While the world grapples with the negative impact of COVID-19 on other health programming achievements, Firozabad - one of the 20 cities supported by The Challenge Initiative for Healthy Cities (TCIHC) in India - has consistently demonstrated an upward trend in family planning usage indicators. Firozabad's careful planning and tenacity allowed it to continue providing quality family planning services to its urban poor population during the pandemic. 

One of the major challenges brought on by COVID-19 in Firozabad was that a number of urban primary healthcare centers (UPHCs) were converted into COVID-19 care centers. In addition, staff were reposted at COVID-19 care centers and hospitals, and urban accredited social health activists (ASHAs) were redirected to different locations for COVID-19 survey duty.

Despite the challenges, the Firozabad government did not waiver in its commitment to provide quality family planning services. Dr. Bhanu Pratap Singh, the Urban Nodal Officer in Firozabad, shared the steps that he and other city governance staff took under the leadership of the Chief Medical Officer (CMO) to ensure family planning remained available to the urban poor:

He listed as examples:

• Monthly fixed-day static (FDS) services for permanent methods at district women's hospitals (DWHs) as a result of TCIHC advocacy efforts

• District facilities conducting whole site orientations with TCIHC's support

• A city health plan (CHP) completed at the end of 2019, under the chairmanship of the District Magistrate and with TCIHC support

• Budget for holding quarterly review meetings already included in the program implementation plan (PIP)
  

Dr. Singh said they were just beginning to implement their city health plan when COVID-19 struck in March 2020 and lockdowns were imposed.

By late June, Dr. Singh said Firozabad once again began monitoring progress at quarterly review meetings and the DWH's Chief Medical Superintendent (CMS) noticed family planning indicators dipping. FDS days at DWHs had been limited to two days a week, but a decision was made to offer family planning services at DWHs every day from 8:30am-1pm during COVID. Another challenge they faced was making sure every patient was tested for COVID before service delivery.

With COVID as the city's top health priority, Firozabad decided to reorient 92% of its urban ASHAs in June 2020 with TCIHC's technical assistance. The reorientation focused on how to approach family planning solutions while keeping COVID in mind. It also covered how to process orders through the Family Planning Logistics Management Information System (FPLMIS) to ensure ASHAs had adequate supplies of short-term methods for household visits and how to ensure referrals for long- acting methods by accompanying interested clients to DWHs while the UPHCs were providing care for COVID patients.

Dr. Singh believes the city health plan - the product of a rigorous exercise mandated by the National Health Mission - led to the outcome seen in Firozabad and he recommends that other cities consider developing such a plan. This emerging best practice has the potential to strengthen a city's resilience to withstand natural disasters and emerging pandemics.

"With TCIHC's coaching and mentoring support, Firozabad had taken a number of steps in 2018 and 2019 to prioritize the family planning program. We reaped benefits from those exercises at the time of COVID." - Dr. Bhanu Pratap Singh Urban Nodal Officer, Firozabad, Uttar Pradesh

TCIHC's support of the development process for the innovative city health plan was also a key factor in enabling Firozabad to continue quality family planning service provision despite COVID-19. City officials made a commitment to have the city health plan guide their efforts and regularly reviewed activities and data against it. In addition, it conducted routine FDS at DWHs and, as soon as the government allowed UPHCs to hold FDS days again, the city bounced back with all facilities providing all family planning methods in line with COVID-19 protocols.

As a result, Firozabad's DWHs saw a 418% increase in annual client volume for long-acting reversible contraception (LARCs), according to Health Management Information System (HMIS) data from the DWHs (Fig. 1). This accounts for 968 LARC users since June 2020, when the lockdown was relaxed. At the UPHC level, the total number of family planning acceptors increased 20% from June 2020 to February 2021, with short-term acceptors contributing over 39% to this increase (Fig. 2).

Dr. Bhanu Pratap Singh, Urban Nodal Officer, Firozabad

• COVID-19 demonstrated the importance of having a city health plan, which served as a guide to ensure no health area was overlooked.

• Review data and activities regularly to plan for and maintain success.

For reading this story on TCI University please visit: https://tciurbanhealth.org/project/despite-covid-19-firozabad-keeps-client-volume-up-at-district-womens-hospitals-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/.

The Challenge Initiative for Healthy Cities (TCIHC) in Uttar Pradesh, India, aims to increase access to sexual and reproductive  health (SRH) information and services for adolescents and youth in urban environments. TCIHC is partnering with the Government of India's national adolescent health program called Rashtriya Kishor Swasthya Karyakram (RKSK) to offer adolescent-friendly health services (AFHS) at urban primary health centers (UPHC) for the urban poor. 

Because UPHCs are nested within complex social and cultural settings, health service providers working at UPHCs maintain their own beliefs and value system. Healthcare systems can also influence provider actions in the form of policies and norms. These influences may induce provider biases, leading to a lower quality of care, especially for unmarried adolescents.

