5) Description of health product/service offering: Nalamdana, meaning "Are you well?" in Tamil, uses innovative communication methods to provide health information to illiterate and marginalized audiences in the urban and rural slums of Tamil Nadu. Initially, Nalamdana addressed a wide variety of health topics ranging from alcoholism, cancer prevention and suicide prevention to clean water and personal health and hygiene. In 2000, after seven years of working closely with the communities, Nalamdana zeroed in in on HIV/AIDS and Maternal and Child Health as the two areas most critically in need of knowledge intervention. Nalamdana's basic belief is that every person, however marginalized, has a basic right to complete and accurate information as well as the right to make his or her own choice. With target audiences being mostly illiterate, Nalamdana has chosen traditional street plays, tele dramas and interactive media to transmit health information. A typical Nalamdana show begins and ends with an evaluation. Weeks before the play is enacted, a pre-play survey records current knowledge levels and misconceptions about the relevant health issue in the community. Information about social taboos, cultural mores and habits is collated and then woven into a play staged in the community and modelled on traditional Tamil theater and hugely popular Bollywood cinema. Each stageing is followed by a post-play interactive session, in which members of the audience take center stage engaging in lively discussions and arguments in front of their peers and actively participate in a question and answer session. Finally, Nalamdana counsellors return to the community after a day or two to complete the follow-up and hold small group discussions about issues raised in the play. Contingent on particular needs of any specific community, these post-play sessions has repeatedly led to the launch of new, community-based health initiatives and projects.

6) Description of innovation: The novel element of the Nalamdana approach consists in the combination of scientific pre- and post-play surveys and evaluation methods with the use of traditional forms of Tamil theatre to address illiterate target audiences. Maternal and child health and even more so HIV/AIDS are sensitive topics in a very traditional society, in which sexuality is surrounded by a cloak of silence and cultural taboos. Issues of sex and gender, marital behaviour and reproductive health are typically not addressed openly, misconceptions abound, and stigma is widespread against people living with HIV/AIDS. Consequently, it is all the more important to speak the language of the target audience. Further to the pre-play surveys, plays are finetuned to reflect local customs: characters speak and dress the way the specific community does; the story is about people like them, the situations on stage mirror the daily lives, where domestic problems are resolved. Familiar songs are used as background music to create the right ambience, in which actors (themselves recruited from underpriviledged communities) rise to be true heroes. Thus, Nalamdana street plays grab the attention of everyone in the community, with audiences totalling on average 500 to 700 people completely engrossed in the various adventures of the leading characters in a passionate, filmy-style drama. Audience identification has proven a key to success in the communication of the underlying health message. This has been documented through the post-play surveys, which have demonstrated that Nalamdana's response-driven participatory methods fulfill the need for communication media to reflect the changing nature and knowledge level of audiencies and integrate their micro beliefs (such as sexual taboos, attitudes, misconceptions about pregnancy, etc).

7) Operational model: As described above, Nalamdana's core activities include street plays along with pre- and post-play surveys among the mostly illiterate target audiences. However, special situations and demands for further action by the communities have led to follow-up projects. One of the most prominent follow-up projects has been the creation of interactive training materials that can be shared both with the audiences to deepen the knowledge of specific health issues and with partner organizations (NGOs, foundations, etc) interested in making use of Nalamdana's communication concepts. Activities are targeted exclusively at low-income and marginalized populations. Within this target group, Nalamdana encourages social integration. For instance, in Muslim communities with strict gender separation, men and women have been known to sit alongside to watch the play; and communities have been seen to reach out to previously stigmatized persons living with HIV/AIDS after the play.

