have begun developing their own child protection policies. Communities are now better
aware, and committed to protecting their children from child labour, child marriage, child trafficking, violence,
and abuse.
UNICEF C4D
76
Theory of Change
Communities are now sensitised, mobilised, and committed to the protection of child rights. FBOs in the
intervention villages actively participate in social and religious events to engage with community and
influence them on children’s rights. They are also developing their own Child Protection Policy to protect
children’s rights
FBOs have increased

FBOs engage with the
knowledge on child rights FBOs facilitate access
community on violation
and the implications of to services and provide
of rights through religious
rights violation. They are referrals to families on the
and social events, and
better sensitised and identify use of services related to
influence them to secure
platforms for community child rights.
children’s rights.
engagement.
Capacity development Community engagement Facilitating convergence
Partnering with FBOs to influence social norms and address child rights.
Prevalence of child marriage, child labour, child trafficking, and violence against children
in the community.
77
Situation Area of
Practices like child labour and child marriage deprive
Intervention
children of their childhood, health, and education,
Map not to scale

putting them at risk of a poor health and immunity,
violence, and sexual abuse – all in violation of their
basic rights[2]. According to the Census of India 2011,
4.3 million children aged between 5-14 years were
working[3], and 27 percent women aged between 20-24
years were married as children[4]. Telangana
In the Mahabubnagar and Khammam districts of the Mahabubnagar
Indian state of Telangana, the percentage of women Khammam
who get married and bear children before they turn 18 is
relatively higher than the state and national averages[5]. Intervention State
Child marriage aside, child labour, child trafficking,
Intervention District
and violence against children are also prevalent in
the two districts. UNICEF’s report on the condition of any country or territory or the delimitation of any frontiers.
of child workers states that 6.6 percent children in Source: http://d-maps.com/carte.php?num_car=4183&lang=en
Mahabubnagar and 4.4 percent in Khammam district
were involved in child labour in 2011 – the former being Widespread social approval of child marriage is among
higher than the state (4.9%) as well as national (3.9%) the most critical factors that drive high prevalence of
average[6]. As far as human trafficking goes, Telangana child marriage in the community. Other norms and
ranks 4th in the country[7]. beliefs that cause this are:
Social norms around child marriage[8]: • Economic considerations: Unmarried girls are
considered an economic burden to the family.
Percentage of women aged 20-24 years, who were
A girl is considered Paraya Dhan, or someone
married before the age of 18 years
who belongs to her future husband's family.
8% Hence, parents are unwilling to invest in their
11% daughters' education and nutrition. To reduce the
17% high cost of wedding ceremonies, children are
15% married during other community celebrations.
For instance, when a communal feast is held
Percentage of women aged 15-19 years who were
in honour of the death of an elderly person,
already mothers or pregnant at the time of National
the opportunity is seized to carry out marriage
Family Health Survey (NFHS)-4
celebrations ﹘ serving the dual purpose of
4% saving money and ending the mourning with an
5% auspicious and happy event.
4%
• Gender norms: Girls and women are perceived
7%
to have an inferior position in society. Major
Children engaged in labour decisions like marriages are taken by the father
27% or by head of the family, who is usually a man.
26%
• Safety and security: Communities view child
31%
marriage as a means to save the family honour,
46%
which they fear losing in case of a premarital
sexual relationship. This is grounded in the
0 10 20 30 40 50 prevalent gender norm of the virginity of girls.
Khammam Mahabubnagar Telangana India
Figure - 1: Prevalence of child marriage, early pregnancy, and Consequently, marriages are arranged either
child labour immediately after or before a girl attains puberty.
78
• Custom of dowry: The understanding of many The study concluded that:
families is that the girl’s natal home must bear the
• FBOs shelter orphans, children with a single
expenses of bringing her up and arranging for her
parent, and other children from poor economic
dowry. Girls are married off early – as the dowry
backgrounds.
amount increases with the age and education
level of the girl.
• FBOs functioned in isolation and most of them were
Faith Based Organisations not registered with the government. They were
either self-funded or supported by philanthropists,
Seventy FBOs that were visited by the most and did not avail government schemes and
number of vulnerable children were identified in entitlements for children.
Mahabubnagar (64 Muslim, 4 Hindu, and 2 Christian),
and twenty in Khammam (6 Muslim, 7 Hindu, and 8
Christian). UNICEF conducted a baseline study on the • Smaller FBOs, while well-intentioned, lacked a
identified FBOs to understand their background and the comprehensive understanding about child rights
status of children who came in contact with them. and child protection issues.
Adolescent boys at a Madarsa (Islamic

FBO Mahabubnagar district).
Method
FBOs were identified as change agents, and their moral influence, FBOs and religious leaders highly
capacities were built to comprehend child rights issues impact the social and cultural life of communities[9].
and entitlements, and engage with the community Moreover, religion and spirituality have a profound
to influence and change social norms around them. effect on the norms and behaviours in a society, thus
UNICEF partnered with Centre for World Solidarity influencing children’s development. FBOs have the
(CWS) and FBOs to initiate the ‘Securing Child Rights’ potential to positively reinforce protection and promote
programme in Telangana in January 2017.
resilience among children. Behaviours influenced by
Partnering with Faith Based Organisations cultural values affect children’s development and can be
challenged and redressed by FBO leaders.
Faith Based Organisations, apart from having deep
and trusted relationships with their communities, often The idea of partnering with FBOs for securing the
have strong linkages with the most disadvantaged and rights of children came about after a special Polio
vulnerable members, especially children. Due to their Immunisation Campaign was successfully conducted by
79
the government and UNICEF in Hyderabad. FBOs were
Child rights
instrumental in increasing the intake of Inactivated Polio
Vaccine (IPV)[10]. This campaign was backed by a strong Life, survival, and development of children
communication and social mobilisation component to
increase awareness and mobilise the community for Child participation
vaccination with active support from media, community-
based organisations, and medical professionals.The Best interests of the child
objective of the partnership was to:
Non-discrimination
1. Mobilise FBOs and leaders to influence social
norms and practices that impact child rights. Child protection rights
2. Have FBOs and their leaders participate in local
FBOs and child rights
religious and social events and talk about children’s
issues such as child marriage, school drop-out,
Programmes with child rights perspective
and violence.
Capacity Development of FBOs Use of Interpersonal Communication (IPC)
The capacity of FBOs was developed on various

key issues, to work on child rights and change social
norms that violate child rights. UNICEF developed an
SBCC kit to train FBOs. It contained posters, stickers,
and flip books addressing child labour, child marriage,
child trafficking, and violence against children. Facts
for Life[11] videos on Social and Behaviour Change
Communication related to health of mothers and
children were also used.
Key topics included:
A young girl at a shelter run

by an FBO in Mahabubnagar.
A caretaker at a shelter home run by an

FBO in Mahabubnagar.
Action
Identification of FBOs
UNICEF and CWS carried out the mapping of FBOs

operating in the two districts. Twenty FBOs[12] were
identified in each district to implement the intervention.
This identification was based on the following criteria:
1. They were from districts where the implementation

partner was functional.
2. They were willing to work for children’s

development as change agents.
80
A baseline survey was carried out to ascertain the Convergence meeting with district-level officials
FBOs’ understanding on child rights. Many of them
UNICEF facilitated meetings between the FBOs
engaged in social services for children but did not
and officials from Child Welfare Committee (CWC)
essentially understand their rights. [13]
, Integrated Child Development Services (ICDS)
Consultation workshops
[14]
, and Childline[15]. The objective was to increase
the FBOs’ awareness on government schemes and
UNICEF and CWS held workshops in January 2017 at entitlements for children. District officials and Childline
the district level to mobilise and blend FBOs with the representatives shared their experiences in dealing
programme. The workshops sought to understand the with issues of child marriage, child labour, child
nature of FBOs, their work, and their understanding trafficking, violence against children, and child sexual
of child rights issues in the community. Through the abuse. Convergence meetings helped FBOs work in
collaboration with government systems for
workshops, FBOs understood the importance of
greater impact.
various factors that drive the current behaviour of
the communities. They also volunteered to receive Participation of FBOs in community events
training on child rights to influence the children and
communities around them. UNICEF, with FBOs, identified religious events and
festivals in the two districts. FBOs participated in these
Capacity development of Faith Based Organisations social and religious events to engage with communities
on issues of child rights, influence norms and practices,
UNICEF trained active members of select FBOs, and
and link the communities with the government schemes.
Master Trainers, who trained at least three other members
of the FBO on child rights. Capacity development helped They also identified public spaces such as anganwadi
improve knowledge among FBOs regarding government centres[16] and local government buildings to discuss
schemes and entitlements for children. Capacity specific child protection issues with the community.
development helped improve knowledge among FBOs These discussions were based on their observations of
on the importance of securing child rights and their role in child rights in religious events, and covered laws and
influencing communities for social change. remedial measures on child protection.
Girls at a Madarsa in Mahabubnagar.

This is the room they sleep in.
81
Boys studying at an FBO-run shelter in
Mahabubangar after school hours.
Results Caselet 1
Community meetings, Seethamma Thanda,

UNICEF’s partnership with FBOs has led to the following
Bandameedi Palli
results:
FBO leaders regularly participated in community
Behaviour change in FBOs meetings at Seethamma Thanda, Bandameedi
FBOs are better sensitised to deal with children and Palli. FBOs explained child rights to the
ensure that child rights are not violated. They have community with the help of FFL videos during
IPC sessions. Community meetings concluded
realised the importance of a child protection policy for
with an oath-taking by the members, stating that
their organisations and are willing to access entitlements
they will ensure no child marriage takes place,
for children through various government schemes.
no child goes to work, and no child is abused.
This triggered a sense of responsibility among
FBOs as change agents
the community members. A series of follow-up
FBOs participate in the community gatherings and sessions were conducted by FBO coordinators
influence families to secure the rights of children. FBOs with the community on various issues pertaining
also conduct IPC sessions with families where child to child rights, thereby resulting in change
rights were reported to be violated. in behaviour. As FBO leaders belonged to
the same community, they could effectively
influence behaviour change. As a result, 1)
FBOs influencing communities
three family members re-enrolled boys in the
FBOs have motivated communities to: government school, 2) six families made a
commitment in community meetings that they will
• Send their children to school instead of work
get their girls married only after 18 years of age,
• Take the commitment to not marry them off before and 3) eight families ensured that their daughters
the legal age who had dropped out of school acquire
vocational training.
• Collectively ensure that children are protected from
child rights issues
82
Caselet 2[1] Transformative Change
Community meetings, Madarsa Madeer FBOs who were earlier not aware of children’s rights
Mahammadeeya have come forward to develop child rights policies for
The FBO held community gatherings in small their own organisations. UNICEF facilitated meetings
groups (50-60 participants), as well as large ones with FBOs in July 2017 regarding child protection
(more than 500 participants). Religious leaders policies. They discussed:
from the FBO who were trained on child issues,
child rights, and social norms, addressed the • The need for a child protection policy among FBOs
community members during these gatherings —
to positively use their moral and spiritual influence • Existing protection protocols, if any
in all communities to reduce the vulnerability
• Advantages of having a child protection policy
of children.
In Rajapur village of Balanagar Mandal, two • Specific preferences, if any, in terms of
such community gatherings were conducted by protection protocols
Madarsa Madeer Mahammadeeya to mobilise
• FBOs are aware of their role in influencing
the community and address social norms around
communities to secure child rights
the identified issues. The FBO leader from
the Madarsa addressed community members
on issues related to children, their rights,
K Sharvanna, Sandeepani Avasam.
consequences of child marriage and child labour,
and importance of education. Parents, Frontline
Workers (FLWs), self-help group members, and
other village-level stakeholders participated
in these gatherings. IPC sessions using FFL
videos steered discussions around issues related
to children. These gatherings addressed by
FBO leaders have motivated the community to
proactively respond to the violation of child rights.
During one of the interactive sessions, community
members came forward to discuss the case of
16-year-old Rafeeq who resides in the same
community. He lost his mother at the age of
seven, and his father remarried. He was never
interested to go to school, nor was he aware of
the importance
of education. His parents are daily wage
labourers who struggle to make ends meet.
Rafeeq started working at the age of nine,
doing the petty business of selling old papers/
Child protection policies ensure that everyone
clothes, iron pieces, and plastic trash. Community
members made plans to ensure that the child associated with the FBOs: 1) is committed to influence
is in a safe environment where his rights are the social norms that violate child rights, and 2) protects
secured. Community members (an anganwadi children from c) getting married before the legal age, b)
teacher, village elders, and an FBO leader) visited labour, and c) violence and abuse.
Rafeeq's home and encouraged his parents to
send him to school. A series of IPC sessions Through this intervention, UNICEF has strengthened
were taken up by the community, along with the its partnership with FBOs, who are among the primary
FBO leader, to influence the behaviour of the caretakers of vulnerable children, and influence the
family. As a result of the collaborative effort by the community to bring about change in social norms. The
community and FBO, Rafeeq's parents agreed to learnings from Mahabubnagar and Khammam can be
send the child to a Madarsa. used as a key strategy to work across Telangana, and
other parts of India where similar situations exist.
83
84
In Summary
Action
UNICEF, in collaboration with
the Centre for World Solidarity,
and Faith Based Organisations
(FBOs), implemented an initiative
to secure child rights in two district
of Telangana. It aimed to address
high child marriage rates and other
Workshops were held at the
child protection issues like violence
UNICEF and CWS identified district level to sensitise FBOs
and sexual abuse, through the
twenty FBOs in each district on the various factors driving
capacity building of FBOs. Here is to implement the intervention. community behaviour. They
a blueprint of how the intervention A baseline study was underwent capacity training to
was rolled out in the Khammam carried out to ascertain their improve knowledge on child
and Mahabubnagar districts of understanding of child rights. rights issues.
Telangana.
Apart from anganwadi centres UNICEF facilitated meetings

and local government buildings, between FBOs and officials from
religious events and festivals Child Welfare Committee (CWC),
were identified where FBOs could Integrated Child Development
engage with communities about Services (ICDS), and Childline to
child rights, influence norms and increase the FBOs’ awareness
practices, and sensitise about on government schemes and
government schemes. entitlements for children.
FBOs are better FBOs participate in the

capacitated and have community gatherings and
realised the importance of influence families to secure
a child protection policy. rights of children. They also
They access entitlements conduct IPC sessions with
for children through various families where child rights
government schemes.
were reported to be violated.
Results
FBOs have engaged

with communities to
influence social norms.
85
Child
Protection
Policy
ild on
Ch cti
te cy
Pro Poli
Earlier, FBOs were not completely

aware of children’s rights. They
have now come forward to develop
child rights policies for their own
organisations. These policies ensure
that those associated with the FBOs
protect children from early marriage,
labour, violence, and abuse, and are
committed to influencing social norms

that violate these rights.
UNICEF has strengthened its

partnership with FBOs, who are
among the primary caretakers of
vulnerable children and influence
the community to effect change in
social norms. The learnings from
Mahabubnagar and Khammam can
be used as a key strategy to work
across Telangana, and other parts of
India where similar situations exist.
86
References
[1]
http://www.cwsy.org/
[2]
https://www.unicef.org/protection/57929_57977.html
[3]
http://labour.nic.in/sites/default/files/Census-2001&2011.pdf
[4]
NFHS-4 (National Family Health Survey-4). International Institute for Population Studies.
[5]
Ibid.
[6]
UNICEF, 2015. State of Child Workers in India.
[7]
http://ncrb.nic.in/StatPublications/CII/CII2015/chapters/Chapter%206A-15.11.16.pdf
[8]
United Nations Children’s Fund, Reducing Child Marriage in India: A model to scale up results, UNICEF C4D,
New Delhi, 2015
[9]
https://www.unicef.org/media/media_4537.html
[10]
Around 3,00,000 eligible children were administered fractional doses of IPV injections over a period of seven days,
from 20-26 June 2016.
[11]
Facts for Life videos, published by UNICEF, contains essential information that families and communities need to
know to raise healthy children.
[12]
This is a pilot project by UNICEF, based on budget a total of 40 FBOs were finalised.
[13]
Child Welfare Committees (CWCs) have been designated by law as the final district-level authorities for the care,
protection, treatment, development, and rehabilitation of children in need of care and protection.
[14]
Integrated Child Development Services (ICDS) is an Indian government welfare programme which provides food,
preschool education, and primary healthcare to children under 6 years of age and their mothers.
[15]
Childline India Foundation is a non-government organisation (NGO) in India that operates a telephone helpline
called Childline, for children in distress. It was India's first 24-hour, toll-free, phone outreach service for children.
[16]
Anganwadi centres were started by the Indian government in 1975 as part of the Integrated Child Development
Services program to combat child hunger and malnutrition.
87
7
PYARHI
Breaking the Taboo and Culture
of Silence in Bihar
For girls, menarche marks the onset of puberty. But poor menstrual practices can severely affect their
education and health outcomes as they grow into women. UNICEF, with the Government of India and
Integrated Development Foundation (IDF), initiated a social and behavioural change intervention called
Promoting Young Adolescents Reproductive Health Initiative (PYARHI) from 2014 to 2016, in 14 blocks
of Nalanda and Vaishali districts of the Indian state of Bihar. The programme aimed to improve menstrual
health and hygiene management among adolescent girls through social and behaviour change approaches –
community dialogue, capacity development, interpersonal communication, and advocacy. UNICEF developed
a communication package consisting of five Facts for Life (FFL) videos, a Paheli Ki Saheli (Friends of
Riddles) package, and one life skills module for this purpose. UNICEF also trained adolescent girls, Frontline
Workers (FLWs), mothers, fathers, and teachers on Menstrual Health and Hygiene Management (MHHM)
and menstrual absorbent disposal practices. As a result, MHHM and disposal practices have improved
among girls and women in the two districts. Further, UNICEF has collaborated with the government to
incorporate: a) the learning of PYARHI to flagship programmes addressing adolescent issues, and b) MHHM
in the formal education system of India.
88
Theory of Change
Improved menstrual health
Communication package – five Facts for Life videos, Paheli ki

Saheli, life skills module
Capacity Interpersonal Community

development communication dialogue Advocacy
Adolescent girls, Frontline Health Workers, Mothers,

Fathers, Community Members
1. Lack of knowledge and clear understanding around

menstrual health and hygiene management
2. Silence, embarassment, and misconceptions around

menstruation
3. Social restrictions for menstruating girls
4. Lack of communication between girls, mothers, and

FLWs around menstruation
89
Bihar
Map not to scale

Vaishali
Nalanda
Situation
Adolescence, the stage of a child’s growth between • Only 45 percent menstrual cloth users and 50
10 to 19 years, is considered an age of opportunity for percent of the sanitary napkin users changed their
physical, emotional, and mental development. This is menstrual absorbents twice a day.
a crucial time of being that forms a sense of identity
for boys and girls. This juncture involves decisions on • Girls did not use detergent to wash their menstrual
how their lives will be shaped; making them their own cloth and did not dry it in the sun.
agents of change[1]. It is a transitional period which
• The preferred form of disposal was burying it in
requires protection, care, and access to educational
the ground (66 percent cloth users, 54 percent
and health services. For girls, correct knowledge about
sanitary napkin users). 23 percent cloth users and
menstruation and its proper management is critical to
24 percent sanitary napkin users disposed the
reproductive and sexual health. But over 113 million
absorbent by throwing it in a pond.
adolescent girls in India need a safe environment that
offers guidance during the onset of menarche. The reasons for poor MHHM were manifold and can be
understood from different lenses:
UNICEF conducted a formative research in 2013 to
determine the existing knowledge, attitudes, practices, Community: Menstruation is indicative of a girl's ability
and norms related to Menstrual Health and Hygiene to get married and bear children. However, in the
Management (MHHM)[2] among post-menarche girls communities, menstruation was perceived to be an impure
and women in Vaishali and Nalanda districts of Bihar[3]. process, and menstruating women were considered
The findings indicated that MHHM and disposal unclean. This belief was attributed to the dark, thick, and
practices were poor among adolescent girls in the unpleasant smelling blood released during menstruation.
following ways: This period imposed various restrictions on girls, such
as limited mobility and interaction with men. Moreover,
• 85 percent girls preferred to use cloth as menstrual
menstrual blood was linked to the fertility of a woman;
absorbent. 96 percent used old clothes and 28
hence, menstrual absorbents were disposed with care by
percent didn’t wash the menstrual cloth when used
burying them in the soil rather than burning.
for the first time during the cycle.
90
Family: Families with adolescent girls believed that
it was their responsibility to protect the purity of their Field facilitator talking about her
experiences during menarche.
daughters and enhance chances for a good marriage.
Both fathers and mothers had limited understanding of
the physiology of menstruation and its hygiene. They
did not allow their menstruating daughters to: a) touch
certain food items like pickles, onions, potatoes, b)
enter the kitchen or any place of religious significance,
c) have a bath, d) move freely, and e) interact freely
with men. Fathers had little or no discussion with
their daughters about menstrual hygiene. Mothers
themselves followed poor MHHM practices and
were unable to teach their daughters. They did not
communicate well with their daughters about MHHM,
pre- or post-menarche, and looked at it as a topic
to be ashamed of.
Frontline Workers (FLWs) and teachers: FLWs

(including Accredited Social Health Activists (ASHA)
[4]
, anganwadi workers[5], Auxiliary Nurse Midwives[6], Method
SABLA[7] staff) and teachers lacked communication
skills and had minimal information regarding Given the culture of silence and misinformation
menstruation. The majority believed that menstruation around menstrual hygiene, UNICEF, with Johnson
was a process through which the body released bad & Johnson, the Government of India, and Integrated
Development Foundation (IDF), implemented
blood and heat. Therefore, they did not oppose the
Promoting Young Adolescents Reproductive Health
cultural myths and taboos surrounding menstruation.
Initiative (PYARHI) from 2014 to 2016. The programme
They were unable to communicate with or support the
aimed at incorporating a Social and Behaviour Change
adolescent girls around them on issues of menstruation.
Communication (SBCC) strategy to improve MHHM
Adolescent girls: More than 80 percent of girls were among adolescent girls in rural areas. PYARHI was
completely unprepared for menarche. Mothers and implemented in 1,607 villages in 14 blocks of Nalanda
friends gave them incomplete and sometimes even and Vaishali districts of Bihar[8]. The objectives of the
incorrect information about menstruation. Hence, girls programme were to empower:
were scared when they first started menstruating; 1. Adolescent girls to:
they accepted the restrictions and taboos imposed on
them without questioning the logic behind it. Almost • Talk freely and not be embarrassed about
all adolescent girls expressed low confidence in menarche
burning menstrual absorbents for disposal. They felt
• Understand menstruation and the benefits of
embarrassed and humiliated over the restrictions.
menstrual hygiene
Around 73 percent adolescent girls were unaware of the
importance of washing menstrual cloth with soap and • Have the confidence to discuss and negotiate for
drying it in the sun to disinfect. menstrual hygiene products
These circumstances highlighted the need to improve • Improve hygienic management of their
knowledge around MHHM and disposal of menstrual menstruation
absorbents, and in turn improve the reproductive health
• Dispose the menstrual absorbent in an
of girls and women. Providing appropriate knowledge environment-friendly manner
and skills on MHHM to girls would act as a trigger for
them to talk freely and create a gateway to engage 2. FLWs and teachers to conduct interpersonal
about other women empowerment issues. communication and community mobilisation
91
sessions that promote understanding of menstrual • Paheli ki Saheli (Friends of Riddles) communication
hygiene and its management. package consisting of five short films, a storybook,
personal diary, apron (displaying the female
To achieve the above objectives, the following
reproductive organs to explain menstrual cycle),
strategies were adopted:
and posters. It provided information on: a) how
• Capacity development of FLWs, teachers, and to prepare for menstruation, b) Menstrual Health
adolescent girls and Hygiene Practices, and c) the effects of
menstruation on girls.
• Community dialogues to engage adolescent girls’
groups, mothers, fathers, and the community • Five Facts for Life (FFL) videos, which provided
information on key issues that affect mothers and
• Interpersonal communication with adolescent girls children, focused on addressing myths, gender
through field functionaries (identified by IDF at the issues, and a father’s role in MHHM.
block and village level for capacity development of
primary stakeholders) and FLWs • Kishoriyon se Baatcheet (talking with adolescent
girls) for FLWs to improve their interpersonal
• Advocacy with the government to sustain the communication skills with adolescent girls.
results of the programme
• A life skills module was used to improve decision
To build the capacity of adolescent girls and women and making, problem solving, and interpersonal
to improve interpersonal communication, the following relationships for adolescent girls.
communication materials were used by UNICEF:
Shama Parveen talking about how she convinced

her parents to build a toilet at home.
92
Action
Capacity development of field functionaries Capacity development of adolescent girls
IDF identified 90 field functionaries at the block UNICEF planned to reach out to at least 80 percent of
and village level. A block-level field functionary the adolescent girl’s population in 14 blocks of Vaishali
was chosen for each block, and a village-level field and Nalanda.
functionary was chosen for every 15-20 anganwadi
• Field functionaries trained adolescent girls
centres. They were responsible for capacity
at anganwadi centres through fortnightly or
development of stakeholders under the programme.
monthly meetings. They discussed the process
• UNICEF oriented field functionaries about of menstruation, preparedness for menstruation,
PYARHI, its scope, importance, and use of importance of hygiene, safe disposal of menstrual
communication material given to them. They absorbents, importance of nutritious food, myths and
were trained on MHHM during a 4-day residential misconceptions, and support required by adolescent
girls through videos. Paheli Ki Saheli storybook was
workshop. UNICEF also organised a four-day
read out and explained by the field functionaries,
residential training on life skills[9] for 28 field
which helped them facilitate the sessions.
functionaries from both districts. It helped them
Adolescent girls displayed a keenness to read the
develop critical and creative thinking, effective
story books as they were interesting, simple,
communication skills, negotiation skills, empathy,
and interactive.
coping mechanisms, and its applications in
everyday life. • Field functionaries facilitated sessions with
adolescent girls with the help of FFL videos. The
• Field functionaries identified all 3,267 anganwadi videos were entertaining and easy to comprehend.
centres and formed two adolescent girls’ groups Tabs helped the functionaries in spreading the
at each centre with the help of FLWs. Each group messages effectively, as they was easy to handle
had 25 girls so that field functionaries could and carry. They used an apron with the female
communicate with them effectively. Anganwadi reproductive organ drawn on it, from the Paheli
centres were the focal point of activities, where ki Saheli package, to explain the physiology of
all meetings were organised. menstruation.
A field functionary training adolescent girls at an Anganwadi

