The Challenge Initiative for Healthy Cities (TCIHC) works with city governments in Uttar Pradesh, India, to implement and  sustain reproductive health solutions through its innovative coaching model. Recently, five additional cities, including Mau, joined the partnership to receive TCIHC coaching support. 

The TCIHC coaching model is structured to support all levels of the hierarchical government health system. This includes support at the city officials' level and urban primary health center (UPHC) level, including Auxiliary Nurse Midwives (ANMs) and Accredited Social Health Activists (ASHAs). as in other TCIHC-supported cities, TCIHC followed its coaching model in Mau to provide conceptual and practical 'know-how' and transfer capacity to local government stakeholders so they can implement high-impact interventions. Mau began implementing in January 2021.

Two government functionaries from Mau recently shared changes they have witnessed as a result of TCIHC's coaching. Dr. P. K. Rai, Additional Chief Medical Officer/Family Planning Nodal officer shared:

Before we joined hands with TCIHC, we were not regular in validating mapping and listing of slums areas. As a result, we were unaware of the health needs of the left-out population. Though urban ASHAs were onboard, they were untrained in family planning. It was mostly the oral contraceptive pills or tubectomy that we offered as a choice to the women. With TCIHC coaching, we have learnt to identify such gaps across the service delivery points, demand generation, reporting, etc.

We learnt that to activate UPHCs for provisioning long-acting clinical methods, service providers need to be trained on new contraceptives and reoriented on IUCD. We took this requirement to the CMO [Chief Medical Officer] who supported us to formulate a training plan. We also conducted a joint visit with TCIHC coaches to the UPHC to oversee the facility, assess FP stock and review progress. We have started taking measures on all fronts. We just printed urban health index register (UHIR) for distribution to ASHAs. All of these steps are expanding access to quality family planning services and yielding good results. However, more work is required to reduce gaps. TCIHC has pioneered a new way of thinking and working in us; I am confident our partnership with TCIHC will help the urban poor to meet their family planning needs."

Dr. Jawed Akhtar, Medical-Officer-In-Charge (MOIC) of the Bharhu ka Pura UPHC, echoed similar sentiments: "TCIHC offers a unique coaching approach. TCIHC has coached us on identifying gaps and opportunities for improving family planning services. For example, we could not start Antral diwas (Fixed Day Static service) at our UPHC as our staff nurse and ANMs were untrained. We had a dysfunctional autoclave [used for sterilizing medical instruments and supplies]. We identified such gaps by using the facility readiness checklist of TCIHC. We learnt that there are line items in the PIP [the government of India's planning and budgeting process] which we could utilize to equip the facility. TCIHC also coached us on HMIS reporting and data validation practices. Today, as a focal person for the UPHC, I ensure that quality family planning services are provided to clients by following all the protocols set by the government of India. I am glad that we have TCIHC's support to efficiently and effectively drive the urban family planning program in Mau."

TCIHC's coaching support has also positively impacted Shimla Yadav, an ANM at the Bharhu ka Pura UPHC, who shared: "[The] TCIHC team coached me on how to strengthen the capacities of ASHAs, how properly fill the UHIR register and utilize it for decision making. I am transferring these skills to my ASHAs. It is only after the TCIHC intervention that ASHAs of our UPHC have received UHIR."

The HMIS data below indicates that TCIHC's coaching activities are beginning to show results as Mau is on a progressive path. All four UPHCs in Mau are observing a substantial growth in family planning services uptake as apparent from January to June 2021 data in comparison to the same period the previous year. UPHCs of Mau are lined up for district quality assurance committee (DQAC) visits and certification, which will enable its UPHCs to add IUCD services to the basket of choice of family planning methods.

The city of Mau has embraced TCIHC's high-impact interventions and started to fill critical gaps in demand generation activities and quality of family planning services. Furthermore, the city is preparing to take steps to improve the use of data for decision-making, combat family planning supply stock-outs, procure the needed equipment for family planning service delivery, strengthen data quality mechanisms, and initiate a visit of DQAC to its UPHCs for assessing quality standards - all while having to address several other competing health priorities, including COVID-19 care and treatment needs.

For reading this story on TCI University please https://tciurbanhealth.org/tcihc-coaching-empowers-mau-to-scale-up-family-planning-high-impact-interventions/

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 coaching support provided by The Challenge Initiative for Healthy Cities (TCIHC) to city governments in Uttar Pradesh (UP) emphasizes the importance of quality of care as a key pillar in providing voluntary, informed choice family planning services. 

As a result, city governments have built management and coordination mechanisms that enhance the quality and availability of family planning services. The TCIHC-supported city of Gorakhpur illustrates the local government's commitment to improved quality of care after receiving TCIHC coaching.

