Suritesh Dagur serves as city manager for The Challenge Initiative for Healthy Cities (TCIHC) in Bareilly, the eighth largest city in Uttar Pradesh. Before transferring to Bareilly, she worked with the government of Saharanpur - one of the first five TCIHC cities - to scale-up TCIHC's proven interventions. Below, she reflects on what she learned from her work in Saharanpur and how she used those learnings to make progress in her new TCIHC city of Bareilly. 

"My story goes back to the time when I had joined TCIHC as the City Manager of Saharanpur. After working for a year in this city known for its wood carving, I had managed to accelerate the uptake of family planning solutions in its urban primary health centers (UPHCs). But, my success story in Saharanpur took a twist when I was transferred to Bareilly - a new TCIHC city in Uttar Pradesh. This sudden transformation brought back the same feeling I had when I joined Saharanpur a year ago. I felt I was at ground-zero again, but I also sensed responsibility and high expectation for myself. I wanted to replicate the success of Saharanpur in Bareilly. I reflected back on my experience in Saharanpur, and I realized that I knew how the system works, the process and very well understood the way I had to move forward with my mission."

As I landed in Bareilly, I felt an 'air of indifference' in the system as if everyone had accepted the way things were. Most of all I found that the system behaved differently from what I was used to in Saharanpur and people were not ready to accept TCIHC - which was the way in Saharanpur too at the beginning. I knew the best way to activate the system was to demonstrate a result that the health leadership of Bareilly had never achieved from urban areas until now. So, I started by getting orders for the special fixed day static service/family planning day (FDS/FDP) (also referred to locally as 30-hour magic +) for two facilities to coincide with World Population Day. The situation was not at all in our favor as supplies and instruments were missing from the UPHCs. I managed to arrange for the IUCDs kits and infection prevention equipment and instruments were borrowed from a private facility to give quality services to the clients. However, the biggest hurdle was untrained service providers as no staff nurse was trained on IUCD insertion in Bareilly. I ran around to get special orders from the Chief Medical Officer (CMO), who asked the facility Medical Officers to be on duty on the day of FDS. My team of field program assistants (FPAs) and field program coordinators (FPCs) worked hard in the field with the frontline workers [ASHAs and AWWs] to mobilize potential clients. The way we worked around the clock to make FDS a successful event was a shock to the system."

On July 19, 2018, we had our first FDS in Bareilly at two facilities - UPHCs in Gher Zafar Khan and Subhash Nagar. It was like a fair. Twenty-seven clients voluntarily chose to get an IUCD inserted on this single day at both facilities. It was the largest number of IUCD accepters in an urban area of Bareilly to date. The results were shared with all the government officials. They were happy with the results, but the results were not enough to break the ice. Soon, FDS became a one-day wonder for the system."

The high impact approach (HIA) tools helped me a great deal whenever I encountered a dilemma. I had used them many times in Saharanpur, but now it was time to do the same in Bareilly in order to get good results. Although the HIAs are very impactful at all engagements with stakeholders, the data for decision-making tool is one that can break the ice anywhere. The best part is that government already has data in its system through HMIS and other reports. Data comparison at any point of time (between the HMIS and project records) is a very good tool for any project as it is the only way by which the performance can be measured and helps inform decision-making as well. I used data for decision-making as an advocacy tool after the FDS and the results had poured in for FP uptake. I went to the office of the National Urban Health Mission (NUHM). Luckily, that day the NUHM Nodal Officer, Urban Health Coordinator and the City Community Process Manager (CCPM) were all in the office. I had made up my mind that today is the day when I will break the ice and present our project as their own necessity. I needed for them and the system to own the project. With this thought, I requested the Data Cum Accounts Assistant (DCAA) to share the file of monthly reports. DCAA had her apprehensions and did not comply with my request at first, instead she asked me to speak to the Nodal Urban Officer since she saw the data is proprietary and sensitive to those outside the system. I was prepared for this situation, so I spoke to the Nodal Urban Officer and convinced him that the only way to move forward with FP programming in the city was to analyze the data from HMIS. I explained to him that data is the only way by which we will be able to understand the situation right now and help the system in further planning for FP. The Nodal Urban Officer was convinced and directed the DCAA to provide the data."

As expected, the HMIS data on family planning hadn't been analyzed and whatever data that was submitted from the UPHCs were still in the hard copy. The DCAA had no clue as to whether correct reporting was being done or not. I analyzed the reports for June 2018 to July 2018 and prepared a presentation along with the excel sheet of the reports. The analysis showed many discrepancies, such as many UPHCs reporting PPIUCDs, which was actually being done at the District Women's Hospital. Another major flaw was that the NUHM - which oversees the public health sector - was reporting services provided at the private facilities by their ASHAs in their own reports. These findings were compared to last year's reports. The difference in the report that I prepared from the FDS versus what was being submitted by the UPHCs was eye opening for them."

The NUHM team said that this is a really grave issue that the right reports are not coming in from the UPHCs. The Nodal Urban Officer asked me to 'Kindly share the reports with us over email. The one which you have prepared is the right one. We want to understand the performance of UPHCs.' The NUHM team also made a note that 'data anomaly' and wrong reporting were major issues to be discussed during the next review meeting."