centre at one of the meetings.
93
• Two adolescent girls' groups of around 25 girls members and field functionaries. With
each were formed at every anganwadi centre to 1,836 anganwadi centres across the blocks of
facilitate effective communication. Meeting in small Vaishali and Nalanda, 3,673 adolescent girls'
groups has given girls an opportunity to get familiar groups were formed over the two years.
with each other and built a good rapport with the
Platform for adolescents to express

challenges faced by them.
94
• Field functionaries reached out to middle and high • With two peer educators in each adolescent girls’
schools to orient adolescent girls in large numbers. group, 7,344 peer educators were trained in total.
Initially, discussions revolved around the importance
Capacity development of FLWs and teachers
of nutritious food, Iron Folic Acid tablets, biological
changes, and female reproductive organs to ease A three-day residential training programme was
the girls into dialogue. Next, the field functionaries organised by UNICEF and the government in both
discussed the process of menstruation, importance districts to orient female teachers, one each from
of hygiene and proper use of napkins, and safe 32 schools[12].
disposal of the same. Trained school teachers
also supported field functionaries in organising the • The trainings were conducted through participatory
meeting. During the project period, a total of 33,844 activities using SBCC materials and mock sessions
adolescent girls were reached out to in 301 schools. to enhance their knowledge and skills on MHHM.
Trained school teachers were responsible for
Selection and training for Peer Educators conducting sessions with adolescent girls in their
respective schools.
Peer Educators, between the ages of 15 to 17, were
selected based on their education, willingness to • Field functionaries trained FLWs[13] from identified
participate and communicate with other girls about anganwadi centres on the skills for conducting
MHHM, and the ability to articulate clearly. They were effective and interactive meetings and providing
responsible for mobilising girls and interacting with their counselling on MHHM. Field functionaries were
peers on MHHM. supported by FLWs in conducting sessions in
• Two Peer Educators were selected in each anganwadi centres.
adolescent girls’ group. Apart from MHHM, field
Engagement with mothers and fathers
functionaries trained peer educators on five life
skills: a) self-awareness, b) creative thinking, c) • More than 36,000 mothers were sensitised on
effective communication, d) empathy, and e) coping menstruation and related issues during monthly
mechanisms. meetings, so that they could share it with their
• In addition to life skills, there were discussions on daughters. Functionaries encouraged mothers to
biological, emotional and psychological changes share first-hand experiences on how they dealt with
in adolescents, gender issues, and the difference their first menstrual cycle, and what support they felt
between sex and gender. The field functionaries they needed at that time. This exercise sensitised
used different training methods including role play them and made them empathise with the needs and
and games. expectations of their daughters.
School girls advocating menstrual hygiene.
95
• Field functionaries reached out to fathers session with fathers and explaining the importance
of adolescent girls to sensitise them about of nutritious food, safety, and dignity of their
menstruation. FFL[14] and Paheli ki Saheli[15] videos daughters during menstruation.
helped the field functionaries in facilitating the
Adolescent girls watching and

listening to FFL videos.
96
Community Dialogue Engagement with Government Officials
IDF organised video screenings for community UNICEF regularly shared the progress of PYARHI
engagement, which helped to build an enabling with the Education, Health, and Women and Child
environment for adolescent girls with no major Development[16] Departments.
challenges.
• UNICEF organised a state-level dissemination
workshop to share the experiences and learnings
• Paheli Ki Saheli and FFL videos talked about the
of PYARHI.
emotional support and safe environment required
for girls at the time of menstruation. • Representatives from the government line
departments, non-governmental organisations,
• Fathers, mothers, adolescent girls and boys, local adolescent girls, Peer Educators, FLWs, and field
leaders, self-help group members, and FLWs functionaries shared their experiences from PYARHI
participated in the meetings. and jointly reviewed the outcome of the programme.
A field facilitator showing

Paheli Ki Saheli videos to adolescent girls.
Results
Results of PYARHI are documented at the level of • 65% understand the importance of safe and
adolescent girls, mothers, FLWs, and field functionaries. environment-friendly disposal of
All stakeholders have improved knowledge on the menstrual absorbents
physiology of menstruation, MHHM, and disposal
b) Attitude and perception:
practices leading to better practices[17].
• More than 70% of 1,98,911 the girls that were
Adolescent Girls
reached freely talk about menarche. Adolescent
1,98,911 adolescent girls were trained on MHHM issues girls confidently discuss MHHM with their friends,
through PYARHI. Knowledge, attitudes, and practices sisters, and mothers.
related to menstruation have since improved among
• Around 47% adolescent girls now share their
adolescent girls[18].
issues with their mothers, and 62% of them even
a) Knowledge discuss issues with their friends.
Out of the 1,98,11 girls reached: • They are not embarrassed to follow hygienic
practices during menstruation, like drying the
• Around 80% can describe biological changes menstrual cloth in the sun or buying sanitary
which take place at the time of puberty napkins from shops.
• 78% are aware about the process of menstruation • Many girls experimented with restrictions such
and the importance of maintaining hygiene as eating pickles, touching vegetables, burning
97
menstrual absorbents, and entering the kitchen.
They found no correlations between menstruation
and these activities. Hence, they do not believe in
these restrictions anymore.
“I joined the adolescent girls group in our

village and got to know about the importance
of maintaining hygiene during menstruation.
However, we did not have a toilet at home and
had to go out in the open. I felt very embarrassed,
especially during menstruation. I told my parents
“Earlier we used to dig deep pits and dispose our about this, but they refused because of financial
sanitary napkins in it, or throw it somewhere far issues. I did not lose hope and tried to explain to
away from home. Now we collect and burn it at them again and again about my embarrassment
the end of our menstrual cycle. Some women in and about the need to maintain hygiene.
my neighbourhood still tell me that we shouldn’t
burn our menstrual absorbent because we will During the festival of Eid, I told my father not to buy
become infertile. But my cousin just conceived a gifts but to gift me a toilet. I convinced my siblings
baby despite burning her absorbents. So, I know and my mother not to buy new clothes on Eid. My
this is all just a myth.” father was finally convinced and built a toilet.”
Hani Kumari, 18 Shama Parveen, 17

Bhuj Patti, Vaishali District Narayanpur Buzurg, Vaishali District
c) Practices: Frontline Workers
• Girls now change the menstrual absorbent at least • FLWs talk freely about MHHM with girls as
twice a day. they understand it is critical for an adolescent
girl’s health. They address queries raised
• They wash the menstrual absorbent with soap or by adolescent girls such as the cause,
detergent, and dry it out in the sun. duration and management, dealing with
• 47% girls dig a pit to bury the menstrual cloth, and pain and discomfort, and cleanliness during
13% burn it to dispose it. menstruation.
Adolescent girls negotiate with their family members • They talk about nutrition, advise girls to
and ensure the construction of toilets at home to consume green vegetables, cook in copper
manage their menstruation. Around 46% girls now utensils, and consume iron tablets to avoid
have toilet facilities at their home while a bathroom is anaemia.
available for 36%.
98
“ASHA workers were able “Initially, I was one of the
to view menstruation in adolescent girls trained
a positive light through under the programme.
PYARHI. They have But later I joined as a field
improved knowledge functionary in Vaishali
about menstruation and district under PYARHI.
know how to communicate During our training,
effectively with adolescent UNICEF held discussions
with us about menstrual
girls. Menstrual hygiene
health. They dispelled all
knowledge among ASHA
our misconceptions regarding menstruation, and
workers has improved. Their confidence has also
gave examples for us to understand better.
improved, which helps them perform their job
better.” Menstruating girls in our village are asked not
to touch pickles because we were considered
Nibha Rani Sinha unclean during that time, so the pickle will spoil.
District Community Mobiliser, Vaishali District We need to question whether it's correct. Those
who manufacture the pickle cannot do so without
touching it and it is made mostly by women. The
Field functionaries manager does not come and ask all working
women whether they are menstruating or not
• Field functionaries were shy to work for
before they are allowed in the factory.”
menstruation-related issues in their village, but
now they are proud to be doing so. Chanda, 20
Field Functionary, Bairai,
• They are not ashamed to talk about menstruation
Vaishali District
with other girls. They communicate openly about
MHHM with them.
• They have experimented and dispelled all Mothers

misconception surrounding menstruation.
Mothers communicate with their daughters about
• Field functionaries follow improved menstrual menstruation to help them prepare for the onset
hygiene and menstrual absorbent of menarche and follow hygienic practices during
disposal practices. menstruation.
Personnel from IDF engaging with an

adolescent girls' group.
99
Adolescent girl explaining the physiology of menstruation.
As a result of the evidence emerging from PYARHI, socially vulnerable and marginalised communities.
the Education Department of Bihar has integrated Teachers and school wardens trained on Paheli Ki
MHHM as part of their curriculum in lower secondary Saheli communication package have been allocated
schools and Kasturba Gandhi Balika Vidyalayas across 38 districts of Bihar to implement the
(KGBV). KGBVs are residential schools for girls from programme.
100
In Summary
UNICEF, with the Government of India
and Integrated Development Foundation
(IDF), initiated a social and behavioural
change intervention called Promoting
Young Adolescents Reproductive
Health Initiative (PYARHI). It aimed
to improve Menstrual Health and
Hygiene Management (MHHM) among
adolescent girls. Here’s a blueprint of
how the intervention was rolled out in 14
blocks of Nalanda and Vaishali districts
of the Indian state of Bihar.
Action
Field functionaries were oriented

on the scope and importance of
PYARHI and given training on
MHHM. They developed critical
and creative thinking, effective
communication skills, negotiation
skills, empathy, coping, and its
application to everyday life.
Adolescent girls were trained

Peer educators were selected, by field functionaries about safe
and various stakeholders MHHM practices through the
were sensitised on MHHM. Paheli Ki Saheli storybook and
Community dialogue was FFL videos. They discussed
facilitated, and government matters such as process of
officials were constantly given menstruation, importance of
the progress of the invention. hygiene, proper use of napkin,
and its safe disposal.
101
Results
Adolescent girls are now aware

of the realities of menstruation, Frontline Health Workers
and discuss menarche freely. and field functionaries are now
They follow the right MHHM more confident to work on
practices without being menstruation-related matters
ashamed, and are recognising in villages and discuss MHHM
the myths and misconceptions practices with adolescent girls.
built around them.
Mothers communicate
with their daughters about
menstruation and prepare
them for the onset of
menarche and the hygienic
practices associated with it.
MHHM has been made a part of

the curriculum in Lower Secondary
schools and Kasturba Gandhi Balika
Vidyalayas (KGBV) by the Education
Department of Bihar. Trained on
the Paheli Ki Saheli communication
package, teachers and school
wardens have been allocated
across 38 districts of Bihar to further
implement the programme.
102
References
[1]
https://www.unicef.org/adolescence/
[2]
The (i) articulation, awareness, information and confidence to manage menstruation with
safety and dignity using safe hygienic materials together with (ii) adequate water and
agents and spaces for washing and bathing with soap and (iii) disposal of used menstrual
absorbents with privacy and dignity.
[3]
http://www.mdws.gov.in/sites/default/files/Menstrual%20Hygiene%20Management%20
-%20Guidelines.pdf
[4]
Accredited social health activists (ASHAs) is community health workers instituted by the
government of India's Ministry of Health and Family Welfare (MoHFW) as part of the
National Rural Health Mission (NRHM). They are local women trained to act as health
educators and promoters in their communities.
[5]
Anganwadi workers are responsible for anganwadi centres which is a type of rural mother
and child care centre in India. They were started by the Indian government in 1975 as
part of the Integrated Child Development Services program to combat child hunger and
malnutrition.
[6]
Auxiliary nurse midwife, commonly known as ANM, is a village-level female health worker
in India who is known as the first contact person between the community and the health
services.
[7]
The Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (RGSEAG) SABLA is
a centrally sponsored program of Government of India initiated on April 1, 2011 under
Ministry of Women and Child Development.
[8]
Given the time and resources available.
[9]
Kishorio se prabhavi Baat Cheet Ke Kaushal, develop skills to counsel their peers
[10]
80 percent of 4,02,821 girls in 75 percent villages of Nalanda and Vaishali districts
were planned to reach out as per time and resources available for the programme
implementation.
[11]
Meri Saheli Meri Maa, Mahwari Pe Khul Ke Charcha, Amma Ji Kahti hain, Pratiyogita and
Bapu.
[12]
Rolled out as a pilot component in the programme.
[13]
To As per available time and resources for programme implementation.
[14]
‘Bapu (Father)’ from FFL videos.
[15] ‘
Father becomes Friend’ video from Paheli ki Saheli.
[16]
Integrated Child Development Services (ICDS) is an programme which provides food,
preschool education, and primary healthcare to children under 6 years of age and their
mothers.
[17]
From Key Informant Interviews of primary stakeholders and programme documents.
[18]
Pre-post assessment results of PYARHI Particulars.
[19] ‘
Father becomes Friend’ video from Paheli ki Saheli.
103
8
Behaviour Change
Communication
through mobile
technology
Promoting IYCF practices among
caregivers in Tamil Nadu
Tamil Nadu (TN), India’s southernmost state, ranks 5th in the Inequality-adjusted Human Development Index
(IHDI)[1] in the country. The IHDI indicators show that the state’s performance in economic, educational, and
health areas puts it ahead on the Human Development Index. According to National Family Health Survey
- 4, the percentage of children under the age of six months who are exclusively breastfed in TN is 48.3%,
as compared to the national average of 54.9%. This is despite TN having the highest institutional delivery
rate in India, at 99%[2]. The large gap between institutional deliveries and breastfeeding practices led to the
conception of this initiative. To improve the Infant and Young Child Feeding (IYCF) practices, UNICEF ﹘ in
partnership with Integrated Child Development Services (ICDS), Government of Tamil Nadu ﹘ initiated a pilot
to improve adoption of IYCF practices using mobile phones for message communication. This was carried
out in two blocks in the districts of Salem and Villupuram, which were selected in consultation with the ICDS
department. The intervention included the following undertakings: phone messages to mothers, counseling
of mothers, capacity building of Frontline Workers (FLWs), and orientation of fathers. These messages
were customised for mothers receiving antenatal and postnatal care, with each message focusing on one
of the following ﹘ health, nutrition, and hygiene practices. As a result of this intervention, the Interpersonal
Communication (IPC) skills and knowledge levels of FLWs have improved. There is also an increase in
engagement between FLWs, mothers, and their family members. The ICDS department now has a pool
of resources trained in Social and Behaviour Change Communication (SBCC), which can be used in the
implementation of other interventions.
Theory of Change
Improved knowledge of IYCF Improved knowledge and
Improved knowledge IPC skills, pool of resource
practices, engagement, and
and practices persons available
communication with wives
Fathers and other Frontline Workers

Mothers
care givers
Counseling and
IYCF Messages Capacity Building of FLWs
Educational Services
Low rate of breastfeeding,

Limited communication
lack of knowledge about
skills, high workload of
optimal IYCF practices, limited
FLWs, inadequate focus on
communication between FLWs
IYCF practices by doctors
and mothers on IYCF practices
DEMAND SUPPLY
Salem
Villupuram
Tamil Nadu
Map not to scale

Situation
The Ministry of Health and Family Welfare (MoHFW) On the other hand, challenges from the supply point of
defines Infant and Young Child Feeding (IYCF) view are:
practices as “a set of recommendations to achieve • High workload on FLWs
appropriate feeding of newborns and children under • Limited IPC skills among FLWs
two years of age so that they achieve optimal nutrition • Generic and non-contextualised messages given by
outcomes in populations”. A study showed that the FLWs to the stakeholders
risk of an infant dying was 97% less among those • Inadequate focus on imparting IYCF practices to
children who were breastfed as compared to those who mothers by doctors
were not[3].
To help improve the adoption of IYCF practices,
In Tamil Nadu, challenges faced from the demand point UNICEF[5] partnered with ICDS, Government of Tamil
of view are: Nadu, and implemented a pilot that leverages mobile
• Low breastfeeding rate: Percentage of children under phone messages. This was an experimental initiative
the age of six months who are exclusively breastfed intended to examine and evaluate the feasibility, time,
in TN is 48.3% as compared to the national average cost, and possible loopholes of mobile phone-based
of 54.9%[4] messaging services for the desired SBCC ﹘ with focus
• Lack of knowledge among women about the on adoption of IYCF practices among caregivers and
importance of optimal IYCF care providers. A total of 24 messages in the vernacular
• Limited communication between FLWs and mothers language, Tamil, were sent every Friday to each of the
on IYCF practices like early initiation of breastfeeding five categories of stakeholders during this
and exclusive breastfeeding intervention period.
The objectives of this initiative were:
1. To enhance the adoption of IYCF practices

Method
among stakeholders through SMS by using
When designing this intervention, UNICEF, in
mobile phones as tools for behavioural change
consultation with ICDS, decided to use mobile phones
as a communication platform. As of April 2017, data
2. To provide immediate counseling services to from Telephone Regulatory Authority of India (TRAI)
the stakeholders and educate them on IYCF shows that there are a total of 1,174[6] million wireless
practices through video films phone subscribers in India, of which 43% are rural
subscribers. TN alone accounts for 8%[7] of the total
3. To improve the IPC skills of FLWs during house in India. Mobile phones have become an important
communication platform that help reach participants
visits and group meetings
residing in remote locations promptly. Because of the
widespread use of mobile phones and a high literacy
4. To extract recommendations from the learnings rate (Male ‒ 89%, Female ‒ 79%[8]) in TN, UNICEF
for the government to extrapolate as an decided to use mobile phones for the delivery of
innovative initiative for the ICDS programme IYCF messages.
The pilot undertook the following strategies:

The initiative was implemented from February to April
2017 in two blocks, namely Magudanchavadi in Salem IYCF messages through mobile phones: In the two
district and Marakkanam in Villupuram district. These intervention blocks, phone messages were delivered to:
two districts were selected based on the following
• Expectant mothers (for antenatal healthcare
factors: practices)[9]
• Low intake of Antenatal Care and Postnatal Care • Mothers in the postnatal phase
services
• Mothers of children aged 0-6 months
• High number of beneficiaries among all categories
(refer Table 1) • Mothers of children aged 6-12 months
• Mothers of children aged 12-24 months

• Maximum number of service providers on
board in these blocks at that point of time (36 in
1. Capacity development of FLWs: FLWs were
Magudanchavadi and 17 in Marakkanam) trained to build their IPC skills and aid the delivery
• Presence of UNICEF consultants to provide necessary of focused and contextualised IYCF messages to
the participants. Facts for Life (FFL) videos[10] and
hand-holding, support, and supervision
flip books were used for these trainings.
Groups No. of No. of Total
Beneficiaries Beneficiaries
2. Counseling and educational services: The
Marakkanam Magudanchavdi
(Villupuram) (Salem)
counseling and educational services conducted
imparted IYCF knowledge to mothers, and to
Antenatal 911 596
Mothers sensitised fathers and mothers-in-law. FFL videos
Pregnant were used by FLWs to further elucidate the IYCF
901 619
Mothers
messages to mothers receiving antenatal and
0-6 month
901 619 postnatal care.
old children
6-12 month
old children 1,103 574
1-2 year old

children 1,931 1,286
Total 5,747 3,694 9,441
Table 1
FLWs were trained to build their IPC skills and to
aid delivery of contextualized messages.
Action
FLWs from 209 sub-health centres were covered as Disturb (DND)[13] service. Discussions were held
part of this intervention. with the technical agency handling the phone
message dissemination to override DND and deliver
Training of FLWs: FLWs were trained on IPC and
the message.
the importance of behaviour change communication.
They were taught to conduct effective two-way • Illegible messages: 32%[12] of the beneficiaries
communication by using the GATHER[11] principle. received box images instead of text messages.
The training also focused on the usage and impact In such cases, FLWs first tried to readjust phone
of mobile phones for information dissemination for settings and correct the error. If the problem was still
behaviour change. Examples from other states, not resolved, they visited these households, showed
where mobile phones were used as a platform for them the messages, and discussed the content.
behaviour change, were shared and discussed
• Male ownership of mobile devices: Mobile phones
with trainees.
in the house were primarily owned by male
Messages to mothers and follow up counseling by members, who carried it to their workplaces.
FLWs: A total of 9,441 mothers[12] across both blocks Further, those working in towns returned home
were covered in this pilot. The phone messages were only once a week. The probability of them sharing
contextualised and specific to the life cycle stage of the these messages with their wives was uncertain and
recipient. For example, expectant mothers were sent rendered the messages useless. To address this, it
messages on the consumption of nutritious food on a was decided that:
daily basis.
- FLWs would visit 10 such households every day
During the intervention, the team came across a few to educate and counsel the mothers on the
challenges that blocked the effective delivery of text message of the week.
message-based communication. Listed below are the
- Fathers would be oriented on the importance of
challenges, and the solutions provided for the same.
IYCF practices for a mother and child, and the
• Non-receipt of messages: 440[12] stakeholders did not father’s role in ensuring they are appropriately
receive messages as they had activated the Do Not cared for.
Each FLW visited 10 households a day to
educate and counsel mothers on
IYCF practices.
Orientation of fathers: Fathers were informed of the at the end of the session they were asked for written
phone messages and the importance for them to read, feedback. The feedback showed that all fathers[15] found
understand, share, and discuss the messages with these messages useful in understanding IYCF, and said
their spouses. A total of 113 fathers[14] participated, and it helped them take due care of their wives.
Results
[16]
Interaction with male members to orient them about

the programme and importance of phone messages for
The results from the pilot initiative can be seen across their wives.
four stakeholders:
Frontline Health Workers
• The IPC skills of FLWs improved, and they now

engage participants in dialogue, listen to and
counsel mothers and their families.
• Capacity building activities have helped increase

knowledge about IYCF practices.
• FLWs now deliver customised communication

messages to mothers. Earlier, FLWs would
communicate messages to mothers without
focusing on their life stage, whereas now they • A few of the mothers also reported that they
deliver contextual and relevant messages. The felt assured, as the government was giving due
FFL videos have helped them remember the right importance to their healthcare by sending them
message for the right audience. personalised messages.
• This intervention has helped enhance the Fathers

self-confidence of FLWs in conducting health • They now have knowledge about IYCF practices
and nutrition counseling for stakeholders. like colostrum feeding and share it with other
caregivers in the family.
“When I meet pregnant mothers • Husbands have become more involved as fathers
now, I counsel them on not just and have started to tend to their wives’ healthcare
regular hospital visits but also on needs during and post pregnancy. Mothers reported
that their husbands accompany them during
consumption of nutritious meals on a hospital visits and ensure consumption of nutritious,
regular basis.” wholesome meals.
ICDS
S Gowri, FLW from Magudanchavdi
• Owing to improvement in the IPC skills and
knowledge about IYCF practices in FLWs, a
Examples recalled and shared by FLWs of resource pool well-versed in SBCC has been
Marakkanam block are timings, amount, and duration of created in the ICDS department. This resource
breastfeeding. A majority of the mothers were also able pool can be employed for other ICDS programmes
to recall the messages they had received. as well.
Mothers • Social mobilisation abilities of FLWs have also

improved.
• Knowledge of the mothers on IYCF-related
practices have improved. Few themes the mothers • As a result of this intervention, demand for services
are informed about include: importance of iron and from participants in the intervention blocks has
folic acid tablets, importance of colostrum, feeding- increased[17].
position, time and method, foremilk and hindmilk,
and breastfeeding during sickness.
• The messages also served as a reminder for

mothers to follow up on their health checkups.
A group of FLWs interacting with their
supervisor.
FLWs participating in a programme to
share their experience and feedback.
“IPC is a strong component of nutrition counseling for Caselet 2
reducing malnutrition in the state. Further, through
this initiative, the department has realised that men P. Shanti of Magudanchavadi
should also be part of interventions aimed at bringing block, Salem district, was six
behaviour and attitude change. The department has months pregnant when her
shared the initiative and results of the intervention with husband started receiving the
the state cabinet members, and there are ongoing phone messages. Her husband
discussions about scaling up this initiative in a phased showed her the messages, soon
manner in other blocks of the state.” after which an FLW visited and counseled her
-Ms. J M Yamuna Rani, Deputy Director, and her family members. She feels that as a
ICDS Department, Tamil Nadu result of these messages, her husband started
buying fruits for her, ensured that she got ample
Caselet 1
sleep everyday, and tried to help her with day-
S. Gowri has been an FLW to-day household chores. This helped her stay
for the last 10 years in healthy and happy during her pregnancy.
Magudanchavadi block, Salem
district. In all her years of
FLWs
work, she believed that it was her role to provide
“Previously, young pregnant women were afraid
information and the mother's was to listen to her
of delivery and the accompanying pain. After our
advice. After undergoing training under UNICEF's
counseling, they are mentally prepared for it and do
intervention, she started to use the GATHER
not fear the childbirth process. Similarly, mothers would
principle in her interactions. As a result, she
give jaggery water to infants but they are now aware of
listens attentively to the mothers, other family
exclusive breastfeeding and its importance, and have
members, and only then offers counseling. She
thus stopped this practice.”
feels this intervention has helped her deliver
-S. Sumati, Marakkanam block, Villupuram district, TN
services efficiently, perform her role better, and
engage more effectively with the community.
In Summary
UNICEF, in partnership with Integrated Child
Development Services (ICDS), Government
of Tamil Nadu, initiated a pilot to improve
adoption of IYCF practices using mobile
phones for message communication. Here’s
a blueprint of how the intervention was rolled
out in two blocks, in the districts of Salem
and Villupuram, which were selected in
consultation with the ICDS department.
Action
FLWs from 209 sub-health centers 9,441 mothers received

