Mini University in Jharkhand Shares Lessons Learned from Implementing TCI’s InterventionsContributors: Deepti Mathur
The Challenge Initiative (TCI) supports the implementation of proven, high-impact family planning interventions (HIIs) by strengthening the capacity of city governments.
There is a need to discuss steps to strengthen planning and health services. I invite TCI’s team from Uttar Pradesh (UP) to share their experiences and lessons learned from implementing HIIs in UP.
Dr. Birendra Prasad Singh, Director In Chief, Health Services
In India, TCI holds “mini university” (mini-u) workshops where cities more experienced in implementing HIIs share their transformative effect with less experienced cities. When the National Urban Health Mission (NUHM) and family planning (FP) stakeholders in Jharkhand learned about these learning opportunities, they organized a joint mini-u workshop in November 2023 with PSI India to disseminate HIIs throughout the state.
The workshop included city officials from the TCI-supported cities of Ranchi, Bokaro, Deoghar, Dhanbad and East Singhbhum, as well as 17 cities not supported by TCI. Also in attendance were NUHM representatives and family planning stakeholders, including the Planning. The workshop also sought to support and prepare TCI Director in Chief (Health Services); the State Nodal Officers for the NUHM, Family Planning, and IEC; the NUHM’s State Program Manager and the State Coordinator- Family master coaches by facilitating knowledge acquisition from experienced coaches in high-performing cities.
During the workshop, Dr. Ranjit Prasad, NUHM’s State Nodal Officer, highlighted the need to build staff capacity to meet increasing urban population demands, while Dr. Pushpa, the State Nodal Officer for Family Planning, advocated for focusing on reversible family planning methods, postnatal family planning, and adolescent sexual and reproductive health. In addition, Dr. Lal Manjhi, the State Nodal Officer for IEC, urged workshop participants to engage fully and learn best practices from the experienced cities.
A special session on learning and takeaways from implementing TCI’s HIIs was conducted by Master Coach Dr. Jaskaran Singh Gangwar, an Additional Chief Medical Officer from Amroha, and Ahsan Ali, a District Urban Health Coordinator from Uttar Pradesh. They provided examples illustrating the successful implementation of HIIs in UP and discussed the potential for adopting similar strategies in Jharkhand.
Using UP as an example, Dr. Jaskaran highlighted how PSI India helped implement HIIs in the State and emphasized the importance of departmental convergence for success. Ali explained the referral mechanism and stressed the need for managers and coordinators to take responsibility.
Jharkhand city officials expressed curiosity about the strategies employed in UP to overcome challenges and enhance service quality. Their conversation covered topics such as the scarcity of skilled professionals, the role of fixed day services (FDS) in addressing the manpower crisis, the provision of intrauterine contraceptive device (IUCD) services at the UPHC level, the referral system, service convergence and coordination among different departments.
The mini-u prompted the NUHM to request TCI coaching and implementation of FDS in neighboring non-TCI-supported cities.
Officials from Newest TCI State of Bihar Learn from Two TCI Model Cities – Lucknow and AgraContributors: Deepika Anshu Bara, Parul Saxena, Manish Saxena, Nitin Dwivedi, Vivek Malviya, Samarendra Behera and Hitesh Sahni
The Challenge Initiative’s (TCI’s) goal is to build resilient health systems by transferring capacity to local governments so that high-impact family planning (FP) and adolescent and youth sexual and reproductive health (AYSRH) interventions are sustained after a city’s engagement ends with TCI. TCI accomplishes this through a coaching methodology that coaches and mentors local governments in the implementation of these interventions. To build resilient systems, TCI India enlists the help of high-performing graduated cities – such as Lucknow and Agra in Uttar Pradesh (UP) – that received TCI support to become self-reliant, to start up new TCI states such as Bihar.
TCI’s successful coaching model sparked interest from senior state officials from the Bihar government, who requested a visit to these two UP cities to learn from their experience. The learning visit helped the State Health Society (SHS) of Bihar – which included the National Urban Health Mission’s (NUMH’s) State Program Manager, Deputy Director of FP, and the NUHM State Finance Manager from SHS Patna – to quickly accelerate their start-up process before the state begins efficiently and effectively scaling TCI interventions in seven cities.
