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Tales
 
ASHA Helps Woman Move Beyond Just Surviving to Live Life to the Fullest
Accredited Social Health Activists (ASHAs) are empowering women like Rani Burman living in Madhya Pradesh, India, to seek a better tomorrow. The Challenge Initiative for Healthy Cities (TCIHC) supports local governments in Indian states like Madhya Pradesh to strengthen the capacity of urban ASHAs to provide quality family planning counseling and referrals to meet the needs of women like Rani. 

"I was flying on my new scooty; my dreams were turning into reality. Life was a Bliss! All thanks to Pooja Didi. Yet I clearly remember the day when Pooja Didi first visited me. I was eating only rice. She had asked, 'Why are you eating only rice? You have small children; you must eat a healthy and balanced diet.' My eyes had welled up and she sat there quietly. Once I felt better, I shared that ever since the birth of my second daughter financial hardships increased for us. My husband and in-laws wanted a male child so my husband did not spare money for us; instead, he spends most of his earnings on alcohol. Today I at least had rice to eat. Pooja Didi comforted me and left with a promise to return."

From that day, she would visit me often, sometimes to give iron-folic tablets or to immunize my children or to just inquire about my health. One day, she cited her example and encouraged me to work and earn for the family. I told her that I had completed my secondary education but my husband does not like the idea of my working outside of the house. Didi jolted me to think of making a change in the drudgery of my life. One afternoon, when Didi came, my husband was home. She checked about children's health and started a conversation around the importance of family planning and also prodded upon the idea of my working outside of the house. She reasoned without fear that these two decisions will only make life better for us. My husband was moved. A few days later, I asked my husband if I could look for a job. To my surprise, he gave his nod. I soon found one and gradually found a better one as a receptionist at a hospital. Pooja Didi was elated!"

Financial independence boosted my confidence. I started expressing myself. I told my husband that I know that the family desires to have a male heir but given that we already have two daughters and our income is also not sufficient to support this current family of six members including his parents. Thus, we must do something about family planning as we cannot bear the cost of upbringing one more child. My husband approved and asked me to inquire all about family planning from ASHA Didi. Next time, when Pooja Didi visited us, she explained all the family planning choices and clarified our doubts. We decided to adopt a permanent family planning method as we wanted to be free."

These two decisions have changed my life. Not only am I free from the constant pressure of producing a male child but I have become independent too and also gained respect from my family and society. I am determined that my daughter will do advanced studies and become a doctor or a police officer. I have learnt not to fear life but to live life."

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 visit https://tciurbanhealth.org/tcihc-urban-tale-asha-helps-woman-move-beyond-just-surviving-to-live-life-to-the-fullest/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, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

The 2BY2 Matrix Helps ASHAs and ANMs Aligarh, India, Prioritize Family Planning Clients
The Challenge Initiative for Healthy Cities (TCIHC) has been improving the family planning knowledge and skills of urban Accredited Social Health Activists (ASHAs) since it began supporting local governments across three states in India in 2017. To further strengthen the health system and support urban ASHAs and Auxiliary Nurse Midwives (ANMs) - who supervise ASHAs - TCIHC introduced its "2BY2" matrix to help prioritize potential family planning clients as well as meet their other health needs more efficiently. In a recent interview, Dr. Lalit Kumar, the Joint Director of Health and Family Welfare in Aligarh, explained the impact the 2BY2 matrix is having. 

Urban ASHAs in Aligarh have been successfully coached through the Lead, Assist and Observe (LAO) [coaching] model of TCIHC. The program's MIS [management information system] data indicate that the LAO model is improving ASHA's knowledge of family planning, attitude towards counseling skills and require minimal support in terms of planning and monitoring. ... TCIHC team had, hence, decided to move to the next step with devising a tool, which helps 'prioritize.' TCIHC has helped us understand how significant it is to track eligible couples for family planning. This 2BY2 matrix has given us guidance on how to increase efficiency of ASHA, without investing additional resources and increase their reach not only for family planning but for other health areas, like routine immunization also."

The Aligarh Division government was so impressed after TCIHC introduced the 2BY2 matrix in November 2019 that it has now diffused it to non-TCIHC supported cities in the division.