At this time, the Urban Health Coordinator said, 'We never knew that the reports were wrong; I request you to kindly check the data of our UPHCs regularly. In fact, you can take the reports weekly from our facility and share with us, so that at the month end, we have the right report to be presented in our review.' The moment he said this, I introduced TCIHC's data for decision-making tool to him. I briefed him on how the specified indicators and steps mentioned in this tool help to monitor and do better activity planning. He was very impressed with the way TCIHC works, and immediately created a WhatsApp Group ... to have correct FDS reports on the same day as they occur. This was the day when NUMH and the system recognized TCIHC's value and better understood that we are here to help strengthen their system."

Later, the Nodal Urban Officer and Urban Health Coordinator asked me to coach the pharmacists and medical officers of the UPHCs on how a report should be prepared. He further prepared a schedule of joint visits of CCPMs and FPCs to UPHCs so that the CCPMs can better understand the reports and how they are to be prepared correctly. This was the turning point for the TCIHC in Bareilly."

For reading this story on TCI University please https://tciurbanhealth.org/in-their-own-words-using-data-for-decision-making-in-bareilly-helps-tcihc-accelerate-work/

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 (TCI) seeks to strengthen the capacity of local governments to better serve the health needs - specifically the family planning needs - of the urban poor. The urban landscape is a complex and challenging environment that requires adaptive approaches and continuous learning. However, self-motivation and ownership by health system change agents are required so that others within the health system, civil service and community are inspired. 

Community health workers collect many important data points in various registers, but because the data isn't used by them, the importance of collecting it is often undervalued. In the recent past, the Government of India (GoI) introduced the urban health index register (UHIR) as a data collection tool to consolidate the various registers. Yet, community health workers were overwhelmed by the complexity of the tool.

TCI then devised the 2BY2 prioritization tool to highlight the most valuable information of interest and use to community health workers from specific data collected in the UHIR. This visual tool is designed to instill in a last-mile health worker the behavior of using data for decision-making.

Anita, an urban accredited social health activist (ASHA), serves as a role model to other ASHAs in maintaining her UHIR and using TCI's 2BY2 prioritization tool to better serve the households in her catchment area. Anita recently shared her experience using these tools with the Medical Officer in Charge of the Majholi urban primary health center (UPHC) in Moradabad and what it has meant for her personally and professionally:

As an urban ASHA, I am assigned to a population of 2,000 urban poor residents. I am expected to complete the details of population of that area in the UHIR or ASHA diary, as we call it locally in Uttar Pradesh. Before I received coaching from TCI, my register was never complete. I found it bulky and a laborious task to update it regularly. Moreover, I did not understand its various sections.

The TCI team explained its various sections, coached me on how to simplify this task and practically transfer the details from available sections to complete the remaining sections. They made me aware that by updating the register, I can extract information into a family planning due list. This activity is eligible for a certain portion of incentives announced by GoI. Also, other information from UHIR can be retrieved to claim incentives as per government schemes, like the ensuring spacing at birth (ESB) scheme.

Gradually, I learnt about the 2BY2 Prioritization Tool and I observed how this due list can be analyzed to identify non-users of modern methods. We could just use this number to plan our household visits. My supervisor also coached me on this prioritization tool and it became a regular feature of discussion and agenda during the monthly ASHA-ANM (auxiliary nurse midwives) meetings.

It had started to come into practice, but COVID disrupted all identified and routine activities. I felt helpless. At that time, ANM didi with support from TCI coached me virtually on continuing the completion of UHIR and devising a due list. Therefore, at the time of COVID also, I could fill the 2BY2 matrix and serve the family planning needs of the people of my area. I also identified the need for short-acting methods and shared the demand with ANM didi."

As a result of effectively using these data tools, Anita has continued to be able to claim Rs.300 for updating her UHIR in the time of COVID and meeting the family planning needs of clients in her area, earning her appreciation and recognition at the UPHC monthly meetings.

To know more about our work, visit https://tciurbanhealth.org/2by2-tool-in-uttar-pradesh-helps-ashas-appreciate-the-value-of-using-data-for-decision-making/.

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/.

When The Challenge Initiative (TCI) in India engaged the city of Moradabad in May 2018, most Accredited Social Health Activists (ASHAs) had little knowledge of family planning - especially long-acting spacing methods - due to limited or no training. 

For them, family planning meant female sterilization. They rarely engaged with Mahila Arogya Samitis (MAS) to seek support from these women's support groups in addressing myths and misconceptions related to family planning and tackling social barriers (including the ones posed by gatekeepers) that these community groups could help influence. At the same time, MAS also had limited knowledge and information about family planning.

As a result, family planning uptake in Moradabad was low, given very few women knew much about the variety of family planning methods available to them, let alone felt supported and informed to make a decision on the matter.

