The Challenge Initiative (TCI) recently expanded its reach to Jharkhand state in India in response to their request for technical support to advance family planning efforts in five cities: Ranchi, Bokaro, Dhanbad, Deoghar, and East Singhbhum.
. Dr. RachitBhushan
Jharkhand’s capital city of Ranchi had an almost stagnant family planning program before implementing TCI’s high-impact practices and other interventions (HIPs & HIIs). Almost all urban Accredited Social Health Activists (ASHAs) had not had a specific family planning orientation for many years. Urban primary health centers (UPHCs) also needed capacity strengthening to improve documentation.
In collaboration with TCI, city government officials and UPHC staff were promptly coached on HIPs & HIIs. Through early mentoring support, the medical officer-in-charge (MOIC) conducted a facility needs assessment of UPHCs to find gaps, and then develop an action plan to resolve them and start delivering quality family planning services.
Among the gaps identified during coaching discussions were low awareness of modern family planning methods in the community and poor visibility of family planning at UPHCs. Dr. RachitBhushan, MOIC of the Risaaldar Nagar UPHC, noted: “The majority of my FP clients are women. However, they are hesitant to discuss FP with a male doctor. As a result, when a woman arrives at the clinic seeking FP information, she looks for a staff nurse.”
to establish “FP Counseling Corners” at UPHCs, which
complied with the government’s privacy guidelines.
All seven MOICs showed interest and inquired about the requirements of establishing such a corner. They discussed the idea with their staff as well.
The TCI team supported them in creating a prototype layout of an FP Counseling Corner and listed the required materials. The MOICs determined that all the commodities and IEC materials listed were available. All that was required was a “sacrosanct space,” with a table, chairs, and a display featuring family planning commodities, job aids and IEC material. The MOICs made auxiliary nurse midwives (ANMs) responsible for managing the FP Counseling Corner, where they counsel eligible clients and help them make an informed choice when selecting a family planning method.
FP Counseling Corners are being noticed and appreciated by other government officials. The Public Health Manager of Ranchi, Mr. Shishir Roy, stated: “We are noticing the benefits of this concept because people who were previously hesitant to ask for FP commodities now take condoms or OCPs from the FP corner. As a result, FP data is increasing. We are now planning to focus on community mobilization and outreach activities, and I am confident that with TCI India’s assistance, we will achieve even better results in the near future.”
Dr. Rachit is equally happy as he reported that in his UPHC, women are no longer hesitant as they visit the FP Counseling Corner to clarify their doubts, seek answers to their family planning questions and receive counseling as well. He now wants to have a female gynecologist scheduled on particular days at the UPHC to support the provision of both maternal and child health and family planning services.
The successful demonstration of this approach drew the attention and interest of the government. TCI shared this in review meetings and advocated scaling it up in other TCI-supported cities. As a result, the FP Counseling Corner concept has now been adopted by all the remaining four intervention cities in Jharkhand, including Bokaro, Dhanbad, Deoghar and East Singhbhum.
STRENGTHENING THE LINKAGES BETWEEN COMMUNITY STRUCTURES AND THE HEALTH SYSTEM IN MORADABAD, UTTAR PRADESH
When The Challenge Initiative (TCI) in India engaged the city of Moradabad in May 2018, most Accredited Social Health Activists (ASHAs) had little knowledge of family planning - especially long-acting spacing methods - due to limited or no training.
For them, family planning meant female sterilization. They rarely engaged with Mahila Arogya Samitis (MAS) to seek support from these women's support groups in addressing myths and misconceptions related to family planning and tackling social barriers (including the ones posed by gatekeepers) that these community groups could help influence. At the same time, MAS also had limited knowledge and information about family planning.
As a result, family planning uptake in Moradabad was low, given very few women knew much about the variety of family planning methods available to them, let alone felt supported and informed to make a decision on the matter.
An ASHA named Heerawati said after she received TCI training and coaching on family planning methods, she felt empowered. She was applauded in an ASHA-ANM monthly meeting, where she shared how with the help of MAS members she helped a woman adopt a family planning method of her choice. She said she remembered that during one of her routine household visits, she told a young woman named Moni about family planning and her method choices for spacing between children. But she said Moni's mother-in-law stopped her from adopting any family planning method. She then tried counseling the mother-in-law on the advantages of family planning for young first-time parents, but Heerawati was unable to change her mind. The next thing she knew, Moni was pregnant with her second child.
