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TCIHC Coaching Empowers Mau to Scale-up Family Planning High Impact Interventions
The Challenge Initiative for Healthy Cities (TCIHC) works with city governments in Uttar Pradesh, India, to implement and  sustain reproductive health solutions through its innovative coaching model. Recently, five additional cities, including Mau, joined the partnership to receive TCIHC coaching support. 

The TCIHC coaching model is structured to support all levels of the hierarchical government health system. This includes support at the city officials' level and urban primary health center (UPHC) level, including Auxiliary Nurse Midwives (ANMs) and Accredited Social Health Activists (ASHAs). as in other TCIHC-supported cities, TCIHC followed its coaching model in Mau to provide conceptual and practical 'know-how' and transfer capacity to local government stakeholders so they can implement high-impact interventions. Mau began implementing in January 2021.

Two government functionaries from Mau recently shared changes they have witnessed as a result of TCIHC's coaching. Dr. P. K. Rai, Additional Chief Medical Officer/Family Planning Nodal officer shared:

Before we joined hands with TCIHC, we were not regular in validating mapping and listing of slums areas. As a result, we were unaware of the health needs of the left-out population. Though urban ASHAs were onboard, they were untrained in family planning. It was mostly the oral contraceptive pills or tubectomy that we offered as a choice to the women. With TCIHC coaching, we have learnt to identify such gaps across the service delivery points, demand generation, reporting, etc.

We learnt that to activate UPHCs for provisioning long-acting clinical methods, service providers need to be trained on new contraceptives and reoriented on IUCD. We took this requirement to the CMO [Chief Medical Officer] who supported us to formulate a training plan. We also conducted a joint visit with TCIHC coaches to the UPHC to oversee the facility, assess FP stock and review progress. We have started taking measures on all fronts. We just printed urban health index register (UHIR) for distribution to ASHAs. All of these steps are expanding access to quality family planning services and yielding good results. However, more work is required to reduce gaps. TCIHC has pioneered a new way of thinking and working in us; I am confident our partnership with TCIHC will help the urban poor to meet their family planning needs."

Dr. Jawed Akhtar, Medical-Officer-In-Charge (MOIC) of the Bharhu ka Pura UPHC, echoed similar sentiments: "TCIHC offers a unique coaching approach. TCIHC has coached us on identifying gaps and opportunities for improving family planning services. For example, we could not start Antral diwas (Fixed Day Static service) at our UPHC as our staff nurse and ANMs were untrained. We had a dysfunctional autoclave [used for sterilizing medical instruments and supplies]. We identified such gaps by using the facility readiness checklist of TCIHC. We learnt that there are line items in the PIP [the government of India's planning and budgeting process] which we could utilize to equip the facility. TCIHC also coached us on HMIS reporting and data validation practices. Today, as a focal person for the UPHC, I ensure that quality family planning services are provided to clients by following all the protocols set by the government of India. I am glad that we have TCIHC's support to efficiently and effectively drive the urban family planning program in Mau."

TCIHC's coaching support has also positively impacted Shimla Yadav, an ANM at the Bharhu ka Pura UPHC, who shared: "[The] TCIHC team coached me on how to strengthen the capacities of ASHAs, how properly fill the UHIR register and utilize it for decision making. I am transferring these skills to my ASHAs. It is only after the TCIHC intervention that ASHAs of our UPHC have received UHIR."

The HMIS data below indicates that TCIHC's coaching activities are beginning to show results as Mau is on a progressive path. All four UPHCs in Mau are observing a substantial growth in family planning services uptake as apparent from January to June 2021 data in comparison to the same period the previous year. UPHCs of Mau are lined up for district quality assurance committee (DQAC) visits and certification, which will enable its UPHCs to add IUCD services to the basket of choice of family planning methods.


The city of Mau has embraced TCIHC's high-impact interventions and started to fill critical gaps in demand generation activities and quality of family planning services. Furthermore, the city is preparing to take steps to improve the use of data for decision-making, combat family planning supply stock-outs, procure the needed equipment for family planning service delivery, strengthen data quality mechanisms, and initiate a visit of DQAC to its UPHCs for assessing quality standards - all while having to address several other competing health priorities, including COVID-19 care and treatment needs.

For reading this story on TCI University please https://tciurbanhealth.org/tcihc-coaching-empowers-mau-to-scale-up-family-planning-high-impact-interventions/

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/.