were trained on behaviour change contextualised information
communication. They were taught specific to their pregnancy stage.
to disseminate information via They were visited by FLWs,
mobile phones, apart from other who counseled them on the
capacity building initiatives. messages they received.
Fathers were oriented on the

importance of the messages
received on their phones.
They were encouraged to
be more participative in their
child’s care.
Results
FLWs have enhanced Mothers feel assured that the

communication skills. They government is invested in their
are now able to effectively healthcare. There has been
engage and counsel mothers an increased uptake of IYCF
and fathers on IYCF practices. practices since the intervention.
Fathers have become more

involved, and actively tend
to the pregnancy needs of
their wives.
Capacity building of FLWs

has resulted in the formation
of a pool of resources in the
ICDS department who are
well versed in SBCC.
References
[1]
http://www.undp.org/content/dam/india/docs/inequality_adjusted_human_development_index_for_indias_state1.pdf
The IHDI combines a country’s average achievements in health, education and income with how those achievements are distributed
among country’s population by “discounting” each dimension’s average value according to its level of inequality. Thus, the IHDI is
distribution-sensitive average level of human development.
[2]
National Family Health Survey-4 (2015-2016)
[3]
Nomita Chandhiok, Lucky Singh, Kh. Jitenkumar Singh, Damodar Sahu, Arvind Pandey, ‘Does Breastfeeding Have an Effect
on Infant Mortality in India? An Analysis of National Family Health Survey Data’, September 2015 (http://file.scirp.org/pdf/
OJPM_2015091611264436.pdf)
[4]
Source: NFHS-4
[5]
Within UNICEF, Communication for Development and Health units worked together on this initiative.
[6]
http://www.trai.gov.in/sites/default/files/PR_No_43_Eng_13_06_2017.pdf
[7]
V-1-Less vulnerable, V-2-Moderately vulnerable, V-3-High vulnerable and V-4-Extremely vulnerable.
[8]
Source: National Family Health Survey-4
[9]
Though IYCF focuses on postnatal mothers and infants, based on data and field experience, UNICEF felt it important to include
pregnant mothers. Proper maternal health and nutrition, as well as quality of care at delivery and during the newborn period can
help to to address health problems like low birth weight, birth defects, etc.
[10]
The list of Ammaji video films used is: AN & PN care, exclusive breastfeeding, early initiation and colostrum feeding, growth
monitoring, nutrition and care for girl child, diarrhoea-causes & prevention, diarrhoea-home based management and handwashing
with soap.
[11]
GATHER stands for the following six activities: Greet, Ask, Tell, Help in the decision-making, Explain, Return. An FLW is expected to
do in each of her interaction.
[12]
Source: Programme monitoring data
[13]
https://www.google.com/url?q=https://en.wikipedia.org/wiki/Do_Not_Disturb_
[14]
Source: Internal UNICEF report on the intervention.
[15]
Of the 113 respondents, only 86 who could read and write undertook the feedback.
[16]
These results are based on interaction with ICDS, UNICEF, FLWs and participants (mother and fathers)
[17]
This is anecdotal and based on interaction with government functionaries in ICDS department.
Registry&sa=D&ust=1508313389786000&usg=AFQjCNE98ZAMEvlYUxsw2kXRNx8FfIRODA
[18]
This includes traditional healers, traditional leaders and members of the self governing bodies.
[19]
Based on key informant interviews with stakeholders and programme documents.
[20]
The Ministry of Rural Development, a branch of the Government of India, is entrusted with the task of accelerating the socio-
economic development of rural India. Its focus is on health, education, drinking water, housing and roads.
[21]
[22]
[23]
Based on key informat interview with Odisha UNICEF C4D state representative and programme document.
[24]
NRHM is an initiative undertaken by the government of India to address the health needs of underserved rural areas.
[25]
Integrated Child Development Services (ICDS) is an programme which provides food, preschool education, and primary healthcare
to children under 6 years of age and their mothers.
[26]
Sarva Shiksha Abhiyan (Education for All Movement), or SSA, is an Indian Government programme aimed at the universalisation of
elementary education "in a time bound manner", as mandated by the 86th Amendment to the Constitution of India making free and
compulsory education to children between the ages of 6 to 14, a fundamental right.
9
Mamta Abhiyaan
Sneha, Suraksha, Samman
Improving maternal, child, and
adolescent health through
SBCC in Madhya Pradesh
Globally, about 800[1] mothers die every day of preventable causes related to pregnancy and childbirth ﹘ of
which India alone accounts for 20%[1]. The state of Madhya Pradesh (MP) has the highest Maternal Mortality
Ratio (MMR) at 2,212 per 1,00,000 live births. The Infant Mortality Rate (IMR) is 51[2] ﹘ 24 percent higher than
the national figure. The Department of Public Health and Family Welfare (DoPHFW), in partnership with UNICEF,
launched the Mamta Abhiyaan in 2013. The objective of Mamta Abhiyaan was to strengthen the Information,
Education, and Communication (IEC) Bureau of the Government of Madhya Pradesh (GoMP). This was to
promote 12 gateway behaviours, and mobilise elected representatives, health officials, community leaders, and
family members to prioritise and value maternal and child health. The initiative was designed and developed
following extensive consultations with DoPHFW, and GoMP at the state, district, block, and village level. A robust
evidence generation exercise was conducted to design the Mamta Abhiyaan with a wide range of stakeholders,
and was rolled out across all the 51 districts in the state. Capacity building and monitoring frameworks were
developed to enhance effective execution of the campaign. One of the media innovations launched as a part
of Mamta Abhiyaan was the Mamta Rath (van), a key vehicle of communication. It was a unique combination
of outreach media and mass media products, social mobilisation, group counselling, referral services, and
distribution of medicines and supplements. 313 such vehicles toured an equal number of blocks across 51
districts in the state. Approximately 1.3 million USD was leveraged from the government to provide Reproductive,
Maternal, Newborn, Child, and Adolescent Health (RMNCH+A) services in 52,000 villages. The success of
the Mamta Abhiyaan has highlighted the importance of SBCC for the effective delivery of RMNCH+A services.
GoMP also recognised the need for a health education cadre, and has filled various positions at the district and
block level by re-allocating human resources within the bureau. The IEC bureau was restructured as Social and
Behaviour Change (SBC) cell through an official order by GoMP dated 5th June, 2014.
Theory of Change
HEALTH SYSTEM
STRENGTHENING
Mamta Rath
Restructuring of IEC Improved performance of Creation of resource pool

Bureau to fill the vacancies RMNCH+A indicators trained in SBCC
Progressive increase in
Evidence-based decision allocation for SBCC rather
Creation of SBCC cell
making as a practice is than IEC in successive
within the IEC Bureau
adopted by DoPHFW Programme Implementation
Plans (PIPs) 2014 onwards
Roll out of Mamta Abhiyaan which includes the capacity development,

communication package development, Mamta Rath design and roll-out
Consultation with state Formative Research to

Desk Review: Identification
government and senior identify communities' beliefs,
of 12 Gateway Behaviours
DoPHFW officials knowledge and practices
Communication capactiy Media Environment Study to

understand the communication
assessment and development of
infrastructure and reach of
Capacity Development Framework different mediums across the state
Mamta Abhiyaan – An evidence based approach to improve the perfomance

of 12 RMNCH+A indicators by using a multi-dimensional communication
focused campaign
Poor performance of state on Communication capacities of

Inadequately staffed
critical health indicators like IMR health department officials in
IEC department
and MMR IEC Bureau are limited
Ad hoc activity-based communication Need to identify a platform

strategy ofIEC Bureau of Department to reach and communicate
of Public Health and Welfare with people at scale
(DoPHFW) department
Situation Area of
The state of Madhya Pradesh (MP), with a score of Intervention
0.451[3], ranks low on the Human Development Index
(HDI). It has the highest Maternal Mortality Ratio
(MMR) ﹘ 221[4] ﹘ which is 32 percent higher than the
national figure. The infant mortality rate (IMR) for MP is
also high at 51[5] ﹘ 24 percent higher than the national
figure. Inadequate infrastructure and a low number of
skilled health staff add to the supply-side challenges in
the health system in MP. On the other hand, demand
for health services is also low; caste disparities, gender
norms, education, and economic inequity influence the
demand and uptake of health services in rural areas[6].
The state has an IEC bureau, a nodal unit which is
responsible for planning, implementing, and overseeing
Madhya Pradesh
Map not to scale

the IEC activities under the supervision of DoPHFW. It
had large number of staff vacancies ﹘ 40 percent to
80 percent at block and district level respectively[7] ﹘
and was struggling to provide quality communication Intervention State
support. It followed an activity-based approach and This map does not reflect a position by UNICEF on the legal status
lacked an evidence-based communication strategy to of any country or territory or the delimitation of any frontiers.
promote NHM outcomes. GoMP recognised the need
to adopt a robust and comprehensive communication
strategy to deliver quality healthcare services at scale. to improve demand for health services, with a special
UNICEF, in collaboration with DoPHFW and GoMP, focus on the 12 RMNCH+A behaviours. It included
launched Mamta Abhiyaan in 2013 with a focus to large-scale capacity building plans to equip the health
develop and implement a comprehensive Social and staff with SBCC skills to effectively implement the
Behaviour Change Communication (SBCC) strategy. campaign. A multimedia innovation in the form of
This strategy pushed for collaborated efforts to reach Mamta Rath was rolled out to cover all villages across
families, communities, and health service providers 51 districts.
The launch of the Mamta Abhiyaan with

Honourable Chief Minister Shivraj Singh Chouhan
and UNICEF ambassador Madhuri Dixit.
Madhuri Dixit addressing
the audience at the launch
of Mamta Abhiyaan.
Method
1. Consultations with Key Stakeholders 2. Evidence Generation
As a first step, UNICEF conducted three This was done for the development of a communication
iterative rounds of consultations with key officials strategy that included desk review, formative research,
media environment assessment, and communication
from DoPHFW, MP. These discussions were
capacity assessment.
conducted to:
• Help identify key issues, barriers, and • Desk review: National Health Mission (NHM) lists
enablers to achieve better health outcomes 50+ behaviours that should be practiced across the
in MP RMNCH+A life stages. UNICEF, in consultation with
the DoPHFW through a desk research, identified 12
• Update and discuss findings from the formative gateway behaviours[8] spread across the five life
research, communication capacity gap stages[9]. Gateway behaviours are ones which, when
assessment, and media environment assessment adopted, lead to positive outcomes on other
carried out by UNICEF behaviours. For example, better reproductive health
behaviour improves maternal health outcomes, thus
• Gather feedback on the communication strategy preventing maternal deaths and promoting the birth of
being designed healthier babies.
12 Gateway Behaviours
Maternal health:
• Early registration and complete
Reproductive health: follow-through of Antenatal Care (ANC)
• Use of 100 IFA tablets during pregnancy
• Use of contraceptive and
birth interval methods • Identification of high-risk pregnancies and
immediate provision of healthcare
• Safe medical termination of pregnancy
Newborn health:
Child health: • Increasing institutional deliveries through

Janani Express Yojana, and encouraging
• Encouraging Routine complete Postnatal Care (PNC) within 48
Immunisation (RI) hours of delivery
• Use of ORS for diarrhoea • Feeding colostrum, early initiation of
management breast milk, and exclusive breastfeeding
• Correct newborn care practices including
cord, thermal, and kangaroo care
Adolescent health:
• Delaying the age of marriage and
childbirth
• Encouraging regular uptake of
IFA tablets
• Formative research: Following the desk review, a This led to the formulation of an overall communication
formative research was carried out to understand framework, including a media plan for Mamta Abhiyaan.
the communities' knowledge, beliefs, and practices The media plan detailed out the multimedia message
around the gateway behaviours. It also aimed content, frequency of messages, communication
to realise barriers and enablers that influenced medium, timeline, and the cost of media plan.
the adoption of these behaviours. The barriers to
• Communication capacity assessment: Capacity
healthcare identified were:
assessment exercises were conducted with the health
At individual level: Inadequate knowledge about communication staff from DoPHFW. The findings from
healthcare practices this study brought out deficiencies in communication
skills and capacities among the health officials across
At family level: Adequate knowledge at the
different levels (district, block, village). A capacity
individual level, but lack of family support in health-
building framework for SBCC was developed based on
seeking behaviours
the findings of this assessment. The framework
At community level: Adequate knowledge at the identified the following key elements for an effective
individual, family, and community level, but lack of capacity building initiative:
health-seeking behaviours in the community norms
• Customised competency-based training[11] for the
At system level: Adequate knowledge at the health staff
individual, family, and community level but lack or • Identification of change agents called ‘role models’[12] at
unavailability of good quality services the block level
• Study of media environment in the state: A research
• Restructuring of IEC bureau to develop ownership
on the media environment in the state was carried
towards SBCC programmes within the cell
out, which studied the availability of communication
-related assets[10], media consumption patterns for • Building commitment to performance within the health
newspapers, radio, and mobile, and most effective department, thereby developing a dynamic and new
channels of communication for the intended audience. organisational culture
A mother with her infant for a weekly

check-up at the Aganwadi clinic.
FLWs were trained on SBCC
and IPC skills.
3. Communication Strategy Design 4. Advocacy with the Highest Level of Bureaucracy

Based on its evidences and research findings, the and Political Leadership
strategic communication approach of ‘Sneha-Suraksha-
This resulted in active leadership of the Hon. Chief
Samman’ (Care-Protection-Respect) was developed as
Minister and Hon. Health Minister, along with the
part of Mamta Abhiyaan. This strategy addressed three
Principal Secretary, DoPHFW, and Mission Director,
key audiences:
NHM, right from the campaign’s inception to its roll
• Family and community members who should out. At the request of the Hon. Chief Minister, the
provide Sneha (Care) to the mothers communication strategy was also presented to all
elected representatives of the Madhya Pradesh
• Community leaders and elected representatives
Assembly. With good communication and relevant
who should provide Suraksha (Protection) to the
advocacy, a celebrity was roped in as UNICEF’s brand
mothers
ambassador for the campaign.
• All health services providers, from Frontline
In 2014, DoPHFW and UNICEF jointly conducted
Workers (FLWs) to doctors and nurses, who should
three meetings with the Health and IEC staff from all
treat mothers with Samman (Respect)
51 districts and blocks to orient them about a) Mamta
Communication including the theme and logo was Abhiyaan, b) their roles and responsibilities in rolling it
developed, and existing communication materials were out, c) capacity building and monitoring of framework, d)
repurposed as part of Mamta Abhiyaan. Mamta Rath Mamta Rath, e) the development of a communication
(van), an innovative mobile communication vehicle, was plan to be integrated in the Programme Implementation
developed as part of this initiative. It was designed to Plan (PIP).
mobilise FLWs, interact with and counsel the community,
and provide health service and referrals.
An ASHA worker engaging
community members.
Action
Restructuring the State Health IEC Bureau: Mamta Abhiyaan: It was the core strategy launched
The GoMP restructured the IEC bureau under the with an objective to:
Ministry of Health and Family Welfare (MoHFW)
● Promote the 12 gateway behaviours
and created four verticals ﹘ research and planning,
capacity building, mass media and publicity, and ● Strengthen the SBCC strategy and activities
evidence generation (monitoring & evaluation). A
departmental promotion committee meeting was ● Mobilise the elected representatives to prioritise
conducted to fill the health-educator vacancies at the maternal and child health issues in their
district and block level. 41 out of the total 51 vacant electoral constituencies
Media Education and Information Officer (MEIO) posts
Mamta Rath: A key component of the Mamta Abhiyaan
were filled at the district level, and 139 out of 313
was the Mamta Rath ﹘ a vehicle to promote behaviour
block extension educators were filled at the
change in the community. It was an audio-visual van
block level.
that disseminated information on RMNCH+A, and
Capacity building: Based on the capacity assessment followed the strategic approach of the campaign ﹘
framework developed, capacity building of different Sneha-Suraksha-Samman. The Mamta Rath served
officials was undertaken by UNICEF. These trainings as a platform to provide consultation, counseling
were done in an iterative manner across the state. services, referrals, and health-related entitlements to
Across the 313 blocks, a total of 1,878 health women, children, and adolescents. It had the following
functionaries were trained on different communication communication tools on it:
aspects based on their role and the communication plan.
Posters: 12 poster
of the gateway
behaviours were
placed on the exterior
of the van
Television spots: 12 television

spots on the gateway behaviours
were played on the Mamta Rath.
Mamta Geet: An These television spots were
anthem saluting the intertwined with messages from
mothers of the state the Hon. Chief Minister Shivraj
Singh Chouhan, and UNICEF
ambassador, Madhuri Dixit
Mamta Videos: Thirty five

20-minute-long Mamta videos on
Mamta corner: This
the 12 behaviours were available
component provided 11
on the vehicle. The Rath facilitator
essential drugs for clients
would select one of the life-
in need
saving behaviours and play the
corresponding video
The media environment study conducted earlier was child health, was brought in to enhance visibility and
used to design the above-mentioned components of the acceptance of the intervention among the people of
communication package. The study helped understand the state.
the reach, penetration, and audience of the different
A detailed action plan was developed for effective
media platforms across the different geographic regions
implementation of the campaign, focusing on roles
of the state.
and responsibilities of each health functionary
The vehicles covered 52,000 villages across 51 districts across levels for every activity. For Mamta Rath,
on a bi-monthly basis. At each village, the vehicle capacity development trainings focusing on Planning-
displayed television commercials and educational Implementation-Evaluation (P-I-E) was conducted for
videos, played the Mamta anthem, and conducted a the officials[15].
discussion with the group through a facilitator. In these
Monitoring and Action: A robust monitoring framework
discussions, the messages in various IEC materials
was established to review progress on a concurrent
were discussed with reference to the local context. It
basis. The monitoring plan looked at quantifiable
was a platform for counseling, distribution of IFA tablets,
indicators which were defined for all levels (state,
ORS sachets, sanitary napkins, and conducting referral
district, and block) and classified into process,
to health services. Frontline Health Workers (FLWs)
performance, and outcome measures. Regular
called ASHA were given the responsibility of mobilising
monitoring and review of the Mamta Abhiyaan was
mothers, caregivers, and community givers on the day
undertaken at the block, district, and state level by
of the visit and delivering information about the Rath’s
DoPHFW. Different health programmes at the state
scheduled visit to the village.
level maintained nine[14] online databases with live
dashboards to track the programmes’ target, reach, and
A nurse in the Gram Arogya Kendre other elements. Data from these was used to analyse
established within Anganwadi in each village. the progress and take evidence-based action for course
improvement and correction. Similar reviews were also
carried out at the district and block level on a regular
basis. In addition to these reviews, monitoring visits
were carried out by different health functionaries[15]
of DoPHFW, MP to verify the quality and reach of the
programme. This exercise helped the department
document progress of the initiative, which acted as
evidence and helped add validity to the implementation
carried out by the DoPHFW staff and officials.
Gram Arogya Kendra (GAK): Under the campaign,

GAKs were established within anganwadi[13] centres in
each village of MP. These GAKs dispensed 17 essential
medicines which were distributed by FHVs to the
community members in time of need.
UNICEF facilitated a presentation in the State Assembly

to inform and sensitise elected representatives about
the Mamta Abhiyaan’s strategy. Their role of Suraksha
Anganwadi workers played a key
(protection) to the children, daughters, and mothers role in effective implementation of
in their constituencies was highlighted. Madhuri Mamta Abhiyaan.
Dixit, UNICEF’s brand ambassador for maternal and
Mamta Abhiyan leveraged many innovative
tools to highlight better health practices.
Results
• ‘Mamta Abhiyaan ﹘ Sneha, Suraksha, and The success of the Mamta Abhiyaan has
Samman’ was selected in the prestigious global highlighted the importance of the Health
conference organised by American Public Health Education cadre, and the GoMP managed to fill
Association (APHA), and a paper on the same the vacant positions of Block Extension Educator
was presented in 2016. (BEE) and MEIOs in all the 313 blocks and 51
districts respectively. This was achieved through
• Mamta Rath, the innovative media initiative, was
Departmental Promotion Committee (DPC)
identified and recognised by the Government of
meetings and reorganisation of human resources
India (GoI). It was documented as an innovation
within the bureau.
in the coffee table book launched by the Hon.
Health Minister of India, Shri J P Nadda. Indicators of the progress made in maternal and child
health service delivery are:
• GoI recognised MP as being the best state to
implement Mission Indradhanush (MI) as well as • Immunisation of 219,859 children who were
the Intensified Mission Indradhanush campaign dropouts from previous immunisation drives
(IMI), a special purpose vehicle of GoI to ensure
full immunisation of all pregnant womenand • Registration[16] of 15,825 newborns
children up to two years of age. Immunisation
• Immunisation of 86,171 pregnant women
targets one of the critical health indicators related
to infants in the overall RMNCH+A life cycle. • Distribution of Oral Rehydration Solution (ORS)
packets and Zinc tablets among 92,398 children
• The government considered Health Education
Officers to be a dying cadre and, as a result, • Leveraging 1.3 million USD from the government
there were very high vacancies in this sector. to provide RMNCH+A services in 52,000 villages
Adolescents were given information about
importance of IFA tablets and motivated for
regular IFA tablet consumption practice.
Health System Strengthening Enhanced SBCC capacities
Through structural changes, the initiative has led to DoPHFW now has a pool of master trainers in the
strengthening of the state IEC bureau as a Social SBC cell trained on the use of SBCC, who could act as
and Behavioural Change cell in the state. GoMP internal resource persons for training other officials on
has, through an official order dated 5th June 2014, SBCC. A resource pool of 293 health educators from 51
constituted an SBC cell under the supervision of districts has been created to facilitate SBCC trainings
DoPHFW. The state has managed to create a structure focused on IPC and social mobilisation. 318,461 USD
right from the state to the village level to effectively roll was mobilised from the DoPHFW to roll out a bridge
out any communication strategy. The objectives of the training programme for 46,787 frontline workers in 14
SBC cell are: IMI districts. The DoPHFW effectively coordinated a
total of 1,337 batches of field training across the 14
• To accelerate result achievement of RMNCH+A districts.
goals in NHM using SBCC strategies
Communication plan for actions integrated in PIPs
• To bring positive change in maternal and child
health practices using mass media and traditional There has been progressive increase in allocation
mediums of SBCC rather than IEC in successive Programme
Implementation Plans (PIPs) since 2014, especially
• Capacity building of district and block-level staff in terms of reduction in mass media allocation and
officials on the use of SBCC strategy for effective increase in mid-media and IPC interventions.
delivery of healthcare services that will lead to
improvement in RMNCH+A indicators
Caselet 1
Communication strategy
The success of the campaign in MP showcases the Bhupendra Singh Pawar is the Block
potential of DoPHFW in terms of strong processes to Community Mobiliser (BCM) of Aron block,
develop an evidence-based communication strategy for Guna district, MP. As part of the Mamta
better RMNCH+A outcomes. Apart from development of Abhiyaan he attended trainings on gateway
the strategy, 1.3 million USD was mobilised from GoMP behaviours, SBCC, and Mamta Rath. He says,
for effective roll out across 52,000 villages.
“The trainings have been very useful for me
as a BCM. Through the trainings, I have learnt
new and innovative methods to mobilise the
community and increase demand for health
services. I now know who my actual audience is
and how I should communicate with them to get
their attention. The campaign motivated me to
work for mothers and children in my community.”
Bhupendra has selected 30 GAKs out of a
total of 133 in his block to do focused work and
improve maternal and child health indicators.
The Mamta Rath – a key component

of the Mamta Abhiyaan programme.
In Summary
DoPHFW and GoMP, in partnership with
UNICEF, launched the Mamta Abhiyaan
in 2013. The objective was to strengthen
the Information, Education, and
Communication (IEC) bureau of GoMP,
promote 12 gateway behaviours, and
mobilise stakeholders to prioritise and
value maternal and child health. Here’s
a blueprint of how the intervention was
rolled out in all 51 districts in Madhya
Pradesh.
Action
Health functionaries were

capacitated on different
GoMP restructured the communication aspects
IEC bureau under the based on their role and
MoHFW, and a departmental the communication plan.
promotion committee meeting For officials, the capacity
was conducted to fill the building focused on
health-educator vacancies at Planning-Implementation-
the district and block level. Evaluation (P-I-E).
DoPHFW undertook Mamta Rath ﹘ an audio-visual

GAKs were established
regular monitoring van ﹘ was introduced to
within anganwadi centres.
and review of Mamta promote behaviour change in
They dispensed 17
Abhiyaan to document the community. It disseminated
essential medicines, which
the progress of the information on RMNCH+A
FLWs distributed to the
initiative add validity to through posters, TV spots, and
community when needed.
its implementation. videos among other methods.
A paper on ‘Mamta Mamta Rath was
Abhiyaan ﹘ Sneha, documented as an
Suraksha, and Samman’ innovation in the coffee
was presented at the global table book launched by
conference organised by the Hon. Health Minister
Results
the American Public Health of India, Shri J P Nadda.