"Previously, I did not have much confidence in discussing family planning with women of my area as I did not know much about it. Like others in the community, I feared IUCD (intrauterine contraceptive devices). In 2019, TCI organized a two-day orientation on FP where I learnt about all the methods, their side effects, and ways of handling client's myths and misconceptions. I clarified my doubts on IUCD, injectables and others. I learnt how MAS members can be helpful in dealing with mothers-in-law who sometimes pose difficult questions or prevent adoption of FP by a young woman of their house. I felt a rush of confidence in me." - Heerawati An ASHA in Moradabad
This story motivated other ASHAs to work with MAS members in their communities to counsel women to adopt family planning methods of their choice.
eligible couples and is one of the expert ASHAs at her
urban primary health center (UPHC), Majholi.
As a result of these efforts to strengthen linkages between the community and facility, the overall uptake in family planning services at the city level for Moradabad has improved by 97% - from 7,694 family planning users at the time of baseline to 15,136 users as of June 2021 (Fig.1). At the same time, this represents a 197% increase at the UPHC level - from 4,266 family planning users at baseline to 12,649 users as of June 2021
"I was dismayed as I had seen Moni as a frail woman. After her second delivery, I spoke to Mahila Arogya Samiti members and requested them to counsel Moni's mother-in-law so that she does not conceive yet again and get burdened. MAS members invited Moni and her mother-in-law in their next group meeting where they counseled both of them. Moni soon visited and met the UPHC doctor who explained the basket of choices to her.
I kept on following up with Moni and assured her that the side effects of any FP method are temporary and there is no need to be afraid of any method as it will improve her life. Finally, Moni asked me to help her avail injectable contraceptive." - Heerawati An ASHA in Moradabad
The Challenge Initiative (TCI) has been supporting the local government in Jhansi (Uttar Pradesh, India) since June 2018.
Dr. Anil Kumar
Chief Medical Officer
Jhansi, Madhya Pradesh
Unique and Inclusive Partnership Approach
Dr. Kumar said he was excited by TCI’s approach from the very beginning when TCI invited him and other local government stakeholders working in the urban health system to take part in a ‘Know Your City’ exercise. As a result of this exercise, he immediately reached out to the District Quality Consultant and staff mentor for maternal health and conducted a gap analysis of all urban primary health centers (UPHC). With gaps identified, they developed and executed on a mitigation plan.
unique and inclusive partnership approach along with coaching and
high-impact approaches are leading to additional family
planning clients in his city.
Coaching and High-impact Approaches
TCI shared with Dr. Kumar and other city officials the success other cities have seen with TCI’s high-impact approaches. When TCI began to coach them and UPHC staff on how to implement the high-impact approaches, they immediately began to see how these approaches could help Jhansi. Their first step was to roll out the fixed day static (FDS) service approach. Before engaging with TCI, only two facilities had started FDS. By August 2018, all 12 UPHCs in Jhansi were providing assured quality family planning services on FDS days. With continued coaching from TCI, Dr. Kumar issued a training calendar for service providers on the new contraceptive method, Antara. By January 2019, the UPHCs were offering Antara, having expanded the methods of choice to poor urban women.
Results from Engagement with TCI
Dr. Kumar shared how TCI’s coaching support around reviewing, using and sharing data with stakeholders has not only demonstrated the success of TCI’s high-impact approaches but has caused a ripple effect:
“We had understood the power of data. We regularly presented our work in urban family planning at DHS reviews and this grabbed the attention of Superintendents of Community Health Centres (CHCs), other block level functionaries. With regular reviews, we had good programmatic insights to inform us of the change that was visible through data. A favorable environment for prioritizing family planning had been created. But it was in a divisional review meeting that I was handed over the CMO series. This particular event and afterwards, I received much applause and recognition, which was the game changer in catching the attention of other two districts, Jalaun and Lalitpur in the divisions.”
Dr. Kumar invited the CMOs of Jalaun and Lalitpur for a divisional diffusion workshop. Dr. N.D. Sharma, CMO of Jalaun, readily accepted the invitation and said the progress made by Jhansi was impressive, noting how the high-impact approaches contributed to improvements in family planning services.
