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/.

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:

• 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/.

"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/.

When The Challenge Initiative (TCI) in India engaged the city of Moradabad in May 2018, most Accredited Social Health Activists (ASHAs) had little knowledge of family planning - especially long-acting spacing methods - due to limited or no training. 

For them, family planning meant female sterilization. They rarely engaged with Mahila Arogya Samitis (MAS) to seek support from these women's support groups in addressing myths and misconceptions related to family planning and tackling social barriers (including the ones posed by gatekeepers) that these community groups could help influence. At the same time, MAS also had limited knowledge and information about family planning.

As a result, family planning uptake in Moradabad was low, given very few women knew much about the variety of family planning methods available to them, let alone felt supported and informed to make a decision on the matter.

An ASHA named Heerawati said after she received TCI training and coaching on family planning methods, she felt empowered. She was applauded in an ASHA-ANM monthly meeting, where she shared how with the help of MAS members she helped a woman adopt a family planning method of her choice. She said she remembered that during one of her routine household visits, she told a young woman named Moni about family planning and her method choices for spacing between children. But she said Moni's mother-in-law stopped her from adopting any family planning method. She then tried counseling the mother-in-law on the advantages of family planning for young first-time parents, but Heerawati was unable to change her mind. The next thing she knew, Moni was pregnant with her second child.

"Previously, I did not have much confidence in discussing family planning with women of my area as I did not know much about it. Like others in the community, I feared IUCD (intrauterine contraceptive devices). In 2019, TCI organized a two-day orientation on FP where I learnt about all the methods, their side effects, and ways of handling client's myths and misconceptions. I clarified my doubts on IUCD, injectables and others. I learnt how MAS members can be helpful in dealing with mothers-in-law who sometimes pose difficult questions or prevent adoption of FP by a young woman of their house. I felt a rush of confidence in me." - Heerawati An ASHA in Moradabad

This story motivated other ASHAs to work with MAS members in their communities to counsel women to adopt family planning methods of their choice.

Heerawati has so far successfully motivated more than 100 eligible couples and is one of the expert ASHAs at her urban primary health center (UPHC), Majholi.

As a result of these efforts to strengthen linkages between the community and facility, the overall uptake in family planning services at the city level for Moradabad has improved by 97% - from 7,694 family planning users at the time of baseline to 15,136 users as of June 2021 (Fig.1). At the same time, this represents a 197% increase at the UPHC level - from 4,266 family planning users at baseline to 12,649 users as of June 2021 (Fig. 1).

"I was dismayed as I had seen Moni as a frail woman. After her second delivery, I spoke to Mahila Arogya Samiti members and requested them to counsel Moni's mother-in-law so that she does not conceive yet again and get burdened. MAS members invited Moni and her mother-in-law in their next group meeting where they counseled both of them. Moni soon visited and met the UPHC doctor who explained the basket of choices to her. I kept on following up with Moni and assured her that the side effects of any FP method are temporary and there is no need to be afraid of any method as it will improve her life. Finally, Moni asked me to help her avail injectable contraceptive." - Heerawati An ASHA in Moradabad

For reading this story on TCI University please https://tciurbanhealth.org/strengthening-the-linkages-between-community-structures-and-the-health-system-in-moradabad-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/.