The Challenge Initiative for Healthy Cities (TCIHC) in India uses a Quality Assurance (QA) approach that is designed to ultimately lead to a client's satisfaction with family planning service delivery. India's National Urban Health Mission specifies dedicated attention and focus on bringing QA to services such as family planning across all service delivery points including urban primary health centers (UPHCs). 

In Ujjain, Madhya Pradesh, TCIHC recently conducted an analysis of a Quality Assessment checklist that the medical officer in charge (MoIC) of the Sanjay Nagar UPHC completed with her staff. Dr. Jyoti Gadam was surprised by the findings and said no one had ever done such an analysis of her facility before. The analysis revealed the following issues:

Since at least November 2018, the UPHC had low volume of about 700 to 800 clients per month

Only two auxiliary nurse midwives (ANMs) and four accredited social health activists (ASHAs) were working for the facility although 13 ANMs and ASHAs were sanctioned for the facility

The intrauterine contraceptive device (IUCD) insertion kit had not been utilized since February 2019

TCIHC recommended establishing a Quality Improvement (QI) committee to help collectively identify issues, come up with solutions to address them and then monitor those solutions. Dr. Gadam formed a QI team in April 2019 and its first meeting in May 2019 brought together ASHAs, ANMs, the pharmacist, staff nurses and others to discuss the low volume situation and a possible solution. All of the ASHAs and ANMs agreed to mobilize the community to make them aware of the timing and services available at the facility. The committee also discussed the IUCD issue and agreed to begin utilizing the IUCD kit more.

Other issues discussed in subsequent QI meetings included the injectable Antara that was only administered during the fixed day static services/family planning day. Because of an increase in outpatient volume, the committee decided to make the injectable available to all clients any day of the week. It also assessed data showing a three-fold increase in client volume to 2,000-2,500 clients per month, a clear indication of ASHAs becoming more active in mobilizing clients.

Dr. Gadam said TCIHC also helped them with other aspects, such as staff morale and family planning counseling.

"We oriented the staff nurse on the importance of counseling and I advised her to counsel each client coming to the clinic on family planning choices and lifestyle maintenance for general well-being," she said "To set a precedent, I started investing time in counseling clients on all methods of family planning and other health aspects."

Due to regular QI meetings, the Sanjay Nagar UPHC scores on the TCIHC quality assessment checklist improved from 80% in May 2019 to 92.5% in September 2019. These QI meetings streamlined the process of identifying issues and finding mutually agreeable solutions with staff, Dr. Gadam said. "These meetings have made the UPHC team realize that minor issues can be tackled by them on their own, like getting an IUCD kit and making the IUCD services available; like a staff nurse spending a little extra time on counseling a client on family planning choice has made basket of choice available to women," she said

TCIHC has successfully advocated for the formation of QI committees in all of its supported UPHCs across 31 cities. As of November 2019, 502 UPHCs have formed QI committees and most hold regular monthly meetings. As a result of this effort, nearly all UPHCs are counseling on family planning choice.

For reading this story on TCI University please https://tciurbanhealth.org/tcihc-quality-assurance-approach-lets-uphc-staff-tackle-quality-issues-on-their-own/

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 graph on the next page shows comparative HMIS data of family planning clients served at UPHCs from March 2018 to March 2019. Average family planning uptake per month also increased in UPHCs by 66% when compared to the previous year. These results were due to TCIHC's use of near-time, real-time data for decision-making to inform all programming - a long-held TCIHC guiding principle.

TCIHC analyses data from HMIS every month to identify success levers and challenges. In January 2019, analysis of HMIS and project data indicated that cities were falling behind previously set goals on meeting the estimated demand for family planning for the year.

With the GOI's fiscal year ending at the end of March, TCIHC introduced the Mission March concept as a concerted effort to accelerate city performance related to family planning. The word 'mission' was meant to indicate that work was required in a mission mode where each effort was focused and coordinated to improve the city's family planning demand.

TCIHC city team presented its comprehensive Mission March roadmap at divisional and monthly family planning review meetings and sought government buy-in. The GOI directed Nodal Officers of its National Urban Health Mission (NUHM) to support the drive. Then, TCIHC-supported Urban Nodal Officers and Coordinators reviewed eligible couples data from the family planning due-list kept by every Accredited Social Health Activist (ASHA). Next, the team utilized the ASHA monthly meeting platform to orient ASHAs on what was expected leading up to the Mission March. TCIHC emphasized streamlining the due-list of eligible family planning clients from the Urban Health Index Registers (UHIRs), making sure all interested clients were routed to service delivery points of their choice.

Thus, those requiring secondary family planning services were directed to district hospitals and medical colleges, and those seeking pills, condoms, injectables and IUCDs were directed to UPHCs. At the same time, the team coached the ASHAs on providing correct family planning information to clients and mobilizing the community on the fixed-day static (FDS) service day, which is also referred to as family planning day (FPD).

"During Mission March, all ASHAs, ANMs and AWWs worked as team to reach out to more men and women with family planning messages. Getting more family planning clients was our prime mission. TCIHC team and medical officers of UPHCs guided us on how to improve our efficiencies. Now, family planning is a part of my daily counseling." - Kusum Lata Kashyap Urban ASHA Lucknow, Uttar Pradesh

The Anganwadi workers (AWW) of Integrated Child Development Services were also engaged to refer family planning clients from slums to service delivery points on FDS/FPD. The team also worked with Auxiliary Nurse Midwives (ANMs), who referred family planning clients from Urban Health Nutrition Days (UHND) and routine immunization sessions.