Dr. Sharma shared: “I find the following in particular of tremendous importance: coaching availability through TCI University, the role of a functional CCC [City Coordination Committee], sustainability of antral diwas [FDS] and strengthening ASHAs. I am pleased to share that Dr. Jain, Nodal Officer of Jhansi, his team at Divisional Urban Health Consultant and the Divisional Program Manager have all extended their support in coaching our geography teams so that we too can scale up these high impact approaches in Jalaun.”
Jhansi is now well-positioned to take on the role of a mature TCI city and support diffusion and capacity transfer of the high-impact approaches to Jalaun.
Ahsan Ali, an Urban Health Coordinator with the National Urban Health Mission (NUHM) in Amroha, is a master coach for the graduated city. He recently shared his thoughts on how the city is doing after graduating from TCI.
Urban Health Coordinator,Amroha
The goal of The Challenge Initiative (TCI) is to support the greater self-reliance of local governments to scale up family planning and adolescent and youth sexual and reproductive health (AYSRH) high-impact interventions (HIIs), leading to sustained improvements in urban health systems and increased use of modern contraception, especially among the urban poor. From the onset of engagement with TCI, the local government is set on a path towards self-reliance to transform and sustain an impactful urban family planning program. In February 2021, five cities in Uttar Pradesh, India, successfully transitioned to the graduation phase of TCI, no longer requiring direct coaching and technical support from TCI.
departments, which has shown positive results
after graduation especially.
“Since the inception of TCI, we have considered the initiative a part of NUHM. In February 2021, Amroha moved to the graduation stage. And since then, we have not faced any major challenge. Since graduation, I have mainly utilized approaches such as using data effectively, fixed-day static (FDS) service, strengthening urban ASHAs and convergence for implementation and to coach staff of the health department. The best part is without any follow-up every Thursday all urban primary health centers (UPHCs) are organizing weekly FDS/Antral diwas because facility staff, ANMs (auxiliary nurse midwives), and ASHAs (accredited social health activists) are well-coached on their responsibilities, and FDS reports are timely submitted to us.
In large convergence platforms, like District Health Society, NUHM, and FP Review meetings, I present urban family planning data and ensure action points are developed and adhered to. Based on family planning HMIS data, I prioritize low-performing UPHCs and, along with Nodal Sir [another master coach], plan a regular visit to the facilities. Through these joint visits, I coach UPHC staff and support them in mitigating challenges. Recently, I resolved the supplies issue by taking the support of the FPLMIS Manager, also coached by me. He reoriented the UPHC staff on the online indenting process, and this step has improved the family planning results of low-performing UPHCs.
The quarterly city coordination committee meetings are conducted timely, and I ensure that representatives of other departments accomplish tasks assigned to them.
The only challenge we have faced is to coach newly appointed urban ASHAs regularly, as this is not a stable position. For this, we took advantage of the ASHA and ANM monthly meeting as a capacity-building platform to mentor new ASHAs on family planning counseling skills through ANMs. We ensure that in each ASHA and ANM meeting, staff from NUHM department participates and coaches the community health workers on any relevant health topics and sets their monthly priorities.
Moving forward, we are strengthening the use of the 2BY2 prioritization tool to assist ASHAs to prioritize their family planning clients, and help make timely decisions based on the aggregated 2BY2 matrices.”
TCI’s master coaches are ensuring that the impact created during TCI’s direct engagement is sustained. Their continued role in capacity transfer, decision-making and oversight of implementation of the high-impact interventions is making a noticeable increase in Amroha’s annual family planning client volume at the UPHC and city level – which includes UPHC and district level facilities.
The graph shows the 40% and 14% increase in annual client volume at the UPHC and city level, respectively, for two fiscal years (i.e., from April 2019-March 2020 to April 2020-March 2021). Similarly, HMIS data on intrauterine contraceptive devices and Antara (injectable contraceptive) uptake at the UPHC and city level in the last six months after graduation indicates that the city’s performance following the worst period of the COVID-19 pandemic is back on track both at the UPHC and city level.
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.
UPHC NaglaTikona, Uttar Pradesh
TCIHC is partnering with the Government of India’s national adolescent health program called RashtriyaKishorSwasthyaKaryakram (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.
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 ‘BhrantiaurKranti’ (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 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.
