The Daranganj urban primary health care center (UPHC) in Prayagraj city (Allahabad, Uttar Pradesh) is alive with the sound of  excited chatter, laughter and happy noises. That's because it is Adolescent Health Day (AHD) at the facility - a day where unmarried adolescent boys and girls ages 15-19 years can seek a variety of health services and engage with facility staff. 

Holding AHDs is a strategy under Rashtriya Kishor Swasthya Karyakram (RKSK), a Government of India (GOI) program launched by the Ministry of Health & Family Welfare to improve health-seeking behavior among young unmarried adolescents, 10-19 years of age.

However, RKSK guidelines emphasize that AHDs can only be conducted in facilities classified as adolescent-friendly health centers (AFHCs), a classification that was limited to just secondary and tertiary care facilities such as district women hospitals and medical colleges. Limiting services to the higher level of care facilities restricted linkages between primary and speciality care services, especially for vulnerable populations, like unmarried boys and girls and the urban poor.

I always thought it is only when one is sick we go to a clinic. One can also go to a clinic when we need information about our health is something I just came to know." - A 15-year-old girl who attended the AHD at the Daranganj UPHC

The Challenge Initiative for Healthy Cities (TCIHC) helped the RKSK program get UPHCs classified as adolescent friendly in five TCIHC-supported cities - Allahabad, Firozabad, Gorakhpur, Saharanpur and Varanasi. A critical feature of an AFHC is the presence of a dedicated counselor for adolescent services. Working with the Chief Medical Officer (CMO), TCIHC identified one staff nurse from each of the 96 UPHCs in the five cities and strengthened their capacity to provide adolescent health counseling, following the RKSK curriculum.

In addition, a staff-wide whole site orientation (WSO) - which ensures that all staff have a basic understanding about adolescent and youth sexual and reproductive health needs - was conducted in all 96 UPHCs to guarantee a welcoming and accessible environment for unmarried youths to access sexual reproductive health (SRH) information and services. Nearly 1,300 UPHC staff, including doctors, staff nurses, janitors and pharmacists, were oriented on providing SRH information and services to both married and unmarried adolescents and youth, 15-24 years of age, as a result.

Until this WSO happened, I had never thought that something special needs to be done for adolescents. In fact, all the staff of this facility never felt that adolescents have any such [contraceptive] need. However, I realized that adolescents also have this need when I saw 60 boys and girls turn up on the day of AHD." - Medical-Officer-In-Charge (MOIC) of Shahpur UPHC, Gorakhpur

With staff trained, it was then time to improve the provision of adolescent-friendly supplies at the UPHC. TCIHC utilized city coordination committee (CCC) platforms to inform city officials on the importance of stocking iron and folic acid (WIF), Albendazole (deworming medicines), sanitary napkins, multivitamin tablets and condoms. By coordinating efforts with RKSK at the state level, TCIHC succeeded in establishing stocks of the needed supplies at the UPHC. With this, UPHCs added adolescent services to their citizen charter, which had not been previously included.

In November 2019, TCIHC supported AHDs at select UPHCs in the five cities. Accredited Social Health Activists (ASHA) and Anganwadi Workers sensitized and mobilized the community. Mobilizing boys and girls for the AHD was made easier because the ASHAs could refer to their urban health index registers (UHIR) to identify households with 15- to 19-year-old boys and girls.

I feel such an event should be conducted once every month. Earlier, I wondered what will happen but I saw several boys and girls of my age had turned up here and, upon meeting them, I felt this is a wonderful platform where we can ask questions, share our thoughts and suggest also." - A teenage boy who attended the AHD at the Daranganj UPHC

As per RKSK guidelines, the half-day AHD included a nutrition kiosk and private counseling corner for boys and girls. Providers trained in AFHS by TCIHC conducted "circle time" with boys and girls, respectively. The sessions integrated games to break the ice between providers and participants and provide SRH information. A game developed about self-risk perception set the ground work for a frank discussion on SRH. Following the activity, participating boys and girls were invited to write down questions with respect to SRH, which were then answered by the MOIC or staff nurse.