Over the course of the two-day visit in May 2022, the Bihar team held deep dive discussions with the Joint Director, Family Welfare (Directorate, Govt. of UP) Chief Medical Officer (CMO), National Health Mission Family Planning (NHM – FP) team, District Program Manager, Additional CMO of FP, Medical Officer-In-Charge (MOIC), staff nurse, Auxiliary Nurse Midwife (ANMs) and Accredited Social Health Activist (ASHAs) in both cities to better understand the TCI program, its interventions – most of which closely align with the global High-Impact Family Planning Practices or “HIPs” – and how to achieve and sustain meaningful results.
The Bihar team was coached by TCI master coaches and other local government staff in Lucknow and Agra, who shared their experience and knowledge about implementation and the importance of public-private partnerships for better fixed day static (FDS) service delivery. They also heard how TCI empowered urban primary health centers (UPHCs) to significantly contribute to the urban family planning program through MOIC and urban staff nurse trainings on newer contraceptive methods (i.e., Antara and Chhaya) and IUCD insertion. Other expertise shared included the importance of data review and monitoring of urban indicators by first strengthening the capacity of ASHAs to prioritize potential couples by age and method user/non-user through use of the 2BY2 matrix tool.
During discussions with UP state government officials, the Additional CMO of FP from Lucknow explained how the evidence-based interventions introduced by TCI led to observable quantitative and qualitative changes in family planning in urban Lucknow.
A NMH-FP official in UP also shared what he saw as the most significant changes as a result of engagement with TCI: “TCI India, with their technical support, coached government officials at the state and the city level to strengthen the urban FP program, and tremendous achievements have already been seen. First, UP embraced FDS. Initially, PIP funding were available for FDS at UPHCs in 20 TCI India demonstration cities. Later, the state government expanded FDS as ‘Antral Diwas’ in over 75 districts, where the PIP funds are granted for quarterly meetings and orientations of ASHAs and ANMs. Secondly, the state government endorsed the evidence-based interventions and shared them with city officials for implementation.”
The Bihar team is now reviewing these learnings as it prepares to roll out the TCI India model in the state by investing resources to implement TCI’s interventions and improve family planning access and urban
TCI’s Collaboration with OB-GYN Society Helps Further Strengthen Capacity in Three Indian StatesContributors: Dr. Sangeeta Goel, Deepika Anshu Bara, Hitesh Sahni and Deepti Mathur
In collaboration with the Family Welfare Committee (FWC) and the District Obstetric & Gynecological (Obs/Gynae) societies of the Federation of Obstetric & Gynecological Societies of India (FOGSI), TCI India hosted a webinar series for its members and other service providers across the supported states of Uttar Pradesh (UP), Bihar and Jharkhand.
FOGSI is a national body of all registered obstetricians and gynecologists working in the public and private sector. It includes a membership base of more than 30,000 registered gynecologists. The webinar series offered contraceptive technology updates, clarified myths and misperceptions, and provided an opportunity for service providers to interact with some of the leading family planning experts in India.
Dr. Jyoti Vajpayee
Family planning expert Dr. Jyoti Vajpayee appreciated the efforts of the FWC of FOGSI towards promoting family planning services. As part of her opening remarks, she stated that India has reached the replacement fertility level and that this medical fraternity of doctors, nurses, auxiliary nurse midwives (ANMs) and frontline workers deserves recognition for this achievement. She noted that government regulations and the work of agencies, like TCI India, have also helped in promoting spacing methods
This collaboration between TCI and FOGSI was mutually beneficial because FWC is charged with raising awareness and providing technical updates on the Government of India’s family planning program and external practicing bodies through its Sankalp Program. Aligning with this vision, the webinars were designed and led by FWC and District Obstetric & Gynecological societies with support from TCI that focused on coordination efforts between the national body with the district societies and invitees and identifying the thematic areas for the series, which included:
• Newer long-acting reversible contraceptives (LARCs) and limiting options
• Oral pills – benefits outweighs risks
• Procedures and devices
• Tailoring contraception and family planning counseling, where FOGSI FWC and other FOGSI stalwarts provided recent updates on FP methods and also clarified queries and concerns of providers.