An ASHA named Heerawati said after she received TCI training and coaching on family planning methods, she felt empowered. She was applauded in an ASHA-ANM monthly meeting, where she shared how with the help of MAS members she helped a woman adopt a family planning method of her choice. She said she remembered that during one of her routine household visits, she told a young woman named Moni about family planning and her method choices for spacing between children. But she said Moni's mother-in-law stopped her from adopting any family planning method. She then tried counseling the mother-in-law on the advantages of family planning for young first-time parents, but Heerawati was unable to change her mind. The next thing she knew, Moni was pregnant with her second child.

"Previously, I did not have much confidence in discussing family planning with women of my area as I did not know much about it. Like others in the community, I feared IUCD (intrauterine contraceptive devices). In 2019, TCI organized a two-day orientation on FP where I learnt about all the methods, their side effects, and ways of handling client's myths and misconceptions. I clarified my doubts on IUCD, injectables and others. I learnt how MAS members can be helpful in dealing with mothers-in-law who sometimes pose difficult questions or prevent adoption of FP by a young woman of their house. I felt a rush of confidence in me." - Heerawati An ASHA in Moradabad

This story motivated other ASHAs to work with MAS members in their communities to counsel women to adopt family planning methods of their choice.

Heerawati has so far successfully motivated more than 100 eligible couples and is one of the expert ASHAs at her urban primary health center (UPHC), Majholi.

As a result of these efforts to strengthen linkages between the community and facility, the overall uptake in family planning services at the city level for Moradabad has improved by 97% - from 7,694 family planning users at the time of baseline to 15,136 users as of June 2021 (Fig.1). At the same time, this represents a 197% increase at the UPHC level - from 4,266 family planning users at baseline to 12,649 users as of June 2021 (Fig. 1).

"I was dismayed as I had seen Moni as a frail woman. After her second delivery, I spoke to Mahila Arogya Samiti members and requested them to counsel Moni's mother-in-law so that she does not conceive yet again and get burdened. MAS members invited Moni and her mother-in-law in their next group meeting where they counseled both of them. Moni soon visited and met the UPHC doctor who explained the basket of choices to her. I kept on following up with Moni and assured her that the side effects of any FP method are temporary and there is no need to be afraid of any method as it will improve her life. Finally, Moni asked me to help her avail injectable contraceptive." - Heerawati An ASHA in Moradabad

For reading this story on TCI University please https://tciurbanhealth.org/strengthening-the-linkages-between-community-structures-and-the-health-system-in-moradabad-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/.

ASHA Nazreen Gulzar developed a novel way to remind herself to take her contraceptive pill each week so she does not miss a dose. After she shared her technique with women in her community, they started doing the same thing. 

Like Nazreen, more than 6,000 urban ASHAs have become more effective as health educators and promoters in their communities. The Challenge Initiative for Healthy Cities (TCIHC) supports local governments in Indian states, like Madhya Pradesh (MP), to strengthen the capacity of urban ASHAs through its 'Lead-Assist-Observe' coaching and mentoring model.

As the pressure cooker whistled, Nazreen - an Accredited Social Health Activist (ASHA) and mother of two living in Bhopal, Madhya Pradesh - went straight to the kitchen where her eyes fell on her non-hormonal weekly contraceptive pill Chhaya hanging right next to her utensil rack. She smiled and immediately took her pill. This is her way of reminding herself to take her pill as prescribed each week given that she acknowledges being forgetful: "I attribute non-regular use of family planning method to my forgetfulness," she said.

She explains below what made her decide to choose Chhaya and how she came up with her method of reminding herself to take it.

"Two years back, we were using condoms, but I always remained fearful of becoming pregnant as my husband did not use them consistently. Will I get my periods? I found myself tormenting over the same question. In addition, in my role of an ASHA, I counsel couples in my slum area about the various contraceptive methods available to them at no cost. I motivated nearly 96 women from my catchment area to adopt a contraceptive method in the last four years. Yet, I was living in fear of unwanted pregnancy myself.

In 2017, when the Government of India launched two new contraceptives - Antara (injectable contraceptive) and Chhaya (Centchroman/non-hormonal pill) - TCIHC team built my understanding of these methods and enabled me to counsel couples on these methods also. This non-hormonal pill interested me as it was to be taken only once a week. I began taking it but I missed a dose just two weeks after I had started it. It was then that I devised a reminder for myself. I started hanging the packet near the cooking area in the kitchen. This way I am constantly reminded of my Chhaya dose and ever since I have never missed any dose.

I realized that this physical reminder worked for me. I shared this 'mantra' with women in the community who have adopted a method which requires reminders, like oral contraceptive pills, injectable contraceptive and condoms. They liked the idea, and is now used by several women in the community. When I advise women on family planning, I always give my personal experience of how my life has changed ever since I started continued use of family planning methods."- Nazreen Gulzar Urban ASHA, Bhopal, MP

By conducting household visits, ASHAs play a major role in identifying coronavirus patients at this critical time. TCIHC has supported the Government of India (GOI) in Uttar Pradesh (UP), MP and Odisha by developing self-care messages for its frontline health workers, including urban ASHAs and their supervisors, Auxiliary Nurse Midwives (ANMs).

For reading this story on TCI University please visit https://tciurbanhealth.org/tcihc-urban-tales-ashas-contraceptive-reminder-technique-spreads-through-her-community/.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/.