The state of Uttar Pradesh (UP) has issued a directive to designate one day a week for Antral diwas (translated as "Spacing  Day") to ensure quality family planning services at urban primary health centers (UPHCs). The UP government made this decision based on the impact that fixed day static/family planning days (FDS/FPD) for birth spacing methods - a proven approach from The Challenge Initiative for Healthy Cities (TCIHC) - has had in the 20 TCIHC-supported cities of UP since 2017. This decision means the approach is now being diffused to 75 districts for both urban and rural populations in the state. 

Two Chief Medical Officers (CMO) from TCIHC-supported cities in UP offer their thoughts below about statewide scale-up, as well as what the situation was like prior to TCIHC's partnership and what changes contributed to increasing access and uptake of family planning services in their cities.

In comparison to FY2015-16, there is tremendous growth in reach and uptake of family planning services by Saharanpur's urban poor population. In 2015-16, UPHCs existed but were not equipped to provide family planning services, except short-term methods (condoms and oral contraceptive pills), because there were no additional choices of methods available, such as intrauterine contraceptive device (IUCD), injectable contraceptive (Antara); neither were IUCD kits available; nor were urban ASHAs trained on how to counsel clients on family planning methods during their household visit. Since 2017, Saharanpur is receiving technical support from TCIHC. In order to ensure family planning services to urban poor population, TCIHC has developed high impact approach/best practice tools, with the help of which these best practices can be scaled up to cover large populations.

We took advantage of these tools, especially fixed day static/family planning day (FDS) approach. Initially, when we rolled out FDS, we faced some issues like absence of equipment, untrained providers, irregular supplies but we sorted them out, and, most importantly, potential clients of family planning services were identified and linked by ASHAs to UPHC as they received coaching from TCIHC. Now, FDS by its new name 'Antral diwas' is rolled out across ALL urban and rural PHCs (primary health centres). I believe this step will help the potential beneficiaries of family planning services and we will match the national average of family planning." Dr Baljeet Singh Sodhi, Chief Medical Officer, Saharanpur

The experience in Lucknow was similar to that of Saharanpur - even though the cities are quite unique from each other.

At present (2019-2020), Lucknow is providing family planning services through its entire system of 52 UPHCs and eight CHCs (community health centres), while five year ago [2015-2016] the situation was contrast. At that time, UPHCs existed but were not equipped to provide family planning services except short-term methods, condoms and oral contraceptive pills, because there were no additional methods, no IUCD kits and urban ASHAs were also not trained on family planning. The biggest factor contributing to the enormous change in family planning service uptake is because of the development of our UPHCs and urban CHCs. Over these years, the establishment, trained human resources, commodities and supplies have all improved. And, with the help of ASHA, the community has become confident and interested in services. All of these areas have contributed in advancing and improving the family planning program. Efforts were made to situate UPHCs in those locations, which could be easily accessed by urban poor populations. Also, trained ASHAs were posted in urban poor slums. As a result, young couples residing in urban poor slums were some of the major beneficiaries of the urban family planning program.

Throughout this journey, we had technical support of TCIHC who had experience in urban family planning, supported by evidence, and based on this experience, they developed simple tools, which helped us move forward. One of the tools was FDS. With the support of TCIHC, we rolled out FDS in a staggered manner across all our UPHCs and UCHCs and we received good results out of this. We initiated IUCD and Antara at these centres. Young couples benefited the most from these additional method options and, as a result, overall family planning users increased. ASHAs also played an instrumental role in this as their competency was enhanced on family planning client counselling due to TCIHC coaching and mentoring. Success of FDS was evident by the fact that government had to make budgetary provisions for FDS in cities supported by TCIHC. But, now, this has been expanded in the form of 'Antral Diwas' to all rural and urban PHCs across all 75 districts, which further illustrates not only the impact of the approach but government's commitment to its sustainability."-Dr. Narendra Agarwal, Former Chief Medical Officer, Lucknow

For reading this story on TCI University please https://tciurbanhealth.org/tcihcs-fixed-day-static-family-planning-day-approach-diffuses-statewide-in-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/.

