This project identified opportunities for radical improvements in vaccine delivery and uptake towards the achievement of excellence and near-total vaccine coverage in regions similar to Bihar, India. - Conduct user-centered research and design to improve vaccine delivery. - Study behaviors, practices and attitudes of frontline workers and recipients. - Identify key dimensions of the delivery challenge. - Generate and validate concepts and solutions through collaborative brainstorming and dialogue with field data.

1. Introduction
Identification of Immunization
Challenges in North Bihar, India
It aims to describe a comprehensive approach to
the identification and documentation of barriers
to vaccine delivery in northern Bihar, India.
In the last 3 years, however, Bihar has seen
substantial improvement. New health initiatives
by the National Rural Health Mission (NRHM)
such as Muskaan in 2007, have contributed to an
increase in routine immunization rates in Bihar
from 24.4% to 41.4 %.
I spent several months shadowing front-line
health workers, interviewing families, and
observing community life. And came away with
a deep understanding of the dynamics of routine
immunization: How front-line providers think
about their work; how communities view the
public health system; how various incentives
motivate action – or fail to do so; how a lack of
resources or environmental conditions constrain
the ability of workers to reach certain areas.
Using the tools of design, I began exploring
innovative ways to overcome the obstacles that
were identified.
Vaccine Delivery Innovation Initiative
Kishanganj, Bihar
2.3 Ethnography | Vaccine Delivery Innovation Initiative 36

2. Size of the circle denotes,
time spend in the perticular phase
Objective
9 months
Research
Framework
Analysis
Concept
Detailing Conclusion
Methodologies
Fieldwork Concept
Generation
ConceptTesting
& Refinement
Project Phases
2.3 Ethnography | Vaccine Delivery Innovation Initiative
Experience
Designer
38

3. This project identified opportunities for radical
improvements in vaccine delivery and uptake
towards the achievement of excellence and near-
total vaccine coverage in regions similar to Bihar.
• Conduct user-centered research and design
to improve vaccine delivery.
• Study behaviors, practices and attitudes of
frontline workers and recipients.
• Identify key dimensions of the delivery
challenge.
• Generate and validate concepts and
solutions through collaborative brainstorming
and dialogue with field data.
Acc. - Accountant
ANM - Auxiliary Nurse Midwife
ASHA - Accredited Social Health Activist
AWW - Anganwadi worker
BCG - Bacillus Calmette-Guerin
CDPO - Child Development Project Officer
DIO - District Immunization Officer
DLHS - District level household survey
DPT - Diptheria Pertusis Tetanus
EM - External Monitor
HH - Head of Household
HM - Health Manager
ICDS - Integrated Child Development Scheme
LS - Lady Supervisor
MO - Medical Officer
MOIC - Medical Officer in Charge
NFHS - National Family Health Survey
OPV - Oral Polio Vaccine
PHC - Primary Health Centre
PPP - Public Private Partnership
RCH - Reproductive and Child Health
RI - Routine Immunization
RL - Religious Leader
SC/ST - Scheduled Cast/Scheduled Tribe
UNICEF - United Nations Children Fund
UIP - Universal Immunization Programme
VH - Village Head
WHO - World Health Organization
Glossary
Objective
MOIC (Medical Officer incharge diagnosing a patient
2.3 Ethnography | Vaccine Delivery Innovation Initiative 40

4. 3
Framework
The framework guided us through out project.
The team began to formulate hypothesis based
on the initial round of background research dummy
field work. The steps were
Secondary Research
Probe on the historical changes in India’s
immunization status, key initiatives their impacts
and immunization practices in Bihar were gathered
Dummy feild work
To get an idea of the real scenario on field an initial
dummy field work was conducted, which can acted
as a good starting point
Expert Interviews
A list of immunologist and public health programs
experts were interviewed to gauge the existing
scenario of immunization in Bihar
Hypothesis creation
A tentative list of questions arising from dummy
field work and literature review were framedExpert Interviews
MOIC addressing the ANM in the weekly Tuesday meeting
2.3 Ethnography | Vaccine Delivery Innovation Initiative 42