Youth-Led Workshops Engage Youth in the Design of AYSRH Programming in Uttar Pradesh
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/.

Addressing Provider Bias through Whole-Site Orientation in Uttar Pradesh, India
The Challenge Initiative for Healthy Cities (TCIHC) in Uttar Pradesh, India, aims to increase access to sexual and reproductive  health (SRH) information and services for adolescents and youth in urban environments. TCIHC is partnering with the Government of India's national adolescent health program called Rashtriya Kishor Swasthya Karyakram (RKSK) to offer adolescent-friendly health services (AFHS) at urban primary health centers (UPHC) for the urban poor. 

Because UPHCs are nested within complex social and cultural settings, health service providers working at UPHCs maintain their own beliefs and value system. Healthcare systems can also influence provider actions in the form of policies and norms. These influences may induce provider biases, leading to a lower quality of care, especially for unmarried adolescents.

To address this, TCIHC coached RKSK to launch its high-impact whole site orientation (WSO) best practice to orient all staff in an UPHC on the SRH needs of adolescents and youth. The WSO also addresses any biased attitudes and beliefs towards youth SRH issues that staff may hold that could unintentionally cause harm. Working within the health system, TCIHC in collaboration with RKSK coached the Medical Officers In-Charge (MOICs) of the UPHCs to conduct WSO without TCIHC or RKSK support for all facility staff to create a more enabling environment for adolescents that also ensures quality adolescent-friendly health services.

In Aligarh, Dr. Arshiya Sherwani, MOIC of UPHC Nagla Tikona, has facilitated WSO with her staff. In the interview below, she shares with TCIHC her experience and reflections on the changes she has observed after WSO.

Discovering my own biases

In December 2020, TCIHC virtually coached me on the goal and objective of orienting all UPHC staff though a WSO. The coaching I received was in fact a behavior change intervention aimed at reducing my own bias. Unsurprisingly, I discovered that social norms were driving my biases. The most pervasive social norm was the significance of sexual abstinence before marriage. And, therefore, my attitude and belief was that contraceptives were meant for married couples only. I recognized that my attitude towards the provision of contraceptives is shaped primarily by client's age, parity and marital status. I realized youth must pass through many barriers to access SRH. Provider bias is one of the gates. TCIHC provided orientation material based on RKSK guidelines. I received 'how-to-guidance' on conducting a values clarification exercise through a whole site orientation for all staff.

After equipping myself, in January 2021, I conducted WSO sessions for my entire UPHC staff at the facility irrespective of cadre and technical skills, which included staff nurse, lab technician, pharmacist, Auxiliary Nurse Midwives (ANM), Accredited Social Health Activists (ASHA), support staff etc. With support from TCIHC, I attended a youth-led City Consultation Workshop (CCW) in Aligarh organized by RKSK. Here I had heard adolescents and youth candidly share their opinions and desires on SRH issues. I was a bit shocked but I immediately realized the necessity of SRH care for unmarried adolescents and youth. TCIHC initiatives - the AYSRH CCW and WSO - both changed my mindset about the importance of providing SRH information and services to adolescents and youth."

Facilitating a whole-site orientation

Facilitating the WSO session was a learning experience for me. The design of activities, such as role plays and cases studies, enabled my staff to overcome non-technical biases rooted in attitudes and beliefs, without explicitly saying that they are doing this. An interesting attitude that emerged was that of staff engaging with young clients from parental perspective. The belief that we are in a better, more informed position to make decisions for clients. I encouraged WSO participants to raise concern without hesitation. This created a non-threatening environment for them to ask and clarify their indecisions. I addressed their questions related to menstruation, puberty and physical changes associated with adolescence. While it was difficult, I was determined to discuss contraceptive needs and behaviors of unmarried adolescents and teenagers and invested time in discussing this topic.