Quality assurance (QA) is one of the nine high-impact family planning approaches that The Challenge Initiative for Healthy Cities (TCIHC) uses when working with city governments. TCIHC provides technical support to urban primary health centres (UPHCs) to establish quality improvement committees, conduct a periodic quality assessment using a simplified checklist, develop and monitor a plan of action and ultimately be certified by the district quality assurance team for offering quality services. 

After TCIHC partnered with the City Health Department in Berhampur, Odisha, to implement the QA approach in all seven of its UPHCs, quality measures improved significantly. This improved quality was recognized nationally with all seven TCIHC-supported UPHCs of Berhampur earning the Kayakalp Award.

In 2019-2020, all seven TCIHC-supported UPHCs of Berhampur earned a Kayakalp award. Three UPHCs received first place and two others were recognized as runners up while the remaining UPHCs received a commendation award. Kayakalp Awards are a national initiative launched in 2015 to improve and promote the cleanliness, hygiene, waste management and infection control practices in public health care facilities and incentivize high-performing facilities.

Mr. Lamodar Digal, City Program Manager In-charge, National Health Mission (NHM) Berhampur, shared why this recognition is significant:

All seven UPHCs of the city achieved Kayakalp Award in 2019 as they followed QA guidelines, which improved the quality aspects of service delivery including hygiene, infection control mechanism and supported UPHCs in internal facility assessment. This is significant because in 2017-18 UPHCs were new. There were barriers related to biomedical waste management, training of staff on quality parameters and most of all since NUHM [National Urban Health Mission] was new, no other department took ownership [of quality assurance]. At this time, TCIHC worked with the city health team and actually gave shape to the vision of the Commissioner of Berhampur who wanted to 'Make UPHCs the first choice of treatment for people" of Berhampur and wanted them to qualify for the highest certification of quality, which is 'Kayakalp' and National Quality Assurance Standards (NQAS)."

In 2017-18, UPHCs provided only oral contraceptive pills and service providers, while Auxiliary Nurse Midwifes (ANMs), staff nurses and Accredited Social Health Activists (ASHAs), were unaware of the full array of method choices and were not trained to provide them. TCIHC helped coach ASHAs on counseling techniques, organized hands-on trainings of ANMs on all method choices, and ensured staff nurses received training on the provision of intra-uterine contraceptive device (IUCD) and the injectable contraceptive Antara. As a result of these efforts, family planning became an integral part of the services provided at the UPHC. Digal said TCIHC support made the difference.

Before TCIHC's technical support, we did not even imagine that one day we would be able to provide expanded choices of family planning, including long-acting reversible methods at UPHC."

But expanding the availability of IUCDs and injectables made quality a more prominent concern. As a result, TCIHC began supporting the quality assurance approach by having field program service assistants (FPSA) - who coach UPHC staff - incorporate family planning in the quality improvement meeting at UPHCs and district quality assurance committee (DQAC) meetings at the district level. This particular step not only prioritized issues in family planning but also helped uncover many other gaps related to quality, infrastructure, supplies, etc. These issues were discussed during DQAC meetings as well. The support also included the introduction of a simple checklist for family planning based on the NQAS guidelines. This simple checklist helped UPHC staff to self-monitor quality parameters. In addition, each UPHC in Berhampur created a family planning corner, which provided privacy for family planning counseling and services.

As a result of these measures, family planning was strengthened at each UPHC and this contributed to increased scores for both Kayakalp and NQAS and eventually helped each UPHC win both. Digal explained the mindset shifts that the QA approach has sparked at the UPHCs and among the communities that they serve:

Our UPHCs are now 'AMA clinic' (meaning 'Our Own Clinic') in the real sense. 'AMA clinic' was the slogan given by the Berhampur Municipal Corporation (BeMC), but it turned into a reality once we, the city government, got TCIHC's technical support. Our people around UPHCs are happy as there is no need to go to the district hospital or higher level hospital for primary health services, including family planning."

These QA measures of Berhampur inspired several cities in Odisha and the neighboring state of Madhya Pradesh to visit Berhampur UPHCs to learn more. Two more cities supported by TCIHC - Rourkela and Puri - also won Kayakalp commendation awards, thus validating that the right family planning approach can help a UPHC score for Kayakalp award. In addition, since TCIHC's inception in 2017, all seven UPHCs of Berhampur have increased the availability of all family planning choices for the urban poor population, especially reversible methods, such as IUCD, injectable contraceptive and non-hormonal pills.

