A long queue stood outside the counseling room at the Chhatrichowk civil dispensary in Ujjain, Madhya Pradesh. But Maya Yogi, a lady health visitor (LHV) stationed there, was in no hurry. She knows how important it is to allow each client the time they need for often culturally sensitive discussions about family planning. She believes that establishing good rapport with clients and allowing sufficient time for an in-depth conversation helps reduce anxiety and eliminate their fears. 

When The Challenge Initiative for Healthy Cities (TCIHC) helped the dispensary initiate a fixed day static/family planning day (FDS) approach, the team found that Maya was well-suited to be trained on IUCDs and Antara. Once re-oriented, she was given the basket of choice job aid and also trained on effective counseling skills. Maya was already a good counsellor and these new opportunities developed her interest further in family planning.

Maya often tells her clients they have nothing to worry about and gives them her phone number to call her anytime if they are confused or need help. She believes it is important for a service provider to gain the trust of a woman.

"After all, her body will undergo changes initially. So, there is a lot of fear of the unknown, even when a woman comes on her own to adopt a family planning method. During a counseling session, I not only describe how a method works but also detail out possible side effects that can occur in the beginning as the body adjusts to a contraceptive. I prefer to use educational materials and job aids to ensure that the client has all of the information needed to make an informed decision. No two clients are the same. I first gauge the knowledge level of the person and then address their queries and concerns regarding family planning methods. This builds trust between my clients and me. I make it a point to clear misconceptions pertaining to contraceptive methods by giving easy to understand examples. Once the clients have accurate information about the methods, they agree and accept the method they want to use."

The compassion and empathy with which Maya counsels women has not only earned her respect but has made her a preferred family planning service provider. As a result, she was recognized and celebrated by the Ujjain city government for her contributions to the city's family planning program. In just one year, she has helped 523 women adopt a contraceptive method of their choice.

For reading this story on TCI University please visit https://tciurbanhealth.org/tcihc-urban-tales-ujjain-dispensary-lady-health-visitor-becomes-preferred-family-planning-counselor/.You can read all previous stories also at https://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, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

After receiving TCIHC coaching support, Gurdeep Birla, the Divisional Urban Health Consultant of Saharanpur, shared what the high-impact approaches have meant to the district and how they are integral to the district's family planning program success:

Earlier in district level review meetings, discussion was limited to permanent methods only. It was when the city partnered with TCIHC that more FP choices were made available at the urban primary health centers for the community through TCIHCs HIA on FDS, capacity building of urban Accredited Social Health Activists (ASHAs), data for decision-making (D4D) and capacity building of providers, etc. We, in the system, realized the non-availability of data on many important programmatic aspects, like age, number of children, etc. TCIHC's coaching made ASHA) competent in completing the Urban Health Index Register (UHIR) and later with the 2BY2 prioritization tool, we learnt to identify community health workers [such as ASHAs and their supervisors, Auxiliary Nurse Midwife (ANMs)] who required more mentoring in order to increase FP uptake by the community.

With the holistic coaching on demand generation, service delivery and advocacy, we were now able to review several data dimensions, such as client uptake during routine vs FDS days, completeness of data from HMIS reporting, timely indenting of FP commodities through FPLMIS [Family Planning Logistics Management Information System] and preparation and use of due list for client prioritization. Besides, with our UPHC staff coached on HMIS and D4D, the errors in FP data at HMIS level started reducing.

The coaching that we received on the D4D HIA in particular helped our staff from 31 UPHCs as they learned which FP indicators need to be reviewed, platforms where FP data must be reviewed and who should review it to influence decision-making. As a result, we are able to efficiently advocate in the review meetings. Hence, we started preparing accordingly for each review, like for district review meeting, we would analyze HMIS data and for a UPHC level ASHA-ANM meeting, UHIR and 2BY2 data were mainly discussed.