Association (APHA).
There’s now better GoI recognised MP as being

knowledge of the importance the best state to implement
of a Health Education cadre, MI as well as IMI, a special
and GoMP has managed to purpose vehicle of GoI to
fill the vacant positions of ensure full immunisation of all
BEE and MEIOs. pregnant women, and children
up to two years of age.
The success of Mamta

Through structural changes,
Abhiyaan in MP reveals the
the initiative has led to
potential of DoPHFW to
strengthening of the state IEC
develop an evidence-based
bureau as an SBC cell. There
communication strategy for
now exists a structure, right
better RMNCH+A outcomes.
from the state to the village
The 1.3 million USD mobilised
level, to effectively roll out
from GoMP enabled effective
any communication strategy.
roll out across 52,000 villages.
DoPHFW now has a pool of

There is now an increased master trainers in the SBC cell
allocation of SBCC as trained on the use of SBCC,
opposed to IEC in successive capable of training other officials
PIPs since 2014, especially in on the same. 293 health
terms of reducing mass media educators from 51 districts form
allocation and increasing mid- a resource pool, and facilitate
media and IPC interventions. IPC and social mobilisation-
focused SBCC training.
References
[1]
http://UNICEF.in/Whatwedo/1/Maternal-Health
[2]
National Family Health Survey-4, measured in 1,000 live births.
[3]
http://www.undp.org/content/dam/india/docs/inequality_adjusted_human_development_
index_for_indias_state1.pdf
[4]
SRS 2011-2013, measures in 1,00,000 live births.
[5]
National Family Health Survey-4, measured in 1,000 live births.
[6]
https://equityhealthj.biomedcentral.com/track/pdf/10.1186/1475-9276-10-
59?site=equityhealthj.biomedcentral.com
[7]
UNICEF report.
[8]
Gateway behaviours are key behaviour in a life stage which, if addressed, would have a
positive outcome on the subsequent events in the same and following life stage.
[9]
The five life stages are reproductive, maternal, newborn, child and adolescence.
[10]
Example: television, Radio/Transistor, Telephone/Mobile and Internet.
[11]
The competency trainings would focus on the following three aspects: technical, managerial
and communication skills of health staff.
[12]
As per the study, the audience needs to be given examples – they need to know about the
benefits of adopting the behaviours as well as the negative consequences of not adopting
or discontinuing the behaviours. They need to meet or see role models to understand how
the behaviours change has worked.
[13]
Anganwadi is a mother and child care center in every village in India. They were started by
the Indian government in 1975 as part of the Integrated Child Development Services
programme to combat child hunger and malnutrition.
[14]
The 9 databases are Health Management Information System (HMIS), Human Resource
Management & Information System (HRMIS), EqMIS, Mother and Child Tracking System
(MCTS), Janani Shishu Suraksha Karyakram (JSSK), Nikshay, Financial Management
Information System (FMIS), ASHA software, e-Aushdhi
[15]
This includes health staff from DoPHFW, specifically; Block programme managers (BPM),
Block community mobiliser (BCM), Block Extension Educator (BEE) District programme
managers (DPM), District Media Education and information officer (DMEIO) and Deputy
DMEIO.
[16]
Most of these were home-based delivery and children not registered in the Mother and
Child Tracking System (MCTS).
10
Supportive Supervision
to Improve Demand for
RMNCH+A Services in
North Karnataka
Karnataka is a progressive state in India, but it shows disparity in development within the state ﹘ northern
Karnataka lags significantly in many development indicators compared to the south. According to the Human
Development Report for Karnataka[1], majority of the northern districts have low ranks in health indicators. The
report shows that the Infant Mortality Rate (IMR), and Maternal Mortality Rate (MMR) are all higher than the state
average, while doctor-patient ratio is lower. Eight[2] of the northern districts fall under the High Priority Districts[3]
(HPDs) in the state. Changing these indicators for the better require long and concerted efforts from the health
department. One of the first steps taken to strengthen the health system was to enhance the skills and knowledge
of the Frontline Health Workers (FLW). UNICEF, in partnership with State Institute of Health and Family Welfare
(SIHFW), Karnataka undertook a Social Behaviour Change Communication (SBCC) intervention in select villages
of the eight HPDs. The objective was to improve the knowledge, interpersonal, and communication skills of
FLWs called Accredited Social Health Activist (ASHA) and health functionaries (supervisory staff like DHEOs
and BHEOs), which would lead to improvement in health services in these districts in the long run. As part of
the intervention, SBCC training was imparted to 2,256 health functionaries at district and block level. These
health functionaries, in turn, acted as Master Trainers and trained health workers in their work jurisdiction. In the
subsequent phase, UNICEF implemented Supportive Supervision (SS) that aimed to help FLWs improve their
interpersonal communication skills. Supportive Supervision recognised the crucial role of FLWs as agents of social
mobilisation, and intended to help them and their supervisors deliver the last mile service in an informed and
engaging manner. As a result of this intervention, performance of FLWs and health functionaries has improved,
and they are now able to engage effectively with the community. It has strengthened the health departments’
SBCC capacities, and Supportive Supervision has improved their ability to monitor and improve the performance
of their workforce.
Theory of Change
Health system strengthening for improved, effective, and relevant communication that
can influence improvement in the health and health indicators of stakeholders.
Frontline Workers (FLW) Supervisors of FLWs SIHFW
• Approximately 1,886 FLWs • 103 health education officials • An enabling Supportive

across eight districts received were trained on SBCC Supervision environment and
training on SBCC. management. a resource base trained in SS
was created among the health
• They engaged with the • FLW supervisors and mentors
officials.
community, and had effective now montior and provide
and relevant conversations with appropriate and contextualised • SIHFW has better ability to
mothers. feedback to each of the FLWs. assess the performance of their
health functionaries.
• Their performance improved. • Their training pedagogy has
improved and become more
effective.
Phase 1: The SBCC, IPC, and facilitation skills of health Phase 2: Supportive Supervision was planned and
functionaries was strengthened. rolled out in all the eight districts.
Engagement with SIHFW, and launch of initiative to improve

the SBCC, IPC skills of FLWs and their knowledge about
the relevant Reproductive, Maternal, Neonatal, Child, and
Adolescent (RMNCH+A) Health indicators.
Poor status of health indicators

Lack of skilled Frontline Workers No Supportive Supervision in the select high priotity
(FLW) trained in SBCC and IPC. system for FLWs. villages in the eight HPDs in
North Karnataka.
Karnataka
Map not to scale

Intervention State
Situation
The state of Karnataka is in the southwestern region To improve the health services in North Karnataka
of India, with wide developmental gaps between the in the long term, the Reproductive, Maternal,
northern and southern regions of the state. Historical Newborn, Child, and Adolescent Health (RMNCH+A[6])
neglect of the northern region along with poor programme required strengthening of the system
leadership are two key factors that have widened this and capacity building of its workforce, enabling
gap within the state. In 2007-2008, the per capita them to deliver and execute their roles more
income of South Karnataka was 1.3 times that of North effectively. UNICEF, in partnership with SIHFW,
Karnataka[4]. This also reflects in the health indicators, Karnataka implemented an SBCC intervention in all
infrastructure, and health services in the northern the eight HPDs from 2014 to 2016. The objective
region. According to Karnataka’s Health Management was to improve the knowledge and Interpersonal
Information System (HMIS), all the HPDs in the state Communication (IPC) skills of the health functionaries,
had an IMR higher than the other districts for three which would lead to improved health service delivery
consecutive years, from 2014 to 2017[5]. in these districts.
Supervisors and mentors conducting

a Supportive Supervision visit in
Sriguppa block of Bellary district.
FLWs were trained to engage with the participants and
ASHAs showing an Ammaji community influencers to promote the demand and
video to women and children utilisation of health services, and the practice of desired
in Haglur village, Bellary.
behaviours around child, adolescent, and maternal
health. They engage with the participants primarily
through IPC sessions (one-to-one as well as group
IPC) and community meetings using different types of
communication aids.
In the second phase of the implementation, Supportive

Supervision was planned and rolled out in all the eight
districts. Key characteristics of the programme were
that:
• Supervision was conducted in a respectful and non-

authoritarian way to enable FLWs to continuously
improve their performance.
• Supportive Supervision visits were used as

an opportunity to improve the knowledge,
communication, and interpersonal skills of
the FLWs.
The Supportive Supervision model aimed at following

up with trained FLWs at the community level to
Method provide on-the-spot guidance and support through

the supervisory cadres. The focus was to enhance
the quality of transaction between FLWs and the
The intervention engaged with the following cadres of
participants.
health functionaries at the district and sub-district level:
The four steps in Supportive Supervision were:
• Frontline Workers: ASHA and ASHA facilitators[7]
• Mentors: ASHA mentors responsible for training

and mentoring FLWs 1. Identification of supervisors
• Supervisors: Block Health Education Officers

(BHEOs) and District Health Education Officers
2. Planning of regular Supportive
(DHEOs) responsible for overseeing and Supervision visits
implementing SBCC activities of all the health
programmes of the department
3. Conducting the Supportive
The first phase of the intervention focused on Supervision visits
strengthening health functionaries’ SBCC capabilities,
IPC, and facilitation skills. The trainings had the
following objectives:
4. Regular follow-up
1. Strengthen SBCC skills
2. Improve comprehension about role of facilitator and A Supportive Supervision format was developed by
facilitation skills UNICEF and SIHFW. The format captures FLWs’
performance against the nine communication themes
3. Provide knowledge about RMNCH+A programmes
related to antenatal and postnatal care practices
4. Strengthen and improve IPC skills with the use of followed by pregnant and lactating mothers respectively.
‘Facts for Life’ (FFL) videos[8] These are detailed in Table 1 in the ‘Action’ section.
Action
The programme was implemented in priority villages[9] Supervision for the next 6 months. Each MT visited
identified in the eight HPDs. Training was provided on and observed interaction between FLWs and mothers
two broad aspects, i.e., (i) SBCC, IPC, and facilitation for antenatal or postnatal health care every month[11].
skills, and (ii) Supportive Supervision. Details of the 98 supervisors conducted a total of 1,644 Supportive
training provided under each aspect is elaborated Supervision visits covering 464 FLWs. During this
below: period, the supervisors:
• Observed while the FLWs interacted with pregnant

Type of Health officials Number
trained of officials and lactating mothers and their family
training
trained
• If required, intervened and demonstrated how
1,512 interactions should be conducted for the effective
FLW
Training on delivery of key messages for improving demand
SBCC generation
Mentors and
146
supervisors
• After the completion of the visit, they provided
Training on detailed feedback to the FLW on communication
SBCC Supervisors 103 and IPC skills and methods for their improvement
management
• Recorded their observation in the Supportive
Training on IPC Supervision format
and facilitation FHV 374
skills Table 1: Supportive Supervision Training topics
SBCC management training entailed educating the Antenatal Care Postnatal Care
health functionaries on how to plan, implement, and
monitor the programmes that have SBCC as their Danger signs in Early
central approach. In each of these trainings, Ammaji ANC breastfeeding
Helluttare videos[10] were used to train the participants
on SBCC skills. Apart from theoretical sessions, Tetanus Kangaroo care of
the training also included mock exercises for the immunisation newborn
participants.
Early initiation
Exclusive
Training on Supportive Supervision and exclusive
breastfeeding
breastfeeding
121 mentors and supervisors were trained as Master
Trainers (MTs) on Supportive Supervision and use of Promotion of birth Promotion of hygiene in
preparedness newborn
the format developed for the purpose. These master
trainers, in turn, trained the remaining mentors and Danger signs in
Promotion of
supervisors in their respective blocks and districts. newborn and mothers
institutional delivery
They were imparted knowledge on nine different post delivery
communication themes related to Antenatal Care Nutrition and IFA Immunisation
(ANC), Postnatal Care (PNC), and the communication
approach to be used when interacting with women on
ANC checkup Follow-up visits
these themes.
Usage of ORS during
The Supportive Supervision trainings aimed to improve Birthweight
diarrhoea
FLW supervisors’ knowledge and facilitation skills to
help them monitor, observe, and give feedback to FLWs Estimated date of
on not just the content but their communication skills Spacing method
delivery
as well. MTs were then asked to conduct Supportive
Results
This intervention aimed at health system strengthening • Out of the 554 FLWs visited, 521 had a monthly
by way of establishing a systematic process for work plan.
Supportive Supervision for ASHAs to strategically and
• 2,300 couples with a single child were contacted
effectively implement SBCC interventions[12].
and IPC on spacing between two children was
The performance of FLWs has improved after this carried out.
programme. They are able to:
• 1,700 registered pregnant women were interacted
• Identify and take prompt action in critical antenatal with during the last reporting month, and IPC on
and postnatal cases ANC was conducted. Of these, 290 pregnant
women with signs of danger were referred to the
• Communicate better with the community and
health facilities.
motivate them to adopt the suggested health
behaviours • 362 community meetings were organised by FLWs
in the last reporting month.
• Reflect on their work to improve their communication
skills and the content of their messaging
• Document their work and follow a rigorous

reporting method
Mentors and supervisors of FLWs:
• Are able to monitor and provide appropriate and

contextualised feedback to each of the FLWs
• Have an improved training pedagogy and

A mentor giving feedback to an ASHA
incorporate the learning from SBCC trainings in all
using the Supportive Supervision format.
their training sessions
• Recognise the importance of Supportive Supervision

and its contribution in helping them perform their
Veeramma, an ASHA facilitator, wanted to
role better
practice the skills she learnt in the training and
The performance of SIHFW health officials has contribute to the society at large. Prior to the
improved. Specifically, they: training, she confined her visits to only pregnant
or lactating mothers. However, post training, she
• Are now able to assess the performance of their
realised she was able to communicate better with
peripheral health centre officials and FLWs
all community members, even on matters which
• Rigorously monitor and supervise work; handhold were beyond her defined role. Recalling one such
and demonstrate effective supervision incidence, she talks about how she was actively
involved in preventing a child marriage in her
• Use Supportive Supervision data for gap analysis
community by engaging in a dialogue with the
and take targeted actions across the HPDs
girl’s family. She explained the ill-effects of child
• Are able to incentivise good performance marriage, as well as the child marriage prohibition
• Have been able to create an enabling environment act and punishment under the same. With the
of Supportive Supervision help of her fellow FLWs, not only was she able to
convince them to postpone the marriage, but also
Supportive Supervision to continue education of adolescent girls.
3,764 Supportive Supervisions visits were conducted for Veeramma
554 FLWs between January and December, 2017. The ASHA Facilitator, Hosapete block,
following was observed from the Supportive Supervision Bellary district
data for the last reporting month.
A mother with her infant child.
Her ASHA convinced her to
have an institutional delivery.
Transformative Change Caselet 2
Engagement with the community has increased and

the FLWs now have greater commitment towards
their work. The programme has strengthened the
health departments’ SBCC capacities, and Supportive
Supervision has improved their ability to monitor and
improve the performance of their workforce[13].
Caselet 1
Mr. Ishwar Dasappanavar is the district health

education officer of Bellary. His main role is to
promote health and family welfare programmes
in the district with key focus on the SBCC
component of these programmes. Mr. Ishwar has Mrs. Sujatha is currently a Taluka ASHA mentor in
also received training on Supportive Supervision Bellary block. She was trained as a Master Trainer
as part of the UNICEF intervention which, he during the SBCC and Supportive Supervision
mentions, has helped him monitor his staff and training. She felt it helped her improve not only
their performance. As a result of this intervention, her own interpersonal skills, but also her training
the FLWs’ communication skills have improved. pedagogy. After this intervention, she conducts
He says, “The biggest change for me has her trainings in an interactive manner, promoting
been the capacity development of my frontline dialogue between the trainer and trainees. Her
staff from the trainings. My staff is now able to improved performance was recognised by her
document and share their work as well as stories seniors as well, and is now considered a key
of positive cases.” SBCC trainer in the district.
In Summary
UNICEF, in partnership with State Institute
of Health and Family Welfare (SIHFW),
Karnataka undertook a Social Behaviour
Change Communication (SBCC) project
in eight HPDs in North Karnataka. The
intervention enabled FLWs, health
functionaries, and the health department in
general to perform better and engage more
effectively with the community. Here is a
blueprint of how the intervention was rolled
out in priority villages in the eight HPDs.
Action
Health functionaries were

trained on SBCC, IPC,
facilitations skills, and
Supportive Supervision at
the district and block level.
........ ........
UNICEF adopted a Trained health functionaries

Supportive Supervision acted as Master Trainers,
approach, and aimed and coached the FLWs
to help FLWs, health in their district. They
functionaries, and ASHA imparted knowledge on
improve their IPC skills. communication issues.
Results
Mentors and supervisors

The performance of FLWs
of FLWs have started
and health functionaries
monitoring and providing
has improved, and they are
appropriate feedback, and
now able to engage more
possess better training
effectively with the community.
know-how.
SIHFW health officials

can better assess
performances,
supervise work, and
take targeted actions.
The health departments’

FLWs have the skill and SBCC capacities have
commitment towards their strengthened, and they have
work and engage more an improved ability to monitor
with the community. and better the performance of
their workforce.
References
[1]
http://www.in.undp.org/content/dam/india/docs/human_develop_report_karnataka_2005full_
report.pdf
[2]
These districts are Bellary, Kalburgi, Raichur, Koppal, Vijayapura, Yadagir, Bagalakote and
Gadag.
[3]
Based on the Maternal and Child Health Indicators, a composite index was developed
by Government Of India in order to identify the High Priority Districts (HPD) under the
health sector reforms to reach the Millennium Development Goals. Based on these
indices, 184 districts across 25 states in the country have been identified as High Priority
Districts.
[4]
Shiddalingaswami H, Raghavendra V K, D.M. Nanjundappa Chair, December 2010,
Regional disparities in Karnataka: A district level analysis of growth and development,
Dharwad.
Reporting Years 2016 – 2017 2015 - 2016 2014 - 2015
Other Other Other

District Type HPD HPD HPD
Districts Districts Districts
IMR (Source: reported

13.37 12.85 14.62 12.27 17.03 12.27
data HMIS)
[5]
HMIS is a digital intiative of the Department of Health and Family Welfare (DoHFW),
Government of India (GoI).
[6]
Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) is a flagship
scheme of the National Rural Health Mission (NRHM) , Ministry of Health and Family
Welfare, Government of India.
[7]
ASHA Facilitators also work like ASHAs having a fixed population but will supervise
5-6 ASHAs and acts as a communication link between ASHAs and the ASHA mentor,
BHEO.
[8]
Facts for Life (FFL) videos provide vital messages and information for mothers, fathers,
other family members and caregivers and communities to use in changing behaviours and
practices that can save and protect the lives of children and help them grow and develop to
their full potential.
[9]
Priority villages in a HPD were selected basis their performance on the health
indicators.
[10]
Kyunki Ammaji Kehti Hain videos has a total of 42 episodes; these are part of Fact for Life
videos that provides essential information about various health practices and government
health schemes available for the people. The videos have information on each stage of the
RMNCH+A life cycle.
[11]
Each Master Trainer was expected to visit a minimum of 4 such interactions; 2 each with
ANC and PNC stage mothers.
[12]
These results are anecdotal and based on the programme data and inputs from the district
health education officers, block education officers, SIHFW team, and UNICEF Karnataka
team.
[13]
This change is anecdotal and based on the interactions with the district health education
officers, block education officers, SIHFW team and UNICEF Karnataka team.
11
MAHIMA
Breaking the Taboo
Around Menstruation in
Jharkhand
Two hundred million women in India lack knowledge of menstrual hygiene and disposal practices[1],
adversely affecting their education and health outcomes. UNICEF thus initiated Menstrual Health and
Hygiene Management for Adolescent Girls (MAHIMA) in 2013, in partnership with the Government of
Jharkhand and local non-government organisations like Development Network (DevNet) and Lohardaga
Gram Swarajya Sansthan (LGSS). This social and behavioural change intervention focused on seven blocks
of East Singhbum and Gumla districts of Jharkhand. It aimed to improve Menstrual Health and Hygiene
Management (MHHM) among adolescent girls via three Social and Behaviour Change Communication
(SBCC) approaches, namely, community dialogue, capacity development, and interpersonal communication.
UNICEF developed a communication package consisting Facts for Life (FFL) videos, a Paheli Ki Saheli
(Friends of Riddles) package, and a life skills module. The package was meant for adolescent girls, Frontline
Workers (FLWs), mothers, and teachers. Adolescent girls' and mothers’ groups were formed to facilitate
interpersonal communication and improve knowledge of menstruation among the participants. Thanks to
MAHIMA, the community addressed myths around menstruation, which eased restrictions on menstruating girls.
Knowledge and practices related to menstrual health and hygiene have improved among adolescent girls,
their mothers, teachers, and FLWs in the two districts. Girls now talk about menstruation freely and negotiate
for the adoption of sanitary products. In addition, they now burn menstrual absorbents as a means of
disposal. MAHIMA has helped adolescent girls and the community at large to effectively break the silence
around menstruation. Moreover, UNICEF has collaborated with the government to incorporate the learnings
of MAHIMA into flagship programmes addressing adolescent issues in Jharkhand.
UNICEF C4D
Theory of Change
1. Improved knowledge on physiology of menstruation, MHHM, and disposal practices among community
members, adolescent girls, mothers, FLWs, teachers.
2. Better MHHM and disposal among adolescent girls and other women in the community.
3. Adolescent girls associated with MAHIMA are empowered to speak openly and negotiate for better
health and hygiene.
4. Mothers, FLWs, and teachers openly communicate with adolescent girls about menstruation.
Community Capacity Interpersonal

dialogue and development of communication for
social mapping of NGO staff, FLWs, adolescent girls'
of adolescent girls peer educators, groups and mothers'
and FLWs and teachers group meetings
UNICEF in partnership with non-government organisations implemented Menstrual Health and

Hygiene Management for Adolescents Girls (MAHIMA) Communication tools: 5 Facts for Life videos,
Paheli ki Saheli, life skills education
Poor MHHM and disposal practices among adolescent girls
Community: Adolescent Girls: Mothers: FLWs and teachers:

• Put restrictions on • Unprepared for • Had little • Lacked accurate
menstruating girls menstruation since they communication with information on MHHM
lack knowledge on the their daughters on
• Poor treatment • Limited
topic menstruation
and neglect of girls communication skills
who have reached • Social restrictions • Concurred with the
• Believed in the
menarche imposed on them restrictions put by the
misconceptions
community
• Low self-esteem, around menstruation
plagued with feelings of • Had limited knowledge
embarrasment and shame on MHHM
Map not to scale