For reading this story on TCI University please https://tciurbanhealth.org/tcihcs-qa-approach-leads-to-national-recognition-for-behrampurs-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/.

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/

Dr. Pravin Kumar Bharti is the Deputy Chief Medical Officer and Nodal Urban Health with the National Urban Health Mission (NUHM) in Mathura (Uttar Pradesh, India). He has six years of experience across a wide spectrum of urban health issues. He recently sat down with The Challenge Initiative for Healthy Cities (TCIHC) to share his experience with TCIHC and TCI University (TCI-U). TCI-U includes an India toolkit, which has codified high-impact approaches (HIAs). These approaches are being scaled up through TCIHC in three states: Uttar Pradesh, Madhya Pradesh and Odisha. The India toolkit features 15 HIAs, which strengthen service delivery and supply, demand generation and advocacy components of family planning and adolescent and youth sexual and reproductive health (AYSRH) interventions. The toolkit provides standardized and contextualized information, resources and 'how-to-do' guidance, which can be easily customized to meet the city requirements for rapidly scaling up evidence-based family planning and AYSRH interventions. In 2019, the government of Uttar Pradesh, Madhya Pradesh and Odisha endorsed and approved the high impact approaches and tools of TCIHC, expanding the reach and ultimately impact of them. 

When did you first learn about TCIHC and TCI-U?

In February 2019, TCIHC had organized a State Conclave where the state of Uttar Pradesh endorsed nine HIAs [high-impact approaches] of TCIHC. This is where I first learned about TCI-U. At that time, I was holding the position of District In-Charge, Control Room, Mathura. As a result of my interest in family planning and urban health, I was nominated by CMO [Chief Medical Officer], Mathura, to participate in the State Conclave. As soon as I returned [from the State Conclave], I registered myself and my colleagues on TCI-U with the support of TCIHC City Manager."

What motivated you to first use TCI-U?

I developed a keen interest in TCI-U when during a meeting in March 2019 with the Chief Medical Officer, he required some job-aids related to Accredited Social Health Activists (ASHA) and he asked TCIHC City Manager for support. TCIHC City Manager quickly browsed TCI-U and downloaded the required information from the resource section linked to the HIA [high impact approach] on Urban ASHAs. I was impressed. And, from that day onwards, I have kept hard copies of the HIAs on my desk and access them on TCI-U as well."

How have you used TCI-U?

The high impact tools have helped my department understand fixed day static/family planning day (FDS) approach, role of Mahila Arogya Samiti in demand generation for family planning, importance of convergence between various departments for improving family planning indicators, use of family planning data, funds allocated under Program Implementation Plan (PIP), etc. Moreover, I have downloaded government approved materials like - 'All method poster' from TCI-U; this poster is now displayed in all Urban Primary Health Centers of Mathura. Even this poster is used on FDS days and routine service days as well in Outreach Camps to counsel clients on family planning methods. I have also downloaded the 'Pregnancy screening checklist,' which was given to staff nurses and community health workers to identify potential clients. TCI-U has helped me improve family planning practices across cadres, including NUHM [National Urban Health Mission] staff to field-level workers. I also navigate TCI-U to learn other countries' innovations and ideas also."

What are your overall impressions of TCI-U?

Urban family planning requires a lot of innovations and TCI-U is one such platform that provides innovative proven approaches. I like everything about TCI-U because it helps to understand our roles better, provides ways to get quick results and offers solutions to overcome potential challenges. That it is my job to improve family planning indicators and take decisions. TCI-U helps me do that. I have taken a couple of assessments related to the HIAs and earned certificates, which I find to be the most exciting part. TCI-U is a well-structured website, which provides comprehensive information and resource materials."

Like Dr. Bharti, around 35 government officials are registered on TCI-U from Mathura and most of them have completed the assessments for the high-impact approaches and received certificates.

For reading this story on TCI University please https://tciurbanhealth.org/in-their-own-words-nuhm-deputy-cmo-in-mathura-likes-innovations-found-in-tci-university/

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/.