Apart from the review meetings, on other meeting platforms like the Health Partner Forum meeting, due to TCIHC coaching, we were able to ensure focus on FP along with other agenda items. It was during one such meeting that a decision was taken to install direction sign boards to increase visibility of UPHCs and to facilitate easy access to them. In a city coordination committee meeting, we noticed that the client uptake for long-acting reversible methods was increasing and to meet the increased community demand, the committee decided to ensure three sets of IUCD kits at least at all the UPHCs. During National Urban Health Mission review meeting, it was decided that ASHA-ANM meeting must be called after each FDS is held. Of late, in a service providers meeting, we shared the success in urban FP and suggested the district's technical support unit utilize TCIHC's HIAs and 2BY2 tool.

We have learned that unless we review data regularly success cannot be met because we will fail to notice the gaps at the right time [to make corrective actions]. Being aware of this now, we have regularized our review meetings, improved data quality and utilize data for decision-making."

As a result of TCIHC's partnership with Saharanpur district, the women of Saharanpur and Muzzafarnagar now have an expanded mix of contraceptive methods with sterilization now representing a smaller proportion among the methods available in the basket of choices.

Source: District level HMIS, June 2016-Mar 2021. To prevent overestimation of short-term methods, HMIS data has been adjusted using standard couple-year protection, which is the total estimated protection provided by contraceptives in a one-year period.

*i). Condoms are also offered as a choice of method to people who visit health facilities.

*ii). COVID-19 pandemic has greatly impacted Year 5, especially from April 2020 to March 2021. This period in the graph is dominated by short-term methods as a result of government-imposed lockdowns, limited movement of communities and their fears concerning visiting facilities for longer acting methods.

For reading this story on TCI University please https://tciurbanhealth.org/improving-saharanpur-districts-family-planning-data-also-improves-its-family-planning-program/

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/.

Historically, family planning in India has been dominated by female sterilization, and Accredited Social Health Activists (ASHAs) receive monetary benefits when they accompany women and men for sterilization. However, the unmet need for spacing births is highest, especially among young married women between 15- to 24-years-old. 

"The Government of India (GoI) established the Essential Spacing at Birth (ESB) benefits to encourage birth spacing and for the promotion of long-acting reversible and other temporary contraceptive methods. The ESB scheme provides a result-based benefit to ASHAs who counsel newly married couples and first-time parents on the benefits of childbirth spacing and contraception.

While the ESB scheme was extended to urban ASHAs, they had not been able to reap any ESB-related benefits since it was neither well understood by them nor by their supervisors, Auxiliary Nurse Midwives (ANMs). Hence, ESB scheme reported almost no claims at the time in which TCIHC began its support to the cities of Uttar Pradesh from 2016 to 2018.

TCIHC saw this as an opportunity not only to serve potential clients with the full choice of methods, meeting the unmet need of a great proportion of women, but also motivate ASHAs by unlocking resources that the GoI had already committed for this cause.

TCIHC uncovered scheme-related nuances and supported city and state officials to provide orientation to ASHAs and ANMs on the ESB scheme and simultaneously advocated with the family planning division at city and state levels to activate ASHA ESB benefits provided under the scheme.

At the outset, ASHAs felt that the scheme involved complicated paperwork and multiple levels of approvals. TCIHC coaches worked with ASHAs to help them promote informed choice when counselling women by explaining spacing methods as well as permanent methods during their household visits. Besides this, TCIHC coaches demonstrated the effectiveness of the urban health index registry (UHIR) to record information that can be easily retrieved when submitting claims. The coaching built AHSAs' understanding of the ESB scheme as an investment with long-term returns and little to no extra effort.

One such urban ASHA has served in Firozabad since September 2016. With over three years of experience, she is familiar with and regularly updates her client records and UHIR. However, she was not aware of the ESB scheme. With the coaching that she received from TCIHC, she was able to gather evidence and supporting documents to make ESB claims.

Earlier I did not know that I could get an incentive if a couple in my area delays their first pregnancy or spaces subsequent births... Now I have a priority list of clients and I update my eligible couple list very carefully to claim the benefit. - Hemandri, urban ASHA, Firozabad

For reading this story on TCI University please https://tciurbanhealth.org/msc-booklet-2/

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/.