The webinar series consisted of eight webinars that were attended by more than 1,000 service providers from 40 districts in UP, Bihar and Jharkhand. This translated to covering the following districts.
• 15 districts in UP: Lucknow, Kanpur, Moradabad, Shahjahanpur, Aligarh, Meerut, Mujaffarnagar, Mau, Agra, Prayagraj, Ayodhya, Firozabad, Varanasi, Bareilly and Etawah.
• 8 districts in Bihar: Patna, Bhagalpur, Purnia, Muzaffarpur, Darbhanga, Gaya, Sitamarhi and Katihar.
• 4 districts of Jharkhand: Ranchi, Jamshedpur, Bokaro and Dhanbad.
Some of the keynote remarks included hearing from:
• Shobha N. Gudi, Chairperson of FWC, FOGSI, who reminded members that counseling is very crucial and side effects resulting from any method, like menstrual irregularities and lower abdominal pain, must be explained to the client.
• Basab Mukherjee, Vice President, FOGSI, who discussed the significance of using the Medical Eligibility Criteria wheel, particularly for COCs, and under which circumstances they should be used with caution or avoided altogether.
• Madhuri A. Patel, Secretary General, FOGSI, who highlighted the need to extend quality family planning services to the last mile, and for this, she recommended building the capacity of service providers at the grassroots level – which this webinar series and TCI India is attempting to do in urban areas of UP, Bihar and Jharkhand.
• Shyam Pyari Jaiswar, President, Lucknow Obs/Gynae society, who highlighted critical points such as using the GATHER approach, method specific counseling, being non-judgmental and empathetic to clients and emphasized building capacity at all service providers’ levels.
The webinars were greatly appreciated by all participants – that is, members of FOGSI and the district societies. For example, Dr. Anita Singh, President-elect of AOGS, Bihar and Jharkhand, called for continued education through such webinars on more family planning related topics in the future.
TCI Supports Government-Led Family Planning Workshop for Kanpur Factory WorkersContributors: Deepti Mathur and Parul Saxena
The Challenge Initiative (TCI) provides technical support to the Government of Uttar Pradesh to help reduce preventable maternal and neonatal mortality among the urban poor population by increasing the accessibility and availability of modern contraceptives. As part of this government-led initiative, TCI India recently joined forces with the Confederation of Indian Industries (CII) in an effort to engage the corporate sector to improve the quality of life of vulnerable populations living in UP slums and daily wage workers in large and small factories.
In April 2022, TCI India supported the Chief Medical Officer in Kanpur, CII’s Northern Region and the Shubham Goldiee Masale group (an Indian spice manufacturer) in holding a sensitization workshop at a Goldiee Masale factory in Kanpur. Forty female factory workers attended the workshop to learn more about reproductive and family planning needs and services, and how to access those services.
Dr. Kanchan Mala Gupta
Kanpur, Uttar Pradesh
Dr. Kanchan Mala Gupta – a TCI master coach who is also the Medical Officer In-Charge of the Dharipurwa Urban Primary Health Center, Arjun, and Divisional FPLMIS Consultant for the National Health Mission in Kanpur – facilitated the workshop and explained the benefits of family planning.
“Family planning enables women to make informed choices about their sexual and reproductive health. Having small families allows parents to invest more in each child. Children with fewer siblings tend to stay in school longer than those with many siblings.”
She detailed the advantages, effectiveness and side effects of each modern contraceptive method. She also made workers aware of the Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs) in the community who can provide information and counseling services, and the various service delivery points (UPHCs, district hospitals, medical colleges, accredited private facilities, UHNDs) where they can get the method of their choice.