The Challenge Initiative for Healthy Cities’ (TCIHC’s) state-level advocacy efforts successfully convinced the General Manager of Rashtriya Kishor Swasthya Karyakram (RKSK)
Lucknow, Uttar Pradesh
The government of India’s adolescent health program – of the critical importance of meaningfully engaging youth in policy and strategy development that aims to work for them.
This was the first time that a workshop brought together adolescents to partner with government stakeholders – including the Chief Medical Officer, state General Manager for RKSK, and other key decision-makers and health leaders from all departments – to devise an adolescent and youth sexual and reproductive health (AYSRH) strategy. Lucknow city leaders acknowledged they had not realized how great the demand was for sexual and reproductive health information and services by adolescents and youth.
workshops in three Uttar Pradesh (UP) cities, including Lucknow
Prior to this workshop, the contraceptive needs of adolescents and youth went unheard, unregistered and unrealized. The following eye-opening comments were shared during a recent youth-led city consultation workshop in Lucknow.
Amisha Gulati, a 19-year-old girl from Lucknow, said: “If we ask our elders anything related to our body changes, they get annoyed and give dissatisfactory answers. Our teachers also skip the chapters related to reproductive health and tell us to read these chapters at home. I don’t understand as every girl undergoes these changes. They have many doubts, myths and taboos related to menstruation, physical changes, pregnancy, etc. Girls must have correct information about all these before getting married so that they can take care of themselves and their family, but it does not happen!”
Pankaj Mishra is a 17-year-old boy and added this to what Amisha shared: “Boys joke about these issues and never take them seriously. Teachers and parents do not talk about puberty, menstruation, masturbation, etc. ever with us. We also hesitate in asking them anything related to these matters. Actually, the whole environment is not adolescent friendly. It would be great to have a counsellor who keeps our discussions confidential and gives correct knowledge.”
The medical officer of Lucknow, Dr. ShaliniVerma, agreed that the situation has been problematic, saying: “Adolescents do have lots of questions, but they are unable to discuss these with their elders. Moreover, they are subjected to immense pressure from parents on academic excellence and the objective of a career. Sexual and reproductive health issues add to their stress, as their questions and needs remain unanswered.”
During the Lucknow workshop, government stakeholders worked in partnership with adolescents and youth to identify gaps and solutions and develop not only an AYSRH strategy but also an action plan to serve better serve the needs of adolescents and youth. The final action plan includes the following decisions:
• Special Fixed Day Static (FDS) service every month for first-time parents at the urban primary health center (UPHC) level
• Whole-site orientation for UPHC staff at the UPHC level
• One day per month fixed at UPHCs for an adolescent health day
• Convergence among different departments and engaging RKSK team and adolescents and youth in regular City Coordination Committee (CCC) meetings
• Representation of each department in city-level review meetings and RKSK planning meetings
Other TCIHC-supported cities in Uttar Pradesh have now requested similar support to hold their own youth-led consultation workshops. Consequently, all 10 TCIHC AYSRH scale-up cities have successfully organized these workshops with the support of National Health Mission budget and TCIHC coaching and technical assistance.
Seven of the 10 cities demonstrated their political commitment to youth engagement in carrying out their workshops virtually as a result of the COVID-19 lockdown. TCIHC’s coaching of nodal officers, especially the urban family planning and RKSK ones, helped them to plan, organize and manage the virtual workshops.
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.
Ujjain, Madhya Pradesh
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. JyotiGadam 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
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.
The Daranganj urban primary health care center (UPHC) in Prayagraj city (Allahabad, Uttar Pradesh) is alive with the sound of excited chatter, laughter and happy noises.
Shahpur UPHC, Gorakhpur
. That’s because it is Adolescent Health Day (AHD) at the facility – a day where unmarried adolescent boys and girls ages 15-19 years can seek a variety of health services and engage with facility staff.
However, RKSK guidelines emphasize that AHDs can only be conducted in facilities classified as adolescent-friendly health centers (AFHCs), a classification that was limited to just secondary and tertiary care facilities such as district women hospitals and medical colleges. Limiting services to the higher level of care facilities restricted linkages between primary and speciality care services, especially for vulnerable populations, like unmarried boys and girls and the urban poor.
a Government of India (GOI) program launched by the Ministry of
Health & Family Welfare to improve health-seeking behavior
among young unmarried adolescents, 10-19 years of age.