In addition, UPHC medical officers were entrusted to track the ASHAs' monthly plans to ensure maximum coverage, meeting the contraceptive needs of non-users on the ASHAs due-list. A formal WhatsApp Group was created by Nodal Urban Health Officer and Urban Coordinator of each city to track and review UPHC data daily and mitigate any challenges faced by any particular UPHC. TCIHC team ensured that this WhatsApp Group was regularly updated with FDS/FPD data. To manage any human resource gaps that may arise during this period on the FDS/FPD day at any UPHC, all trained staff were informed by the medical officers about the Mission March and were requested to support family planning services during FDS/FPD in nearby UPHCs wherever required.

At the same time, TCIHC supported the UPHC team to arrange two months of supplies of family planning commodities to meet higher demand. Condoms and oral contraceptive pills were made available to ASHAs so they could readily provide family planning services during daily household visits and monthly outreach camps conducted by UPHCs. Most significantly, TCIHC worked with the city government to strengthen data and reporting during this month in particular.

Mission March not only helped men and women access and obtain their family planning method of choice, but also created a sense of ownership among the government, UPHC staff and community health workers for family planning services. GOI officials noted IUCD uptake data from March 2019 was 282.69% higher than March 2018. In fact, 64.5% of overall IUCD acceptors from January to March 2019 came from March 2019. Mission March successfully demonstrated that if all units worked together towards a common goal, more and more family planning clients can be served.

"Mission March successfully demonstrated that if all units worked together towards a common mission, more and more family planning clients can be served. Each month, family planning clients are increasing and we intend to maintain this pace.." - Dr. A.K. Singh Additional Chief Medical Officer and Nodal NUHM Kanpur, Uttar Pradesh.

For reading this story on TCI University please visit: https://tciurbanhealth.org/project/a-mission-march-in-india-leads-to-311-increase-in-annual-client-volume-at-tcihc-supported-facilities/

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 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/.

The Challenge Initiative for Healthy Cities (TCIHC) in India learned early on that if certain steps were taken to "activate" a  TCIHC-supported city's urban primary health centers (UPHCs), then delivering quality family planning services became easier and quicker. 

Meerut - an city in the Indian state of Uttar Pradesh - successfully activated 42% (10 out of 24) of its UPHCs within five months of its engagement with TCIHC by following those steps. Yet the data did not reflect significant positive trends in contraceptive uptake, especially related to long-acting reversible methods (LARCs). During a data review meeting in New Delhi, the TCIHC team noted that Meerut was situated within the low-performing block of cities.

Although the city learned how to activate UPHCs from the first five TCIHC cities, as outlined in its Eight Steps to Activate a New City for Family Planning approach, Meerut faced two major stumbling blocks at its UPHCs: a lack of trained service providers and not enough family planning equipment.

TCIHC's City Manager shared these issues with the Meerut health department. To address the lack of required equipment, the city government suggested and approved the use of funds from an underutilized budget category for patient welfare called Rogi Kalyan Samiti. The funds purchased intrauterine contraceptive device insertion kits, boilers and other equipment, which were then provided to the UPHCs in need.

To address the lack of service providers, TCIHC worked with the Nodal Urban Officer of the National Urban Health Mission to map all existing trained service providers. They found that many lady health visitors (LHVs) - who at a minimum have been trained as auxiliary nurse midwives (ANMs) - posted in UPHCs were already trained on IUCD insertions. Subsequently, the Chief Medical Officer of Meerut issued a directive urging all LHVs to support providing family planning services during fixed-day static services/family planning days (FDS/FPD).

"We productively utilized our existing human resources for strengthening family planning services. I am thankful to TCIHC for helping us find a quick solution for this ongoing problem. In fact, I will explore this solution for strengthening other health programs as well, like tuberculosis." - Meerut's Deputy Chief Medical Officer

As a result of these efforts, all 24 UPHCs were activated to provide quality family planning services by June 2019. According to the Health Management Information System (HMIS) data from UPHCs, district hospitals and medical colleges, TCI has contributed to a 107% increase in annual family planning client volume in Meerut as of December 2019, accounting for a reversal of a negative trend from the city's lowest point in November 2018. This translates to a 9,060 increase in the annual number of family planning clients. Most noticeably, Meerut reversed its downward trend of LARC acceptors as noted by the gray line in the chart above, which is also when the first performance review meeting took place.

With TCIHC's commitment to long-term sustainable solutions, it helped facilitate the training of staff nurses and ANMs on IUCD insertion through a government-contracted agency, Hindustan Latex Family Planning Promotion Trust, in July 2019. Once trained, staff nurses and ANMs received supportive supervision and coaching support from the LHVs on IUCD insertion.

As a result, Meerut saw a 167% increase in annual LARC users, according to HMIS from UPHCs, district hospitals and medical colleges. In looking at just the UPHC level data, there was a massive 725% increase in LARC acceptors from November 2018 to December 2019. This accounts for 5,992 more LARC clients seen.

This clearly demonstrates how optimal utilization of existing resources and regular data performance reviews can yield groundbreaking results. The city of Meerut not only reversed a negative trend in LARC acceptors but also demonstrated how simple changes can result in a surge in uptake of LARC acceptors.

"I am happy that I can avail family planning services of my choice from nearby Zakir colony UPHC. Because a few months back when I visited the district hospital for the same, I had to return without availing services due to high client load. Even the district hospital is quite far from my place. Now whenever I meet any woman of my area interested in family planning, I tell her about our nearby facility." - Zahida Parveen 24-year-old mother of three.

For reading this story on TCI University please visit: https://tciurbanhealth.org/project/negative-larc-trend-reversed-after-meerut-data-review-leads-to-more-equipment-and-trained-providers-at-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/.