Sarita, a Goldiee Masale factory worker in Kanpur, attended the workshop: “This was the first time I attended an orientation session in the factory which was for the benefit of my health. I never took services from government facilities but now I would like to avail family planning service from a UPHC near to my place because now I know it provide range of and quality family planning services.”
Due to the overwhelming positive response to this government-led workshop – supported by TCI in collaboration with CII – the government plans more such family planning orientation workshops in other
PSI India, TCI’s Partner in India, Wins Prestigious Workplace AwardContributors: Deepti Mathur
The Challenge Initiative’s (TCI’s) partner in India – Population Services International, India – has earned a Great Place to Work® Certification from the Great Place to Work® Institute.
The Great Place to Work® Institute carried out an independent survey across PSI India in September 2021 and found that 92% of those working for PSI India feel proud of their association with it; 87% believed in the credibility of management while the Trust Index is at 87%, followed by 85% employees reporting that PSI India is a fair place to work.
On October 19, 2021, PSI India – a leading not-for-profit organization dedicated to improving the quality of life and well-being of the people in India – was designated a Great Place to Work – Certified™.
Great Place to Work® Institute is a global management research and consulting firm that works with over 10,000 organizations globally every year. This certification is a pioneer Employer of Choice recognition that organizations aspire to achieve, and is a Gold Standard in identifying and recognizing Great Workplace cultures.
TCI and its parent organization – the Bill & Melinda Gates Institute for Population and Reproductive Health – are proud to be working with PSI India to support the family planning and reproductive health needs of women and girls living in India’s poor urban communities.
Uttar Pradesh National Health Mission and TCIHC Develop Integrated Family Planning Media CampaignContributors: Deepti Mathur and Mukesh Sharma
The Challenge Initiative for Healthy Cities (TCIHC) in India believes a positive attitude towards family planning is key to increasing the adoption of modern contraceptives by giving agency to women in decision-making. With this goal in mind, TCIHC collaborated with the National Health Mission in Uttar Pradesh (NHM-UP) to develop an integrated family planning media campaign aimed at young and low parity couples.
In July 2021, in coordination with World Population Day, the NHM-UP released the campaign featuring five video public service announcements (PSAs) on its social media platforms. The NHM, the Government of UP and the State Innovations in Family Planning Services Project Agency (SIFPSA) co-branded campaign has five method-specific spots, developed under the leadership of the NHM’s Mission Director.
The package of five Hindi-language family planning videos has created a buzz and drawn the attention of several government counterparts, allied organizations and people in general. In a short period, NHM-UP’s Facebook page viewership has increased with the PSA on birth spacing trending at the top with more than 2,000 views, 500 likes and 150 comments.
The NHM-UP and TCIHC grounded the entire campaign within the concept of women’s empowerment. The videos position a dialogue between a husband and a wife that clearly shows the wife openly discussing contraceptives and asserting her voice. It aims to make contraceptives a symbol of freedom with a woman making her own choice regarding the number and spacing of her children – a choice that can significantly impact her health and well-being. The specific objectives of the campaign are to bring about behavior change in decision-making by actively involving women in the process, and to increase awareness about various modern contraceptive methods and dispel any myths or misinformation about them.
All five PSAa are free to air on all platforms, including television, cable, social media and static screening (i.e., cinema halls) for four years. Uttar Pradesh stakeholders believe this campaign is destined to give more power and agency to women when making a contraceptive choice.
TCIHC Hosts Mini University and Study Tour for New Cities in Uttar PradeshContributors: Deepti Mathur & Parul Saxena
The Challenge Initiative for Healthy Cities’ (TCIHC) approach is locally owned, adaptable, results-driven and embeds coaching within the existing government health system in India to build the confidence of government counterparts to drive sustainable scale-up of family planning and adolescent and youth sexual and reproductive health (AYSRH) interventions.
