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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/.

Reaching First-Time Parents in the TCIHC-Supported Youth-Friendly Cities of Uttar Pradesh
The Challenge Initiative for Healthy Cities (TCIHC) in India worked strategically through its adolescent and youth sexual and  reproductive health (AYSRH) program to reach first-time parents with informed-choice counseling and modern contraceptive services over a six-month period ending June 2019 in five cities in Uttar Pradesh (Allahabad, Firozabad, Gorakhpur, Saharanpur and Varanasi). 

The first step was to make sure young first-time parents were visible, so they can receive appropriate services, including contraception, so TCIHC coached and mentored active urban Accredited Social Health Activists (ASHAs) to identify them from their urban health index registers (UHIR). This effort included coaching to make sure the ASHAs knew how to complete their UHIRs, develop lists of women based on age and parity (i.e., number of children), and devise a priority list of young first-time parents. At the same time, TCIHC worked to overcome provider bias to ensure providers and facility staff were aware of the latest medical guidelines and had accurate knowledge on all the methods available for young first time-parents at both the facility (medical-officer-in-charge and staff nurse) and community level (ASHA worker). "

Studies have shown that low parity can be a barrier to accessing some family planning methods. Data from the Urban Reproductive Health Initiative (URHI) found that 90% of the providers restricted access to female sterilization and intrauterine contraceptive device (IUCD) based on the number of children that a client has. Of this, 65% of doctors required a client to at least have one child and 63% of all traditional birth attendants believed that a woman can opt for an IUCD only if she had two children or more. As a result, a plan was devised to conduct whole site orientation (WSO) - a TCIHC proven approach - on adolescent-friendly services at urban primary health centers (UPHCs) in the five cities. Following this, the TCIHC team garnered support from city health teams to organize special fixed day static (FDS) services - another TCIHC proven approach - for first-time parents. These efforts significantly increased contraceptive uptake among first-time parents, aged 15-24, as illustrated in Figure 1. Forty-one percent of all women aged 15-24 accepting a family planning method at a UPHC were first-time parents, across the five TCI AYSRH cities, as compared with 28% in the 26 TCIHC-supported cities implementing TCI's proven family planning solutions in Uttar Pradesh, Madhya Pradesh and Odisha with no special focus on AYSRH.

Upon learning about the AYSRH impact, many of the TCI cities implementing family planning only informally began adding AYSRH activities. As a result, these cities also began to exhibit increased results in reaching women 15-24 years and referring them to FDS (Figure 2). While TCIHC AYSRH cities still reached more young women, ages 20-24, (50.3%) than TCI family planning only cities (42%), the fact that there is not a large gap between the two different city groups speaks to the scalability of the AYSRH approaches.

For reading this story on TCI University please https://tciurbanhealth.org/reaching-first-time-parents-in-the-tcihc-supported-youth-friendly-cities-of-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/.

TCIHC Helps Urban Primary Health Centers Become Adolescent-Friendly in Allahabad, India
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/.

Despite COVID-19, Firozabad’s City Health Plan Keeps Client Volume Up at District Women’s Hospitals, UPHCs
While the world grapples with the negative impact of COVID-19 on other health programming achievements, Firozabad - one of the 20 cities supported by The Challenge Initiative for Healthy Cities (TCIHC) in India - has consistently demonstrated an upward trend in family planning usage indicators. Firozabad's careful planning and tenacity allowed it to continue providing quality family planning services to its urban poor population during the pandemic. 

One of the major challenges brought on by COVID-19 in Firozabad was that a number of urban primary healthcare centers (UPHCs) were converted into COVID-19 care centers. In addition, staff were reposted at COVID-19 care centers and hospitals, and urban accredited social health activists (ASHAs) were redirected to different locations for COVID-19 survey duty.

