PSI India - Slide show
Tales
 
Creating Family Planning Coaches Within the Health System in Indore

Years ago, in a tribal area of Madhya Pradesh, Rajni witnessed the death of a 15-year-old girl who had just given birth  for the second time.

"I was just 22 years old myself and had completed only one year in my job as an ANM. Upon the death of the young mother, all of us were very sad. And, I still recall that the doctor had said family planning could have prevented this young woman's death."

Forever etched in her mind, this sad memory motivates her to promote family planning.

"I am committed to offering family planning services to both men and women as a way to save lives. While providing family planning services, I ensure screening clients properly by checking weight, blood pressure, hemoglobin and ruling out pregnancy. I orient and counsel male group meetings in slum areas to increase knowledge and change mindsets related to family planning. As a result, I have motivated three men for non-scalpel vasectomy."

Rajni is trained in providing the full range of contraceptive methods, including intrauterine contraceptive device (IUCD) insertion and injectable contraceptives (Antara). She conducts regular meetings with Accredited Social Health Activists (ASHAs) in her area and coaches them to better plan household visits by first properly filling out their registers and using them to prioritize visits and deliver tailored counseling messages. Rajni and the ASHAs she coaches follow a systematic approach to ensure that all eligible couples in the community receive family planning information and have access to their methods of choice. She explains:

"With the help of ASHAs, we keep a record of couples that are newlyweds and those who have one child, and approach them on a priority basis for family planning counseling. Whenever an ASHA faces any challenge, I accompany her during the home visit and support in family planning counseling."

Rajni firmly believes that family planning is key to the health and well-being of the entire population. Her passion and commitment towards promotion of family planning was acknowledged by the Indore government on Aug. 15, 2019, when she was recognized as the best performing ANM.

For reading this story on TCI University please visit: https://tciurbanhealth.org/tcihc-urban-tales-creating-family-planning-coaches-within-the-health-system-in-indore/ 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/.

Soon-to-Be Graduated City of Kanpur Shares Implementation Learnings with Two New Uttar Pradesh Cities
The Challenge Initiative's (TCI's) 'business unusual' approach supports deep engagement with city governments to widen the  impact of its evidence-based family planning (FP) and adolescent and youth sexual and reproductive health (AYSRH) interventions. Cities that "graduate" from TCI's direct support effectively sustain the interventions through coaches embedded within the health system that are recognized as TCI "alumni." This recognition positions these graduated cities as learning laboratories from which newer TCI cities can observe and learn. 

Kanpur, a TCI-supported city in Uttar Pradesh, is nearing graduation from TCI direct support and recently shared what it learned from its implementation experience with two sister cities, Etawah and Farrukhabad. Soon after joining TCI in March 2021, key representatives from Etawah and Farrukhabad were invited by TCI-trained Kanpur city master coaches on a study tour to witness firsthand how Kanpur implemented TCI's high-impact interventions.

At the beginning of the study tour, Additional Director (AD), Kanpur, Dr G. K. Mishra laid out his expectations and emphasized: An essential component of a successful urban family planning program is its data reporting and management mechanism. I encourage new cities to develop a HMIS [health management information system] FP data-flow plan representing the entire process of data collection from field to HMIS upload, and submit it to Divisional Urban Health Consultant, Kanpur. Post review and completeness of the data, the Kanpur division will use it for decision-making for all the health programs of the division."

After participating in a mini-university and the study tour, Etawah and Farrukhabad have been able to not only rapidly scale up the high-impact interventions but also achieve promising results. Dr. Sushil Kumar, Nodal Officer of Etawah, and Rajeev Pathak, District Urban Health Coordinator (DUHC) of Farrukhabad, discussed how both learning opportunities contributed to their success.

Dr. Kumar shared: Etawah has a population of 300,000 people and yet has only four urban primary health centers (UPHCs). Added issues of staff crunch, COVID vaccination drive, low capacities of ANMs [auxiliary nurse midwives] and ASHAs [accredited social health activists] on the subject of family planning and low levels of awareness and acceptance of family planning by urban slum population were some of the challenges faced by us when we joined the TCI.