Jharkand
Gumla
East Singhbum
Situation
Adolescence is the critical transitional period this cloth with soap, 80 percent of the girls were
from childhood to adulthood, when gender norms unaware of the importance of drying and storing the
and identities are shaped. For girls, the onset of same in a hygienic manner.
menstruation marks the transition into puberty. In
For the community, the onset of menarche indicated
India, however, a large number of adolescent girls lack
that the girl was mature enough for marriage and
appropriate and adequate knowledge of menstrual
procreation. Menstruation was also considered unclean
health and hygiene. Around 71 percent of adolescent
and impure, so girls were barred from entering the
girls are unaware of the concept of menstruation until
kitchen and places of religious significance. They were
menarche, and 88 percent of menstruating women
also prohibited from touching food items like pickles,
use old fabric, rags, sand, ash, wood shavings,
onions, and potatoes; the common misconception
newspapers, or hay as menstrual absorbents[2]. Poor
concluded that these would get spoilt if touched by a girl
menstrual hygiene in turn leads to negative health
on her menstrual cycle.
and education outcomes[3]. Health problems such as
bacterial infections, burning, and itching are a result Adolescent girls were unprepared for menstruation,
of this poor hygiene, and the lack or unaffordability of as their mothers or FLWs hadn’t discussed this
facilities and sanitary products forces menstruating girls with them. Around 32 percent of girls knew nothing
to drop out of school[4]. about menstruation before its onset, leaving them
frightened and confused. They lacked knowledge about
UNICEF conducted a baseline study in 2013 to menstruation, its physiology, hygiene, management,
determine existing knowledge levels, attitudes, and the health implications of poor menstrual hygiene
practices, and norms related to menstrual health and practices. They accepted the social restrictions imposed
hygiene behaviours. This study was conducted among during menstruation and were embarrassed to discuss
adolescent girls in Gumla and East Singhbhum districts the same with their family and FLWs. The baseline
of the Indian state of Jharkhand. The findings indicated survey found that 54 percent of girls felt humiliated
that MHHM and disposal practices were poor among due to the imposed restrictions. Hence, they sought
adolescent girls. Majority (98%) of the girls used the information from their friends and often received
same cloth for multiple cycles. Although they washed incomplete and incorrect knowledge.
Caselet
of their age group who could talk to them. Mothers were
Anju is a 16-year-old girl from Ghatshila block inclined towards their daughters receiving the right
in East Singhbhum. She began menstruating at information. About 95 percent mothers were positively
the age of 10. The day she reached menarche, inclined towards adolescent girls learning about
she locked herself in a room for hours as she menstruation before its onset.
did not know anything about menstruation.
Anju sought her mother's advice, but her
Peer educator communicating to
instant reaction was to keep quiet and not adolescent girls about MHM.
discuss it. She received incomplete and
incorrect information in hushed tones, mostly
on what to do, what to use, and the restrictions
she must follow. Her mother asked her to use
a piece of cloth. Anju silently suffered from
foul-smelling discharge and severe itching in
her genital area. She wasn’t allowed to enter
the temple or touch certain food items during
menstruation. She often contemplated the
restrictions imposed on her and what made
menstruation so shameful.
Mothers had limited communication with their

adolescent daughters on menstruation, as the topic was
considered shameful. They told their daughters what to
do, what to use, and the restrictions they were under.
There was, however, no discussion on the physiology
of menstruation and maintenance of hygiene. Even if
mothers did discuss it, they lacked accurate knowledge
and did not follow proper MHHM themselves. They did
not question any restrictions on adolescent girls either.
FLWs and teachers had misconceptions and believed Method

in the social restrictions around menstruation. While
they lacked the communication skills required to UNICEF, in partnership with the Government of
discuss MHHM with others, their understanding of the Jharkhand, implemented Menstrual Health and Hygiene
same was also minimal. A cloth used as a menstrual Management for Adolescents Girls (MAHIMA) in seven
absorbent was symbolically considered a woman’s blocks of East Singhbhum and Gumla districts of
womb and it was believed that drying/burning of the Jharkhand from 2013 to 2015. The intervention was
menstrual cloth would result in the drying/burning of implemented by local non-government organisation
the womb, making it infertile. Hence, they were against (NGO) partners — Development Network (DevNet) and
the burning of menstrual absorbents for disposal. Lack Lohardaga Gram Swarajya Sansthan (LGSS).
of accurate information coupled with myths stopped
The programme incorporated learnings from
them from supporting adolescent girls. Additionally,
discussions with the different stakeholders involved,
lack of knowledge and communication, along with
such as: a) the government, b) implementation partners
the misconceptions and social restrictions around
— DevNet and LGSS, and c) adolescent girls (through
menstruation negatively affected the well-being of
the baseline study findings). A state-level workshop was
adolescent girls.
held with the Departments of Education, Health and
Baseline results revealed opportunities to prepare girls Family Welfare, Women and Child Development, and
and break the taboo around menstruation. Girls were Drinking Water and Sanitation to implement MAHIMA
open to the idea of interacting with a ‘peer’ — a person in Jharkhand.
Objectives and approach of MAHIMA
MAHIMA was a Social and Behaviour Change 3. Community dialogue to build rapport with the
Communication (SBCC) intervention whose objective community, introduce communication around
was to improve knowledge and practices around MHHM menstruation, and identify participants.
among adolescent girls. The programme aimed
Communication tools used
at breaking the culture of silence around menstruation,
encouraging girls to discuss the issue freely, and The tools used for the programme were built on
negotiate the adoption of hygienic practices the learnings of the Girls’ Adolescent Reproductive
during menstruation. Rights: Information for Management and Action
MAHIMA enhanced knowledge, addressed attitudes, Programme (GARIMA)[7] implemented earlier in Uttar
perceptions, and norms of the community around Pradesh[8]. The communication package by UNICEF
menstruation through three SBCC approaches: used for MAHIMA comprised:
1. Interpersonal Communication (IPC) among Three Facts for Life (FFL) Videos: Addressing
adolescent girls, between them and their mothers, myths, gender issues ('Hero Number 1') and the role
and between them and FLWs — Sahiyyas of fathers (Bapu) were extensively used.
(Accredited Social Health Activists)[5] and Sevikas
(anganwadi workers)[6]. A Paheli ki Saheli (Friends of Riddles) package:
Consisting of films, a storybook, a personal diary,
2. Capacity development training and skill building and posters, through which MHHM-related
of NGO field functionaries, FLWs, teachers, and issues were presented to the participants in an
adolescent girls. audio-visual format.
Adolescent girls going through the

communication materials.
An activity-based life skills module: Developed within cloth and sanitary napkins, along with the hygienic
the context of MHHM to enable open communication management of their menstrual cycle, and disposal of
between participants and informed decision making. these absorbents.
Themes captured in the communication package were: The effect of menstruation on a girl’s life: Helped
participants understand that menstruation is a normal
Preparation for menstruation: Which dealt with the
physical phenomenon, and that restrictions imposed on
physiology of menstruation, gave details on what to do
adolescent girls were unfair. It encouraged adolescent
during menarche, and how to initiate discussions.
girls to consult FLWs to deal with any mental and
Menstrual health and hygiene practices: Provided physical discomfort during menstruation.
knowledge on available menstrual absorbents like
Facilitator conducting a session on menstrual

health using the Paheli ki Saheli book.
Peer educator
communicating with an
adolescent girl.
Action
UNICEF trained 48 NGO field functionaries (of the • UNICEF educated all 1,723 FLWs available in the
implementation partners) working at the district seven blocks on why menstruation occurs and the
and block level, who were responsible for building importance of maintaining menstrual hygiene. They
participants’ capacities. were made to understand that, as FLWs, it is their
duty to talk to adolescents about their health and
Social mapping of adolescent girls and FLWs nutrition, including menstrual hygiene. To this end,
they were encouraged to organise monthly meetings
UNICEF reached out to all 1,058 villages through
with adolescent girls.
NGO field functionaries across seven blocks in the
two districts, and facilitated discussions that created • Around 1,100 peer educators locally known as
familiarity around MHHM. A mapping exercise identified prerikas, were identified among the adolescent girls
adolescent girls and FLWs in these villages. In addition, either by the girls themselves or the villagers. Peer
NGO field functionaries held dialogues with the educators were trained by NGO field functionaries
communities, to enhance common knowledge around regarding challenges related to menstruation. They
menstruation in the village. shared their own experiences, which encouraged
the girls to be open about the issue. Peer educators
Capacity development of FLWs, peer educators were trained twice, through FFL videos and the
and teachers Paheli ki Saheli package, on the three key aspects
of MHHM – maintenance, cleanliness, and disposal.
Capacity development of FLWs, peer educators, and It was then their responsibility to spread this
teachers was carried out to ensure correct and complete message to other girls in their group. They were
understanding of menstrual health and hygiene. It given training on life skills – to negotiate with family
enhanced their IPC skills which helped them conduct members on the adoption of hygienic products and
sessions and organise group meetings with girls and private spaces to manage menstruation. They were
their mothers. also taught to dispose menstrual absorbents in an
environment-friendly manner. Peer educators were Mothers’ group meetings
taken for cross-learning exposure visits and training.
Monthly mothers’ group meetings were held separately.
Additionally, girls from Gumla visited East Singhbum
They were facilitated by FLWs and focused on
and vice versa.
enhancing the mothers’ knowledge of MHHM.
1. Mothers were encouraged to communicate with

Peer educators were girls of the age group 13-17 their daughters on preparedness for menarche
years, and were selected based on the following and related issues and its hygienic management.
criteria : Mothers were also guided to help their daughters
explore hygiene products.
1. Education up to 8th standard
2. Willingness of the family to let her participate 2. Through these meetings, mothers gained the
in discussions with other girls on menstrual confidence to send their girls to trainings that
management helped them learn about their health and well-being.
3. Clear articulation District-level dissemination workshop
A dissemination workshop on the MAHIMA project

was organised by UNICEF to share learnings and
• Teachers were trained by NGO field functionaries seek opportunities to scale up. Adolescent girls
on MHHM-related issues. They were motivated from government-aided schools, NGOs working on
to engage their students on menstruation and, in adolescent-related issues, and representatives from the
turn, understand challenges the students faced to Departments of Health, Education, Social Welfare, Youth
manage menstruation during school hours. The Affairs, and Drinking Water and Sanitation were present
programme reached out to government schools and at the workshop.
hostels in the blocks, covering 1,900 teachers and
hostel wardens.
Rina, a peer educator, is pictured
with her mother, who no longer
Adolescent girls’ Group
imposes restrictions on Rina when
she is menstruating.
Peer educators facilitated monthly meetings in
each village with 15-20 adolescent girls, supported
by FLWs.
• The meetings were structured and theme-based,

and conducted with the aid of the communication
package developed by UNICEF and an
activity-based life skills module. FFL videos, Paheli
ki Saheli films, storybooks, diaries, and posters
helped keep the participants engaged. It included
entertaining videos, interesting riddles, and catchy
phrases to grab the audience’s attention.
• Menstrual hygiene was explained by also

stressing on the importance of taking a bath daily
and changing the menstrual cloth thrice a day.
Washing the cloth with soap and drying it in the
sun, keeping it in a clean place after use, and
ultimately either burying it in a deep pit or burning
in an incinerator was encouraged. The groups
were a space where girls could talk about these
issues freely.
Results
The programme successfully reached out to the
marginalised population in the two districts. did not attend school, enter temples, or play
Results of MAHIMA were documented at different like she used to before. Her family did not let
levels — adolescent girls, mothers, and NGO field her consume sour food items or have a bath
functionaries. As a direct impact, knowledge on for the entire duration. These practices and
physiology of menstruation, MHHM, and disposal restrictions left Rina confused and she often
practices increased among the participants, leading wondered why menstruation was considered an
to better practices[9]. embarrassment. There was no one she could
speak to about her queries and dilemmas. She
Adolescent girls was introduced to MAHIMA in 2014, but she
Adolescent girls now follow menstrual hygiene and safe was hesitant to be a part of the programme
disposal practices like: as she did not understand what it was about.
Later, she joined one of the training sessions
1. Using a menstrual cloth or sanitary pad during thinking it would help. After frequent requests
menstruation, which is changed three to four times from the NGO, she started interacting with the
a day. block coordinator, village health workers, and a
few mothers from her village. The discussions
2. Washing the menstrual absorbent with soap and helped improve her knowledge on menstrual
drying it out in the sun without being embarrassed. hygiene. She learnt that menstrual absorbents
They now keep it alongside their clothes, instead of must be changed frequently, washed with soap,
storing the cloth in a damp and dirty corner. dried in the sun, and stored in a clean space
along with other clothes. She understood that
3. Digging a deep pit to bury it in or burning it as an the ultimate mode of disposal is to burn the
ultimate step of disposal, as opposed to throwing it menstrual absorbent. Initially, she was hesitant
in water bodies. to dry the cloth in the open and dispose it by
burning, but when everyone started talking
4. Challenging restrictions on the burning of a about menstruation openly, she gathered the
menstrual cloth, as well as the restrictions on courage to do it. Since Rina’s mother attended
touching and consuming certain food items during the sessions with her, she received her support
menstruation by carrying out these practices. as well.
Caselet Rina believes that the most significant

impact MAHIMA had on her life is that her
Rina Kumari is a 21-year- misconceptions have been clarified. She no
old girl from Gumla district longer believes that she should not enter
in Jharkhand. She lives in temples during menstruation. She has learnt
Nagpheni village with her to question the restrictions her family imposed
family. She began menstruating on her. She also tested these restrictions and
when she was 14 years found that they were untrue. She touched
old, but did not have any and ate pickles while menstruating, without
information about it. At first, she didn’t inform experiencing any ill effects. She now believes
her mother due to embarrassment; instead, that menstruation is a natural phenomenon
she gathered information from her friend on among girls who can give birth. Now she has
what she needed to do. Rina had to eventually the courage to speak to her mother openly
inform her mother after one year because she about menstruation. Rina wants to share
suffered from severe stomach aches. Her mobility this information with her future husband
was then restricted during menstruation. She and children.
Adolescent girls discussing menstrual
hygiene with the help of Paheli ki Saheli.
Mothers NGO field functionaries
• Communicate with their daughters to prepare them • Earlier had the same misconceptions about the
for the onset of menarche and teach them hygienic physiology and practices around menstruation as
practices to follow during menstruation. the other women from the community.
• Support their adolescent daughters in choosing • Dispelled the misconception that burning a used pad
an appropriate menstrual absorbent, keeping it or cloth would cause infertility, and instead followed
clean, and disposing it safely. They talked to other improved MHHM and disposal practices.
members in their family to build a private space for
• Discussed menstruation openly. They went against
their daughters to manage menstruation.
several restrictions and were then convinced
• Reduce restrictions on mobility and their daughters’ that these were baseless. They then encouraged
routine activities. They understand that the blood colleagues and girls to do the same.
released during menstruation is not impure, and let
girls touch and consume all kinds of foods.
“Once there was an accident in the family, and
I had used a towel to wipe off the blood from
Caselet
the injury. I was menstruating at the time. In the
Manju Devi Lakhra evening, I went to wash both pieces of cloth and
discusses menstrual smelt both. They smelt exactly the same. This
hygiene with her convinced me that menstrual blood is not impure
daughter, Anupama blood — it is just blood.”
Tirkey, 20. They
reside in Nagpheni Neelam Lakra, Cluster Coordinator
in Gumla district of
Jharkhand. MAHIMA
Teachers
was implemented in
their village in 2014. • Communicate openly with female students about
Manju previously had little communication with menstruation, understanding the challenges they
her daughter about menstruation; the topic was face while attending school.
considered shameful. Since the menstrual blood
looked dark, it was thought to be unclean and • Regularly orient girl students about MHHM.
hence impure. • Support girls with academics when they are
Thanks to MAHIMA, Manju discussed menstruating.
menstruation with other mothers and health
workers. This helped her realise that she
should also speak to her daughter openly.
Since then, she has been able to talk to
Anupama regarding her experience of
menstruation. Manju supports her daughter
in buying menstrual pads and disposing them
safely. She has reduced restrictions on her
mobility and doesn’t mind when she touches
food items or goes to the temple while
menstruating. With Manju’s support, Anupama
is now a peer educator in their village. It has
helped her daughter be confident and encourage
others to practice improved menstrual health
and hygiene. FLWs in East Singbhum.
Transformative Change she got a chance to ask questions about
menstruation. During monthly meetings, she
There is evident transformation among communities,
freely interacted with her peers and elders on the
adolescent girls, and other women associated with
subject without any restrictions. She was selected
the programme. With improvement in their knowledge,
as a peer educator by the girls in her adolescent
communities are now open to discussing menstruation.
girls’ group. As a peer leader, she was trained
Importantly, adolescent girls and women are
in hygiene management as well as life skills to
empowered to confidently speak about issues faced
negotiate for hygiene options with her family. She
during menstruation and negotiate for better health
was given the ‘Paheli ki Saheli’ book and shown
and hygiene[10].
Facts for Life videos to help her understand the
Adolescent girls issue better. She got answers to all her questions
and helped her friends who were still struggling
Girls speak freely, and confidently discuss menstruation
with these questions. She faced some resistance
and MHHM with peers, mothers, FLWs, and teachers.
initially as her friends looked at the subject
with shame, but eventually they joined the
Ruma Karmakar (in front),16, from East adolescent girls’ group and began openly
Singhbhum district learnt about MHHM discussing menstruation.
via the MAHIMA intervention.
Ruma believes what happened to her must

not happen with other girls in the village. She
has a 9-year-old sister, with whom Ruma talks
about menstruation so that she is not caught by
surprise. She urges all adolescent girls to ask
questions about menstruation openly.
Girls in the two districts are empowered to confidently

negotiate with their families for private spaces to
maintain hygiene. They have convinced their families
Caselet to construct the same in order to change menstrual
absorbents. Around 900 girls had safe enclosures built
Ruma Karmakar is a 16-year-old girl from East in the homes, either with help from family members or
Singhbhum district of Jharkhand. She lives with by themselves.
her family and studies in 10th standard. Ruma
started menstruating when she was 10 years old Caselet
and at the time, no one had spoken to her about
During the baseline survey, it was found that more
it. She was scared and could not understand what
than 90 percent girls were reluctant to burn their
was happening. When she informed her mother
menstrual absorbents. Girls spent the entire day
that she was hurt and bleeding, her mother told
using the same piece of cloth during menstruation
her in a hushed tone that she has now become
because they were afraid of someone seeing
mature. It was Ruma’s sister who advised her to
them while they change. After their association
use a menstrual cloth and said that now she was
with MAHIMA, several girls spoke to their mothers
a ‘grown-up girl’. Subsequently, in the coming
and negotiated with them to arrange for a private
days, her mother did not allow her to visit the
space which they could use to clean themselves,
temple, enter the kitchen, or touch pickles.
especially during menstruation. This was not
The village Frontline Workers informed Ruma easy to do, as initially their parents refused, but
about MAHIMA. She attended the adolescent slowly, after the girls explained their needs, the
girls’ group meeting, where, for the first time, parents agreed. Around 900 girls have built safe
enclosures in their homes with the help of their and practicing yoga to subdue the pain. She
parents and now use it to comfortably change also advised them to consume a nutritious diet,
their menstrual cloths. including green vegetables. She uses the Paheli
ki Saheli books to get her message across.
Frontline Workers
NGO field functionaries
• Conduct monthly meetings with adolescents on
health and hygiene including menstrual hygiene, as NGO field functionaries started believing that, for them
this is critical for improved health. to influence other women to practice improved MHHM,
they had to undergo a change themselves.
• Support and encourage girls to communicate
freely about menstruation and the challenges it
poses. They address queries raised by adolescent An NGO field functionary
girls during these meetings such as the cause of interacting with a peer educator.
menstruation, its physical manifestations, and the
correct use of sanitary pads.
• Suggest ways in which girls can manage their pain

and discomfort. They talk about nutrition, advise
them to consume green vegetables, cook in copper
utensils, and consume iron tablets to stay healthy.
Caselet
Chedni Devi is an
anganwadi worker in
Podha centre of Gumla
district of Jharkhand.
Even though she was a
Frontline Worker in her
village, she did not have the
knowledge or confidence
to talk about Menstrual
Health and Hygiene to adolescent girls in
her village. Chedni Devi believes she gained
appropriate knowledge of menstruation only after
attending the discussions under the MAHIMA
programme. It gave her the confidence to speak
and support girls from her village. Chedni Devi
understood her role in educating girls and started
conducting monthly meetings with girls. These
meetings centred around maintaining health and
hygiene, often focusing on menstruation and its
importance. She gave suggestions to girls and
answered their questions on menstruation. Most
of the girls would ask her how to manage their
pain and discomfort during menstruation. She
talked to them about applying hot water packs
In Summary
Action
UNICEF, in collaboration with
the Government of Jharkhand,
Development Network (DevNet),
and Lohardaga Gram Swarajya
Sansthan (LGSS), implemented
an initiative to improve Menstrual
Around 1,100 prerikas
Health and Hygiene Management
UNICEF conducted a were trained by NGO field
(MHHM) among adolescent girls in
mapping exercise in 1,058 functionaries on three
two districts of Jharkhand. Here is villages to identify FLWs and key aspects of MHHM –
a blueprint of how the intervention adolescent girls. NGO field maintenance, cleanliness,
was rolled out in seven blocks of functionaries then facilitated and disposal. They shared
Jharkhand’s East Singhbum and discussions with the their experiences, which
Gumla districts. community around MHHM. encouraged the girls to be
open about the issue.
Teachers were trained by

NGO field functionaries to
engage their students on
menstruation and, in turn,
understand the challenges
students face while
managing menstruation
during school hours.
Results
Adolescent girls follow Mothers teach daughters

menstrual hygiene and hygienic practices to follow
disposal practices like during menstruation, and have
washing the menstrual reduced restrictions on mobility
absorbent with soap, drying and touching food. They also
it in the sun, and ultimately encouraged family members
burning the absorbent as a to build private spaces
means of disposal. for daughters to manage
menstruation.
NGO field functionaries

dispelled misconceptions, and Teachers communicate openly
instead followed improved with female students about
MHHM practices. They went menstruation, understanding
against several restrictions the challenges they face while
and were then convinced that attending school and support
these were baseless. They then girls with academics while
encouraged colleagues and they are menstruating.
girls to do the same.
Adolescent girls now confidently
discuss menstruation and MHHM
with peers, mothers, FLWs, and
teachers, and are empowered to
confidently negotiate with their
families for private spaces to
maintain hygiene. Around 900 girls
had safe enclosures built in the
homes, either with help from family
members or by themselves.
NGO field functionaries now see
that, in order to influence other
women, they must practice
improved MHHM themselves.
FLWs conduct monthly meetings

with adolescents on menstrual
health and hygiene and
encourage girls to communicate
freely about the issue. FLWs
dispel misconceptions and follow
improved MHHM. They also
suggest ways in which girls can
manage their pain and discomfort.
References
[1]
https://www.dasra.org/cause/improving-menstrual-health-and-hygiene-and-hygiene
[2]
https://www.dasra.org/cause/improving-menstrual-health-and-hygiene
[3]
http://www.sswm.info/content/menstrual-hygiene-management
[4]
http://www.mdpi.com/1660-4601/9/8/2772/html
[5]
In Jharkhand, Sahiya is the term used in place of ASHA. They are the central agents in the
community health programmes. The Sahiya is nominated by Village Health Committee as
outreach worker and selected by the community to support the service providers on health
issues with focus on reproductive and child health needs and services.
[6]
Anganwadi workers, known as Sevika in Jharkhand, are responsible for providing a
number of vital services including pre-school education, supplementary nutrition, nutrition
counselling, growth monitoring, and so on. Anganwadis are part of the Integrated Child
Development Scheme (ICDS), a centrally-sponsored scheme whose norms are set by the
Government of India.
[7]
UNICEF partnered with IKEA Foundation on GARIMA programme. The project aimed at
piloting a social and behaviour change communication strategy on menstrual health
and hygiene management among rural adolescent girls in the age group 10-19 years in
three districts of eastern Uttar Pradesh - Jaunpur, Mirzapur and Sonebhadra from 2013
to 2014.
[8]
Uttar Pradesh is a state in North India.
[9]
Based on programme documents and key informant interview with the State C4D
representative.
[10]
Based on key informant interview with the State C4D representative.
[11]
The Ministry of Health & Family Welfare of the Government of India has launched a health
programme for adolescents in 2014,for the age group of 10-19 years, which would target
their nutrition, reproductive health and substance abuse, among others.
12
Ek Kilkari
System Strengthening for Routine
Immunisation in Chhattisgarh
The state of Chhattisgarh is located in the central part of India, and was carved out of Madhya Pradesh in
2000. Census of India (2011) shows that 30 percent of the state’s population is tribal. Only 59.3%[1] children
here in the age group of 12-23 months are fully immunised. The state has a limited number of skilled Frontline
Health Workers (FLWs), most of whom have poor communication skills. One of the biggest challenges here
is the low demand of healthcare services from stakeholders[2]. The Department of Health and Family Welfare
(DoHFW), Government of Chhattisgarh, partnered with UNICEF Communication for Development (C4D) to
develop and implement a communication strategy aimed at improving Routine Immunisation[3] (RI) in the state.
UNICEF also identified the need to target social norms that hinder the promotion of RI-related behaviours.
The programme was implemented in five High Priority Districts (HPD[4]). As part of the programme, capacity
building of FLWs and health officials on SBCC, sensitisation of the community and faith leaders, and an RI
drive was carried out. This helped increase the demand for healthcare services from the community, improved
the immunisation rate, built capacities of FLWs, created a skilled resource pool in the health department, and
motivated the FLWs towards better service delivery.
Theory of Change
Strengthening of
Increase in demand
Increased knowledge health systems with
from communities
and confidence of defined communication
leading to an increase
the FLWs plans and trained
in immunisation rate
health officials
Involving tribal Use of mid-media Close monitoring of

Building technical panchayat leaders and and outdoor media immunisation drive
and SBCC skills of faith leaders to enhance which includes folk art to ensure complete
the FLWs message delivery and forms like Kalajatha to coverage and quick
acceptance in the deliver RI messages resolution of issues
communities
• Poor communication skills of Frontline Health

Workers
• Shortage of skilled Frontline Health Workers
• Limited technical knowledge about Routine
Immunisation among Frontline Health Workers
• Low demand of formal healthcare services
by tribal communities due to prevalent social
norms around health
Chhattisgarh
Map not to scale