In March 2021, the Basantpur urban primary health center (UPHC) in Gorakhpur became the first UPHC in Uttar Pradesh to earn a National Quality Assurance Standards (NQAS) award. NQAS certification is the highest-ranking quality accreditation in India. Only a minuscule percentage of UPHCs have NQAS certification.

Dr. Pallavi Srivastava, Medical-Officer-In-Charge at the Basantpur UPHC, shared how TCIHC-supported high-impact interventions related to quality family planning service delivery has also led to an increase in the uptake

"Four years ago, our entire focus was on immunization. At that time, our staff was untrained on contraceptive methods; the UPHC did not have any IUCD insertion kit. In fact, the OPD [outpatient department] load was only 20-30 patients as compared to this day when the OPD load has increased by many folds - no less than 100 patients visit the UPHC every day."

Dr. Srivastava believes the coaching that she and the entire staff of the Basantpur UPHC received from TCIHC has made all the difference, especially in improving the quality of care that they provide - which contributed significantly to them earning the NQAS award.

She explained that family planning is a critical component of the NQAS checklist, which has more than 1,500 quality indicators, including family planning, maternal and child health (MCH), counseling and Family Planning Logistics Management Information System (FPLMIS) indenting, appropriate and timely health management information system (HMIS) updates, commodity availability and patient satisfaction response forms. Dr. Srivastava said: "Before engagement with TCIHC, we did not have any Quality Improvement (QI) committee, nor did any District Quality Assurance Committee (DQAC) visit ever happen. With TCIHC coaching, we coached our community health workers, like ANMs (auxiliary nurse midwives) and ASHAs (accredited social health activists), on identifying and prioritizing FP clients, online indenting, etc. TCIHC coached us on its Quality Assurance high-impact approach, and demonstrated the utility of the quality assessment checklist in identifying gaps and resolving them. We formed a Quality Improvement (QI) committee with their support and started regular QI meetings. We noticed how the quality assessment checklist made it easy for us to identify gaps. All of these efforts played a crucial role in helping us achieve the NQAS status."

Dr. Jaswant Kumar Mall, Divisional Consultant of Quality Assurance of Gorakhpur oversaw the NQAS preparations for the UPHC and he believes that other UPHCs could learn from Basantpur's experience and also earn NQAS certification. He shared that to achieve similar success other UPHCs should:

• Continually refresh the skills of staff by having them attend refresher courses and new training

• Strengthen the capacity of ASHAs

• Regularly discuss issues related to family planning client mobilization in ASHA-ANM meetings

• Regularly use the QI checklist to identify gaps and address them during QI committee meetings

He noted that information and guidance on all of these success factors are available in TCI University.

As a result of these efforts, TCIHC has contributed to a 94% increase in annual long-acting reversible contraception (LARC) client volume at the city level in Gorakhpur from 3,222 users at baseline to 6,239 users in June 2021 (Figure 1). This increase accounts for 61.5% at the UPHC level from 2,808 LARC users at the baseline to 4,534 users in June 2021.

Facilitating the local governments' ability to implement proven quality of care interventions can effectively activate the local health system to provide quality family planning services in a sustainable manner.

For reading this story on TCI University please visit: https://tciurbanhealth.org/pdfviewer/gorakhpur-tales-of-impact/#page=

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/.

Nirmesh Kashyap is an Auxiliary Nurse Midwife (ANM) from Firozabad who works with adolescents in the city's slum areas. Here, she recalls one of her most memorable experiences helping a young adolescent patient: "For the last two years, I am conducting community adolescent health day in slum areas where I meet adolescents, 15 to 19 years old, and use interactive games provided by TCIHC to trigger discussion on SRH (sexual and reproductive health) issues. 

Community adolescent days are generally reverberant with the chatter of adolescents who turn up for the event. However, on 4 March 2021, I came across a 17-year-old named Suman who was unusually quiet. After the event, along with other adolescents, she was referred to visit the nearest urban primary health center (UPHC) for a facility adolescent health day (F-AHD) to avail adolescent health services.

When she visited on F-AHD, I counseled her on a nutritious diet, mental health issues and menstrual hygiene to help her express herself. She underwent hemoglobin testing, body mass index screening, and accepted sanitary napkins and iron-folic acid supplements. Yet she remained silent. For the next few months, she consecutively visited the UPHC on F-AHD to collect sanitary napkins. During each of her visit, I made efforts to talk to her personally. One day, I inquired if she had some problem or wanted to discuss anything that she had tears in her eyes. During counseling, she shared that a lump in her breast was the cause of her worry and the reason behind her aloofness. Additionally, no one in her family was aware of this issue.