NUHM [National Urban Health Mission] and TCI oriented all the new joining cities through a mini university platform on the family planning best practices. It was interesting to note that our peers, nodal urban officers, ACMOs [Assistant Chief Medical Officers], etc. from TCI's experienced cities had taken time out of their busy schedules to share with us key lessons and tips that could help our cities increase family planning uptake. Later, AD Sir from Kanpur invited our team to experience the implementation of best practices. We returned [to our own cities] rich with learnings and presented the same in the DHS [District Health Society] meeting. Encouraged by the response at the DHS platform, we formed a quick plan and worked with TCI team towards capacity building of providers and community health workers, use of data for decision-making, quality assurance of services, regularizing Antral diwas (FDS), form a city coordination committee, to name a few of the best practices that we put in place. It is because of the first-hand experience of seeing it in a city and then learning from TCI coaches with the help of the 'how to do' toolkit that we could streamline some processes and get started right away. We were delighted to observe a 242% (5,272) increase in the annual family planning client volume from the baseline (1,540) at the city level by August 2021, as recorded in the HMIS."


Pathak added: Hearing about the levers of success from fellow government counterparts during the mini university and then during the study tour increased the confidence level of all city officials as they saw change within the system made by the change makers of the system."

He shared that Farrukhabad made an action plan wherein the city focused on:

  • Orienting Medical Officers in-Charge (MoICs) and pharmacists on ensuring sufficient stock of family planning supplies by coaching MoICs to delegate indenting and procurement of family planning supplies to pharmacists, who then distribute them to ANMs and ASHAs.
  • Referring to the high-impact interventions on TCI University and reaffirming roles and responsibilities of staff nurses, ANMs and ASHAs to implement them.
  • Coaching MoICs to regularly review family planning data, identify gaps and carry out mid-course corrections.
  • Validating data from UPHCs before inputting into the HMIS.
  • Ensuring timely family planning reporting from each UPHC and timely HMIS reporting.
  • Forming quality improvement committees (QICs) at each UPHC and monitoring their work.

This focused plan made Farrukhabad one of the best-performing cities among TCI's new cities. According to the HMIS, TCI best practices have contributed to a 27% (5,869) increase in annual family planning client volume at the city level comparing baseline (4,608) to August 2021.


Both Dr. Kumar and Pathak cannot wait to see the achievements that their cities will continue to accomplish after receiving more TCI coaching and mentoring support in the coming months

For reading this story on TCI University please https://tciurbanhealth.org/soon-to-be-graduated-city-of-kanpur-shares-implementation-learnings-with-two-new-uttar-pradesh-cities/

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/.

Firozabad Staff Nurse Finds Satisfaction in Serving Others
"As a child, I was enamored by the doctor's profession. A mere sight of someone dressed in a white coat brought respect in everyone's eyes. I wanted to be a doctor too! Growing up in a low-middle class family and the financial constraints [we faced] allowed me to only pursue a General Nursing and Midwifery diploma course from Tundla, Uttar Pradesh (UP). I stay in Tundla and travel 70 kms to and from my home to the UPHC in Firozabad. It is far, but I enjoy my work." 

Manisha is a committed staff nurse posted at the Sant Nagar urban primary health center (UPHC) in Firozabad. She supports all government health programs implemented at the UPHC, including family planning. As a result of advocacy efforts by The Challenge Initiative (TCI), she was trained on family planning counseling and how to provide the injectable Antara and insert intrauterine contraceptive devices (IUCDs). Manisha shared how she actively followed up with her family planning clients during the COVID lockdown and her absence from the UPHC: "My mother is a cancer patient. And during the COVID lockdown, she was hospitalized. At that time, I stayed with her at the cancer hospital. I carried my family planning client's register to remind Antara clients about their next due dose. I used to telephonically counsel family planning clients who visited the UPHC. I am happy that in my absence none of the family planning client were returned without availing services"

She also stressed the important role society - in particular the family - plays in supporting or obstructing the uptake of family planning services. She recalled a common situation she often faces:

"While working as a staff nurse, I found that reluctance from the husbands and in-laws are the biggest obstacles preventing a woman from availing family planning services. I remember an incident when a frail woman visited our UPHC to take STI (sexually transmitted disease) treatment. She had seven children. I counseled her on family planning but her husband staunchly refused it. Later, the woman kept on visiting the UPHC for medicines. I was dismayed to see her suffer. Once her husband had accompanied her, I grabbed courage and spoke to him in detail about the poor condition of his wife's health. I explained the benefits of family planning. After a number of counseling sessions, I was able to persuade him to use one of the methods. I felt a sense of relief and satisfaction."

This story highlights the importance of two of TCI India's high-impact approaches - Strengthening Provider Capacity and Male Engagement.

For reading this story on TCI University please visit: https://tciurbanhealth.org/tci-india-urban-tales-firozabad-staff-nurse-finds-satisfaction-in-serving-others/. 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/.

In Their Own Words: Using Data for Decision-Making in Bareilly Helps TCIHC Accelerate Work
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/.

 
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