5. 1. Beneficiary Home visit
3. Depth Interview
2. Day - In - Life Ethnography 4. Mini Group Discussion
5. Clinics Visit
Home visits with specific profiles such as
pregnant mothers and neonatal families were
conducted in order to understand the difficulties
in following the current immunization process.
Specific question areas around challenges of
infrastructure, societal influences like caste and
community were probed to gain insights around
the perceptions of the service.
To acquire insights around process of delivery,
information dissemination and policy making
a series of interviews were conducted with
In order to understand the life and professional
context of field workers namely ANM, ASHA,
AWW who travel through the countryside
dispensing healthcare services. They were
followed on their daily route for three
consecutive days. Insights around,
1. Challenges, Coping strategies and Needs
of Health Workers
2. Qualitative insights into qualities of Moti
vation and Initiative for Health Workers
3. Understanding of Roles and Responsibility
of Health Workers
4. Service Delivery Drawbacks, were gathered
Group discussion involving individual frontline
healthworkers namely ANM, AWW and ASHA
provided insights into glitches during recruitment,
government bureaucracy. They identified
challenges of the existing problems areas
such as untimely payment of incentive, lack of
transportation to Hard-to-Reach Areas render
them ineffective to providing routine services.
Ethnographic visits at vaccination clinics and
local dispensaries reveled that most of them
are quacks and are minting money out of the
consumers. There knowledge comes form
assisting doctors. It providing insights into the
coping strategies of the consumers and pointed
out reasons for consulting such a facility.
Parents and Elder members of the Family
District Immunization Officer, Accredited Chief
Medical Officer, WHO officials
Asha, AWW and ANM
Private health practitioners and quacks
Auxillary Nurse Midwife, Accredited Social Health
Activist, AnganWadi Worker, Lady Health Visitor
Methodology
Senior Healthcare Officers. They being involved
in the daily mechanism of delivering healthcare
service, provided factual insights on the existing
service model, context difficulties, challenges
of delivery and identifying best practices of the
current model, therefore, provided possible
solution areas for designing new systems and
models.
2.3 Ethnography | Vaccine Delivery Innovation Initiative 44

6. Design Diary
A tool to document concepts and problem
statements in form of sketches and doodles
and to document a challenge or innovation
opportunity during field work. It brought fresh
perspective to classic problems of service
delivery. Some of these ideas which were later
built upon as leading concepts.
Vaccine carrier box & disposal system
1. Description
It is important to maintain an ecological balance
and hence an effective disposal system is needed.
2. Observation
• Inappropriate disposal outside Anganwadi
Centre
• The syringes are either burnt or thrown outside
the PHC
• The ANM needs to carry about 15-16 items on
a RI day
3. Concept
Vaccine carrier box serves as a vaccine
temperature control unit. However, given its
size and space, its full potential has not been
explored.
4. Solution Description
• An Integrated Vaccine Carrier which allows
hub cutter, disposal and storage space.
• At the PHC, all the vaccine carrier can be
docked and the waste can be disposed in a
single action format.
5. Impact and Value
• Careless disposal often leads the used
syringes falling in the hands of children.
• Waste material collected over a period can
be effectively utilized.
ANM
Registers
Vitamin - A
Hub Cutter
Iron Tablets
ORS
Syringes
Vaccine
Carrier
3. Paraphernallia, ANM carries every RI day
or
Syringe Disposal
Storage space1 2
Dock Station at Public Health Center (PHC)
2.3 Ethnography | Vaccine Delivery Innovation Initiative 46

7. Enhanced authority & Identification
1. Description
Enhanced authority and identification can facilitate
reach and increased awareness among recipients
2. Observation
• ANM on her way to AWW centre but AWW
and recipients of the zone are unaware of her
arrival
• Dress codes provided to the FHWs are barely
used
3. Concept
Frontline healthworkers do not have an
identification tag, this often leads to beneficiaries
not trusting them or not turning up on the
immunization day. The beneficiaries lack
awareness about these healthworkers, their duties
and schedule.
ID card that updated
the center name where
the ANM needs to go
As the ID card enter the coverage
zone, the operator sitting at the
PHC is updated.
The operator then announces arrival
of the ANM in the locality through
local media such as loudspeakers,
radio, mobile phones
4. Impact and Value achieved
• Mention of a person’s name on a media
source is considered highly there by creating
an authority in the minds of recipients
• Such sources can prove to be useful in
terms of generating a community-wide
awareness of the profile of these FHWs.
2.3 Ethnography | Vaccine Delivery Innovation Initiative 48