To address this, TCIHC coached RKSK to launch its high-impact whole site orientation (WSO) best practice to orient all staff in an UPHC on the SRH needs of adolescents and youth. The WSO also addresses any biased attitudes and beliefs towards youth SRH issues that staff may hold that could unintentionally cause harm. Working within the health system, TCIHC in collaboration with RKSK coached the Medical Officers In-Charge (MOICs) of the UPHCs to conduct WSO without TCIHC or RKSK support for all facility staff to create a more enabling environment for adolescents that also ensures quality adolescent-friendly health services.

In Aligarh, Dr. Arshiya Sherwani, MOIC of UPHC Nagla Tikona, has facilitated WSO with her staff. In the interview below, she shares with TCIHC her experience and reflections on the changes she has observed after WSO.

Discovering my own biases

In December 2020, TCIHC virtually coached me on the goal and objective of orienting all UPHC staff though a WSO. The coaching I received was in fact a behavior change intervention aimed at reducing my own bias. Unsurprisingly, I discovered that social norms were driving my biases. The most pervasive social norm was the significance of sexual abstinence before marriage. And, therefore, my attitude and belief was that contraceptives were meant for married couples only. I recognized that my attitude towards the provision of contraceptives is shaped primarily by client's age, parity and marital status. I realized youth must pass through many barriers to access SRH. Provider bias is one of the gates. TCIHC provided orientation material based on RKSK guidelines. I received 'how-to-guidance' on conducting a values clarification exercise through a whole site orientation for all staff.

After equipping myself, in January 2021, I conducted WSO sessions for my entire UPHC staff at the facility irrespective of cadre and technical skills, which included staff nurse, lab technician, pharmacist, Auxiliary Nurse Midwives (ANM), Accredited Social Health Activists (ASHA), support staff etc. With support from TCIHC, I attended a youth-led City Consultation Workshop (CCW) in Aligarh organized by RKSK. Here I had heard adolescents and youth candidly share their opinions and desires on SRH issues. I was a bit shocked but I immediately realized the necessity of SRH care for unmarried adolescents and youth. TCIHC initiatives - the AYSRH CCW and WSO - both changed my mindset about the importance of providing SRH information and services to adolescents and youth."

Facilitating a whole-site orientation

Facilitating the WSO session was a learning experience for me. The design of activities, such as role plays and cases studies, enabled my staff to overcome non-technical biases rooted in attitudes and beliefs, without explicitly saying that they are doing this. An interesting attitude that emerged was that of staff engaging with young clients from parental perspective. The belief that we are in a better, more informed position to make decisions for clients. I encouraged WSO participants to raise concern without hesitation. This created a non-threatening environment for them to ask and clarify their indecisions. I addressed their questions related to menstruation, puberty and physical changes associated with adolescence. While it was difficult, I was determined to discuss contraceptive needs and behaviors of unmarried adolescents and teenagers and invested time in discussing this topic.

The session on values clarification challenged staff to explore the reasons behind their beliefs, and also reflect on the consequences of their actions when clients are denied contraceptive methods. I tried role plays with the help of the game 'Bhranti aur Kranti' (Myth and Revolution) from RKSK's Peer Educator Training Manual. ASHAs enacted the role of Bhranti who asked questions and Kranti who responded with correct answers with rationale. This game helped in busting myths about SRH needs of adolescents - married or unmarried. Apart from this, I also coached the facility staff on the competencies required for delivering SRH services in a friendly manner, like being non-judgmental, maintaining confidentiality and privacy, building trust, interpersonal skills, etc. I covered topics of nutrition, non-communicable diseases, substance misuse, violence and mental health. This orientation aided staff to recognize and address their unconscious biases related to SRH needs of adolescents, which were mainly associated with gender, marital status and age. I was motivated to see the City Community Process Manager from the National Health Urban Mission (NUHM) participate in the WSO. Meanwhile, through the session, I endeavored to sensitize the staff towards SRH needs of adolescent and covered standards set by RKSK for AFHC [adolescent-friendly health clinic]."

After coaching

After the WSO, I witnessed an explicit change in the attitude of UPHC staff. I observed them being mindful of adolescent needs and being empathetic when counseling them during facility Adolescent Health Days (F-AHDs). WSO had truly prepared the staff. After this, with TCIHC's technical coaching on F-AHD and detailed coaching on how to organize it, we started F-AHDs on the fifth of every month. With management coaching of TCIHC, we arranged reporting formats, sanitary napkins and medicines for adolescents from the Nodal Officer for F-AHDs. We also established a counseling corner for adolescents to maintain confidentiality and privacy. My team of staff nurses and ANMs along with TCIHC-coached ASHAs and Anganwadi worker publicize F-AHDs and encourage adolescents to use the services. These community health workers motivate adolescents from urban health nutrition day and slum areas. Through F-AHD, we promote health-seeking behaviors among adolescent boys and girls and provide services like hemoglobin testing, body mass index screening and provide iron folic acid supplements (WIFS) and albendazole capsules, as required. Additionally, counseling services are offered to each visiting adolescent where they are counseled about nutritious and balanced diet, mental health issues, genital and menstrual hygiene, among other issues.