Intervention State
Situation
According to the District Level Household Survey functionality of their children, they don't see it as a
(DLHS)-3[5], only 59.3 percent children in Chhattisgarh threat to their health.
aged between 12-23 months were fully immunised. The
following issues needed to be addressed to improve Some behaviours prevalent in the community hindered
the immunisation status and bring about a behaviour the Routine Immunisation (RI) of infants. These include
change in the community: practices like delaying first immunisation, declining
immunisation after first vaccination, etc.
• Shortage of skilled Frontline Health Workers (FLW)
in the state Department of Health and Family Welfare (DoHFW),
Government of Chhattisgarh, partnered with UNICEF
• Poor communication skills of FLWs, who were Communication for Development (C4D) to address
unable to conduct effective demand generation these gaps by formulating and implementing a Social
and Behaviour Change Communication (SBCC)
• Low demand of formal healthcare services from
strategy for Routine Immunisation. This programme
within the community
was implemented between 2014 and 2016. Initially, the
• Limited technical knowledge, especially about initiative was implemented in five[6] High Priority Districts
immunisation among FLWs (HPD), and later in three more districts at the behest of
DoHFW. It targeted the following:
Tribals are known for living in isolation from
the mainstream society, and observe their own • Primary stakeholders – parents and immediate
traditions and practices related to health. They caregivers
generally understand disease or illness as being the
• Secondary stakeholders – immediate caregivers
incapacitation of an individual from performing his/
(family and friends), FLWs
her routine work. Their understanding is hence more
in functional terms than clinical, which makes them • Tertiary stakeholders – state, district, and block
neglect symptoms such as cough, cold, headache, level institutions, and the community
weakness, etc. and not consider the same as serious
illnesses, as they don’t hinder them from carrying The focus of this partnership was to strengthen
out daily activities. They have similar notions about behaviours – a key component of the Reproductive,
other health concerns, such as immunisation. Since Maternal, Newborn, Child, and Adolescent Health
lack of immunisation does not hinder the immediate (RMNCH+A[7]) programme.
An infant getting vaccinated at
a primary health centre.
Method
UNICEF C4D formulated the communication strategy spheres of their activity, and jurisdiction of the
in consultation with the state’s Health Department, led tribal panchayat was all-pervasive – right up
by the State Immunisation Officer. The various methods until the introduction of statutory Panchayati Raj
adopted were: (PR) system in tribal areas. Given the stronghold
of these tribal panchayats, tribal community
• Capacity building of FLWs: The training leaders were included in the programme system
administered to FLWs followed an Incremental to enhance acceptability of the programme. They
Learning Training Methodology (ILTM) approach were oriented on the importance of RI and how it
– a progressive learning methodology in which can save the life of a child. They were sensitised
learning goals are broken down into smaller about the role and responsibilities of a community
steps. Each step is spread over a longer period to ensure complete protection of each child
of time and the focus is on ‘learning by doing.’ To through complete immunisation. Their consent
implement this approach, five capsule modules helped pave the way towards acceptance of
were developed using the TARANG SBCC module the programme.
as a base. FLWs were trained incrementally with
each capsule focusing on at least one or two • Harnessing community spaces and platforms
communication skills. in villages for RI messages: Village spaces like
anganwadi centres, panchayat bhawan, and health
• Involving community leaders: The tribal sub-centres were used to communicate messages
communities have their own unique traditional and important information about RI.
systems called tribal panchayats which exercise
considerable power over the social, moral, religious, These messages included information like:
and economic affairs of the tribal community
• Two tetanus vaccines for mothers during
members. Most of these communities have
pregnancy (1st trimester)
preserved their own distinct cultural identities
through their unwritten code of conduct and distinct • 1st dose of BCG vaccine along with a zero
traditional mechanisms to enforce the codes. The dose of polio vaccine for the child immediately
customary laws[8] of the tribes encompassed all after birth
Platforms like antenatal check-up days
were used for routine immunization
communication.
• 1st dose of pentavalent[9] vaccine for the child at • Engaging faith leaders: Faith leaders were
1.5 months engaged in the programme as they have a greater
influence over the population. They were educated
• 2nd and 3rd dose of pentavalent vaccines for the
on the importance of RI, and their proactive efforts
child at 2.5 and 3.5 months along with a polio
were recognised.
vaccine each time
• Mid-media and outdoor media: Popular folk song
• Measles vaccine and 1st dose of Vitamin A for
and dance forms of the state like Kalajatha[10] were
child at 9 months
used to deliver RI messages to the community and
• Leveraging special days: Platforms like Village influence the existing social norms.
Health and Nutrition Day (VHND), and Antenatal
Checkup (ANC) day were also used for RI
communication.
Action
UNICEF invited resource persons from Social Further, the participants[12] were oriented on the making
Mobilisation Network (SMNet), Uttar Pradesh, to of communication action plans, their implementation,
help with planning, implementing, monitoring, and monitoring, and evaluation for the purpose of RI.
evaluation of communication activities during the
Mission Indradhanush campaign. These resources had Workshops for Health Department officials: Eight[13]
extensive prior experience in implementing a similar workshops were conducted to impart knowledge about
programme for a polio vaccination campaign in Uttar the SBCC strategies and approaches, and help officials
Pradesh led by UNICEF. A group of four people was develop communication action plans for their respective
sent to each of the five districts. The following actions districts. These communication action plans included
were undertaken: strategies for social mobilisation, capacity building,
mass media, and internal monitoring and review. At
Capacity building: FLWs and senior health the end of these workshops, each of the districts had
department staff[11] had been trained using the developed a draft communication action plan.
TARANG SBCC module. TARANG training comprises
of a module for skill building. The skills included Street plays: Plays based on local art forms were
communication, counselling, social mobilisation, enacted to spread messages that reach a larger
community dialogue, and social inclusion. These audience in villages. These also served as an
opportunity to interact with community leaders and
trainings honed the capacities of the participants
faith healers, and influence them to promote RI in the
in taking forward the key messages on health
community.
programming. The details of the Training of Trainers
(TOT) held are: Monitored immunisation drive: Each district’s group
worked with the district health official to conduct and
• Five-day TOTs of 22 Master Trainers (MTs) at
monitor the immunisation. Daily meetings to track
the state level
and update the progress of the implementation were
• Five-day TOTs of 185 district and block-level conducted. This RI communication monitoring was
trainers in all eight HPDs done continuously for four months from April to July
2015. All the district reports were collated to help the
• One-day refreshers for all district and block- state department monitor progress and address any
level trainers on capsule modules arising issues.
The immunization drive was monitored

rigorously and concurrently for ensuring
effective implementation.
Mothers holding mosquito nets ‒ an
incentive given to mothers who at-
tend the antennatal check-up in the
Aganwadi clinic.
Result
Following were the results of the intervention: • Behaviour and practice: There is effective delivery
of key messages by the FLWs. They are able
Stakeholders[14]
to communicate better with all members of the
• Enhanced knowledge: They have better community and convince them to adopt healthy
understanding on the benefits of immunisation for behavioural practices. They are now able to put the
their child and ensure they get it at the right time. GATHER approach into practice and use it for the
The stakeholders are able to recall and recollect the effective delivery of key messages on RI.
key messages on RI.
Department of Health and Family Welfare
• Change in behaviour: Mothers now discuss Department
and share information about institutional delivery,
• Knowledge gain: There is an improvement in the
immunisation, exclusive breastfeeding, etc. with
IPC skills and knowledge about RI in FLWs. They
other family members.
are also better informed about the SBCC strategy
• Increase in demand: Enhanced knowledge and and its use in their work.
changed behaviour led to an increase in demand
• Demand for services: As a result of this
generation for RI services among the community.
intervention, demand for services from the
Frontline Health Workers[15] community in all intervention blocks under the
eight[17] districts has increased[18].
• Enhanced knowledge: FLWs have acquired IPC
skills and are well versed with the GATHER[16] • Immunisation rate: There is an increase in
approach. immunisation rate after the programme.
“I have been working as an FLW for the last two decades. I have never been trained in SBCC before. In
the training, I learnt about the basics of a conversation. The training focused on having each and every
participant speak up and partake in the training. The most important lesson for me was understanding that
listening to marginalised groups is critical to help improve the overall society. I use the lessons from the
training in my daily work, and can see that my interactions with stakeholders have changed to become
engaging and contextual in nature.”
Ms. Urmila Dhinar, Mitanin Trainer, Balloda Bazar district, Chhattisgarh
Self-assured and assertive health workers: FLWs
feel more confident about their capacity to deliver
services and convince community members to adopt
health practices. Male FLWs also reported that they
are able to initiate conversations on sensitive topics
like safe sex practices with male members in their
community. Overall, there has been a positive change
in FLWs’ outlook towards socially excluded groups and
their determination to bring about a positive change in
their own areas.
Health system strengthening: Development of a

detailed communication action plan for the state Health
Department to help improve the RI trend in the state.
Further, a resource pool of officials has been created
which is trained in SBCC and has improved knowledge,
communication, and technical skills.
Jharkhand and MP: These two states also adopted

the Incremental Learning Training Methodology (ILTM)
introduced in this intervention, and developed 10 Immunization drive in one of the
capsule modules from the original TARANG Module for Anganwadi clinics.
SBCC skills training.
Caselet
Chitralikha is an FLW and the head of Arjuniya

Panchayat. As Sarpanch, she is expected to
interact with numerous people and help resolve
issues. However, she used to be shy and hesitant,
and tried to elude from her work as Sarpanch. After
receiving training from UNICEF, she now sees a
change in herself, and this has helped her interact
and guide the Mitanins more suitably. The SBCC
training has also made her more confident and
outspoken as an individual. This has had a positive
impact on her work as Sarpanch. She now listens
to all residents in need and attempts to resolve
their issues. More importantly, she actively seeks to
represent the underrepresented and has become
their voice.
Chitralikha, Sarpanch, Arjuniya Panchayat,

Balloda Bazar
There has been a visible increase in
the demand for health services from the
communities in the intervention blocks.
In Summary
UNICEF C4D, in partnership
with the Department of Health
and Family Welfare (DoHFW),
Government of Chhattisgarh,
developed and implemented a
communication strategy aimed at
improving Routine Immunisation
(RI) in the state. Here is a blueprint
of how the intervention was rolled
out in five High Priority Districts
Workshops on SBCC
(HPDs) in Chhattisgarh. UNICEF facilitated
strategies were held for Health
SBCC training for FLWs
Action through the TARANG
Department officials to help
them develop communication
module on communication
action plans (social
skills, counselling, social
mobilisation, capacity building,
mobilisation, community
mass media, and internal
dialogue, and social inclusion.
monitoring and review) for
their respective districts.
Street plays based on local

art forms were performed
to cater to larger audiences
in the villages. This also
helped interact with
community leaders and
faith leaders to influence
them to promote RI.
Stakeholders have FLWs now have enhanced DoHFW has noticed an

better understanding
Result
IPC skills and better increase in the demand

of immunisation and its knowledge on the for their services from
benefits, and discuss GATHER approach. They communities in the
institutional delivery, communicate better and intervention blocks. There
immunisation, and effectively deliver key is also an increase in
exclusive breastfeeding messages on RI. immunisation rates.
with other family members.
There has been a positive
change in the FLWs’ outlook
towards socially excluded
groups. They are more
confident about their capacity
to deliver services and
counsel community members
on health practices.
Detailed communication
plans have considerably
strengthened the local health
departments. There now exists
a resource pool of trained
SBCC officials with improved
knowledge, communication,
and technical skills.
The Incremental Learning

Training Methodology
(ILTM) introduced in this
intervention has been adopted
by Jharkhand and Madhya
Pradesh. Ten capsule
modules were developed from
the original TARANG Module
for SBCC skills training.
References
[1]
Source: District Level Household Survey-3
[2]
Challenges as perceived and shared by UNICEF C4D team.
[3]
Universal Immunization Programme(UIP) provides vaccines against nine life-threatening vaccine
preventable diseases namely, diphtheria, pertussis or whooping cough, tetanus, polio, tuberculosis,
hepatitis B, measles, H Influenza type b and Japanese Encephalitis.
[4]
High priority districts are bottom 25 percent districts within a State (taken according to ranking based on
Composite Index) plus LWE or Tribal districts falling in bottom 50 percent (As per Ministry of Health and
Family Welfare, Government of India).
[5]
District Level Household Survey is a household survey at the district level, conducted by the
International Institute of Population Sciences (IIPS) under the auspice of Ministry of Health and Family
Welfare (MoHFW), Government of India (http://rchiips.org/).
[6]
5 HPDs are Bilaspur, Jashpur, Sarguja, Dantewada and Bijapur.
[7]
Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) is a flagship scheme of the
National Rural Health Mission (NRHM), Ministry of Health and Family Welfare, Government of India.
[8]
These customary laws of the tribal panchayats are based on their mythologies, beliefs, values, traditions,
perceptions of the universe and their transmitted social and cultural heritage through the generations.
[9]
Pentavalent vaccine is given to provide protection from five diseases: Diphtheria, Pertussis, Tetanus,
Hepatitis B and Hib. DPT
[10
Kalajatha is an Indian art form based on dance and music through which messages are conveyed
to people.
[11
Senior Health department staff included IEC Nodal officer and other Officers form the State IEC cell,
National Health Mission state level consultants, District Media officers, Tutors from Nursing Colleges and
Block Education extension officers.
[12
These included District Training coordinator, District Programme Manager, Block Programme Manager,
District media officers.
[13]
Initial 5 workshops were conducted in the 5 HPDS but later on as 3 more districts were added to Mission
Indradhanush, workshops were conducted in these 3 as well, totaling to 8 workshops.
[14
Few of the stakeholder related results are anecdotal.
[15
Findings from ‘SBCC Skills Assessment of Frontline workers’ Report, New Concept Information Systems
Pvt. Ltd., July 2016.
[16]
GATHER stands for the following six activities: Greet, Ask, Tell, Help in the decision-making, Explain,
Return. A FLW is expected to do in each of her interaction.
[17]
Eight districts are Jashpur, Surguja, Bilaspur, Dantewada, Bijapur, Balloda Bazar, Raipur and Korba.
[18]
This is anecdotal and based on interaction with State Immunization Officer of Chhattisgarh.
13
Improving the Lives of Adolescents

in Andhra Pradesh
UNICEF, in partnership with IKEA Foundation and Andhra University, initiated the ‘Improving the Lives
of Adolescents’ programme in the Visakhapatnam district of Andhra Pradesh in 2015. Through Andhra
University, UNICEF collaborated with the National Service Scheme (NSS) ﹘ a central scheme of the Ministry
of Youth Affairs and Sports, Government of India ﹘ which aims at personality development of adolescents
through volunteerism and community service. The intervention intended to increase the autonomy of
adolescent girls and boys over decisions regarding their lives, so as to improve their educational and health
status. Meena Radio Programme, Interpersonal Communication (IPC) videos, and customised training
modules were used to build capacities of adolescents, parents, and the community on adolescent issues.
Select NSS volunteers were trained to be Peer Leaders on leadership and community mobilisation skills, so
they could interact with other adolescents in their colleges and neighbouring communities through community-
based activities, advocacy meetings, and one-on-one interactions. The intervention increased knowledge and
confidence among adolescents, and sensitised the communities about adolescent issues. The programme
has empowered adolescents to become change agents and take critical decisions which affect their life.
Theory of Change
Adolescents become change agents, speak for their rights and
the rights of their peers. Communities protect them against
rights violation.
Improved
knowledge, Improved
motivation, and knowledge
confidence of and interest of
adolescents community
Capacity development Peer Interaction
Community Outreach
SBCC on adolescent issues, life skills, leadership, community mobilisation carried out.
Approaches – street plays, door-to-door interaction, college-level events. Communication
material – Meena audio content, IPC videos, customised booklets.
Partnership with Andhra University

and National Service Scheme.
Prevalence of child marriage, early pregnancy, child labour, anaemia, and

school dropout among adolescents. Adolescents have limited knowledge
about their health, nutrition, and hygiene. There's a need to reduce the
vulnerability of adolescents and increase their autonomy over decisions
impacting their lives.
Visakhapatnam
Map not to scale

Andhra Pradesh
Situation
As per UNICEF’s report on adolescents, 47% women Situation of adolescent girls and boys in
aged 20–24 are married by the age of 18[1] and often Visakhapatnam:
drop out of school, get married, and bear children very
In the district, 52% boys and 58% girls are anaemic[5].
early in life. This has serious implications on maternal
This causes fatigue and affects day-to-day activities
and child health. In India, 47% of adolescent girls are
as well as academic performance, resulting in them
underweight and 56% are anaemic[2]. Child marriage is
dropping out of school.
one of the leading causes for maternal deaths in India[3].
• Young children drop out of school to work for their
Across the country, both adolescent girls and boys
experience social and economic restrictions. Girls face family. In 2012-13, around 3,400 children in the
extensive limitations on their mobility and decision age group of 6-14 years were working as labourers
making, which affects their education, work, marriage, in the district.[6] In 2012-13, the dropout rate in the
and relationships. They are exposed to child marriage, district was 36% in children studying in classes
teenage pregnancy, child domestic work, sexual 1 to 10, and a particularly high 77% for the
abuse, exploitation, and domestic violence. Boys face Scheduled Tribe[7].
issues related to school dropout due to the need for
• In 2013-14, the percentage of boys married under
employment to support the family. Located along the
21 and girls married under 18 was 13.4% and
south-eastern coast of the India, Visakhapatnam is a
17.8% respectively, with a higher percentage in rural
port city and industrial centre in the state of Andhra
areas[8]. Family members get their daughters married
Pradesh. It has a rare mix of urban, semi-urban,
as soon as they reach menarche, fearing they might
rural, and tribal populations. Around 45% of the total
fall in love and marry against their wishes. They also
population of the city of Visakhapatnam dwells in low
fear the sexual harassment or abuse the girls might
income settings[4]. UNICEF commissioned a baseline
face at school.
study in 2014 to generate evidence in the areas of
education, health & nutrition, leisure, participation & life • Adolescents have limited knowledge about
skills, child labour, child marriage, trafficking, violence their hygiene, health, and nutrition, and are
against children, and the access and use of media hesitant to discuss these with others. Often,
by adolescents. they don’t understand the mental, physical,
and emotional changes they are going • Public services and authorities: To provide better
through, and have little to no support services related to health, nutrition, education, and
systems. protection to adolescents, and to promote their
rights among the public department and its officials.
• Girls have restrictions around mobility, and are
not allowed to travel alone or participate in public For this case study, only the first two stakeholders
events. They have no say in decisions regarding have been elaborated upon, since the UNICEF C4D
their own lives ﹘ such as health, education, and programme was actively involved with adolescents,
marriage. families, and community leaders.
To improve the situation in the state, it was critical to UNICEF’s partnership with Andhra University
reduce the vulnerability of adolescents and increase
UNICEF partnered with Andhra University[10], which
their autonomy over decisions impacting
led to a collaboration with National Service Scheme
their lives.
(NSS). Through this partnership, UNICEF reached out
to colleges affiliated to Andhra University, and teachers
who were a part of NSS and acted as NSS Programme
Officers (POs).
The NSS was established by the Ministry of Youth

Affairs and Sports[11] as a voluntary association of
young people called NSS volunteers. NSS POs guide
NSS volunteers with the primary focus on personality
development of students through volunteerism and
community service.
The National Service Scheme (NSS) is an Indian

government-sponsored public service programme
An NSS PO during a peer launched in 1969 under the Department of Youth
leaders workshop. Affairs and Sports of the Government of India.
Aimed at developing a student's personality
through community service, NSS is a voluntary
Method association of young people at the college,
university, and 2nd PU level, working for a
Government of India, in collaboration with UNICEF, campus-community linkage. The scheme is an
IKEA Foundation[9], and Andhra University, initiated extension of academic programmes which aim to
the ‘Improving the Lives of Adolescents’ programme inculcate social welfare in students, and provide
in Visakhapatnam in 2015. Communication for services to society without bias. NSS volunteers
Development (C4D) and UNICEF’s Child Protection try to understand the community in which they
programmes converged their efforts for the intervention. work and understand themselves in relation to
The objective of the programme was to increase their community. They identify their needs and
the autonomy that adolescents have over decisions problems, and involve them in problem-solving,
regarding their lives. For this, UNICEF engaged with which helps them develop a sense of social
three stakeholders: and civic responsibility among themselves. For
problem solving, NSS volunteers utilise their
• Adolescents: To help young girls and boys
knowledge to find practical solutions for individual
speak for themselves and their community to
and community problems, hence gaining skills in
bring change.
mobilising community participation and acquiring
• Families and community leaders (such as leadership qualities. They practise national
Self-Help Groups, Panchayati Raj members): To integration and social harmony, and provide aid
create an enabling environment for adolescents.
material was developed based on baseline survey
during natural and man-made disasters through findings and the existing repository of training material
food, clothing, and first aid to the victims. They on Social and Behaviour Change Communication
adopt villages for intensive development work (SBCC) for adolescent issues. UNICEF used the
such as setting up of medical centres, conducting following communication tools during this intervention:
programmes of mass immunisation, sanitation
1. Meena Radio programme[14]: Meena Radio
drives, and blood donation camps[12].
Programme is a 15-minute long radio programme
aimed at changing perceptions and behaviours that
Capacity development of adolescents hamper the survival, protection, and development
of girls. It uses stories in various media ﹘ print,
UNICEF built capacities of adolescents to ensure that
audio, and video ﹘ to induce Interpersonal
they have the knowledge, skills, and peer group support
Communication (IPC) and dialogue on
for fulfilment of their right to health, education, nutrition,
gender issues.
protection, and participation.
2. IPC tools: These were used for discussions with
NSS volunteers were trained under the programme on
girls and boys, parents, and community leaders.
the following topics:
Communication tools were based on key child
1. Emotional and psychological changes that rights issues, and issues related to child health,
adolescents undergo education, sanitation, and hygiene.
2. Social practices like child labour, child marriage, 3. Posters, leaflets, and flip-books: A set of six
violence against children, sexual abuse, and the booklets on adolescent rights, programmes for
implications of these adolescents, adolescent health and nutrition, and
menstrual health and hygiene was provided to
3. Adolescent health focusing on nutrition, personal NSS volunteers.
hygiene, and sexual health
4. Adolescent rights, entitlements, and laws Adolescent boys discussing

protecting them their opinions and issues.
5. Life skills education
6. Peer interaction
7. Leadership skills
8. Community mobilisation skills
9. Intergender relationships
The C4D programme focused on imparting life

skills, leadership, and community mobilisation skills
to adolescents so they can voice their own issues
and further mobilise and share their knowledge with
adolescents around them.
Using communication strategies and tools
UNICEF C4D promoted adolescent engagement and

participation through Interpersonal Communication
(IPC) and advocacy tools. Training material was
provided to NSS Programme Officers and NSS
volunteers, which comprised of five booklets on the
above-mentioned topics in Telugu[13]. This training
Peer Leader talking to her friends
about adolescent issues.
Action
The ‘Improving the Lives of Adolescents’ programme were uncomfortable to talk about these. Interpersonal
was implemented in two phases and reached 4,000 Communication (IPC) and gender sensitivity trainings
NSS volunteers of 21 colleges under Andhra University. were carried out to help them overcome their
Phase one of the programme was implemented in apprehension.
2015-16 in 18 colleges. Learnings from phase one were
Capacity Development of NSS Volunteers and
incorporated and implemented in phase two during
Peer Leaders
2016-17 in 10 colleges. The learnings were as follows:
Master Trainers trained NSS volunteers on adolescent
1. Advocacy is necessary for the active involvement
issues and its causes and implications. They promoted
of college principals.
dialogue between adolescents to address inter-gender
2. NSS volunteers need to be identified and disparities by giving real-life examples, and showcasing
capacitated with leadership skills, so as to the Meena Radio programme.
involve them as an added layer of resource in
the programme and enable them to be Peer Select NSS volunteers were also trained as Peer
Leaders for outreach sessions in communities and Leaders who would interact with other adolescents and
residential schools. communities around them. Master Trainers provided
life skills education to 1,200 NSS volunteers in junior
3. College-level outreach activities must be carefully
colleges, leadership, and community mobilisation skills
planned, taking into consideration the academic
to Peer Leaders through IPC videos and the Meena
calendar of the colleges.
Radio programme. The idea was to enable them to
Orientation and Capacity Development of NSS negotiate on decisions regarding their lives, and to have
Programme Officers them mobilise other adolescents and communities. The
role of Peer Leaders is elaborated below.
UNICEF trained NSS Programme Officers through
Master Trainers responsible for training them on Peer Interaction
adolescent issues. It was challenging to convince Peer Leaders discussed adolescent issues with
NSS POs to discuss sensitive adolescent issues adolescents in their college ﹘ either individually or
like sexual health and personal hygiene, as they in groups.
1. Each college organised events such as essay
writing, elocution, theatre, sports, and special An NSS volunteer expressing
her opinions during a training
camps centred around the theme of adolescent
session..
issues. Around 6,000 students were reached in 5
colleges through college-level events.
2. In addition, Peer Leaders and NSS volunteers

held interactive sessions with students of 8th and
9th standard in schools on adolescent issues. They
performed skits to put across information on the
prevention of child marriage, protection from child
abuse, maintaining personal hygiene, improving
nutrition, and continuing education. Approximately
18,000 students were reached through classroom
lectures in urban areas. Moreover, NSS leaders
reached out to 2,750 adolescent girls studying in
residential schools/hostels.
Community Outreach
Under the NSS scheme, colleges adopt low-income

areas and villages for 120 hours of community
service by volunteers in an academic year. Around
2,500 adolescents and their families were reached
through community outreach by NSS peer leaders of
five colleges. Under UNICEF’s programme, the Peer
Leaders and NSS volunteers carried out the following
activities in areas adopted by their colleges: Results
• Community-based group activities: NSS UNICEF and its partners have achieved the following
volunteers carried out rallies, performed skits, results in Visakhapatnam district[15]:
displayed posters, and sang folk songs about the Increased knowledge and confidence
implications of practices such as child marriage, of adolescents
child labour, and violence against children.
Adolescents can now understand the emotional and
• Community dialogue: Peer leaders engaged with physiological changes they are going through. There is
the community using IPC videos. improved knowledge on the following:
1. Importance of education
• Advocacy meetings: To encourage communities
to address these issues, knowledge about laws 2. Effects of child marriage and child labour
that protect children was advocated to adolescents’ 3. Legal provisions (rights, entitlements, and laws)
parents and community leaders such as Self-help protecting them against practices such as child
Groups (SHGs), local goverment members, marriage, child labour, violence, and child sexual
and elders. abuse
• One-on-one interactions: Peer Leaders had They express their feelings about changes in their body
one-on-one interactions with adolescents and their and confidently share information about adolescent
parents to discuss the importance of education, issues with their friends, family members, and the
effects of child marriage, and adolescent rights community. Their confidence has increased, and they
and entitlements. can speak freely in public.
“I have been a part of NSS since the last two “I was 13 years old when I got married. I got
years. Our college has adopted the Jalarpet slum each of my three daughters married when they
for community service. Our first experience of were 13, 16, and 18. But now, when I look at the
community service was eye-opening. We went students who come to our house and interact
with a very different mentality but, on our visit, with us to explain the consequences of child
we were shocked to see child brides, 20-year- marriage, I understand that it is a wrong and
olds with children, and children dropping out of illegal practice and contributes to domestic
school. During our initial interaction we found violence, and ill health of the girl. I wish there
out that most of the boys themselves wanted was someone to tell my parents and me that we
to get married early. They were not interested should wait till 18 to get married; our lives would
in studying and do not consider it important. have been better.”
There are various reasons to this attitude, like
B. Satyawati
poor educational infrastructure, poor sanitation
facilities in school, and lack of jobs after school.
After seeing all this, we felt lucky for the lives
we have. We wanted to work for the community.
We performed skits, rallies, wall paintings, and
This initiative has built a supportive environment for
shared our experiences. We also went door to
girls and boys in colleges and the communities they live
door talking to family members of the affected
in. As change agents, adolescents speak for their rights
children. We are proud of what we have done.
and entitlements. They convince their family members
Through this, we have overcome stage fear. We
and community to not practice child marriage and child
have learnt how to interact with the community
labour. Adolescents are persistent about continuing
and express our views. We have learnt to come
their education and, when forced by parents to drop out,
out of our homes and overcome the pressure we
they refuse and convince them to let them complete
have. We have slowly started to motivate others
their education.
through our actions. We work together to talk to
different people.
Girls discussing adolescent
Snighda Priyanka, 20 issues among themselves.
Gayatri school
Adolescent girls participating

in a college-level outreach activity.
Improved knowledge of community
Communities know about implications of social

practices such as child marriage, child labour, violence,
sexual abuse, and child trafficking.
They now know about laws that protect children

against these, and about appropriate ways to address
adolescent issues in their family or community. Families
and communities protect adolescents from their rights
being abused.
Caselet
Few boys join the NSS. This stems
down to a misconception on what
“My name is Madhuri and I am a student of St. activites the NSS engages in.
Ann’s college. I am an NSS volunteer for the
past 2 years. I received training from UNICEF on
adolescent issues in Visakhapatnam, because
of which I understand the consequences of
child marriage. My parents wanted me to get
married when I was 17. But since I had enough
knowledge about the consequences of getting
married at an early age, I knew that this was
not good for me. So, I spoke to the elders of
my family, my father and mother, and explained
to them that I was not mature enough to get
married. To prove my point, I gave examples
of girls in my college who got married and
later dropped out of college. Since I wanted to
continue with my studies, I told them again and
again and, after repeated discussions, I was able
to convince them to postpone my marriage. Now,
I am pursuing a Bachelors of Arts degree and
actively involve in NSS activities as a
Peer Leader.
Madhuri, 20 years old