I discussed her case with the medical officer-in-charge and visited her house. Suman lives with her grandparents. I discussed her health condition with them and advised them to visit the district hospital to seek Rashtriya Kishor Swasthya Karyakram (RKSK - India's National Adolescent Health Program) counselor and doctor's advice. Fortunately, they understood the gravity of the situation and visited the district hospital with Suman.

After a few months, Suman met me at the UPHC but this time, with a wide smile, she shared, 'Didi, doctor operated on me and it was just on time! and it is all because of your timely advice that I am fit and relieved. Thank you didi for helping me.'

I patted her shoulder and assured her that this is what we are here for."

Firozabad is one of the AYSRH cities of TCIHC where ANMs like Nirmesh are coached and sensitized by TCIHC's AYSRH counselors on providing SRH information and services to adolescents in a friendly manner. For the last two years, these coached ANMs are promoting adolescent-friendly health services through community adolescent health day and facility adolescent health day in Firozabad.

For reading this story on TCI University please visit: https://tciurbanhealth.org/tcihc-urban-tales-firozabad-midwife-is-a-beacon-of-hope-for-adolescent-health/ . 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/.

After receiving TCIHC coaching support, Gurdeep Birla, the Divisional Urban Health Consultant of Saharanpur, shared what the high-impact approaches have meant to the district and how they are integral to the district's family planning program success:

Earlier in district level review meetings, discussion was limited to permanent methods only. It was when the city partnered with TCIHC that more FP choices were made available at the urban primary health centers for the community through TCIHCs HIA on FDS, capacity building of urban Accredited Social Health Activists (ASHAs), data for decision-making (D4D) and capacity building of providers, etc. We, in the system, realized the non-availability of data on many important programmatic aspects, like age, number of children, etc. TCIHC's coaching made ASHA) competent in completing the Urban Health Index Register (UHIR) and later with the 2BY2 prioritization tool, we learnt to identify community health workers [such as ASHAs and their supervisors, Auxiliary Nurse Midwife (ANMs)] who required more mentoring in order to increase FP uptake by the community.

With the holistic coaching on demand generation, service delivery and advocacy, we were now able to review several data dimensions, such as client uptake during routine vs FDS days, completeness of data from HMIS reporting, timely indenting of FP commodities through FPLMIS [Family Planning Logistics Management Information System] and preparation and use of due list for client prioritization. Besides, with our UPHC staff coached on HMIS and D4D, the errors in FP data at HMIS level started reducing.

The coaching that we received on the D4D HIA in particular helped our staff from 31 UPHCs as they learned which FP indicators need to be reviewed, platforms where FP data must be reviewed and who should review it to influence decision-making. As a result, we are able to efficiently advocate in the review meetings. Hence, we started preparing accordingly for each review, like for district review meeting, we would analyze HMIS data and for a UPHC level ASHA-ANM meeting, UHIR and 2BY2 data were mainly discussed.

Apart from the review meetings, on other meeting platforms like the Health Partner Forum meeting, due to TCIHC coaching, we were able to ensure focus on FP along with other agenda items. It was during one such meeting that a decision was taken to install direction sign boards to increase visibility of UPHCs and to facilitate easy access to them. In a city coordination committee meeting, we noticed that the client uptake for long-acting reversible methods was increasing and to meet the increased community demand, the committee decided to ensure three sets of IUCD kits at least at all the UPHCs. During National Urban Health Mission review meeting, it was decided that ASHA-ANM meeting must be called after each FDS is held. Of late, in a service providers meeting, we shared the success in urban FP and suggested the district's technical support unit utilize TCIHC's HIAs and 2BY2 tool.

We have learned that unless we review data regularly success cannot be met because we will fail to notice the gaps at the right time [to make corrective actions]. Being aware of this now, we have regularized our review meetings, improved data quality and utilize data for decision-making."

As a result of TCIHC's partnership with Saharanpur district, the women of Saharanpur and Muzzafarnagar now have an expanded mix of contraceptive methods with sterilization now representing a smaller proportion among the methods available in the basket of choices.

Source: District level HMIS, June 2016-Mar 2021. To prevent overestimation of short-term methods, HMIS data has been adjusted using standard couple-year protection, which is the total estimated protection provided by contraceptives in a one-year period.

*i). Condoms are also offered as a choice of method to people who visit health facilities.

*ii). COVID-19 pandemic has greatly impacted Year 5, especially from April 2020 to March 2021. This period in the graph is dominated by short-term methods as a result of government-imposed lockdowns, limited movement of communities and their fears concerning visiting facilities for longer acting methods.

For reading this story on TCI University please https://tciurbanhealth.org/improving-saharanpur-districts-family-planning-data-also-improves-its-family-planning-program/

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/.