8) Human resources: Nalamdana comprises a dozen permanent team members from various backgrounds. Nithya Balaji, a founding member and executive trustee, holds a BSc in Geography from Madras University and draws on her knowledge of communication media acquired during many decades in the advertising industry. Her co-founder Uttarah Bharath, who holds a MHS degree from the John Hopkins School of Hygiene and Public Health and a BA from Wellesley College, has been in charge of designing the surveys and impact studies related to the pre- and post-play evaluation. Co-founder and project director R. Jeevanandham, a Master's graduate with a background in folk arts and videography, is the creative vision behind Nalamdana's plays and communication projects. Other senior staff include professional actors, counsellors and teachers, which work with a group of committed full- and part-time professionals partially recruited from underpriviledged backgrounds such as the communities served by Nalamdana. They all share an intimate knowledge of the cultural context and challenges of their audience as well as unbound enthousiasm and limitless energy towards the cause of public health.

9) Key operational partnerships: From its beginnings, Nalamdana has sought to engage in partnerships with other actors in the field of public health, both to share knowledge and cost. Prominent funding partners include the Ford Foundation, Earthwatch Institute, World Education, the local UNICEF office as well as local corporations. These partnerships are strategic and long-term in nature, and include substantial funding support (Ford Foundation) as well as human resouce exchanges (volunteer programs have been in place with Earthwatch for a number of years). Other short-term partnerships are concluded on specific projects and in specific areas, mainly to share cost and leverage specific knowledge (ie cooperation with PSI in certain city slums).

10) Financial Sustainability

          • Fees charged to clients?: No

          • How do you assure affordability?: close collaboration with funding partners

          • Earned incomes as a percentage of operating costs: 2%

          • Other funding sources: No. As mentioned above, business-social partnerships have been established to guarantee sustained funding. What is more, a number of former Earthwatch volunteers started Friends of Nalamdana in the US, whose purpose is to support the work of Nalamdana in India through a nationwide network of supporters and tax-exempt donations from both private individuals and corporations.

          • Strategy for long-term sustainability: Nalamdana's aim is to pursue the cooperation with existing partners and enlarge the scope of supporting bodies. However, funding remains a constant challenge and puts severe limitations on the scope of possible activities and outreach.

11) Current and Future Impact

          • Total number of clients: ca. 600'000

          • Clients in the past year: 50'000

          • Percentage of low-income clients: 100

          • Impact: The impact on Nalamdana's audience has been wide-ranging in duration and nature. A meaningful improvement of basic health knowledge in the areas of Maternal and Child Health and HIV/AIDS has been documented in the post-play surveys, and numbers of people testing at VTCs upon referral have increased. Nalamdana's activities have in some instances given rise to specific demands by the communities themselves. For instance, after the performance of a play on Maternal and Child Health, an group of adolescent girls in a city slum adressed a request for further training to a Nalamdana counselor during her subsequent visit, which led to the organization of a summer-long course of weekly sessions on the subject. Some members of the audience have joined N as volunteers and staff

          • Overall "market": Nalamdana's approach can easily be adapted to different social settings, as the equal success in Hindu and Muslim, urban and rural communitis has proven. Demand is huge both in Tamil Nadu in India, where 30% of the population of 1.1 bn live on less than USD 1 a day without access to health information.

12) Scaling up strategy

          • Stage of the initiative: Mature stage.

          • Expansion plan: Expansion is hard to achieve in the face of financial constraints. However, Nalamdana's team of professionals has started to train amateur groups in theatre workshops (how to formulate key health messages, write a plot, stage a play in a specific cultural context) in order to increase outreach, and shared interactive resources with other NGOs. The advent of television and film in certain slum communities will entail a partial shift to new media in order to increase outreach within the boundaries of limited financial means.

13) Policy change: to be filled in later

14) Origin of the initiative: A serendipitous encounter between Uttara Bharath and R. Jeevanandam while waiting to meet officials of another NGO led to the first street show on "Health and Hygiene" in a Chennai slum in 1994. At that time, Uttara was looking to use entertaining methods of creating awareness of health issues, while Jeeva and his group of friends were already using street plays to this end and had been working in truck stops through the nights to create awareness of safe sex.

Contact Information:
Nithya  Balaji
Executive Trustee
Nalamdana Charitable Trust
(NGO)
India
Website: www.nalamdana.org