Non-Clinical Staff Play Role in Making UPHCs Adolescent-Friendly
Pooja Kumari works as a janitor at the Aurangabad urban primary health center (UPHC) in Lucknow, Uttar Pradesh. Recently, she participated in a whole-site orientation (WSO), a TCIHC proven approach that targets all staff working in a health facility to become advocates for family planning. All staff receive an "orientation" to gain a basic understanding of family planning and its benefits. At Pooja's facility, the Medical Officer In-Charge conducted WSO for the entire staff on how to provide adolescent-friendly health services. Pooja was overjoyed to be sitting in the same hall as everyone else working for the facility.
With a sparkle in her eyes, she shared: "Since 2015, I am working in Aurangabad UPHC. As a janitor, my role is limited to facility housekeeping duties and responsibilities. When I was invited for WSO, I was somewhat astonished. I thought trainings are meant for medical staff only. At the same time, I was excited to have been counted for this training opportunity. It was a new experience for me. Whole-site orientation helped me to reflect on my adolescence, as back in those days there were hardly any services available for adolescents. In my teens, I could only approach my mother to discuss about menstruation and I don't remember visiting any facility or hospital without any guardian.
WSO changed my mindset. I liked the story of three teenagers titled "Kuchh to log kahenge" (People will say something) [shared during the WSO session]. This story describes how unmarried adolescents face socio-cultural prejudices and stigma when they visit a facility alone. Their fear of being judged inhibits them to seek sexual and reproductive health care information or services. Due to insufficient and inaccurate information, they are left with much curiosity and unresolved issues. The participatory discussion followed by the story helped me to realize the health needs of adolescents and also equipped me with a know-how of how a non-clinical staff [like myself] can also create a conducive environment for adolescents by being non-judgmental and unbiased, regardless of their age and marital status.
I have learned so much from this orientation, both professionally and personally. Today, as a facility staff and as a mother I believe that the environment of a health facility and home should be adolescent-friendly so that they can fearlessly share their problems and get correct information related to sexual and reproductive health issues. In fact, after attending WSO, I have noticed a change in myself as immediately a few days later when some adolescents had visited the facility, I greeted them with a smile. I had never done this before. I am glad that I was considered as an important facility staff who can play a substantial role in creating enabling environment for adolescents."
To learn more about how to conduct WSO, read guidance and access tools for implementing it on TCI University. WSO is a critical component of TCIHC's priority strategies for improving contraceptive use among first-time parents. Learn more about how TCIHC has helped UPHCs become adolescent-friendly in Allahabad and other cities in Uttar Pradesh.
For reading this story on TCI University please visit: https://tciurbanhealth.org/tcihc-urban-tales-non-clinical-staff-play-role-in-making-uphcs-adolescent-friendly/ 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/.
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/.
Unlocking Benefits of 'Essential Spacing at Birth' Scheme
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/.
2BY2 Tool in Uttar Pradesh Helps ASHAs Appreciate the Value of Using Data for Decision-making
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/.
Moving Data Review Meetings to UPHCs in Shahjahanpur Improves Family Planning Service Delivery
In Shahjahanpur, Uttar Pradesh, monthly meetings between Accredited Social Health Activists (ASHAs) and Auxiliary Nurse  Midwives used to take place centrally at the office of the Chief Medical Officer (CMO). But because Shahjahanpur has 94 ASHAs and 25 ANMs, the CMO felt that these meetings were often too crowded, chaotic and unproductive.
The Challenge Initiative for Healthy Cities (TCIHC) recommended that these meetings be moved to the urban primary health center (UPHC) level to limit the number of participants, ensure better engagement of ASHAs and ANMs with other facility staff, provide more regular reviews of data and discuss course corrections. Shahjahanpur's CMO readily agreed and now the meetings are held in UPHCs and family planning indicators are improving."
"I [have] attended 10 such meetings at UPHCs and noticed a surmountable difference," the CMO said. "With a limited number of ASHAs and ANMs, I noticed they were paying attention to the proceedings of the meeting."
The Deputy CMO also witnessed this transformation, and pointed to the following three changes that have taken place:
ASHAs feel more comfortable sharing issues they face in their work. Those who were shy were not able to speak in front of the large audience in the meetings at the CMO office.
The UPHC Medical Officer can now coach the entire UPHC team on method choices for family planning and clarify myths and misconceptions related to them.
Regular UPHC-specific data reviews helps identify issues that need to be addressed, such as supply stock outs.
The Medical Officer In Charge (MoIC) of the Lodhipur UPHC also said holding meetings at the UPHCs was the right move.
"Now, we can review the ASHA diary and Urban Health Index Register ... and FP uptake has increased," said the MOIC. "Earlier, we would know only by the end of six months or one year as to what the performance is but now we know every month."
This active, regular review of data has helped ASHAs better focus their efforts (see chart below), identify areas where coaching support is needed, provide a platform for recognition of high-performing ASHAs, expedite more timely payment processing and unlock funds from the Ensuring Spacing at Birth (ESB) scheme of the Government of India, which was not previously utilized by urban ASHAs.
Moving the location of the monthly ASHA-ANM meetings to UPHCs is proving to be a successful approach across all 31 TCIHC-supported cities. More than 6,000 urban ASHAs are now taking part in such meetings.
For reading this story on TCI University please https://tciurbanhealth.org/moving-data-review-meetings-to-uphcs-in-shahjahanpur-improves-family-planning-service-delivery/
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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