TCIHC’s model triggered demand from the National Health Mission to expand into additional cities in Uttar Pradesh. In response, TCIHC hosted its first virtual Mini University (Mini U) to introduce its high-impact approaches (HIAs) to new city officials from Farrukhabad, Bulandshahr, Etawah, Rampur and Mau by sharing first-hand experience and lessons learned from their implementation in the high-performing cities of Firozabad, Mathura, Jhansi, Agra and Saharanpur. The objective of the Mini U was to share the transformative effect of the HIAs through experienced cities. In attendance were over 48 participants from new and old cities.
Firozabad, Mathura, Jhansi, Agra and Saharanpur, Uttar Pradesh
Across the five experienced cities, it was often repeated how coaching to strengthen leadership capacity along with the technical capacity to plan, implement and manage the HIAs was imperative in increasing access to quality family planning services. As a result, the experienced cities coached new cities by sharing personal experiences of implementing the proven solutions. Champions from Agra and Mathura captivated participants by sharing experiences of using TCI University (TCI-U) to access uniform guidance, resources and guidelines in the India toolkit and learn from other cities’ experiences in the form of the most significant change stories. District Urban Health Coordinator of Mathura shared: “TCI-U provides resources and high-impact tools which guide cities on implementing successful family planning and AYSRH interventions. These evidence-based tools are comprehensive and simple. I have earned numerous assessment certificates from TCI-U. In addition, the Family Planning Community of Practice (FP-CoP) group created by TCIHC fosters a learning and sharing environment between cities where new cities could also join and learn from each other’s experience.”
The District Urban Health Coordinator of Firozabad shared: “When we chose to partner with TCIHC, we received a package of high-impact tools. We executed FDS in ready-to-start facilities with high-performing ASHAs. The results were promising; thus, we introduced FDS in all UPHCs.”
Akash Gutam, District Urban Health Coordinator of Mathura coached all of the Mini U participants on crucial steps for strengthening urban ASHAs to reap benefits from this proven approach and critical cadre of frontline health workers. He shared: “Demand generation is the biggest challenge in an urban family planning program. TCIHC through on-site coaching and mentoring support coached urban ASHAs, MoICs and ANMs in reviewing and monitoring ASHAs’ performance. The high-impact tool, ‘Strengthening Urban ASHA’ has enhanced urban ASHAs’ skills, improved reporting and record maintenance not only for family planning but for other health programs as well.”
On the mapping and listing HIA, District Urban Health Coordinator of Firozabad explained the significance of this tool: “The biggest difficulty was to assess the accurate urban population and area. This tool helped to identify unregistered slums and populations. Based on the new demarcated area, we developed plans, reallocated ASHAs, assessed training needs and estimated funds required for additional ASHAs, infrastructure and resources. This approach is very effective to uncover unserved areas and ensures service provision to the most vulnerable and left out pockets of the population.”
Continuing to Improve Youth Access to Contraceptive Services in the Time of COVID-19 in IndiaContributors: Deepti Mathur, Devika Varghese and Annette McFarland
Although the COVID-19 pandemic has disrupted access to family planning services around the world, the need for these services, particularly for adolescents and youth, remains the same. The Challenge Initiative for Healthy Cities (TCIHC) in India is working to ensure that adolescent and youth sexual and reproductive health (AYSRH) services continue to be available despite the pandemic.
To this end, TCIHC supported Rashtriya Kishor Swasthya Karyakram (RKSK) in Uttar Pradesh to develop COVID-19 guidelines for facility Adolescent Health Days, such as requiring all participants to wear masks and to maintain physical distance from others, so adolescents can continue to safely seek the health services they need during the pandemic.
Dr. Manoj Kr Shukul
Beginning in August, TCIHC-supported cities such as Saharanpur, Varanasi, Gorakhpur and Allahabad in Uttar Pradesh re-initiated facility Adolescent Health Days across 68 urban primary health care centers (UPHCs) for the first time since the COVID-19 pandemic impacted services in March 2020, when many in-person activities were halted. By September, 204 boys and 444 girls had participated in facility Adolescent Health Days in these cities.