8. Analysis
Tracking Recipient
Organizational Dynamics
Identification & Compilation
of Ethnographic Data
Broader challenge areas were identified from the
data set. They were then further categorized into
sub-heads, address each topic while ideating for
potential solution.
One of the key questions addressed, how
to track the recipients when they missed a
scheduled vaccination day or a new birth? The
tools utilized to do so are
1. Spatial Mapping - Maps created by ANM’s of
their coverage zones were studied.
2. Record Keeping - With about 14-15 registers
to maintain, it is a big challenge to update. These
Reporting structure vary highly from district
to district. This results in confusion about the
roles and responsibilities of FHWs. Roles and
Responsibilities of FHWs and Perceptions of
their job are often misinterpreted. They are
more often perceived as doctors by locals and
consulted for medications and even for critical
health issues.
registers were studied for loopholes and why
they act as a challenge
3. Micro Plan - A yearly plan made by
Immunization officers, where ANMs are alloted
coverage zones
Spatial Mapping
Record Keeping
2.3 Ethnography | Vaccine Delivery Innovation Initiative 50

9. Challenges and Barrier to
Routine Immunization
Concept ofTime andTemporality
1. Logistical Issues: Unavailability of basic
facilities such as transportation and field tool
such registers, medicines, injections, etc.
2. Soft Practices: Many jury-rigged methods
were adopted by FHWs on field such as no
real-time updation of records, instead they note
down information in small pieces of paper.
The concept of timing in these rural areas
are mostly day-to-day basis, as most of these
family do not have a calender. Therefore,
making it tough for them to remember the
exact date when their child was scheduled for
immunization.
ANM’s note records on rough paper while on field
Local methods used by ANM’s to identify Immunization age ( The child who is able to touch his ear
with the left hand is 5 years and above, while the other two are not)
No proper roads
Clocks and calendars with deities pictures are one of the most common artifacts found in
the rural households
2.3 Ethnography | Vaccine Delivery Innovation Initiative 52

10. Socio-Cultural Practices
1. Natal Practices: Cultural factor in rural
locations act as a major hindrance toward timely
immunization. For instance, muslim families do
not allow the mother to come out of the house
for a month as they consider this period to be
impure.
2. Child Protection and Safety: Black threads
around the baby’s arm or neck is tied after 6 days
of birth, this leads to the child not getting his first
shot of BCG and OPV1 vaccine.
23 yr old lady, mother of three. According to Hindu customs the mother is not allowed to step outside her room for a month, as she
is considered impure right after her delivery
2.3 Ethnography | Vaccine Delivery Innovation Initiative 54

11. Bubble Mapping: Key Stakeholders
Experience Flow MappingHeuristic tools for channelizing analysis
In order to focus the research analysis and
analyse key players of the RI ecology, it was
necessary to identify Key Stakeholders. Bubble
mapping these key stakeholders illustrated the
significance of the roles played by each player.
It also helps reveal their proximity in terms of
interaction. Frontline health worker and recipient
family are central players here.
Generated experience flow diagrams for
frontline healthworkers and recipient families by
sequentially mapping their work practices and
daily routine. It revealed coordination between
different players in the RI system during various
activities. Highlighted the challenges faced by
FHWs and the adaptive practices employed to
counter them.
MOIC
ANM
AWW AWWs
DAI
ASHA
Mother
& Child
ASHA’s
Husband
Father
Private
Practitioner
Stakeholder Ecology
Advance Preparation
- Preparation of
the site not done in
advance leading to
chaotic worldspace
ANM arrival at RI site
- ANM may arrive
late after the vaccine
carrier is delivered
Courier man
comes to the
session site
Leaves from
session site
Set up the RI
site
Goes to mobilize
recipients
Goes to mobilize
recipients
ASHA comes
to the site
ANM arrives
at the RI site
Goes to the
session site
Reluctant to
go to RI site
Families reaches
RI site with the
health card
Family comes to
RI site without
health cardRecipient not
found at home
She comes
to the site
She consults the ANM
for list of due recipients
and goes for mobilizing
Stays back at
session site
Courier Boy
AWW
ASHA
ANM
Recipient
Key
Players
Pre Administration
Key
Co-ordination
Issues
2.3 Ethnography | Vaccine Delivery Innovation Initiative 56