St. Ann’s college
UNICEF plans to implement the programme in 40 more

colleges in Visakhapatnam and incorporate principals of
schools and colleges into the programme.
Students talking about

adolescent issues.
In Summary
UNICEF, in partnership with IKEA
Foundation and Andhra University,
initiated ‘Improving the Lives
of Adolescents’ programme in
Visakhapatnam district of Andhra
Pradesh. It aimed to increase the
autonomy of adolescents over decisions
that impact their life. This was done in
collaboration with the National Service
Scheme (NSS) in 2015. Here is a
blueprint of how the intervention was
rolled out in the Visakhapatnam district
of Andhra Pradesh.
Action
UNICEF trained NSS Select NSS volunteers were

Programme Officers to trained as Peer Leaders to
improve their confidence to spread awareness among the
discuss issues like sexual adolescents in their community.
health and personal hygiene.
Under the NSS scheme, Through various events and

colleges adopted community one-on-one interactions, Peer
outreach, targeting low- Leaders and NSS volunteers
income areas for 120 hours of discussed adolescent issues
community service in a year. with adolescents in their college.
Results
Adolescents are now better Communities are better aware

aware of child rights and the about the implications of child
legal provisions to protect rights violation. They can
them. They confidently express effectively address adolescent
feelings and share information issues, and are sensitised on
on adolescent issues. laws that protect children’s rights.
Adolescents are now confident UNICEF plans to implement

change agents, speaking for the programme in 40 more
their rights and entitlements, colleges in Visakhapatnam, and
and convincing their families incorporate principals of schools
and communities to not practice and colleges into the programme.
child marriage and child labour.
References
[1]
Anthony, D., 2011. The state of the world's children 2011-adolescence: an age of opportunity.
United Nations Children's Fund (UNICEF), 22.
[2]
Ibid., 21.
[3]
World Health Organisation and UNICEF, 2012. Trends in maternal mortality: 1990 to 2010: WHO,
UNICEF, UNFPA and The World Bank estimates.
[4]
` Registrar General, I., 2011. Census of India 2011. Office of the Registrar General Census Commissioner,
India. Indian Census Bureau.
[5]
Household, D.L., 2012. (DLHS-4), 2012-2013 fact sheet Andhra Pradesh. International Institute for
Population Sciences Deonar, Mumbai. Ministry of health and family welfare, Government of India, 13.
[6]
Child Statistics. 2012-2013. Andhra Pradesh. Directorate of Economics and Statistics, Government of
Andhra Pradesh.
[7]
Child Statistics. 2012-2013. Andhra Pradesh. Directorate of Economics and Statistics, Government of
Andhra Pradesh, 122,126.
[8]
Household, D.L., 2012. (DLHS-4), 2012-2013 fact sheet Andhra Pradesh. International Institute for
Population Sciences Deonar, Mumbai. Ministry of health and family welfare, Government of India, 13.
[9]
IKEA foundation, headquartered in Netherlands, founded by Ingvar Kamprad, works to address
children’s fundamental needs while helping communities fight and cope with climate change.
[10]
Andhra University is among the oldest state universities in India. It offers graduate, postgraduate,
doctoral, post-doctoral, technical, and professional courses.
[11]
The Ministry of Youth Affairs and Sports, a branch of the Government of India, which administers
Department of youth affairs and Department of Sports in India.
[12]
http://nss.nic.in/aboutus.asp
[13]
Dravidian language of a people forming the majority population of the South Indian state of
Andhra Pradesh.
[14]
The Meena Radio Programme is an entertainment-education programme that was developed by
UNICEF in partnership with the Department of Education, Government of Uttar Pradesh (GoUP) and its
Sarva Shiksha Abhiyan (SSA) State Project Office.
[15]
Based on the inputs shared by NSS volunteers, NSS Programme Officers and community during
interactions for this case study's documentation.
14
Empowering communities
and adolescents for
collective ownership of
Child Marriage Free Gram
Panchayats in Rajasthan
Despite the strong laws legislated by the Government of India (GoI) against child marriage[1], the practice
continues across various states in India, including Rajasthan. According to National Family Health Survey (NFHS)
[2]
-4, child marriage is prevalent in Rajasthan with 35.7% boys married below the age of 21 and 35.4% girls
married below the age of 18. The practice is sanctioned across most communities in the state and is associated
with strong social norms[3] around caste and gender, poverty, lack of access to schooling, and cultural practices
like Aata Saata Pratha (bride exchange). Women and Child Development (WCD), Government of Rajasthan
(GoR), in partnership with UNICEF, launched an initiative for the prevention of child marriage by empowering
communities and adolescents to create Child Marriage Free Gram Panchayats (GP)[4]. The initiative adopted the
framework to abandon and shift existing social norms by engaging with the community to formulate new ones
around adolescent empowerment, and giving adolescents the opportunity for further learning and development.
The framework focused on engaging with key influencers ﹘ Panchayati Raj Institution (PRI) members, leaders,
community members, and adolescents themselves ﹘ and imparting to them knowledge about child marriage,
influencing change in their outlook, and empowering them to bring about change. The Sarpanch and Sathins[5]
were seen as catalysts of this social movement for change, and their capacity was adequately enhanced to
effectively deliver their critical role. This included their communication and engagement skills for social and
behaviour change, counselling skills, and a keen understanding of the importance of education and skill building
of adolescents as opposed to the ill-effects of child marriage. During this intervention, a guideline document
for Child Marriage Free Gram Panchayats (CMFGPs) was developed by WCD in collaboration with UNICEF.
As a result of this intervention, adolescents have gained more knowledge about their rights and educational
opportunities. They are also more confident, and have the ability to engage and express their thoughts to
other members of the community. This is evident in the number of girls who have been awarded with GARIMA
Samman for coming forward and taking action against child marriage. Hundred and ten PRI members have been
recognised by the district administration for their efforts to strengthen this initiative against child marriage. By
2017, 175 GPs have declared themselves child marriage-free, and continue to pursue the dream of empowering
their adolescents for a better future with multiple opportunities and alternatives for development.
UNICEF C4D
Theory of Change
Government of Rajasthan Government of Rajasthan

Agency of adolescents Increased dialogue among constituted Garima Balika
communities about child formulated the State
enhanced - knowledge Sanrakashan Samman Strategic and Action Plan
built and confidence marriage and adoption of to reward the girls who
initiative for child marriage- for Prevention of Child
strengthened showed courage and Marriages
free panchayats fought back child marriage
Capacity Development of Changing the norm

GP members, FLWs and through intergenerational
Adoption of Gram
School Teachers on SBCC; of dialogue, public
Panchayat (GP) as
caste and religious leaders, deliberations, and
key platform and GP
service providers in marriages committment, positive
members as influencers
and member of village level sanctions for reinforcing
and change agent
committees on child education new norm, monitoring for
and child marriage compliance
Child Marriage
Existing gender and Limited access to Political patronage to

High cost of marriage
caste norms perpetuate secondary education for caste groups lead to
leads to cyclic poverty
child marriage girls and boys weak enforcement
of law
Rajasthan
Map not to scale

Intervention State
Situation
Child marriage is a practice that finds its roots in the Akshaya Tritiya and Mahashivrathri festivals
Indian history. Over time, the Indian Government has in the states of Andhra Pradesh, Bihar, and
taken numerous steps to strengthen laws against Rajasthan.
child marriage and reduce its existence in the country.
• Poverty, high wedding costs, and other
However, given the social and cultural norms prevalent
economic considerations sometimes drive families
around child marriage, reducing it has been challenging
to marry off their children early. Similarly, big family
for more reasons than one. ‘Reducing Child Marriage in
events/ceremonies[6] provide opportunities to
India’, a UNICEF report written by the Centre for Budget
minimise cost and conduct marriage at the same
and Policy Studies (CBPS), states the following as
event with all members present.
drivers of child marriage in India:
• Lack of easy access to schooling (mainly
• Widely accepted and sanctioned social norms:
distance) combined with low value given to
i Sibling and cross-marriages/Aata education, especially of girls, leads families to
Saata Pratha: One brother-sister pair is marry girls off early, so that the onus of protecting
simultaneously married to another brother-sister her and her chastity (which is equated to family
pair from the same village, tribe, or clan. honour) is transferred to the groom’s household.
ii Linking marriage to ceremonies: Marriage
• Political patronage: Communities with formal
is solemnised along with a large or important
groups like caste panchayats[7] form a key voting
event like Mrityubhoj[6] (UNICEF & ICRW, 2011).
block and often have political connections.
iii Communal relationships: A practice reported from
Enforcement agencies and Frontline Workers
Andhra Pradesh, where parents marry off their
(FLWs) find it difficult to influence and go against
daughters to repay debts. These marriages are
their rules and norms. The other drivers for
solemnised between a bride and groom of
prevalence of child marriage are:
different castes as well.
iv Mass child marriages: On a few auspicious • Gender norms that consider women possessions
occasions, communities conduct mass marriages rather than equals results in their unfair treatment.
of girls and boys. This practice is common during Fear of losing family honour in case of a premarital
sexual relationship and viewing child marriage as produced anecdotal changes led by outliers. A journey
the means to save the family from any possible to initiate collective change was hence envisaged
dishonour is grounded in gender norms around and planned. Given the high amount of homogeneity
virginity. Even the seemingly poverty-driven act within caste groups and strongly demarcated inter-
of marrying off girls in lieu of debt has its roots in caste lines, it seemed apt to initiate work with caste
prevalent gender norms that privilege men in every groups and caste panchayats. Reasonable amount of
respect, while denying a voice to girls. success was achieved through this approach, as the
propensity of individuals to adopt change was higher,
• Strong sanctions against inter-caste marriage
and encouraged by non-ambiguous empirical[10] and
place more importance on dignity and pride than
normative[11] behavioural evidences. Positive aspects of
the choices of a girl or boy. Marriage is perceived
this experience were drawn and taken to the next level
as a solution to escape the negative sanctions[8]
through a GP-driven approach. This approach ensured
of an inter-caste marriage, which leads to many
a larger-scale collective change and adoption of new
families indulging in child marriage. Negative
social norms that could be initiated and sustained
sanctions such as social ostracism and large
through the existing government structure.
fines are imposed to ensure that deviance from
social norms are minimal. Data indicates that child
In India, panchayats form the lowest tier of the local
marriage is prevalent across both genders.
self-governance structure in states, and are responsible
Recognising the criticality of the predicament, for the development of villages under their jurisdiction.
Department of Women and Child Development Their independent nature gives them complete
(WCD), Government of Rajasthan, in partnership jurisdiction over all social, economic, and cultural
with UNICEF[9], launched an initiative for prevention matters within the GP. In consonance with the mandate
of child marriage. The initiative initially adopted of the Gram Panchayat and an underlying emphasis
an individual-case-based approach, followed by on sustainability & scalability of change, a field initiative
a caste-based approach, and finally the Gram towards CMFGs was mutually conceptualised.
Panchayat (GP)-based approach. This progression A detailed guideline was prepared to declare
of the intervention is detailed in the 'Method' panchayats child marriage-free, and was dynamically
section. reviewed as the implementation progressed.
In the districts of Jodhpur and Bikaner, Government

“A panchayat which has the foresight of
of Rajasthan and UNICEF partnered with Urmul
to take this programme to field. Urmul has been
development and opportunities for all
working across different districts of Rajasthan children in its boundary, and ensures
since 1987 on various social issues like women the marriage of girls only after the age
empowerment, livelihoods, child rights, education,
of 18 years and boys after 21 years ﹘
health, etc. Over the years, they have worked
towards betterment of girls across villages. This continuously for three years ﹘ will be
includes their work on prevention of female declared as a Child Marriage Free Gram
infanticide, residential education for girls, vocational Panchayat (CMFGP).”
training, and life skills training. Given the alignment
in their goals, the organisations came together for
this intervention.
Method
Early in the intervention, it was clear that the nature
and proportion of the issue of child marriage was so
intense that an individual-change-centric approach was
not a long-term solution. This approach was resource
intensive, lacked a long-term solution, and at best
Radha's family sharing their views on
the education of girl children.
This plan adopted the social norms framework of towards change, and helped create a tipping
creating a new norm. The process includes the point in the community. These exchanges were
following six sequential phases: planned to ensure that the entire reference group
participated in the change collectively.
1. Identification of key stakeholders,
reference groups, key change-makers, and 4. Introduction of positive sanctions for non-
influencers: This phase involved identification of compliance: Collective ownership was instilled
communication networks, channels, vulnerable
to formulate positive milestones which would in
families and adolescents, key decision makers,
turn help eliminate established externalities and
and gatekeepers in each given GP.
sanctions. This made families aware of other
families which were equally keen on changing the
2. Changing the normative beliefs: Despite the
existence of clearly personal normative beliefs status quo, and ensuring girls and boys had equal
that favoured child marriage due to lack of opportunities to learn and develop rather than get
knowledge, it was clear that people’s preference married early. This included identifying and giving
to engage in child marriage depended on recognition to stakeholders who had shown a
social expectations. In fact, during one-on-one positive deviance and established their own trend.
discussions, it became increasingly clear that
there could exist a case of pluralistic ignorance 5. Creation of new normative expectations: The
where a large number of community members emergence of new behaviour driven by new
privately did not endorse the practice yet publicly normative expectations led to updated empirical
claimed to do so, hence reinforcing the social expectations of the community members.
norm. It was critical to change these beliefs and
ignorance collectively. 6. Observance of compliance to new empirical
expectations: This phase included collective
3. Collective decision-making to change the observation to ensure that all members of
norm: Inter-generation dialogues were initiated, community practice marriage at the correct age.
focusing on reasons for change and providing and education of girls is continued.
opportunities to get exposed to other people's
normative beliefs. It also made stakeholders The details of the steps followed in each of these
aware of an increasing mass of people shifting phases is detailed in the following 'Action' section.
Phase 2: Changing the normative beliefs
Despite being married at
an early age, Radha has
Capacity Building and Sensitisation: Panchayat
continued her education members, FLWs, and school teachers were trained on
and hopes to become Social and Behaviour Change Communication (SBCC).
an officer. This focused on enhancing their communication skills
to engage the community, discuss education and child
marriage-related issues, and be the change leaders in
their own communities. In addition, caste & religious
leaders, service providers in marriages, and members
of other village-level committees were sensitised about
the importance of education for children (especially a
girl child) and ill-effects of child marriage.
Different communication tools like printed material,

wall paintings, display boards at prime locations,
phone messages, etc. were used to spread information
to all members of the community. One such important
communication tool was a caravan which was loaded
with various communication material like posters
and videos, and traversed all schools in villages.
Action Information about government schemes related to

education, and processes for availing these schemes
Phase 1: Identification of key stakeholders, were also distributed by resource persons aboard this
reference groups, key change-makers, and caravan. Family and school-based engagement with
influencers parents, teachers, members of school committees,
and other community structures were undertaken to
As a first step, the districts were categorised into three
sensitise about child marriage and the importance
﹘ high, medium, and low child marriage-prevalence
of education for children by Sathins, PRIs, and CSO
districts based on the secondary data. A total of
members.
14 districts with high prevalence of child marriage
in the state were identified. Within these districts, Phase 3: Collective decision-making to change
high prevalence blocks and Gram Panchayats were the norm
identified based on the secondary data available.
It was important to initiate an inter-generation dialogue
Further, in each Gram Panchayat, communities were
in public spaces. Innovative communication tools and
mapped. Key influencers and gatekeepers such as faith
approaches were employed to stimulate this collective
leaders, caste leaders, and elders were mapped on
engagement. A case in point was a human-puppet
one hand, and vulnerable families on the other. From
interactive show format, which was familiar yet unique.
these, the details of the children, adolescents (10-
The scripts for these shows were based on real events
19 years), and their marital[12] and educational status
that had occurred in the past in relation to adolescent
was collated. The information around communication
networks, channels, and opportunities was also taken girls and boys of the community. The scripts highlighted
into consideration. This exercise was conducted by the the role of fathers and mothers, and how they can
Sathin and, at the end of the exercise, each Sathin had take decisions that would help improve the lives of
a social map of the village highlighting the girls and their children. The puppet shows ended with an open
boys at the risk of an early marriage. Girls and boys discussion among the participants and the facilitator
at risk of getting married early were tracked and their about the importance of education, child marriage, and
status was monitored regularly. The Sathins, in turn, its ill effects on adolescents’ physical and mental health.
were oriented by many Civil Society Organisations These shows were able to evoke a strong response
(CSO) along with Urmul, who came together to from the communities, and many of the participants
implement the initiative in other districts with support were able to understand the impact of their decisions on
from UNICEF and UNFPA. the lives of their children.
Finally, public meetings or Gram Sabhas ﹘ Jaajam Phase 5: Creation of new normative expectations
﹘ with participation from the entire village were
organised, where leaders of the village took public The panchayat members, in agreement and consent
oaths and explained the demerits of child marriage. from the community members, defined the new practice
Self-certification by PRI members, FLWs, and school of ‘no child marriage’ in their panchayats and submitted
teachers enhanced the accountability towards their a plan to the block office of WCD to become child
respective responsibilities to prevent child marriage in marriage-free in three years’ time.
their panchayat. Challenges of families and adolescents
A team of block and district-level experts conducted
towards adherence to this new social agreement was
an impromptu visit to observe the situation of the
understood and addressed by the community. This
village after one year. For a complete year of ‘no child
involved coordinated actions, collective discussion and
decisions, and a series of collective pledges. marriage’ in the Gram Panchayat, the declaration was
made in a block/district-level function. After validation
Phase 4: Introduction of positive sanctions for and internal consultations, the district committee would
compliance to new norm add the panchayat to the list of Child Marriage Free
Ladli samman was initiated in the intervention area to Gram Panchayats, and recommend it to the state-level
reinforce the new practice. This award aimed to honour committee in WCD.
families and adolescent girls who took the initiative to Phase 6: Observance of compliance to new
delay early marriages, as well as underage brides who empirical expectations
continued to stay in their parents’ house and pursue
their education till they turned 18 years old. Cases of Monitoring stability of the new norm and avoiding
such positive deviance were identified and honoured slippage was an important activity undertaken by the
in a community event with large fanfare. The award Sathins and GP members. Maintaining three years
winners went back to their villages and communicated without child marriage was encouraged through
the message of ‘no child marriage’, and shared their monitoring, and a follow up by block and district officials
experience with other community members. As time led to a final certification at the end of three years of
passed, these numbers continued to grow and public no child marriage. This honour was given in a grand
proclamation inspired more families to adopt the function to be a motivation for the villagers to continue
change. practicing the new norm of ‘no child marriage’.
School children enthralled by

the performance.
Results Community
Communities enjoy a sense of honour and responsibility

Following are the results from this intervention:
in providing their daughters security, protection, and
Adolescents access to schooling. They are now empowered to make
decisions for girls from their panchayats and ensure they
• The members of adolescent groups have gained get their due rights.
knowledge about their rights and have enhanced
Hundred and ten PRI members have been recognised by
opportunities of education.
the district administration for their work in preventing and
• Members of the adolescent girls’ group have much strengthening this movement against child marriage.
more confidence, and can express and share
System
opinions with their families and the community
with ease. 173 panchayats have been declared child marriage-
free as a result of this intervention. A prize has been
• As part of the GARIMA Samman, exceptional
constituted to recognise panchayats working towards a
actions of girls have been identified
child marriage-free panchayat.
and recognised[13]:
1. 100 girls have been awarded the GARIMA

“I am the head of my panchayat for the
Samman across different districts for their last three years, and it was declared child
commendable work against child marriage. marriage-free in 2016. According to me, at
2. 2000 girls have become change-makers. They least 60% girls in the village are enrolled
are the ones who have either refused child
in schools and attend regularly. Girls are
more meritorious than boys and perform
marriage or have lent their support to someone
in the state board exam results. A girl is a
else fighting child marriage.
change initiator and, if she gets educated,
Based on the positive response to the Ladli two households get educated. The triggers
samman award in creating change-makers and role of change that led to the child marriage-
models, the Government of Rajasthan adopted and free status of my panchayat are education,
modified it to distribute under the name GARIMA Balika government laws against child marriage, and
Sanrakshan Samman. the support from UNICEF. I did and continue
to encounter opposition from elders in my
village about this, but I have learnt how to
Students, school staff, and local officials negotiate and convince them. My biggest
engrossed in a puppet show.
supporters are the adolescent girls who have
been empowered through the education and
training given by UNICEF. ”
Bhagusan Khilaeri, Sarpanch,
Lakhasar Panchayat, Bikaner
In 2014, the following systemic results were achieved:

• Formulation of guidelines for prevention of child
marriage.
• Launch of Ladli campaign which opposes against
sex determination and sex selection of the
unborn child.
• Launch of an award by the government for Child
Marriage Free Gram Panchayats, and
Zilla Parishad.
Handmade puppets used
in the puppet show.
• In 2015, the Government of Rajasthan constituted • Formulation of the State Strategic and Action Plan
GARIMA Balika Sanrakshan Samman, an award for for Prevention of Child Marriages by the Women
girls who have shown courage and fought back child and Child Development, Government of Rajasthan
marriage. It is held annually on the 24th of January. to create a child marriage-free Rajasthan.
Caselet
Santosh studies in Class 12 in a Senior

Secondary School in Lakhasar panchayat of
Bikaner district. When the UNICEF programme
came to her village, it piqued her interest and she
joined the adolescent group. With leadership and
life skills trainings from UNICEF, she started to
feel more confident about herself and was able to
fearlessly express her opinion on public platforms.
She is now the leader of her adolescent group
and facilitates group meetings. As the leader,
she checks on any early girl dropouts in her
school and follows up to get them back to school.
She strongly opposes the practice of Mrityubhoj
(feast after death) and had protested peacefully
in her village with her adolescent group. As part
of this programme, she was sent to participate
in the International Girl Child Day event in 2016.
According to her, this programme has helped her
become more confident, given her the opportunity
to interact with new people, and participate
in different events ﹘ thereby increasing her
exposure to the outside world.
In Summary
UNICEF, in partnership with Women and Child
Development (WCD), Government of Rajasthan
(GoR), launched an initiative for prevention
of child marriage. The intervention aimed to
empower communities and adolescents to create
Child Marriage Free Gram Panchayats (CMFGP),
by abandoning existing social norms and
engaging with the community to formulate new
ones. Here is a blueprint of how the intervention
was rolled out in Rajasthan for stakeholders like
GP members, leaders, adolescents, and Sathins.
Action
After identifying districts with

a high prevalence of child
marriage, local communities
and government officials were
brought into the fold to initiate
sustainable change.
Ladli Samman was given

to adolescents and their Capacity building on SBCC was
families who took initiative to conducted among panchayat
delay child marriage or put members, FLWs, religious
persistent efforts to continue heads, and community leaders.
the education of their girl child. Different printed and digital
This encouraged the villagers mediums of communication
to actively participate in the were used.
prevention of child marriage.
110 PRI members were
Results
Adolescent groups now have recognised by the district

enhanced knowledge about administration for their work to
their rights. Girls are confident strengthen the movement against
enough to express their views child marriage. The communities
and share opinions with family take pride in providing girl children
members. security and schooling,and
leverage the panchayat to ensure
girls their rights.
173 panchayats have

been declared child
marriage-free as a result
of this intervention.
The Government of Rajasthan Women and Child Development,

has constituted Garima Balika Government of Rajasthan has
Sanrakshan Samman – an formulated a State Strategic and
award for girls who have fought Action Plan for Prevention of
child marriage practices. Child Marriages to create a child
marriage-free Rajasthan.
References
Under Child Marriage Restraint Act (CMRA) 1929, also popularly known Sarda Act after its
[1]
sponsor, Harbilas Sarda who hailed from the State of Rajasthan, the marriage age for girls
was fixed at 14 years and for boys at 18 years which was later amended to 18 years for girls
and 21 years for boys. In 2006, Prohibition of Child Marriage Act (PCMA) was formulated to
include stricter legislations.
NFHS is conducted by the International Institute of Population Sciences (IIPS) under the
[2]
aegis of Ministry of Health and Family Welfare (MoHFW), Government of India to gather
essential data on health and family welfare and emerging issues in this area.
Social norms refer to the unwritten rules that govern social behaviour. More details at https://
[3]
www.UNICEF.org/protection/files/4_09_30_Whole_What_are_Social_Norms.pdf
A gram panchayat is the cornerstone of a local self-government organisation in India of the

[4]
Panchayati Raj system at the village or small-town level and has a sarpanch as its elected
head. There are a total of 2,40,355 GPs in India, and Rajasthan alone has 9,199 GPs
(source: nird.org.in). GP is responsible for conducting the administrative and development
fuctions of the panchayat. This involves solving local dsiputes, undertaking work for safety,
sanitation, health, education, agriculture, etc. in their panchayat. Number of villages under a
gram panchayat are dependent on the population density of the region.
A Sathin is a paid resource appointed in each village by the local governing body. The
[5]
essence of Sathin's role is to give support to the problems of the women of the village as a
friend, mentor and guide.
Examples of such ceremonies include Mrityubhoj and auspicious days such as Akha teej
[6]
and Peepul puniya in Rajasthan. Mrityubhoj is a large feast organised after death of an
elderly family member. Akhateej is the annual spring festival celebrated by Hindus and
Jains. More details at https://en.wikipedia.org/wiki/Akshaya_Tritiya
Caste panchayats are caste-specific juries of elders of a particular caste for a village or a
[7]
higher level in India.
Sanctions are socially defined rules against a member of the community for his/her actions.
[8]
These could be either negative or positive in nature.
Within UNICEF, two departments, Child Protection and Communication for Development
[9]
worked in close cooperation for this intervention.