In addition, TCIHC is providing technical assistance to RKSK to design social and behavior change messages to reach adolescents age 15-19 with targeted, age-appropriate health information. TCIHC developed messages on nutrition, sanitation and personal hygiene practices that aligned with RKSK monthly themes and addressed the COVID-19 pandemic. The messages were shared with adolescents via WhatsApp, a platform many adolescents in India access on their cell phones.
The nutrition and personal hygiene messages were also shared with district officials of 75 cities, including TCIHC-supported cities, other cities, and rural areas, so they can distribute the messages through official channels. All the messages were also tweeted by Dr. Manoj Kr Shukul, the General Manager of the National Health Mission in Uttar Pradesh.
Empowering India’s Frontline Health Workers with COVID-19 Prevention MessagesContributors: Mukesh Sharma, Deepti Mathur and Lisa Mwaikambo
India is the world’s second most populous country, with more than 1.3 billion residents. Ensuring that young women and girls have access to family planning is central to the country’s future development, paving the way for more educated communities and a healthier population. But COVID-19 has placed a heavy burden on India’s health system, which now has to care for patients suffering from coronavirus, test people for the virus and other conduct other allied services.
Many health facilities have been converted into dedicated COVID-19 centers, which means fewer facilities for services such as family planning. Getting messages out to vulnerable populations, such as the urban poor, as to where they can seek family planning services is crucial. Also crucial is protecting frontline health workers that deliver those messages.
The Challenge Initiative for Healthy Cities (TCIHC) in India has supported the Government of India (GOI) in Uttar Pradesh (UP), Madhya Pradesh (MP) and Odisha by developing self-care messages for its frontline health workers, including urban Accredited Social Health Activists (ASHAs) and their supervisors, Auxiliary Nurse Midwives (ANMs).
TCIHC adapted existing GOI information, education and communication materials related to COVID-19 with content specifically for ASHAs and ANMs that integrates family planning messages. The materials instruct ASHAs to take appropriate precautions during field work while reinforcing their important role in helping women avert unwanted pregnancies. Given the lockdown restrictions, TCIHC facilitated this adaptation and finalization of the materials with the GOI through existing WhatsApp Groups.
Once finalized, state officials shared the materials – which were developed in Hindi and customized for all three states – via existing WhatsApp groups of the National Urban Health Mission (NUHM) with urban primary health centers (UPHCs), ASHAs and ANMs.
Given that ASHAs see many clients who prefer birth spacing methods, TCIHC also incorporated messages that encouraged them to replenish and carry their stock of condoms and pills during household visits. TCIHC city teams also coached ASHAs to do telephone follow-up with IUCD clients and help injectable clients get their next dose from a nearby facility. In addition, TCIHC has developed an e-learning module for ASHAs that guides and mentors them on family planning counseling that was tested during the COVID-19 lockdown period. The insights gained were incorporated into the module, which will be rolled out across all TCIHC-supported cities in May.
More than 3,500 state and city government officials and 11,000 ASHAs and ANMs in UP, MP and Odisha (6,190 in TCIHC-supported cities) have been reached with these critical messages to ensure continuity of family planning services during the pandemic. TCIHC continues to regularly provide technical assistance and coaching to its government counterparts and frontline health workers remotely through WhatsApp
Uttar Pradesh and Madhya Pradesh Officially Endorse Nine of TCI’s Proven Approaches for All CitiesContributors: Mukesh Sharma, Hitesh Sahni, George Philip and Parul Saxena
The state governments in both Uttar Pradesh (UP) and Madhya Pradesh (MP) have officially endorsed nine of The Challenge Initiative for Healthy Cities’ (TCIHC) proven approaches that are being used to successfully implement family planning activities in 20 UP cities and eight MP cities. This means TCIHC’s approaches are now available for use in all cities throughout both states (75 total in UP and 47 total in MP).
TCIHC works with the Government of India (GoI) in both states (and Odisha) to implement the following approaches, which were proven effective under the Urban Health Initiative in India (2009 – 2015) and have been adapted for inclusion in TCI University (TCI-U).