The session on values clarification challenged staff to explore the reasons behind their beliefs, and also reflect on the consequences of their actions when clients are denied contraceptive methods. I tried role plays with the help of the game 'Bhranti aur Kranti' (Myth and Revolution) from RKSK's Peer Educator Training Manual. ASHAs enacted the role of Bhranti who asked questions and Kranti who responded with correct answers with rationale. This game helped in busting myths about SRH needs of adolescents - married or unmarried. Apart from this, I also coached the facility staff on the competencies required for delivering SRH services in a friendly manner, like being non-judgmental, maintaining confidentiality and privacy, building trust, interpersonal skills, etc. I covered topics of nutrition, non-communicable diseases, substance misuse, violence and mental health. This orientation aided staff to recognize and address their unconscious biases related to SRH needs of adolescents, which were mainly associated with gender, marital status and age. I was motivated to see the City Community Process Manager from the National Health Urban Mission (NUHM) participate in the WSO. Meanwhile, through the session, I endeavored to sensitize the staff towards SRH needs of adolescent and covered standards set by RKSK for AFHC [adolescent-friendly health clinic]."

After coaching

After the WSO, I witnessed an explicit change in the attitude of UPHC staff. I observed them being mindful of adolescent needs and being empathetic when counseling them during facility Adolescent Health Days (F-AHDs). WSO had truly prepared the staff. After this, with TCIHC's technical coaching on F-AHD and detailed coaching on how to organize it, we started F-AHDs on the fifth of every month. With management coaching of TCIHC, we arranged reporting formats, sanitary napkins and medicines for adolescents from the Nodal Officer for F-AHDs. We also established a counseling corner for adolescents to maintain confidentiality and privacy. My team of staff nurses and ANMs along with TCIHC-coached ASHAs and Anganwadi worker publicize F-AHDs and encourage adolescents to use the services. These community health workers motivate adolescents from urban health nutrition day and slum areas. Through F-AHD, we promote health-seeking behaviors among adolescent boys and girls and provide services like hemoglobin testing, body mass index screening and provide iron folic acid supplements (WIFS) and albendazole capsules, as required. Additionally, counseling services are offered to each visiting adolescent where they are counseled about nutritious and balanced diet, mental health issues, genital and menstrual hygiene, among other issues.

As a result of all of these efforts, the community is now well-aware about adolescent health services availability in our facility and adolescents are regularly visiting the facility and obtaining services. They comfortably talk to us without hesitation and discuss body changes, menstruation, etc. My staff now ensures that no adolescent goes home without availing services. Whenever my staff have any doubts I discuss with them individually and also refresh their knowledge in UPHC level group meetings. At times, we face challenge when adolescents visit the facility without guardian and share about sexual abuse incidences during counseling sessions. We have to refer such cases to the RKSK counsellor at the District Hospital because these are legal issues. In addition, when we have high footfall on F-AHDs, maintaining privacy during counseling session becomes a big challenge. UPHCs will benefit by having dedicated trained counsellor for adolescents, which is currently not in place.

Till date, we have conducted three F-AHDs and provided services to 116 boys and girls. Often RKSK and NUHM officials visit F-AHD and the UPHC and coach us on management of AY and FP services. I also continuously assess the progress of health services uptake, especially AY and FP during the monthly UPHC meeting and address issues and challenges by coaching the staff and discuss plans to improve the services. I can proudly say that in my UPHC, adolescent health services are prioritized and provided in a manner that respects the rights of adolescents, their privacy and confidentiality. Moving forward, to build an enabling environment and for sustainable change, parents, teachers and the community need to be sensitive so that adolescents can seek and utilize SRH services without any hesitation."

Working with 10 more cities across Uttar Pradesh, TCIHC has created 140 such master coaches who have conducted 231 WSOs. Having met this first criteria for AFHC, TCIHC is coaching AY city teams to regularly host F-AHDs and upload data from F-AHDs onto HMIS. In addition, TCIHC is advocating at the state level to get AYSRH counselors placed at UPHCs and, thus, support RKSK's vision of making each UPHC an adolescent-friendly health clinic.

For reading this story on TCI University please https://tciurbanhealth.org/addressing-provider-bias-through-whole-site-orientation-in-uttar-pradesh-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/.

Family Planning Offers New Beginnings for Young Mothers in 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/.

TCIHC’s QA Approach Leads to National Recognition for Behrampur’s UPHCs
Quality assurance (QA) is one of the nine high-impact family planning approaches that The Challenge Initiative for Healthy Cities (TCIHC) uses when working with city governments. TCIHC provides technical support to urban primary health centres (UPHCs) to establish quality improvement committees, conduct a periodic quality assessment using a simplified checklist, develop and monitor a plan of action and ultimately be certified by the district quality assurance team for offering quality services. 