“I always thought it is only when one is sick we go to a clinic. One can also go to a clinic when we need information about our health is something I just came to know.” – A 15-year-old girl who attended the AHD at the Daranganj UPHC
The Challenge Initiative for Healthy Cities (TCIHC) helped the RKSK program get UPHCs classified as adolescent friendly in five TCIHC-supported cities – Allahabad, Firozabad, Gorakhpur, Saharanpur and Varanasi. A critical feature of an AFHC is the presence of a dedicated counselor for adolescent services. Working with the Chief Medical Officer (CMO), TCIHC identified one staff nurse from each of the 96 UPHCs in the five cities and strengthened their capacity to provide adolescent health counseling, following the RKSK curriculum.
In addition, a staff-wide whole site orientation (WSO) – which ensures that all staff have a basic understanding about adolescent and youth sexual and reproductive health needs – was conducted in all 96 UPHCs to guarantee a welcoming and accessible environment for unmarried youths to access sexual reproductive health (SRH) information and services. Nearly 1,300 UPHC staff, including doctors, staff nurses, janitors and pharmacists, were oriented on providing SRH information and services to both married and unmarried adolescents and youth, 15-24 years of age, as a result.
“Until this WSO happened, I had never thought that something special needs to be done for adolescents. In fact, all the staff of this facility never felt that adolescents have any such [contraceptive] need. However, I realized that adolescents also have this need when I saw 60 boys and girls turn up on the day of AHD.” – Medical-Officer-In-Charge (MOIC) of Shahpur UPHC, Gorakhpur
With staff trained, it was then time to improve the provision of adolescent-friendly supplies at the UPHC. TCIHC utilized city coordination committee (CCC) platforms to inform city officials on the importance of stocking iron and folic acid (WIF), Albendazole (deworming medicines), sanitary napkins, multivitamin tablets and condoms. By coordinating efforts with RKSK at the state level, TCIHC succeeded in establishing stocks of the needed supplies at the UPHC. With this, UPHCs added adolescent services to their citizen charter, which had not been previously included.
In November 2019, TCIHC supported AHDs at select UPHCs in the five cities. Accredited Social Health Activists (ASHA) and Anganwadi Workers sensitized and mobilized the community. Mobilizing boys and girls for the AHD was made easier because the ASHAs could refer to their urban health index registers (UHIR) to identify households with 15- to 19-year-old boys and girls.
“I feel such an event should be conducted once every month. Earlier, I wondered what will happen but I saw several boys and girls of my age had turned up here and, upon meeting them, I felt this is a wonderful platform where we can ask questions, share our thoughts and suggest also.” – A teenage boy who attended the AHD at the Daranganj UPHC
As per RKSK guidelines, the half-day AHD included a nutrition kiosk and private counseling corner for boys and girls. Providers trained in AFHS by TCIHC conducted “circle time” with boys and girls, respectively. The sessions integrated games to break the ice between providers and participants and provide SRH information. A game developed about self-risk perception set the ground work for a frank discussion on SRH. Following the activity, participating boys and girls were invited to write down questions with respect to SRH, which were then answered by the MOIC or staff nurse.
The youth asked questions about body changes as a result of puberty and self-image, gender discrimination in families, discomfort when negotiating with a partner when in a relationship, masturbation, and discomfort during menstruation.
A significant number of participants chose to meet with the staff nurse/counselor in private. Distribution of WIFs and Albendazole, screening of hemoglobin estimation and body mass index were made compulsory for every adolescent participant. Referrals were made to the district hospital for more complex services.
As of February 2020, AHDs have been conducted in 70 UPHCs across the five cities with close to 2,500 youth in attendance. Of these, a higher proportion of girls (66%) turned out for the event. However, only half of them went for counseling and clinical screening. And even though only 34% of the participants were boys, a higher proportion of them underwent counseling and clinical screening. This informs the need to build self-efficacy among girls and also that risk-taking behavior may be higher among boys. Interestingly, these results are compelling medical officers of UPHCs to ask ASHAs to inquire as to the health needs of adolescents during their household visits – something that had not happened before.
