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Youth-Led Workshops Engage Youth in the Design of AYSRH Programming in Uttar Pradesh
The Challenge Initiative for Healthy Cities' (TCIHC's) state-level advocacy efforts successfully convinced the General Manager  of Rashtriya Kishor Swasthya Karyakram (RKSK) - 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. 

As a result, TCIHC held youth-led city consultation workshops in three Uttar Pradesh (UP) cities, including Lucknow. 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.

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. Shalini Verma, 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.

For reading this story on TCI University please https://tciurbanhealth.org/youth-led-workshops-engage-youth-in-the-design-of-aysrh-programming-in-uttar-pradesh/

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

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

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

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

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

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

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

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

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

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

TCIHC Coaching on Quality of Care Leads to the First UPHC in Uttar Pradesh Earning Coveted NQAS Award
The coaching support provided by The Challenge Initiative for Healthy Cities (TCIHC) to city governments in Uttar Pradesh (UP) emphasizes the importance of quality of care as a key pillar in providing voluntary, informed choice family planning services. 

As a result, city governments have built management and coordination mechanisms that enhance the quality and availability of family planning services. The TCIHC-supported city of Gorakhpur illustrates the local government's commitment to improved quality of care after receiving TCIHC coaching.

In March 2021, the Basantpur urban primary health center (UPHC) in Gorakhpur became the first UPHC in Uttar Pradesh to earn a National Quality Assurance Standards (NQAS) award. NQAS certification is the highest-ranking quality accreditation in India. Only a minuscule percentage of UPHCs have NQAS certification.

Dr. Pallavi Srivastava, Medical-Officer-In-Charge at the Basantpur UPHC, shared how TCIHC-supported high-impact interventions related to quality family planning service delivery has also led to an increase in the uptake

"Four years ago, our entire focus was on immunization. At that time, our staff was untrained on contraceptive methods; the UPHC did not have any IUCD insertion kit. In fact, the OPD [outpatient department] load was only 20-30 patients as compared to this day when the OPD load has increased by many folds - no less than 100 patients visit the UPHC every day."

Dr. Srivastava believes the coaching that she and the entire staff of the Basantpur UPHC received from TCIHC has made all the difference, especially in improving the quality of care that they provide - which contributed significantly to them earning the NQAS award.

She explained that family planning is a critical component of the NQAS checklist, which has more than 1,500 quality indicators, including family planning, maternal and child health (MCH), counseling and Family Planning Logistics Management Information System (FPLMIS) indenting, appropriate and timely health management information system (HMIS) updates, commodity availability and patient satisfaction response forms. Dr. Srivastava said: "Before engagement with TCIHC, we did not have any Quality Improvement (QI) committee, nor did any District Quality Assurance Committee (DQAC) visit ever happen. With TCIHC coaching, we coached our community health workers, like ANMs (auxiliary nurse midwives) and ASHAs (accredited social health activists), on identifying and prioritizing FP clients, online indenting, etc. TCIHC coached us on its Quality Assurance high-impact approach, and demonstrated the utility of the quality assessment checklist in identifying gaps and resolving them. We formed a Quality Improvement (QI) committee with their support and started regular QI meetings. We noticed how the quality assessment checklist made it easy for us to identify gaps. All of these efforts played a crucial role in helping us achieve the NQAS status."

Dr. Jaswant Kumar Mall, Divisional Consultant of Quality Assurance of Gorakhpur oversaw the NQAS preparations for the UPHC and he believes that other UPHCs could learn from Basantpur's experience and also earn NQAS certification. He shared that to achieve similar success other UPHCs should:

  • Continually refresh the skills of staff by having them attend refresher courses and new training
  • Strengthen the capacity of ASHAs
  • Regularly discuss issues related to family planning client mobilization in ASHA-ANM meetings
  • Regularly use the QI checklist to identify gaps and address them during QI committee meetings

He noted that information and guidance on all of these success factors are available in TCI University.


As a result of these efforts, TCIHC has contributed to a 94% increase in annual long-acting reversible contraception (LARC) client volume at the city level in Gorakhpur from 3,222 users at baseline to 6,239 users in June 2021 (Figure 1). This increase accounts for 61.5% at the UPHC level from 2,808 LARC users at the baseline to 4,534 users in June 2021.

Facilitating the local governments' ability to implement proven quality of care interventions can effectively activate the local health system to provide quality family planning services in a sustainable manner.

For reading this story on TCI University please visit: https://tciurbanhealth.org/pdfviewer/gorakhpur-tales-of-impact/#page=

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/.

Creating Family Planning Coaches Within the Health System in Indore

Years ago, in a tribal area of Madhya Pradesh, Rajni witnessed the death of a 15-year-old girl who had just given birth  for the second time.

"I was just 22 years old myself and had completed only one year in my job as an ANM. Upon the death of the young mother, all of us were very sad. And, I still recall that the doctor had said family planning could have prevented this young woman's death."

Forever etched in her mind, this sad memory motivates her to promote family planning.

"I am committed to offering family planning services to both men and women as a way to save lives. While providing family planning services, I ensure screening clients properly by checking weight, blood pressure, hemoglobin and ruling out pregnancy. I orient and counsel male group meetings in slum areas to increase knowledge and change mindsets related to family planning. As a result, I have motivated three men for non-scalpel vasectomy."

Rajni is trained in providing the full range of contraceptive methods, including intrauterine contraceptive device (IUCD) insertion and injectable contraceptives (Antara). She conducts regular meetings with Accredited Social Health Activists (ASHAs) in her area and coaches them to better plan household visits by first properly filling out their registers and using them to prioritize visits and deliver tailored counseling messages. Rajni and the ASHAs she coaches follow a systematic approach to ensure that all eligible couples in the community receive family planning information and have access to their methods of choice. She explains:

"With the help of ASHAs, we keep a record of couples that are newlyweds and those who have one child, and approach them on a priority basis for family planning counseling. Whenever an ASHA faces any challenge, I accompany her during the home visit and support in family planning counseling."

Rajni firmly believes that family planning is key to the health and well-being of the entire population. Her passion and commitment towards promotion of family planning was acknowledged by the Indore government on Aug. 15, 2019, when she was recognized as the best performing ANM.

For reading this story on TCI University please visit: https://tciurbanhealth.org/tcihc-urban-tales-creating-family-planning-coaches-within-the-health-system-in-indore/ You can read all previous stories also at https://tciurbanhealth.org/topics/india-urban-tale/.

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/.

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

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

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

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

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

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

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

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

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

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

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

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

PSI-TCIHC works with city governments to advance the cause of family planning. To know more about our work, visit https://tciurbanhealth.org/india-toolkit/ and https://tciurbanhealth.org/topics/india/.

 
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