The tool amazed us! It aggregated users and non-users of family planning by ASHA, which in turn, supports understanding of family planning uptake by ANM. Aggregation by age/use at the ANM level establishes service uptake for each of the urban primary health centre (UPHC). The tool signals UPHCs that are performing well in terms of family planning uptake and UPHCs that have a large population of the target audience with unmet need. We could draw out a priority list of ASHAs and ANMs who are performers and those who require mentoring and monitoring. We realized that such a customized tool that drives a 'culture of prioritization' has never been introduced before. Our AD (Additional Director) was impressed so much so that she wanted to replicate this in three non-TCIHC cities, namely Kasganj, Etah and Hathras of Aligarh division. She issued a circular to District Magistrate / Chief Medical Officers (CMOs) of those districts to implement this immediately. Following this, I worked in collaboration with TCIHC City Manager to rollout the 2BY2 matrix in the three selected non-TCIHC cities."

To date, 396 ASHAs and 85 ANMs have been oriented on the 2BY2 tool to help identify eligible family planning clients and/or areas or populations requiring more efforts for voluntary family planning adoption.

When on a visit to Pala Sahibabad UPHC, I observed a 2BY2 matrix in an ANM's hand and, at that time, she told me that, '2BY2 is an amazing tool. Now, I do not sift through various registers of ASHAs as this matrix provides clear information on which ASHA requires more support.'

The 2BY2 matrix has been introduced across all 31 TCIHC-support cities and has already shown great success in instituting a culture of prioritization and data for decision-making, using available data sources and health system structures, which helps ensure sustainability.

For reading this story on TCI University please https://tciurbanhealth.org/the-2by2-matrix-helps-ashas-and-anms-aligarh-india-prioritize-family-planning-clients/

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/.

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/.

ASHAs in Moradabad Help Dispel Myths with Young First-Time Parents

Anita works as an Accredited Social Health Activist (ASHA) in the Asalatpura slum in Moradabad, Uttar Pradesh. One day during household visits, she noticed a short, thin, barefooted girl playing with a six-month-old baby near a sewage drain. Anita asked the young girl to call the mother of the baby. She was surprised when she found out the young girl named Rubina was in fact the mother of the child.

Anita visited Rubina's cramped house where she lived with her husband Rashid and their child, along with four more families. Rubina told her that she got married at 16, has never been to school and works as a rag picker.

Rashid joined the conversation and Anita began counseling the couple on contraceptive methods, but Rubina interrupted her and said, "My Bhabhi (sister-in-law) has told me that I am too young for adopting any contraceptive method." The couple had a strong belief that family planning is not for them as young first-time parents.

Anita was not surprised to hear this myth and was prepared to counsel Rubina and her husband on the benefits of contraceptives, especially given that Rubina is young and just experienced a labor and delivery six months earlier. Rubina described what Anita shared with her: "Anita didi used to bring pictorial leaflets to sometimes explain about personal hygiene, nutritious diet, breastfeeding, immunization, family planning, etc. She explained how a mother's health affects a child's health. This made us rethink our decision to adopt a family planning method. Finally, one day, I visited the nearby urban primary health center with my husband, where the doctor explained the importance of birth spacing and its implications on the health of a young mother and a child. That day, we realized that for many months we have been listening to similar things from Anita didi. As a result, we decided to opt for a long-acting reversible contraceptive method. Also, I started practicing self-care by following the things I learned from Anita didi."

Given such situations, it is important that ASHAs are equipped to provide informed-choice counseling and services to young first-time parents. And, given the importance of key community gatekeepers, such as husbands and other family members, it is critical that they are engaged so that myths and misperceptions do not continue to persist in families and communities in India.

For reading this story on TCI University please visit: https://tciurbanhealth.org/tcihc-urban-tales-ashas-in-moradabad-help-dispel-myths-with-young-first-time-parents/ 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/.

TCIHC Successfully Advocates for Supply Chain Management Tool in Uttar Pradesh Cities
Meeting the family planning needs of those living in Uttar Pradesh (UP) - one of the most populous states in India with over 200 million residents - remains a struggle, especially during health crises such as the ongoing COVID-19 pandemic. One particular challenge that has been overcome with the help of The Challenge Initiative for Healthy Cities (TCIHC) was the need for robust and systematic supply chain management in UP's urban areas. 