Dr. Pravin Kumar Bharti is the Deputy Chief Medical Officer and Nodal Urban Health with the National Urban Health Mission (NUHM) in Mathura (Uttar Pradesh, India). He has six years of experience across a wide spectrum of urban health issues. He recently sat down with The Challenge Initiative for Healthy Cities (TCIHC) to share his experience with TCIHC and TCI University (TCI-U). TCI-U includes an India toolkit, which has codified high-impact approaches (HIAs). These approaches are being scaled up through TCIHC in three states: Uttar Pradesh, Madhya Pradesh and Odisha. The India toolkit features 15 HIAs, which strengthen service delivery and supply, demand generation and advocacy components of family planning and adolescent and youth sexual and reproductive health (AYSRH) interventions. The toolkit provides standardized and contextualized information, resources and 'how-to-do' guidance, which can be easily customized to meet the city requirements for rapidly scaling up evidence-based family planning and AYSRH interventions. In 2019, the government of Uttar Pradesh, Madhya Pradesh and Odisha endorsed and approved the high impact approaches and tools of TCIHC, expanding the reach and ultimately impact of them. 

When did you first learn about TCIHC and TCI-U?

In February 2019, TCIHC had organized a State Conclave where the state of Uttar Pradesh endorsed nine HIAs [high-impact approaches] of TCIHC. This is where I first learned about TCI-U. At that time, I was holding the position of District In-Charge, Control Room, Mathura. As a result of my interest in family planning and urban health, I was nominated by CMO [Chief Medical Officer], Mathura, to participate in the State Conclave. As soon as I returned [from the State Conclave], I registered myself and my colleagues on TCI-U with the support of TCIHC City Manager."

What motivated you to first use TCI-U?

I developed a keen interest in TCI-U when during a meeting in March 2019 with the Chief Medical Officer, he required some job-aids related to Accredited Social Health Activists (ASHA) and he asked TCIHC City Manager for support. TCIHC City Manager quickly browsed TCI-U and downloaded the required information from the resource section linked to the HIA [high impact approach] on Urban ASHAs. I was impressed. And, from that day onwards, I have kept hard copies of the HIAs on my desk and access them on TCI-U as well."

How have you used TCI-U?

The high impact tools have helped my department understand fixed day static/family planning day (FDS) approach, role of Mahila Arogya Samiti in demand generation for family planning, importance of convergence between various departments for improving family planning indicators, use of family planning data, funds allocated under Program Implementation Plan (PIP), etc. Moreover, I have downloaded government approved materials like - 'All method poster' from TCI-U; this poster is now displayed in all Urban Primary Health Centers of Mathura. Even this poster is used on FDS days and routine service days as well in Outreach Camps to counsel clients on family planning methods. I have also downloaded the 'Pregnancy screening checklist,' which was given to staff nurses and community health workers to identify potential clients. TCI-U has helped me improve family planning practices across cadres, including NUHM [National Urban Health Mission] staff to field-level workers. I also navigate TCI-U to learn other countries' innovations and ideas also."

What are your overall impressions of TCI-U?

Urban family planning requires a lot of innovations and TCI-U is one such platform that provides innovative proven approaches. I like everything about TCI-U because it helps to understand our roles better, provides ways to get quick results and offers solutions to overcome potential challenges. That it is my job to improve family planning indicators and take decisions. TCI-U helps me do that. I have taken a couple of assessments related to the HIAs and earned certificates, which I find to be the most exciting part. TCI-U is a well-structured website, which provides comprehensive information and resource materials."

Like Dr. Bharti, around 35 government officials are registered on TCI-U from Mathura and most of them have completed the assessments for the high-impact approaches and received certificates.

For reading this story on TCI University please https://tciurbanhealth.org/in-their-own-words-nuhm-deputy-cmo-in-mathura-likes-innovations-found-in-tci-university/

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/.