Uttar Pradesh (UP) and Madhya Pradesh (MP)
• Mapping and Listing Urban Slums
• Fixed Day Static Services/Family Planning Days
• Strengthening Urban Accredited Social Health Activists (ASHAs)
• Strengthening Provider Capacity
• Using Data Effectively
• Private Sector Engagement
• Planning and Budgeting: Program Implementation Plan
• Engaging Mahila Arogya Samiti (MAS)
In UP, these approaches have so far resulted in:
• 1,310 slum clusters identified resulting in 1.8 million slum residents being linked to health and family planning services in 20 cities.
• 363 Urban Primary Health Centers (UPHCs) organizing weekly fixed-day static services (family planning days) and 329 UPHCs providing intrauterine contraceptive device (IUCD) services for the first time.
• 81% (294) of those UPHCs forming quality improvement teams and assessing service gaps on regular basis.
• District quality assurance committee (DQAC) members visiting UPHCs to assess facility readiness for family planning services for the first time. • Increased uptake of family planning services at UPHCs and family planning referrals from urban health and nutrition days (UHNDs) and outreach camps (ORCs), as a result of coaching and mentoring of urban ASHAs.
• Increased uptake of non-scalpel vasectomy (NSV) as a result of TCIHC’s male participation approach, which resulted in 82 men receiving NSV in just 22 days across 10 cities.
On Feb. 27, 2019, the UP government and the GoI’s National Health Mission (NHM) along with TCIHC – led by Population Services International (PSI) – organized a one-day “State Conclave on Urban Family Planning” for cross-sharing and learning related to challenges and solutions for improving access, choice and quality of family planning services among the urban poor. The event was attended by 230 participants comprising representatives from the Government of India (GoI) and Uttar Pradesh, along with other stakeholders.
In partnership with TCIHC, NHM is scaling up proven approaches to increase access to and demand for family planning to over 20 million people across 20 large UP cities, covering 70% of the state’s total slum population.
At the event, Prof. Rita Bahuguna Joshi, the Honorable Minister of Family Welfare, Mother and Child Welfare for UP; Sri Pankaj Kumar, Indian Administrative Service, Mission Director NHM & Secretary Health in UP; and other dignitaries’ unveiled TCIHC’s toolkit featuring the nine high-impact approaches. Joshi shared that the high-impact approaches are quick, easy-to-adapt strategies that can improve accessibility and use of family planning services. She also said implementing these approaches can help reduce the state’s fertility rate, which is much higher than national average. She urged family planning programs across the state to adapt the tools in their respective programs.
The Government of UP’s endorsement means that the approaches and tools are now approved for use by all government health officials in UP, which will diffuse TCIHC’s impact beyond its 20 cities to an additional 55 cities in UP. Check out the summary report to learn more about the conclave proceedings.
A similar event just held in Madhya Pradesh, India, on May 2, 2019, resulted in the nine approaches – plus an additional one on establishing a referral mechanism – being endorsed by the MP government, thus extending the potential reach beyond the eight TCIHC-supported cities to an additional 39 cities.
Ushering in a New Era of Public-Private Family Planning Partnerships in Uttar Pradesh, IndiaContributors: Deepti Mathur and Mukesh Sharma
The Government of India’s National Health Mission has had a clearly defined policy since 2006 for engaging private health care facilities to provide family planning services under public-private partnerships. Despite this policy, private sector participation has been lukewarm. TCI’s implementing partner in India, Population Services International (PSI), often asked senior members of the Federation of Obstetrics and Gynaecological Societies of India (FOGSI) why private providers did not participate more actively in the national family planning program. They usually said if there were a hassle-free engagement mechanism, its members would happily engage and contribute to the national agenda of family planning. They also said they weren’t seeking large profits but just wanted their own costs to be adequately covered.
Balancing the needs of women to access quality and affordable family planning services with supply is not always an easy task because family planning services for poor women are typically limited to overloaded public sector facilities while the nearest, well-equipped, clean private facility is often out of their reach. To address this supply and demand issue, PSI partnered with other stakeholders and development partners to support Government efforts to make family planning services available to all women as a matter of health rights.