The youth asked questions about body changes as a result of puberty and self-image, gender discrimination in families, discomfort when negotiating with a partner when in a relationship, masturbation, and discomfort during menstruation.

A significant number of participants chose to meet with the staff nurse/counselor in private. Distribution of WIFs and Albendazole, screening of hemoglobin estimation and body mass index were made compulsory for every adolescent participant. Referrals were made to the district hospital for more complex services.

As of February 2020, AHDs have been conducted in 70 UPHCs across the five cities with close to 2,500 youth in attendance. Of these, a higher proportion of girls (66%) turned out for the event. However, only half of them went for counseling and clinical screening. And even though only 34% of the participants were boys, a higher proportion of them underwent counseling and clinical screening. This informs the need to build self-efficacy among girls and also that risk-taking behavior may be higher among boys. Interestingly, these results are compelling medical officers of UPHCs to ask ASHAs to inquire as to the health needs of adolescents during their household visits - something that had not happened before.

AHDs have captured the attention of government officials. As a result, Chief Medical Officers in Allahabad, Firozabad, Saharanpur and Gorakhpur issued directives to conduct facility-based AHDs on the eighth of every month across all UPHCs in their cities.

For reading this story on TCI University please https://tciurbanhealth.org/tcihc-helps-urban-primary-health-centers-become-adolescent-friendly-in-allahabad-india/

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

The Challenge Initiative for Healthy Cities' (TCIHC's) state-level advocacy efforts successfully convinced the General Manager  of Rashtriya Kishor Swasthya Karyakram (RKSK) - the government of India's adolescent health program - of the critical importance of meaningfully engaging youth in policy and strategy development that aims to work for them. 

As a result, TCIHC held youth-led city consultation workshops in three Uttar Pradesh (UP) cities, including Lucknow. This was the first time that a workshop brought together adolescents to partner with government stakeholders - including the Chief Medical Officer, state General Manager for RKSK, and other key decision-makers and health leaders from all departments - to devise an adolescent and youth sexual and reproductive health (AYSRH) strategy. Lucknow city leaders acknowledged they had not realized how great the demand was for sexual and reproductive health information and services by adolescents and youth.

Prior to this workshop, the contraceptive needs of adolescents and youth went unheard, unregistered and unrealized. The following eye-opening comments were shared during a recent youth-led city consultation workshop in Lucknow.

Amisha Gulati, a 19-year-old girl from Lucknow, said:

If we ask our elders anything related to our body changes, they get annoyed and give dissatisfactory answers. Our teachers also skip the chapters related to reproductive health and tell us to read these chapters at home. I don't understand as every girl undergoes these changes. They have many doubts, myths and taboos related to menstruation, physical changes, pregnancy, etc. Girls must have correct information about all these before getting married so that they can take care of themselves and their family, but it does not happen!"

Pankaj Mishra is a 17-year-old boy and added this to what Amisha shared:

Boys joke about these issues and never take them seriously. Teachers and parents do not talk about puberty, menstruation, masturbation, etc. ever with us. We also hesitate in asking them anything related to these matters. Actually, the whole environment is not adolescent friendly. It would be great to have a counsellor who keeps our discussions confidential and gives correct knowledge."

The medical officer of Lucknow, Dr. Shalini Verma, agreed that the situation has been problematic, saying:

Adolescents do have lots of questions, but they are unable to discuss these with their elders. Moreover, they are subjected to immense pressure from parents on academic excellence and the objective of a career. Sexual and reproductive health issues add to their stress, as their questions and needs remain unanswered."