Despite the challenges, the Firozabad government did not waiver in its commitment to provide quality family planning services. Dr. Bhanu Pratap Singh, the Urban Nodal Officer in Firozabad, shared the steps that he and other city governance staff took under the leadership of the Chief Medical Officer (CMO) to ensure family planning remained available to the urban poor:

He listed as examples:

  • Monthly fixed-day static (FDS) services for permanent methods at district women's hospitals (DWHs) as a result of TCIHC advocacy efforts
  • District facilities conducting whole site orientations with TCIHC's support
  • A city health plan (CHP) completed at the end of 2019, under the chairmanship of the District Magistrate and with TCIHC support
  • Budget for holding quarterly review meetings already included in the program implementation plan (PIP)

Dr. Singh said they were just beginning to implement their city health plan when COVID-19 struck in March 2020 and lockdowns were imposed.

By late June, Dr. Singh said Firozabad once again began monitoring progress at quarterly review meetings and the DWH's Chief Medical Superintendent (CMS) noticed family planning indicators dipping. FDS days at DWHs had been limited to two days a week, but a decision was made to offer family planning services at DWHs every day from 8:30am-1pm during COVID. Another challenge they faced was making sure every patient was tested for COVID before service delivery.

With COVID as the city's top health priority, Firozabad decided to reorient 92% of its urban ASHAs in June 2020 with TCIHC's technical assistance. The reorientation focused on how to approach family planning solutions while keeping COVID in mind. It also covered how to process orders through the Family Planning Logistics Management Information System (FPLMIS) to ensure ASHAs had adequate supplies of short-term methods for household visits and how to ensure referrals for long- acting methods by accompanying interested clients to DWHs while the UPHCs were providing care for COVID patients.

Dr. Singh believes the city health plan - the product of a rigorous exercise mandated by the National Health Mission - led to the outcome seen in Firozabad and he recommends that other cities consider developing such a plan. This emerging best practice has the potential to strengthen a city's resilience to withstand natural disasters and emerging pandemics.

"With TCIHC's coaching and mentoring support, Firozabad had taken a number of steps in 2018 and 2019 to prioritize the family planning program. We reaped benefits from those exercises at the time of COVID." - Dr. Bhanu Pratap Singh Urban Nodal Officer, Firozabad, Uttar Pradesh

TCIHC's support of the development process for the innovative city health plan was also a key factor in enabling Firozabad to continue quality family planning service provision despite COVID-19. City officials made a commitment to have the city health plan guide their efforts and regularly reviewed activities and data against it. In addition, it conducted routine FDS at DWHs and, as soon as the government allowed UPHCs to hold FDS days again, the city bounced back with all facilities providing all family planning methods in line with COVID-19 protocols.

As a result, Firozabad's DWHs saw a 418% increase in annual client volume for long-acting reversible contraception (LARCs), according to Health Management Information System (HMIS) data from the DWHs (Fig. 1). This accounts for 968 LARC users since June 2020, when the lockdown was relaxed. At the UPHC level, the total number of family planning acceptors increased 20% from June 2020 to February 2021, with short-term acceptors contributing over 39% to this increase (Fig. 2).


Key Learnings from COVID-19

Dr. Bhanu Pratap Singh, Urban Nodal Officer, Firozabad

  • COVID-19 demonstrated the importance of having a city health plan, which served as a guide to ensure no health area was overlooked.
  • Dedicated FDS days/hours at DWHs can be offered as an alternative during any disaster in which services are interrupted at the UPHC level. But when the situation normalizes, DWHs should have FDS at defined intervals in a month to provide permanent methods to clients referred from UPHCs or directly by ASHAs.
  • Review data and activities regularly to plan for and maintain success.
  • Reorient staff and community health volunteers during any disaster on how to address fears in the community and yet still provide services.
  • Motivate community health workers by recognizing their performance, especially in times of disaster and uncertainty.
  • Service providers, such as staff nurses, are critical for counseling clients, assuaging fears and providing quality family planning services. Thus, reassure them of their safety, refresh their counseling skills and show them appreciation during monthly or quarterly review meetings.

For reading this story on TCI University please visit: https://tciurbanhealth.org/project/despite-covid-19-firozabad-keeps-client-volume-up-at-district-womens-hospitals-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/.

In Their Own Words: NUHM Deputy CMO in Mathura Likes Innovations Found in TCI University
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/.

 
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