Hausala Sajheedari Program
This led to the creation of the Hausala Sajheedari Program which was conceptualized together with the National Health Mission, the government of Uttar Pradesh (GoUP), State Innovations in Family Planning Services Project Agency (SIFPSA) and other family planning partners in Uttar Pradesh. Modeled on an e-governance system, Hausala Sajheedari is a web-enabled digital platform for accrediting private health care providers (an essential precondition for engaging in the strategic purchase of family planning services by the state), and empaneling private sector family planning surgeons (which indemnifies them against family planning procedures). The entire online system was designed to minimize the direct human interface by introducing an end-to-end online solution from application to approvals, reimbursement claim submissions to online payments with built-in transparency and accountability.
Hausala Sajheedari effectively replaced the traditional paper-based application process, which was a tedious, non-transparent herculean task that dissuaded most private sector providers from participating. While this model has shown remarkable early success, it still hasn’t realized its complete potential. Of the 876 facilities accredited under Hausala Sajheedari, only about 30% actively participate in the program, while about 70% remain dormant, despite being registered.
“I am willing to provide family planning services but I don’t have the bandwidth to move around in the community to look for clients. The amount reimbursed (INR 2000/- reimbursed as facility/procedure cost for every sterilization client served) hardly covers my basic costs so I cannot pump in my money to do community mobilization and advertisement,” said one provider in explaining why he does not participate.
The facilities that did participate were benefitting from the demand generation activities of several development partners supported by external donors. This – like any other non-government-led project – was not a sustainable model in the long run. Thus, the demand generation gap in the private sector emerged as one of the biggest gaps in creating a long-term sustainable solution for meeting the family planning needs of women.
In seeking a solution, the project looked at the nature of private providers and realized most were stand-alone private clinics and family planning was not their core business. The private-sector facilities primarily served walk-in clients and hardly engaged in any client mobilization efforts. Evidence shows very few clients walk in on their own for family planning services, particularly those in a lower socio-economic segment. While the demand generation model of the government uses a large network of frontline health workers called Accredited Social Health Activists (ASHAs) who act as first point of contact in facilitating family planning and other health services. The current government policy allows ASHAs to only refer clients to the public sector and not to the private sector.
The solution was to advocate for a change in government guidelines that would allow the ASHAs and other front line health workers to refer clients to private-sector facilities so the client not only has a choice of family planning methods but also where she can avail that service.
PSI and a few other development partners have been on the forefront of advocating for this important policy change with government leadership at the centre as well as state level. Many decision-makers agreed in principle to the benefit of shifting the policy, but were unwilling to act on it. This stemmed from the potential risk of cannibalisation of clients by private sector, as well as a lack of clear evidence for making such a drastic change. When TCIHC launched in May 2017, a senior health official made it clear that they would not make the change unless the benefit of doing so were proven and potential risks were mitigated. However, he indicated that if a state government were to agree to test this model and document the evidence, results and learnings, the Indian government would consider revising the guidelines.
PSI along with SIFPSA requested the Mission Director of the National Urban Health Mission in UP to allow a proof of concept around this issue. With consistent engagement, the UP government leadership agreed to test it by layering it on the already successful Hausala Sajheedari platform for family planning services. The Mission Director agreed to pilot this demand aggregation model in five districts with high total fertility rates (TFR), which were also the chosen districts for the government’s existing Mission Parivar Vikas, a family planning program focused on urban populations.
With additional resources made available under Mission Parivar Vikas plus the technology solution to protect against any potential financial malpractice, the right combination was found to demonstrate the proof of concept of this new demand and supply model. The UP NUHM entrusted SIFPSA to lead the implementation of the pilot, while PSI is the designated technical partner to support the intervention including documenting results and learnings. The implementation cost of more than $200,000 (USD) will be leveraged from SIFPSA.
This advocacy win gives hope that the model will lead to a nationwide scale-up of a similar model by allaying mistrusts and fears in private sector engagement. If proven successful, this demand aggregation