AHDs have captured the attention of government officials. As a result, Chief Medical Officers in Allahabad, Firozabad, Saharanpur and Gorakhpur issued directives to conduct facility-based AHDs on the eighth of every month across all UPHCs in their cities.
When scaling up its signature Fixed Day Static (FDS) services /Family Planning Day (FPD) approach in Mathura
UPHC, Haiza Hospital
India’s seven urban primary health centers (UPHCs), the TCIHC team noticed the facilities themselves needed some improvements. A number of issues needed to be addressed, including poor water supply, improper seating arrangements in the patient waiting area, no family planning counseling area and a lack of family planning informational materials and supplies. But the UPHCs’ regular administrative budget apparently did not cover these types of improvements.
Chief Medical Officer (ACMO) and Nodal Officer of the
National Urban Health Mission (NUHM) agreed
The problem needed to be addressed as it was hampering the quality of family planning services being offered. While everybody agreed on an improvement plan, no one knew how to fund the plan given the budget constraints. TCIHC analyzed the budget more closely and discovered an underutilized fund in a category devoted to patient welfare called “RogiKalyanSamiti” (RKS). Under the guidance of the ACMO, TCIHC developed a detailed report describing what was required to transform the UPHCs into family planning-friendly centers for clients and the benefits of doing so. The district magistrate was impressed after receiving the report and approved the RKS budget expenditure as requested. In addition to painting the walls, the RKS budget was used for condom boxes, fire extinguishers, LED bulbs, ceiling fans and chairs in the client waiting areas, refrigerators, pin/information boards, complaint boxes, water filter repairs, IUCD room slippers and caps, doormats, curtains for counseling areas to maintain privacy, mattresses, tables, blankets and family planning education materials. As a final touch, family planning/FDS themed wall paintings were done alongside a large poster displaying family planning methods.
The transformed UPHCs lifted the confidence of facility staff. The posters and new materials piqued the interest of clients who wanted to know more about family planning methods. ASHAs in the area also were inspired to reach out to clients and refer them to the upgraded facilities. “This has become easy for us to initiate dialogue on FP now that there is a huge basket of choice poster. Many clients themselves ask questions referring to the poster,” said Ms. Bushra, a nurse in the UPHC Haiza Hospital. “However, sometimes we do ask, ‘have you seen that huge poster’?”
As a result of the facility makeovers, client volume for family planning services has increased 13% across Mathura’s seven UPHCs in the first quarter of FY 2019-20, when compared with the same period last year.
According to the World Health Organization, India has the highest burden of tuberculosis (TB), with two deaths occurring every three minutes from TB. But these deaths can be prevented with proper care and treatment.
Gwalior, Madhya Pradesh
Given the effectiveness of The Challenge Initiative for Healthy Cities’ (TCIHC) coaching model for improving family planning and maternal and child health outcomes, USAID asked TCIHC in December 2018 to provide coaching support to strengthen government structures to more effectively identify, treat and care for TB patients. Following its Lead-Assist-Observe (LAO) coaching model, TCIHC began mentoring urban accredited social health activists (ASHAs) in TCIHC-sponsored cities on how to identify potential TB cases, counsel them and refer them to services for proper treatment and care.
Gwalior is a TCIHC city in Madhya Pradesh with a TB prevalence rate of 327 per 100,000 population. Annually, 6,800 patients are diagnosed with TB in Gwalior alone. A 2016 study conducted in three TB units in Gwalior found that most patients belonged to a low socio-economic strata (77.2%), dwelled in overcrowded houses (71.6%) and were in the age group of 16-30 years (40.2%). The study’s findings echo the experience of Poonam Batham, who is 23 years old and lives in NadiPaarTaal, a slum of almost 2,000 people in Gwalior.
two-year-old son and her mother-in-law, depends on daily labour
to make ends meet.
Her community strongly believes that TB is a result of a person being under the influence of black magic or an evil spirit. Additionally, the community elders believe women under the influence of this black magic cannot become mothers again and, therefore, must be isolated from family. People also believe TB can only be treated by traditional healers. Poonam’s mother-in-law believe Poonam was under the influence of black magic, coughing all day and losing weight. As a result, Poonam was isolated from her family members and the community avoided her.