During the Lucknow workshop, government stakeholders worked in partnership with adolescents and youth to identify gaps and solutions and develop not only an AYSRH strategy but also an action plan to serve better serve the needs of adolescents and youth. The final action plan includes the following decisions:

• Special Fixed Day Static (FDS) service every month for first-time parents at the urban primary health center (UPHC) level

• Whole-site orientation for UPHC staff at the UPHC level

• One day per month fixed at UPHCs for an adolescent health day

• Convergence among different departments and engaging RKSK team and adolescents and youth in regular City Coordination Committee (CCC) meetings

• Representation of each department in city-level review meetings and RKSK planning meetings

Other TCIHC-supported cities in Uttar Pradesh have now requested similar support to hold their own youth-led consultation workshops. Consequently, all 10 TCIHC AYSRH scale-up cities have successfully organized these workshops with the support of National Health Mission budget and TCIHC coaching and technical assistance.

Seven of the 10 cities demonstrated their political commitment to youth engagement in carrying out their workshops virtually as a result of the COVID-19 lockdown. TCIHC's coaching of nodal officers, especially the urban family planning and RKSK ones, helped them to plan, organize and manage the virtual workshops.

For reading this story on TCI University please https://tciurbanhealth.org/youth-led-workshops-engage-youth-in-the-design-of-aysrh-programming-in-uttar-pradesh/

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

Shahnaz lives in the Lavkushnagar slum in Uttar Pradesh with her husband Nasruddin. Tailoring is their livelihood, but it offers a meager and insecure income. Shahnaz is very familiar with hardship and has faced many challenges since childhood. 

"I lost my father when I was merely nine years old. My mother, due to low income, couldn't take care of seven children. Hence, as a result of social pressure, she arranged my marriage. I never went to school. I got married at the age of 12 and I conceived soon after my first menstrual period."

Shahnaz had her first child by the time she was 13. Since then, she has added two more children to her family and experienced four miscarriages. The pregnancies, births and miscarriages have taken a toll on Shahnaz's health.

Her husband Nasruddin assumed it was her responsibility to take care of things like family planning and, unfortunately, they never spoke about it. Soon, Shahnaz was pregnant again with twins. In the eighth month of pregnancy, she experienced heavy bleeding and was rushed to a hospital where both were stillborn. The hospital bills were more than she and Nasruddin could afford, so they had to borrow 10,000 rupees for her treatment. Life became tougher still for Shahnaz as she struggled to pay for food and medicine. By the time she turned 28, Shahnaz found the courage and determination to do something about family planning. She decided that the next time an Accredited Social Health Activist (ASHA) knocked on her door, she would not ignore her and miss the opportunity to find out about about family planning method choices. Ultimately, she met with a TCI-coached ASHA and decided to adopt female sterilization as her method of choice. Shahnaz is no longer stressed by the fear of becoming pregnant again.

"When I was child I had many dreams for the future. I wanted to earn [money] and become independent. But, due to early marriage, I could not fulfill my dreams. I don't want my daughters to make the same mistakes I have made in my life. We are educating our daughters so that they hold the power to create their ideal future."

"When I was child I had many dreams for the future. I wanted to earn [money] and become independent. But, due to early marriage, I could not fulfill my dreams. I don't want my daughters to make the same mistakes I have made in my life. We are educating our daughters so that they hold the power to create their ideal future."

Shahnaz is now learning how to read and write from her son. She is also saving some money for the future. Like Shahnaz, thousands of women in India wish to space or limit their family size but are either unaware of or do not have access to family planning choices.

This is why state and city governments in Indian states like Uttar Pradesh are strengthening the capacity of urban ASHAs, with TCIHC's support, to provide quality family planning counseling and referrals to meet the needs of women like Shahnaz.

To learn more about the impact of urban ASHAs and how to adopt or adapt this high-impact approach, check out Enabling Urban Accredited Social Health Activists.

For reading this story on TCI University please https://tciurbanhealth.org/tcihc-urban-tales-family-planning-offers-new-beginnings-for-young-mothers-in-india/You can read all previous stories also athttps://tciurbanhealth.org/topics/india-urban-tale/.

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visithttps://tciurbanhealth.org/india-toolkit/and https://tciurbanhealth.org/topics/india/.

The Challenge Initiative's (TCI's) 'business unusual' approach supports deep engagement with city governments to widen the  impact of its evidence-based family planning (FP) and adolescent and youth sexual and reproductive health (AYSRH) interventions. Cities that "graduate" from TCI's direct support effectively sustain the interventions through coaches embedded within the health system that are recognized as TCI "alumni." This recognition positions these graduated cities as learning laboratories from which newer TCI cities can observe and learn. 