After TCIHC partnered with the City Health Department in Berhampur, Odisha, to implement the QA approach in all seven of its UPHCs, quality measures improved significantly. This improved quality was recognized nationally with all seven TCIHC-supported UPHCs of Berhampur earning the Kayakalp Award.

In 2019-2020, all seven TCIHC-supported UPHCs of Berhampur earned a Kayakalp award. Three UPHCs received first place and two others were recognized as runners up while the remaining UPHCs received a commendation award. Kayakalp Awards are a national initiative launched in 2015 to improve and promote the cleanliness, hygiene, waste management and infection control practices in public health care facilities and incentivize high-performing facilities.

Mr. Lamodar Digal, City Program Manager In-charge, National Health Mission (NHM) Berhampur, shared why this recognition is significant:

All seven UPHCs of the city achieved Kayakalp Award in 2019 as they followed QA guidelines, which improved the quality aspects of service delivery including hygiene, infection control mechanism and supported UPHCs in internal facility assessment. This is significant because in 2017-18 UPHCs were new. There were barriers related to biomedical waste management, training of staff on quality parameters and most of all since NUHM [National Urban Health Mission] was new, no other department took ownership [of quality assurance]. At this time, TCIHC worked with the city health team and actually gave shape to the vision of the Commissioner of Berhampur who wanted to 'Make UPHCs the first choice of treatment for people" of Berhampur and wanted them to qualify for the highest certification of quality, which is 'Kayakalp' and National Quality Assurance Standards (NQAS)."

In 2017-18, UPHCs provided only oral contraceptive pills and service providers, while Auxiliary Nurse Midwifes (ANMs), staff nurses and Accredited Social Health Activists (ASHAs), were unaware of the full array of method choices and were not trained to provide them. TCIHC helped coach ASHAs on counseling techniques, organized hands-on trainings of ANMs on all method choices, and ensured staff nurses received training on the provision of intra-uterine contraceptive device (IUCD) and the injectable contraceptive Antara. As a result of these efforts, family planning became an integral part of the services provided at the UPHC. Digal said TCIHC support made the difference.

Before TCIHC's technical support, we did not even imagine that one day we would be able to provide expanded choices of family planning, including long-acting reversible methods at UPHC."

But expanding the availability of IUCDs and injectables made quality a more prominent concern. As a result, TCIHC began supporting the quality assurance approach by having field program service assistants (FPSA) - who coach UPHC staff - incorporate family planning in the quality improvement meeting at UPHCs and district quality assurance committee (DQAC) meetings at the district level. This particular step not only prioritized issues in family planning but also helped uncover many other gaps related to quality, infrastructure, supplies, etc. These issues were discussed during DQAC meetings as well. The support also included the introduction of a simple checklist for family planning based on the NQAS guidelines. This simple checklist helped UPHC staff to self-monitor quality parameters. In addition, each UPHC in Berhampur created a family planning corner, which provided privacy for family planning counseling and services.

As a result of these measures, family planning was strengthened at each UPHC and this contributed to increased scores for both Kayakalp and NQAS and eventually helped each UPHC win both. Digal explained the mindset shifts that the QA approach has sparked at the UPHCs and among the communities that they serve:

Our UPHCs are now 'AMA clinic' (meaning 'Our Own Clinic') in the real sense. 'AMA clinic' was the slogan given by the Berhampur Municipal Corporation (BeMC), but it turned into a reality once we, the city government, got TCIHC's technical support. Our people around UPHCs are happy as there is no need to go to the district hospital or higher level hospital for primary health services, including family planning."

These QA measures of Berhampur inspired several cities in Odisha and the neighboring state of Madhya Pradesh to visit Berhampur UPHCs to learn more. Two more cities supported by TCIHC - Rourkela and Puri - also won Kayakalp commendation awards, thus validating that the right family planning approach can help a UPHC score for Kayakalp award. In addition, since TCIHC's inception in 2017, all seven UPHCs of Berhampur have increased the availability of all family planning choices for the urban poor population, especially reversible methods, such as IUCD, injectable contraceptive and non-hormonal pills.

For reading this story on TCI University please https://tciurbanhealth.org/tcihcs-qa-approach-leads-to-national-recognition-for-behrampurs-uphcs/

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/.

 
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