During a routine household visit, an ASHA mentored by TCIHC observed Poonam’s condition and for the next few days repeatedly visited Poonam’s house to educate her mother-in-law and husband on TB care and the effectiveness of TB medication. They discussed government schemes for free medication and care from qualified doctors at medical facilities closer to their home. The AHSA convinced Poonam’s husband that she needed medical care and accompanied her to the district hospital. At the hospital, the doctor observed that Poonam was undernourished, weighing just 25 kilograms, and tested her sputum. Once the test results confirmed pulmonary TB, the ASHA supported Poonam in adhering to her treatment plan and making sure she had access to nutrition and care from family during her weekly household visits. Grateful for the ASHA’s intervention and follow-up with her and her family, Poonam said, “I have realized the life of hell and heaven in very short span of time.”
The coaching the ASHA received from TCIHC helped her to effectively support Poonam. The ASHA also dispelled myths about TB affecting fertility in the community. Because Poonam dreams of her son getting a good education and having a successful career away from the poverty of the slums, she and her husband decided that she would use an intrauterine contraceptive device (IUCD) so they would have time and resources to make her dream a reality. Poonam credits the AHSA’s counseling for the decision to adopt a family planning method.
Strengthening the capacity of ASHAs to change social norms and behaviors of vulnerable, under-served communities, strengthens the health system’s response to care for the urban poor. And once a platform is ready with demand generation activities, service delivery and an enabling environment, then several health interventions can be easily and effectively layered on to it. This can be a more efficient way of delivering services to the urban poor.
With this layering of TB services onto the TCIHC platform, the initiative now reaches 2.5 million people living in slums in five cities across Madhya Pradesh. TCIHC-coached ASHAs successfully reached 88,853 households with TB-related information and counseling and linked 3,479 potential TB cases to services for confirmatory diagnosis. As a result, 615 TB cases have been confirmed and linked to services for treatment, treatment adherence support and nutrition support in line with the Revised National Tuberculosis Control Program.
The Government of India charged Dr. PravinJadia, the District Immunization Officer (DIO), and his department with reaching 100% immunization coverage for children in Indore, which is located in Madyha Pradesh (MP)
Dr. Asha Pandit
Indore, Madhya Pradesh
India. Less than 70% of children had completed the immunization schedule but the city’s rapid population growth kept them from knowing exactly how many were in need.
“We realized that for maximum coverage we need to list down complete slum population residing in the urban areas. The urban settings are entirely different from rural, due to the gradual increase in the proportion of population and swift spread out of peri-urban areas,” Jadia said. “It becomes difficult to assess the accurate urban boundaries; hence, demarcation of the area and slum listing becomes a significant component for any successful urban intervention.”
The Challenge Initiative for Healthy Cities (TCIHC) helped Jadia along with various government departments and development organizations implement TCI’s proven mapping and listing approach, which found approximately 230,000 people living in Indore’s slums. The mapping exercise also determined that meeting the health needs of this previously uncounted slum population would require an additional 13 Auxiliary Nurse Midwives (ANMs), 400 accredited social health activists (ASHAs) and 14 urban primary health centers (UPHCs). This data prompted India’s Chief Medical Officer of Health (CMHO) to take action by moving some UPHCs closer to the population, allotting equal population coverage to facilities and community health workers. Staff from dormant facilities were shifted to the functional facilities and medical officers were given the responsibility of monitoring outreach activities and providing technical support to the frontline workers at the site.
“Now, we will be able to cover the entire slum population as all the facilities have equal distribution of population. Now, each ward has one facility and each facility has one Medical Officer In-Charge and ANM. We have initiated monitoring of ASHAs and ANMs for outreach activities,” Jadia said. “This model is strengthening all aspects of reporting, services supplies and it is giving magical results as there is 18% rise in MP immunization data in this four-month duration. MP is on the second position at the national level.”
The mapping and listing exercise of Indore has also been publicly recognized by city officials.
“The shifting and distribution of responsibilities within existing service providers has enhanced outreach and service quality,” said Dr. Asha Pandit, Indore’s district health officer. “In February 2018, there were merely 82 family planning users. And, after area segregation, it increased to 1,014 in August 2018. Today, we have baseline data where we can start any program like tuberculosis, malaria, etc.”
Indore’s mapping and listing exercise defined a clear roadmap for how to replicate this exercise in other cities. Bhopal, another MP city, recently adopted this strategy and found more than 50% of its slum population had been left out of previous estimates.