As a result of all of these efforts, the community is now well-aware about adolescent health services availability in our facility and adolescents are regularly visiting the facility and obtaining services. They comfortably talk to us without hesitation and discuss body changes, menstruation, etc. My staff now ensures that no adolescent goes home without availing services. Whenever my staff have any doubts I discuss with them individually and also refresh their knowledge in UPHC level group meetings. At times, we face challenge when adolescents visit the facility without guardian and share about sexual abuse incidences during counseling sessions. We have to refer such cases to the RKSK counsellor at the District Hospital because these are legal issues. In addition, when we have high footfall on F-AHDs, maintaining privacy during counseling session becomes a big challenge. UPHCs will benefit by having dedicated trained counsellor for adolescents, which is currently not in place.

Till date, we have conducted three F-AHDs and provided services to 116 boys and girls. Often RKSK and NUHM officials visit F-AHD and the UPHC and coach us on management of AY and FP services. I also continuously assess the progress of health services uptake, especially AY and FP during the monthly UPHC meeting and address issues and challenges by coaching the staff and discuss plans to improve the services. I can proudly say that in my UPHC, adolescent health services are prioritized and provided in a manner that respects the rights of adolescents, their privacy and confidentiality. Moving forward, to build an enabling environment and for sustainable change, parents, teachers and the community need to be sensitive so that adolescents can seek and utilize SRH services without any hesitation."

Working with 10 more cities across Uttar Pradesh, TCIHC has created 140 such master coaches who have conducted 231 WSOs. Having met this first criteria for AFHC, TCIHC is coaching AY city teams to regularly host F-AHDs and upload data from F-AHDs onto HMIS. In addition, TCIHC is advocating at the state level to get AYSRH counselors placed at UPHCs and, thus, support RKSK's vision of making each UPHC an adolescent-friendly health clinic.

For reading this story on TCI University please https://tciurbanhealth.org/addressing-provider-bias-through-whole-site-orientation-in-uttar-pradesh-india/

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 result of the COVID-19 pandemic, city governments are faced with numerous management and operational challenges in  meeting the family planning needs of the urban poor. These challenges are compounded by shortages of service providers in urban primary health centers (UPHCs) as several staff were moved to district hospitals for COVID care duties and a large percentage of providers were infected with coronavirus and/or quarantined due to exposure. In cities supported by The Challenge Initiative for Healthy Cities (TCIHC), such as Shahjahanpur and Mathura, city governments have resolved these operational challenges through the use of TCIHC's high-impact approaches to ensure family planning service delivery resumed during the COVID pandemic. 

Shahjahanpur's city government used the city coordination committee (CCC), a convergence platform, to address a lack of service providers at UPHCs, while the city of Mathura harnessed the capabilities of Quality Improvement (QI) committees at UPHCs to resolve issues arising from staffing shortages. Both CCC and QI are part of TCIHC's high-impact approaches: Convergence of Services and Quality Assurance, respectively.

Dr. Laxman Singh, Additional Chief Medical Officer (ACMO) and District Immunization Officer (DIO) of Shahjahanpur shared how he used the CCC approach to address staffing shortages and reopen the UPHCs of the city:

"COVID-19 pandemic adversely affected family planning services in Shahjahanpur. All 10 UPHCs staff were engaged in COVID-19 care and management duties [as a result of government mandate's]; hence, all UPHCs were closed. This affected provisioning of all health services, including family planning services. However, Accredited Social Health Activists (ASHAs) were distributing oral contraceptive pills (OCPs) and condoms in the community during their COVID-19 survey, but clinical family planning services had almost stopped due to unavailability of service providers and this was the biggest concern for us. I shared this concern with TCIHC who coached me to refer to the 'Convergence' approach. I discussed this with my team, including the urban nodal officer and urban health coordinator, and we organized a CCC meeting in September 2020. In that meeting, Nagar Swasthya Adhikari [the municipal officer of health] raised the same concern of non-availability of service providers at the UPHCs. Thus, this committee decided to shift the task of service delivery to trained Auxiliary Nurse Midwives (ANMs). It was decided that, except for immunization day, ANMs will provide health services in UPHCs, including IUCD and Antara services, in routine days and during Antral diwas [Fixed-day static services for spacing methods]. Soon after the CCC meeting, we developed a plan and ANMs were allotted to UPHCs. UPHC staff involved in COVID-19 duty were, however, directed to be present at their respective UPHCs on Antral diwas. In this manner, we were able to reopen all 10 UPHCs and provided method choices to family planning clients. The convergence tool of TCIHC helped us in coping with this challenging situation during the pandemic."