Kanpur, a TCI-supported city in Uttar Pradesh, is nearing graduation from TCI direct support and recently shared what it learned from its implementation experience with two sister cities, Etawah and Farrukhabad. Soon after joining TCI in March 2021, key representatives from Etawah and Farrukhabad were invited by TCI-trained Kanpur city master coaches on a study tour to witness firsthand how Kanpur implemented TCI's high-impact interventions.

At the beginning of the study tour, Additional Director (AD), Kanpur, Dr G. K. Mishra laid out his expectations and emphasized: An essential component of a successful urban family planning program is its data reporting and management mechanism. I encourage new cities to develop a HMIS [health management information system] FP data-flow plan representing the entire process of data collection from field to HMIS upload, and submit it to Divisional Urban Health Consultant, Kanpur. Post review and completeness of the data, the Kanpur division will use it for decision-making for all the health programs of the division."

After participating in a mini-university and the study tour, Etawah and Farrukhabad have been able to not only rapidly scale up the high-impact interventions but also achieve promising results. Dr. Sushil Kumar, Nodal Officer of Etawah, and Rajeev Pathak, District Urban Health Coordinator (DUHC) of Farrukhabad, discussed how both learning opportunities contributed to their success.

Dr. Kumar shared: Etawah has a population of 300,000 people and yet has only four urban primary health centers (UPHCs). Added issues of staff crunch, COVID vaccination drive, low capacities of ANMs [auxiliary nurse midwives] and ASHAs [accredited social health activists] on the subject of family planning and low levels of awareness and acceptance of family planning by urban slum population were some of the challenges faced by us when we joined the TCI.

NUHM [National Urban Health Mission] and TCI oriented all the new joining cities through a mini university platform on the family planning best practices. It was interesting to note that our peers, nodal urban officers, ACMOs [Assistant Chief Medical Officers], etc. from TCI's experienced cities had taken time out of their busy schedules to share with us key lessons and tips that could help our cities increase family planning uptake. Later, AD Sir from Kanpur invited our team to experience the implementation of best practices. We returned [to our own cities] rich with learnings and presented the same in the DHS [District Health Society] meeting. Encouraged by the response at the DHS platform, we formed a quick plan and worked with TCI team towards capacity building of providers and community health workers, use of data for decision-making, quality assurance of services, regularizing Antral diwas (FDS), form a city coordination committee, to name a few of the best practices that we put in place. It is because of the first-hand experience of seeing it in a city and then learning from TCI coaches with the help of the 'how to do' toolkit that we could streamline some processes and get started right away. We were delighted to observe a 242% (5,272) increase in the annual family planning client volume from the baseline (1,540) at the city level by August 2021, as recorded in the HMIS."

Pathak added: Hearing about the levers of success from fellow government counterparts during the mini university and then during the study tour increased the confidence level of all city officials as they saw change within the system made by the change makers of the system."

He shared that Farrukhabad made an action plan wherein the city focused on:

• Coaching MoICs to regularly review family planning data, identify gaps and carry out mid-course corrections.

• Validating data from UPHCs before inputting into the HMIS.

• Ensuring timely family planning reporting from each UPHC and timely HMIS reporting.

• Forming quality improvement committees (QICs) at each UPHC and monitoring their work.

This focused plan made Farrukhabad one of the best-performing cities among TCI's new cities. According to the HMIS, TCI best practices have contributed to a 27% (5,869) increase in annual family planning client volume at the city level comparing baseline (4,608) to August 2021.

Both Dr. Kumar and Pathak cannot wait to see the achievements that their cities will continue to accomplish after receiving more TCI coaching and mentoring support in the coming months

For reading this story on TCI University please https://tciurbanhealth.org/soon-to-be-graduated-city-of-kanpur-shares-implementation-learnings-with-two-new-uttar-pradesh-cities/

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.