Spread across 10 districts of Bihar (500 villages), Project RECOVER Bihar aimed to support the State in vaccinating the lowest coverage rural areas through seamless convergence between the supply and demand sides while ensuring equitable inclusion. Along with vaccinating the hesitant and ambivalent groups, the project’s focus was to develop stakeholder specific solutions for special groups and vulnerable communities. We developed tools to assist last mile service delivery, increase vaccine accessibility, promote a positive vaccination experience, and boost vaccine uptake by addressing multifaceted barriers.
Situational Analysis to understand the problem context
How might we
increase vaccination uptake among ambivalent and hesitant groups in rural Bihar?
ensure vulnerable, marginalised and hard-to-reach communities are included
smoothen service delivery mechanisms and design people-centred interventions
Placing people at the heart of the process by understanding their unique needs, barriers, pain points, motivations, trusted sources.
Working with systemic cogs and looking at the larger picture to better understand service delivery barriers.
Responding to change in real time in an agile and iterative manner - the ability to learn, apply and repeat.
Illustration by Bhanavi Arora
Initial Stakeholder Mapping post situational analysis
The desk research helped the team understand the problem context, existing interventions, discourse and challenges around COVID vaccination delivery and adoption. Synthesis of secondary data points directed the team toward mapping stakeholders and areas of inquiry for the primary research.
Caption: Miro board highlighting the distilled areas of inquiry
Extensive field research with the supply and community side stakeholders captured the gaps in service delivery and barriers to vaccine uptake.
Contextual inquiry (to understand the vaccination process and friction points)
Shadowing refusal break teams and FLWs (to study strategies and barriers)
IDIs (to understand service side and group specific pain points (for chronically ill, pregnant and lactating women, religious and ethnic minorities, disabled persons)
Caption: Contextual inquiry at the vaccination centre of the Primary Health Centre in Runni Saidpur, Bihar
Engaging with the Front Line Workers to understand on-ground mobilisation challenges and biases
Basis the data, the team built a framework to create stakeholder-specific action plans. This provided the teams with the lens to gauge trusted channels of information for various groups, their intent and ability to get vaccinated and external motivations within their socio-economic context. The framework aided understanding of vaccine hesitancy by breaking down beneficiary decision making process.
To analyse the captured data, our team used the following methods:
Data Triangulation from various protocols
User Journey Mapping
Caption: Vaccination journey of the user that exhibits the service delivery gaps
A couple of brainstorming sessions helped us co-create the first set of low fidelity prototypes. These prototypes were then tested with rural cadres and beneficiaries for consistent iterations.
Areas of testing included:
Conceptual clarity and content localisation
Usability for various groups
Positively improves vaccination experience, and service delivery footfall
Caption: Prototype testing with the JEEVIKA cadre in Bihar in collaboration with District and Block Officials
Color coding as identification markers on all prototypes to aid mobilizers with stakeholder specific counseling
Following are some of the tools designed by the team that helped the implementation teams break refusal and vaccinate 249,002 hard-to-reach, marginalized and vulnerable populations using empathy forward strategies.
A foldable light-weight counselling guide for the mobilisers that offers:
Offer verified information to various population groups.
Reinforcing empathy forward counseling techniques
Accessible high inquiry questions basis the data analysed
QR quotes leading to videos of locally trusted sources
Targeted and tested counseling strategies for different vulnerable groups such as chronically ill, elderly, pregnant and lactating women.
Targeted Counseling Guide:
Provide beneficiaries with vaccination date and time slot that are convenient for them, especially for vulnerable groups, daily wage labourers and migrants.
Aid the service providers to better organise the camp, reduce vaccine wastage and footfall.
Based on the research learnings, provide preparedness instructions customised as per the stakeholder group to avoid AEFI symptoms.
Physical reminders given to each due beneficiary prior to the vaccination that:
At-home reminder for beneficiaries pasted at every house door that includes:
Home number and color coding for easy stakeholder identification basis vulnerabilities
Post-vaccination care with three follow-up visits and track AEFI to reassure the hesitant
Highlighted emergency numbers at the family's disposal for accessible counseling and care pre and post vaccination.
Laminated mobile stickers as a reminder for migrant groups to keep a track of their second dose. That includes:
Type of vaccination for migrants and the vaccination staff to refer to in low-internet areas.
Easy access to second dose dates.
Helpline number in case of any post vaccination symptoms.
A Guide to Adaptive Implementation
A Guide to Adaptive Implementation for reaching the last mile: Actionable Learnings from COVID-19 vaccination project, is a practical field guide for anyone looking to employ Adaptive Implementation (AI) in a health program. This proposed approach can be adopted for designing health care interventions among other applications, bridging supply-demand service delivery gaps, strengthening collaborative problem-solving mechanisms, working in resource deficient settings, and tackling health emergencies that demand rapid responses.
RECOVER Bihar Website
The RECOVER Bihar website aims to disseminate the rich experience, learnings, process, and best practices learnt during the course of the project. The website attempts to widen the access to tools and resources from the RECOVER Bihar effort which can act as a blueprint for the larger ecosystem of stakeholders in the development or governance space.