12. Power Dynamics Social Interaction
To understand the power a player shares over
another power level were plotted. This helped
in revealing sources whose power can be
utilized to effect changes, as well as for creating
supervision mechanisms.
A heuristic tool to map the interaction levels of
each player in the system. Frequencies of social
interaction could then be employed for designing
communication strategies for the mother and
the recipient family. It also helped reveal under
utilized resources that can be employed for key
performance areas.
Central players Other players
0.5pt0.75pt1pt1.5pt2pt3pt
MOIC
HM
Acc.
EM
VH
LS
ASHA
ANM
AWW
Mother
CDPO
HH
RL
Acc.
ANM
ASHA
AWW
CDPO
EM
HH
HM
LS
MOIC
RL
VH
- Accountant
- Auxiliary Nurse Midwife
- Accredited Social Health Activist
- Anganwadi worker
- Child Development Project Officer
- External Monitor
- Head of Household
- Health Manager
- Lady Supervisor
- Medical Officer in Charge
- Religious Leader
- Village Head
Central players Other players
1pt 0.5pt1.75pt2pt3pt4pt5pt
AWW
ASHA
other
ASHA
ANM
AWW
Mother
MOIC
HM
Acc.
EM
VH
other
ANMLS
CDPO
HH
RL
Identified key performance areas in the RI system
Enrollment of new recipients
Mobilization
Enable repeat encounter
Education
Supervision
Performance evaluation of FHWs
2.3 Ethnography | Vaccine Delivery Innovation Initiative 58

13. 1. Identifying & Locating recipients
Identifying Challenges
• FHWs do not have a concrete knowledge of
their coverage areas (both boundaries and
households)
• ASHAs do not cover their zones thoroughly
on RI day because they are too big
2.Tracking
FHWs are unable to accurately track recipients
because record-keeping tools are not easily
searchable, most health cards are either
damaged or lost.
3. Supervision
No supervision or feedback mechanisms for
frontline health workers and other officials result
in “apathy” and lack of accountability in the
health care system.
4. Communication
• Recipient families are unaware of the
significance of RI because it is not promoted
at all in the community.
• Recipient families also lack understanding of
the significance of complete immunization.
Consequently, dropouts occur when their
children experience side-effects.
5. Planning
Planning is not data driven ; FHWs are not aware
of the right denominator and not motivated to
enroll many new recipients in the system.
6.Training
Health workers are not trained well enough to
convince families that resist immunization.
Conceptualization
Communication
Concepts generated to create awareness among
beneficiary families
Comparison chart depicting a healthy immunized child and a weak un-immunized child in pain
Audio activated toys in order to create
awareness among the mothers who
are mostly housewives
Balloon marking at the immunization
center in order to mark a specific location
2.3 Ethnography | Vaccine Delivery Innovation Initiative 60

14. Identifying & Locating
One of the key challenges faced by the FHWs,
is to located prospective beneficiaries as well as
spot beneficiaries for subsequent doses.
Supervision
Currently there is a major lack in the supervision
of ground level staff. This particular work on an
effective mechanism to increase supervision
without physical presence of supervisors
AWW conducts a survey of her area, and passes the information to the data operator at the
PHC. A 2-D aerial map of the village is generated
AWW carries a navigational device which provides her with a 3D view of her area. The devices
provides her with the shortest routes to reach the beneficiary
As she closes the house, the devices marks the house and gives an audio feedback. The AWW
reaches the house, takes a photograph of the beneficiary and send it to the database.
A kiosk at every RI site, which monitors the attendance
of FHWs, takes feedback from recipient families and
displays information of the due beneficiaries. The kiosk
transfers the data to the central PHC which takes out a
performance report of the FHWs based on targets.
Village information Block information District information State information
Stepwise data is collected and uploaded, starting from
village to state level on to an online portal. This portal
can be accessed by any of the senior supervisors at
any point of time.
2.3 Ethnography | Vaccine Delivery Innovation Initiative 62

15. Tracking Recipients
AWW encounters a pregnant lady, she takes down all the basic information and informs the ANM
At birth the ANM provides the child with a unique ID and gives her a card which mentions
the next vaccine due date.
On the RI day, child’s medical history is accessed through the unique ID and he is administered
with the right dose of vaccine.
The digital device provides the ANM with the list of children she needs to administer on that
day and the missed recipients.
Communication
• The concept of introducing a toy which creates
awareness about R.I. should also talk about the
due date of vaccine
• The concept of comparing a healthy and an
unhealthy child pictorially will prove beneficial
as it will also communicate with the illiterate
recipients
Identifying & Locating
• Click photographs of new recipients will work.
• The idea of introducing a GPS will aid there
search.
Supervision
• A performance merit list displayed on the
PHC’s notice board will motivate all the FHWs.
• The kiosk should be setup at most of the AWC
with an operator in the initial days.
• The kiosk can also provide meeting timings.
Tracking
• Formal training will be required in order to
optimally use this technology. They seem very
satisfied with the idea of replacing survey
registers with a digital device.
• They like the idea of a digital device as
compared to maintaining bulky survey
registers.
Concept Testing
2.3 Ethnography | Vaccine Delivery Innovation Initiative 64