The Ministry of Health and Family Welfare (MoHFW) rolled out a dedicated Family Planning Logistic Management Information System (FPLMIS) in 2017 to help improve access to and increase use of modern contraceptive methods, but only for rural areas with plans to eventually use it in urban areas. The FPLMIS is an easy-to-use SMS-based application that enables users to monitor and order family planning commodity stocks to minimize interrupted supplies and unavailable contraceptives. At the same time FPMLIS was rolled out for rural use only, TCIHC began supporting UP city governments to implement its high-impact approach fixed-day static /family planning day (FDS) for urban primary health centers (UPHCs), which ensures quality family planning services with a choice of reversible spacing methods at a time and place known to the community. TCIHC also helped them activate outreach camps (ORC) and urban health nutrition days (UHNDs) as functional family planning service delivery points by integrating family planning into their agendas. Availability of family planning commodities at all three of these service delivery points was essential for success, so TCIHC looked for ways to streamline supply chain management to prepare for scaling up these approaches throughout UP and beyond.

TCIHC met with the state family planning division in December 2018 to make the case for advancing the rollout of the FPLMIS in urban areas, explaining how this would strengthen the supply chain at the UPHC as well as the last mile via urban ASHAs, a relatively new cadre of frontline health workers in the urban health delivery system. This would mean potential family planning clients would not be turned away without a method from an ORC or UHND, and no ASHA would have to refuse a method to an eligible family planning client during her household visits due to lack of family planning commodities, specifically oral contraceptive pills (OCP) and condoms. Moreover, this would save time expended by ASHAs, Auxiliary Nurse Midwives (ANMs), pharmacists and medical officers-in-charge in compiling requests for supplies. The state family planning division was convinced by these arguments and approved rolling out the FPLMIS to TCIHC-supported cities.

This decision allowed TCIHC to support the creation of unique identification codes for each cadre and a complete database of service delivery points as well as ASHAs, ANMs and other human resources essential to inform supply and demand of commodities for urban areas and facilities. TCIHC supported district teams in coaching ASHAs and ANMs on how to place orders (indenting process) and UPHC staff on inventory management and distribution of supplies. By May 2019, the FPLMIS was ready to process orders and issue supplies to urban areas through UPHCs, ORCs, UHNDs and urban ASHAs.

Now the FPLMIS tracks critical supply chain management indicators in the 20 TCIHC-supported cities of UP, including procurement status, stock-in and stock-out situations and near expiration status. The updated FPLMIS is helping government officials make quick decisions to address supply chain issues as they can easily track stock availability at all points of service delivery. Dr. Alpana Sharma, the General Manager of Family Planning of UP at the National Health Mission (NHM), explains the significance of this change:

As we have now introduced FPLMIS in urban areas, we see that it has strengthened the monitoring system of family planning commodities, improved logistic and supply chain management and ensured timely availability of contraceptives from state to UPHCs and ASHA/ANM level. This has enabled urban ASHAs to indent [process orders for] required family planning commodities through FPLMIS portal and the system is able to respond in a timely manner. Overall, eligible couples are receiving timely family planning supplies and are able to attain their desired family size. We can clearly see the advantages of FPLMIS over a manual supply chain management as we now have accurate forecasting, timely distribution and less/minimal supply imbalances. We appreciate the support of TCIHC in preparation of complete database of UPHCs, urban ASHA/ ANM and other service providers required for FPLMIS portal."

Results from the 20 TCIHC-supported cities inspired the state to rollout FPLMIS in the remaining 55 districts of UP. Linking UPHCs with FPLMIS has clearly put UPHCs in the drivers' seat as they can control supply chain operations, reduce the imbalance of contraceptive stock and ensure availability to clients in UP's urban areas.

Neeraj, an ASHA at the UPHC Laxmi Nagar in Mathura noted what this change means for her and other ASHAs:

FPLMIS has simplified the indenting and issue of supplies and commodities such as OCP, condoms, pregnancy kit, etc. We just need to send one SMS with details of our requirements and we get these supplies upon our next visit to the UPHC. As a result, now we always have sufficient quantity of family planning commodities and are able to provide to people who desire and need them."

For reading this story on TCI University please https://tciurbanhealth.org/tcihc-successfully-advocates-for-supply-chain-management-tool-in-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/

 
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