Punish Kumar, the Urban Health Coordinator of Shahjahanpur, shared how the government of Shahjahanpur plans to continue implementing this approach since they have witnessed its success, especially during these trying times:

With the technical support of TCIHC, we initiated CCC meetings in Shahjahanpur. So far, this collaborative platform has helped NUHM [National Urban Health Mission] department to collectively work and plan with all urban stakeholders and resolve issues pertaining to urban family planning. During the challenging time of COVID-19, the CCC platform helped us to restart family planning services, including Antara and IUCD services in UPHCs, to meet the family planning needs of the urban poor. We are confident by utilizing this platform we can manage any disaster situation in future also."

Dealing with the same challenge - a shortage of providers at UPHCs to continue family planning services - the city of Mathura encouraged UPHCs to conduct QI committee meetings, where UPHC staff meet and identify solutions to challenges. Jeetendra Singh, a Pharmacist at the Laxmi Nagar UPHC in Mathura and a QI committee member, shared how this meeting played an instrumental role in overcoming this challenge:

The staff nurse of our UPHC was engaged in COVID duty because of which family planning service provision was completely stopped. Many IUCD and Antara clients who visited Laxmi Nagar UPHC on Antral diwas had to return without availing services. This issue was raised in a QI committee meeting. This concern was realized prior to this meeting also and was discussed with TCIHC and they had coached us about the guideline issued by the state government for reinitiating Antral diwas, which stated that in the absence of service providers, trained ANMs can provide services on Antral diwas. The coaching I received helped me present this solution at the QI meeting. This recommendation was accepted, and I felt proud that I could give this suggestion based on TCIHC's coaching. Soon, a government order was issued and a trained ANM was assigned to Laxmi Nagar UPHC and, with her support, we were able to reinitiate family planning services, including long-acting reversible methods during Antral diwas. This step has ensured that none of the clients return home without availing family planning services at least on FDS/Antral diwas days."

The Antral diwas state directive was an outcome of rigorous advocacy efforts of TCIHC's Uttar Pradesh (UP) state team and was issued for all 75 districts, including both urban and rural, to ensure family planning services resume and do not lose momentum gained in addressing the unmet need for family planning in UP.

Dr. Man Pal Singh, Nodal Officer of NUHM of Mathura, highlighted the contribution of the QI committee meeting not only in resolving this issue but in addressing other quality-related issues and gaps:

Many times, we came to know about issues and challenges at UPHCs through QI committee meetings. TCIHC played a major role in institutionalization of QI committee meeting concept at the UPHC level. We started QI committee formation and meeting with the technical support of TCIHC. These meeting help UPHC staff to periodically discuss quality related issues, gaps and find solutions. Laxmi Nagar UPHC staff raised the issue of staff crunch in QI committee meeting, which was hindering family planning services. They then proposed a solution, citing the Antral diwas directive to assign trained ANMs on FDS days at UPHCs. We immediately referred to the mentioned state directive and decided to assign trained ANMs at UPHCs. This decision helped us to resolve this similar issue for all seven UPHCs [across Mathura]. We prepared duty roster of each ANM and, on rotation basis, ANMs started providing family planning services, including IUCD and Antara services in Antral diwas. We also decided that if Antral diwas falls on a holiday then the next working day in the same week is allocated for the Antral diwas. This way we are able to fulfil the family planning needs of the urban poor during the pandemic, as once again they can get family planning services of their choice from their nearest UPHC. Apart from this, I regularly review data with my Data Cum Account Assistance who has been coached on data management by TCIHC and as a result, I am able to see the progress made by all the UPHCs on family planning indicators and other services as well."

Archana Gaur, ANM, Laxmi Nagar UPHC also shared her experience taking on more of a role in family planning service provision during the COVID pandemic:

I am providing family planning services in Laxmi Nagar UPHC. I was given this task because I am trained in IUCD insertion and dispensing Antara injectable. COVID-19 has affected everyone's life, especially the poor who are facing many challenges. I am happy that during the pandemic I am able to serve poor women who need IUCD and Antara services."

After the government-imposed lockdown, these evidence-based approaches have helped many city governments in UP to reactivate UPHCs to deliver accessible, quality and assured family planning services to the urban poor. However, city governments continue to face challenges related to demand generation as client visits for clinical services remain low as people are worried about becoming exposed to COVID-19 and refraining from leaving their homes unless absolutely essential.

For reading this story on TCI University please https://tciurbanhealth.org/tcihc-helps-local-government-address-staffing-shortages-during-covid-19-to-ensure-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/.