[10]
Empirical behaviour consists of a pattern of behaviour such that individuals conform to it as
they believe that most people in their relevant network conform to it.
[11]
Normative behaviour consists of a pattern of behaviour such that people practice or conform
to it as they believe that others in their reference network believe they should do so.
[12]
Within marital status; the following details were checked and updated. If married, whether
they are staying with their parents or at their husband's house.
[13]
Source: Programme Data
15
Narrowing the Gap

Equity Programming
for Improving Routine
Immunisation in Underserved
Municipal Corporations of
Bhiwandi and Malegaon in
Maharashtra
Maharashtra — a state in the Western region of India — is the financial, industrial, and economic capital
of the country. According to the Economic Survey of Maharashtra (2016-2017), the state’s Gross Domestic
Product (GDP[1]) is approximately 15 percent of the country’s GDP[2]. While this indicates high economic
growth, it does not necessarily reflect the overall development of the state. According to the National Family
Health Survey-4, the rate of immunisation (BCG, measles, and three doses each of polio and DPT) for
children aged 12-23 months in the urban areas of Maharashtra is 56 percent — fairly low as compared to the
national average of 64 percent[3]. GoI identified Thane and Nashik districts from Maharashtra as High Priority
Districts (HPDs) under 'Call to Action' [4]. Within these two districts, Bhiwandi (Thane) and Malegaon (Nashik)
were identified as the high focus areas. Given the alignment between the Government of Maharashtra
(GoM) and UNICEF, an initiative was decided upon to ‘Improve the RMNCH+A in Bhiwandi and Malegaon’ in
Maharashtra with strategic focus on RI.
UNICEF used the equity lens approach for this intervention to ensure the vaccination of every child in the
intervention area. To bring about a change in the RI coverage, the intervention targeted three levels of
influencers: Interpersonal (family and friends), Community (mobilisers), and Social Networks (influencers).
An integral and critical part of this intervention was the creation of a cadre of community mobilisers who were
trained on Interpersonal Communication (IPC) skills and given technical training about RI. These mobilisers
conducted one-on-one interactions and organised meetings with mothers, fathers, elders, and religious
leaders. They engaged with them to sensitise them about RI and its importance for a child’s good health. As
a result of this intervention, the demand for health services has increased in both Bhiwandi and Malegaon.
Community mobilisers now have improved interpersonal skills and can support the government for other
development initiatives. The immunisation rate in Bhiwandi has increased by 6 percent after this intervention,
indicating progress towards achieving improved RMNCH+A.
Theory of Change
System Strengthening: Enhanced knowledge

Within the municipal Understanding of the fact among community
corporation, the services Creation of a new cadre members about their
that SBCC is required.
for RI have improved, of community mobilisers health entitlements
Municipal Corporation has
showing results with better within the health system leading to high
agreed to integrate a BCC
coverage of the fully who can be engaged for demand of services
cell in the corporation.
immunised and reduction other programmes. and improvement
in polio vaccine refusal. in health-seeking
behaviour.
Creation of a network
of community mobilsers Social Mobilisation Engaging with
from among the (engagement, discussion multiple stakeholders Capacity building of health
community members and counseling) for and influencers in staff on cold chain and
and capacity building demand generation from the community for communication for RI.
of these mobilisers for the community. gathering support for the
community outreach. intervention.
Government of Maharashtra (GoM) and UNICEF initiated an intervention to ‘Improve the

RMNCH+A in Bhiwandi and Malegaon' with a strategic focus on RI. Use of equity lens by
UNICEF to ensure every child in the intervention area is vaccinated.
Bhiwandi and Malegaon were selected for intervention using the equity, gender, and inclusion lens
to reach every child. In these corporations, there is:
• A majority of Muslim population, which lives in densely populated areas which lack proper
sanitation and hygiene
• Absence of information on RMNCH+A and weak health and ICDS systems, which creates
mistrust between the corporation and community
• Myths and misinformation about immunisation among the community members that discourage
demand for health services
Focus on routine
High economic growth Focus on highly immunisation in the State in
of state, but unequal vulnerable and the Call to Action high priority
human development disadvantaged sections of districts, especially in the
across different parts the population under GoI's low income households in
of the state. Call to Action strategy. urban areas where health
indicators are lower and need
immediate intervention.
Maharashtra
Map not to scale

Intervention State
Situation
The Reproductive, Maternal, Newborn, Child, and health. The National Family Health Survey (NFHS)-4
Adolescent Health (RMNCH+A) 2013 document of shows that the rate of immunisation in urban areas
the Ministry of Health & Family Welfare (MoHFW), of Maharashtra is 8 percent less than the national
Government of India (GOI) details a strategic roadmap average[5]. Similarly, the percentage of children in urban
for accelerating child survival and improving maternal areas in Maharashtra who have received polio, BCG
health with a continuum of care approach. It lays special (for tuberculosis), and DPT vaccines was lower than
emphasis on the most vulnerable and disadvantaged the national urban area statistics. The percentage of
groups, especially in the 264 districts which have been children who had received measles vaccine in urban
identified as high focus areas. The priority population Maharashtra is same as the national average.
for the government includes residents of urban slums
The Department of Health (DoH), GoM identified 10
and tribal areas, vulnerable people falling in the
districts – including two municipal corporations[6] of
categories of Scheduled Castes (SC), Scheduled Tribes
Bhiwandi and Malegaon, falling under Thane and Nashik
(ST), minorities, urban poor, women, and migrants, as
districts respectively – that have low performance in
well as occupation-based groups in the underserved
RMNCH+A, and need concentrated efforts to improve
areas. Reproductive, maternal, and child morbidity is
RI of infants and children. World Health Organisation
more likely to be concentrated in these areas. Reaching
(WHO) data shows that these two municipalities were
the entire identified underserved population would
the last polio reservoirs in the state. Bhiwandi was one
ensure equitable development for all. Further, a specific
of the most challenging epicentres in the country to
focus has been put on strengthening the Routine
eliminate the polio virus, with 7 polio cases identified
Immunisation (RI) programme.
between 2002 and 2008. Similarly, Malegaon has been
The ‘National Call to Action: Child Survival and a very high-risk area for polio wild virus transmission.
Development 2013’ launched by Government of This makes the two municipalities highly vulnerable to
Maharashtra (GoM) is a follow up of this, and focuses resurgence of the polio virus. The high influx of migratory
on accelerating child survival and improving maternal population further increases this phenomena.
About Bhiwandi and Malegaon
Almost half the power looms in India are in Bhiwandi The myths and misinformation about immunisation
and Malegaon — 7 lakh and 3 lakh respectively [7]. among the caregivers further discourages mothers from
These looms attract migrants from the northern states seeking immunisation services. Examples of myths
of Uttar Pradesh, Bihar, and West Bengal who have as shared by the mothers are: "Vaccination causes
migrated and lived in these cities for the last 25 years. illness in children" and "Vaccination causes physical
Bhiwandi and Malegaon have a predominantly Muslim deformities in children". Many of these are based on the
population; 65 percent and 79 percent respectively fear of Adverse Event Following Immunisation (AEFI)
according to Census 2011. Most of them live in high- and misinformation is passed on among and within
density population areas and belong to low-income family members, leading to a larger misunderstanding
households with limited sanitation and hygiene facilities. in the community; in turn hindering immunisation.
RI rates in both were low; 42 percent in Bhiwandi and
39 percent in Malegaon[8]. UNICEF’s core commitment focuses on narrowing this
gap, and reaching the most deprived and vulnerable
Absence of information on RMNCH+A, and weak children. It is evident that deprivation of child rights
health and Integrated Child Development Services is mostly prevalent in the poorest and marginalised
(ICDS) systems created mistrust between the groups. With increasing evidence, a paradigm shift has
corporation and community. According to the NFHS- led to renewed efforts in urban areas, since poverty is
4 data, the immunisation coverage for infants in a critical determinant of inequalities in child survival,
Bhiwandi and Malegaon is 42 percent and 39 percent growth, and development. As UNICEF’s philosophy
respectively, which is way lower than the state and aligned with Government of Maharashtra’s strategy to
national average. 76 percent pregnant women in improve the RMNCH+A (especially RI), it partnered with
Bhiwandi and 85 percent in Malegaon were severely UNICEF to launch an intervention to improve RI in the
anaemic, and the percentage of home deliveries was two identified municipalities.
13.9 percent in Bhiwandi and 6.5 percent in Malegaon[9].
Myths and misinformation about

immunisation discourages mothers from
seeking immunisation services.
Method
UNICEF Communication for Development (C4D) reached out to the community, and bridged the last-
used an equity focused approach for this intervention. mile gap in the health system. The following ‘Action’
The objective was that every child, irrespective of section details the creation process of
their community, caste, and economic status should these mobilisers.
receive immunisation. To identify the most effective
means of targeting immunisation, UNICEF used the Interpersonal Communication (IPC) skill building for
Socio-Ecological Model (SEM) to identify the different community outreach: Mobilisers were trained in IPC
intermediaries who would be able to reach the to reach out to the community, engage with them, and
stakeholders and bring about change. gain their trust. This was necessary, as the community
was known to strongly oppose vaccination and formal
The Socio-Ecological Model healthcare. Strong communication from mobilisers was
key for this intervention to be effective and reach the
Policy/Enabling Environment intended stakeholders.
(national, state, local laws)
OrganiSational Social Mobilisation for demand generation from the
(organisations and social community: Technical training on RI and its benefits
institutions)
was provided to mobilisers. Thereafter, mobilisers
Community engaged with the community to:
(relationships between
organisations)
• Discuss RI and its importance
Interpersonal • Inform about the dates and venue of immunisation

(families, friends, social networks)
• Counsel them to go for immunisation and AEFI
• Support the immunisation process for social

Individual mobilisation
(knowledge, attitudes,
behaviours)
Engaging with multiple stakeholders and influencers:
Mobilisers interacted with multiple stakeholders to gather
support in bringing about a behaviour change in the
community. These included religious and community
leaders, midwives, elected representatives, and loom
owners and supervisors.
Of the five[10] levels in the SEM model, UNICEF
identified three around which the intervention worked.
These were:
• Interpersonal: Comprising of friends, family

members, and social networks
• Community: Comprising of community mobilisers
• Organisational: Comprising of religious and

community leaders, SHGs, and educational
institutions — whether educational or religious —
called madrasa
SBCC System Strengthening with Municipal

Corporation: SBCC strategy endorsement, capacity
building, and supportive supervision for social Mothers in PHC for weekly
mobilisation activities was ensured. A cadre of check-up.
mobilisers created by UNICEF drove this initiative,
One of the housing lanes in
Ansar mohallah.
Action
As part of the intervention, the following activities were Capacity Building:
undertaken:
CMCs: They were trained by UNICEF on IPC and
Creation of Community Mobilisation Network: technical skills related to RI. The focus of IPC skills
Urban areas have their challenges, and this is most was to enhance the CMC’s capacities to engage with
pronounced in the area of community engagement. community members and to initiate conversations
For instance, the enrolment of ASHAs is low and they around their health and health practices. CMCs were
are accountable to the Municipal Corporation Medical taught how to have a two-way conversation using the
Officer Health, under the RCH programme. This GATHER[11] principle.
system is weak with minimal technical and capacity
building opportunities provided to ASHAs. The ICDS Health Staff: A total of 81 and 100 health staff in
and health systems have no convergence, leading to Malegaon and Bhiwandi municipal corporations
anganwadi workers working in isolation in the same respectively were trained on cold chain and
community. With this increasing trust deficit between the communication for RI. Training on cold chain was
municipal corporation and community, it was decided given to impart knowledge about the new vaccines like
that UNICEF would recruit and train a new cadre of pentavalent and injectable polio vaccines.
community mobilisers from the same areas with the Mobilisation drives in the community: Each CMC
intention of helping them bridge the gap and build trust was assigned approximately 500-600 households, and
with their own communities. At the same time, UNICEF asked to conduct field surveys to create a list of eligible
aimed to support the process of behaviour change children and their immunisation status. The CMCs
through social mobilisation activities, and increase the followed this with counselling visits to each household,
demand for services through awareness, discussion, and conducting meetings for mothers, the community,
engagement. For this intervention, community mobilisers and religious leaders. The objective of all this was
were called Community Mobilisation Coordinators to enhance the demand of RI and increase the RI
(CMC). A total of 50 CMCs supported by two supervisors coverage in their respective areas.
were deployed in each of the two corporations.
Support from Influencers: The supervisors interacted • 107 rallies about RI were carried out by children
closely with the influencers and sought their support to from Madrasas
convince families, and spread messages about RI events.
• 26 community meetings, 2,388 mothers’ meetings
This was actively pursued in high resistance areas where
and 7 religious meetings were organised
communities were more resistant than others.
• A total of 9,764 children and 1,485 pregnant women
Apart from this, supportive supervision of cold chain was
were reached through the 881 outreach sessions
carried out during this intervention to identify bottlenecks
and help improve the speed and quality of supply chain In Malegaon:
processes.
• 130 community meetings and 1,490 mothers
During this programme, between April to December meetings were conducted
2016[12]:
• A total of 14,552 children were reached through
In Bhiwandi: 1,187 vaccination sessions.
• The defaulter rate reduced from 60 percent to 55
percent in nine months
A community mobiliser counseling

a mother about her infant's
vaccination during her daily rounds.
Community influencers were actively
involved in this initiative.
Results
System Strengthening: Within the municipal can carry out IPC. They can support the health
corporation, the services for RI have improved as department in implementing programmes in the
demand has increased from the community level. There future as they have established a trusted relationship
is also an understanding that SBCC is necessary and with their community.
the commissioners have agreed to develop a BCC 2. RI coverage has increased from 42% in 2013 to
cell within the RCH programme unit and requested 52% in 2016. (According to the WHO concurrent RI
UNICEF for technical assistance. RI is an entry point monitoring data)
and UNICEF will focus on maternal and child health
and nutrition (reduction of stunting) including violence 3. WHO monitoring data captures refusals between
Feb 2014 to Jan 2017 – 496 households refused the
against children, and girls' education.
oral polio vaccine as of January 2017.
Community[13]: The interaction with CMC and the
4. Continuous System Strengthening of both
doctors has helped them reduce their myths around
the Municipal Corporations is under progress,
vaccination and its perceived ill-effects. They are now and convergence with other departments is a
aware that vaccinations help keep the child & mother way forward to improve services and increase
healthy and safe from preventable illnesses. demand for child survival in an urban context with
underserved communities.
System
1. Cadre of community mobilisers formed: A community

network of social mobilisers is formed which
Transformative Change Caselet 1
Sheeba is mother of 1.5-year-old

Members of the community have improved knowledge
Mohammad Azan. Mohammad
about their entitlement to health benefits like free
is her only son, and she wants
vaccinations, and this has led to an increase in the
to ensure that he stays happy
demand for health services from the community.
and healthy. When CMC Saira
Asad Mirza went for field visits
“As a practitioner of Islam and the leader to capture immunisation data about infants
of this educational institute called Madrasa and children, she was not allowed to discuss
where Islamic education is provided, it is my RI with Sheeba. Sheeba’s mother-in-law had
duty to help people stay healthy and happy. misconceptions about vaccines and their
Prior to this intervention, there was a lot of effects on the children. She believed that
misconception among the community members vaccinations led to sickness in children and
about health and its services. We participated were unnecessary. CMC made multiple visits to
in this intervention and provided support in Sheeba’s house and, on each occasion, spoke
the form of announcements, rallies, and a to her mother-in-law and explained vaccination
space for vaccination camp. We gave a logical and its benefits. The CMC also roped in
explanation on the benefits of RI which was also Sheeba’s neighbours to convince her mother-in-
linked to religion. This increased acceptance of law. After multiple such conversations, she was
vaccination and its benefits in having a healthy able to convince the mother-in-law and meet
child. Now I am starting to see slight change in Sheeba. Sheeba understood the importance of
people's perspection from my community. They vaccinations and agreed to get all the vaccines
have begun to ask about vaccination dates and for her son at the right time. She and her
about other vaccines which they are entitled husband now go together to get him vaccinated
to. They have started to move towards formal as per the vaccination schedule.
health care and avail services from government
health facilities. With continued effort, consistent
demand and uptake of health services can Caselet 2
be created.”
Reshma Dilshad Ansari is mother to a two-
Mufti Mohammed Huzaifa Qasmi, President
month-old child and a nine-year-old daughter.
Jamiat Ulama-E-Hind, Thane
After her daughter’s birth, she had conceived six
times; but all the six children passed away within
a few days of being born. All the deliveries were
A primary health at home by midwives. When this intervention
centre worker.
started, her mother-in-law heard of the CMC
vaccination drive. The mother-in-law brought
the CMC home and asked her to guide them
on precautions to be taken during Reshma’s
pregnancy. The CMC asked them to initiate
prenatal checkups and to have the delivery at a
hospital itself. When Reshma’s son, Mohammad
Qasim was born, she and her mother-in-law
ensured he received his vaccinations. Her son
has survived for two months, and she is hopeful
that he will grow up to be a healthy boy and
have a long life.
In Summary
UNICEF, in partnership with Government of
Maharashtra, devised an initiative to promote
the uptake and acceptance of Routine
Immunisation (RI) in underserved municipal
Action
corporations. This intervention aimed to
create a cadre of community mobilisers
trained on Interpersonal Communication
(IPC) skills and RI. Here’s a blueprint of A community mobilisation
how the intervention was rolled out in the network was created to
municipalities of Bhiwandi (Thane) and bridge the gap between
Malegaon (Nashik). the community and the
municipal corporation. These
community mobilisers were
called Community Mobilisation
Coordinators (CMCs).
CMCs and the existing health

staff were trained on IPC
CMCs conducted
and the technicalities of RI,
meetings with mothers,
so as to generate effective
field surveys, and
awareness and engagement
households to enhance
with the community.
the demand for RI.
Influencers such as religious

and community leaders,
midwives, loom owners,
and elected representatives
were closely interacted with
to spread messages about
RI events.
Results
At the system level, the At the community level,

services for RI have myths and perceived ill
improved. SBCC’s necessity effects have been put to
has been established, and rest. They are now aware
commissioners have agreed that vaccinations help keep
to develop a BCC cell in the a mother and child safe from
RCH programme unit. preventable diseases.
The community has gained

knowledge about their
entitlement to health benefits
like free vaccinations. Their
preconceived notions have been
put to rest, and there is now an
increased demand for health
services from the community.
References
[1]
Gross domestic product (GDP) is a monetary measure of the market value of all final goods
and services produced in a period (quarterly or yearly) of time.
[2]
https://www.maharashtra.gov.in/Site/upload/WhatsNew/Economic%20Survey%20of%20
Maharashtra%202016-17.pdf
[3]
Source: National Family Health Survey-4 by Population Council of India.
[4]
Mission Indradhanush is a health mission of the GoI. It aims to immunise all children under
the age of 2 years, as well as all pregnant women, against seven vaccine preventable
diseases.
[5]
Source: National Family Health Survey-4 by Population Council of India.
[6]
A municipal corporation is a governing body that caters to urban areas with a population of
more than one million. They look after the necessary community services like health,
education, housing, transport, etc. by collecting property tax and fixed grant from the State
government.
[7]
Source: UNICEF internal reports (Bhiwandi: Final 1 ppt for visit and Malegaon: Intensifying
Routine Immunisation in underserved areas of Municipal Corporations of Bhiwandi and
Malegaon in Maharashtra)
[8]
Source: Coverage Evaluation Survey 2013, Government of India.
[9]
Source: Maharashtra State Family Welfare Bureau for the year 2016-17
[10]
The five levels are individual, interpersonal, community, organisational and Enabling
environment/Policy
[11]
GATHER stands for stands for the following six activities: Greet, Ask, Tell, Help in
the decision-making, Explain, Return. One is expected to do all these in his/her
interaction.
[12]
UNICEF Internal Programme data
[13]
This is anecdotal and based on the interactions with the community conducted as part of
this documentation.
[14]
Source: WHO concurrent RI monitoring data
[15]
WHO monitoring data captures refusals between Feb 2014 to Jan 2017.
United Nations Children’s Fund
UNICEF House, 73 Lodi Estate, New Delhi
www.unicef.in
Documented by:
Catalyst Management Services
Designed by:
Pink Lemonade

Untitled

Uploaded by

Untitled

Uploaded by

1

©United Nation Children’s Fund(UNICEF) May 2018

Photo Credits: UNICEF/India/2017

Permission to reproduce any part of the publication is required

United Nations Children’s Fund

UNICEF House, 73 Lodi Estate, New Delhi,

Tel: +91-11-24690401/0409, 40798000

Fax: +91-11-24690410, 246427521

Permission will be freely granted to educational or non-profit organizations.

On behalf of UNICEF, we would like to thank all the State government

Lastly and most importantly, heartfelt thanks and gratitude to our

1. Level of maturity - High/Medium/Low

2. Level of Research - Well Researched/Moderately

3. Geographical Spread of Implementation - High/

A CMS team then interacted with respective UNICEF

The SMART framework adopted to document the

• Situation – Problem situation that the initiative

• Method – Activities initiated to address the situation

• Action – Implementation of aforementioned

• Results – Outcomes of each initiative

• Transformative Change – Larger level impacts

4. Uttar Pradesh - Suramya: Communication to

5. West Bengal - District SBCC cells: System

6. Telengana - Nudging the Norms through Faith

7. Bihar - PYARHI: Breaking the Taboo and Culture

8. Tamil Nadu - Behaviour Change Communication

9. Madhya Pradesh - Mamta Abhiyaan: Sneha,

Gender norms, poverty and

Continuing education as a Using Theatre of the

Adolescent girls and boys

Map not to scale

Castes that are rigid and resistant to change[10]

Middle-order castes with a strong presence in

Progressive castes, where change has

• Significant, widespread presence in terms of Thakor Rabari Valmiki

Hasumati Sarvarkar is a cluster resource

Tejalben Dushuruthbh got a cycle under the

The results from this intervention have been

Kanubhai Prajapathi, the cluster resource person for Anarde

Communication with Groups for adolescent

Theatre of the Adolescent girls There is increased

Communities now Successful

Communities are in Government

The DCPU has achieved

to develop Village Child influencers in

The Udaan initiative is Upscaling includes

Sishu O Matru Suraksha

Able to identify and Guide and counsel Are more sensitive

Orient and sensitise

Traditional healers and

Map not to scale

Intervention District Source: http://d-maps.com/carte.php?num_car=4183&lang=en

Table 1: Reproductive and Child Health indicators

Indicator (2013)9 India Odisha Koraput Malkangiri

MMR** 178 235 245 245

Institutional delivery (%) 78.5 80.8 53.4 52.6

Full immunisation coverage (%) 53.5 68.8 51.6 29.6

Source: Annual Health Survey, 2012-13 *per 1,000 live births

Sishu O Matru Suraksha was based on a partnership

Deshari counseling a mother about her child.

• More than 4000 traditional healers in Koraput and

• Building continuity and consistency into the

Preparatory meetings were Community influencers were

Village healers were made

Together, they disseminated

Interlinkages between NGO partners have been able to

There has been increased Informal caregivers have

The intervention has

Home-based Newborn Care

Precondition 2 Improved social accountibility among Improved awareness and practice in

Voucher designed Print communication

HBNC VOUCHER INITIATIVE

Vouchers distributed RISKS: Disparity in

Concept building, advocacy

Map not to scale

Intervention District Source: http://d-maps.com/carte.php?num_car=4183&lang=en