MCSP India Program Year 5 Quarter 1 Report

OCTOBER – DECEMBER 2018

Submitted on: 1 March 2019

Submitted to: United States Agency for International Development Cooperative Agreement #AID-OAA-A-14-00028

Submitted by: Maternal and Child Survival Program

INTRODUCTION

The Maternal and Child Survival Program (MCSP) is a global U.S. Agency for International Development (USAID) cooperative agreement to introduce and support high-impact health interventions in 27 priority countries with the ultimate goal of preventing child and maternal deaths. MCSP engages governments, policymakers, private sector leaders, health care providers, civil society, faith-based organizations and communities in adopting and accelerating proven approaches to address the major causes of maternal, newborn and child mortality such as postpartum hemorrhage, birth asphyxia and diarrhea, respectively, and improve the quality of health services from household to hospital.

MCSP’s predecessor, The Maternal Child Health Integrated Program (MCHIP) worked in India for its entirety (2009- 2014), supporting the Ministry of Health and Family Welfare (MoHFW) and the National Health Mission (NHM). The program worked with a variety of partners and states to expand access to family planning, improve the quality of midwifery and nursing pre-service education, improve the quality of newborn health care and expand routine immunization coverage.

Current MCSP Program Areas in India:  Family Planning program (FP)  Technical Support Unit-Adolescent Health (TSU-AH)  Human Resources for Health- Health & Wellness Centres (HRH-HWC)

Family Planning: In India, the Family Planning (FP) program under the MCSP (MCSP-FP) is working to expand access to high-quality family planning services and contribute to India’s FP2020 commitments. The program has successfully advocated for introduction of newer contraceptives in Government of India’s FP basket. The program is also undertaking strategic demonstration at 52 selected health facilities for the introduction of new contraceptives through public health system.

Built on the tenets of informed choice, respectful care, gender- sensitivity and community participation in family planning services, MCSP is advocating for the adoption of evidence-based approaches, strategies, interventions and solutions to strengthen the delivery of quality contraceptive services. MCSP is strengthening the ecosystem for delivering quality services by setting up quality counseling services and counseling corners, expanding providers’ as well as trainers’ pool, streamlining facility level management processes, strengthening facility, district and state quality assurance mechanisms, strengthening community linkages and addressing the system level gaps.

Technical Support Unit-Adolescent Health (TSU-AH): Technical Support Unit- Adolescent Health (TSU-AH) under the MCSP provides catalytic support to the National and State Governments in effective implementation of the National Adolescent Health Programme (Rashtriya Kishor Swasthya Karyakram) as well as the School Health Program under ‘Ayushman Bharat’. The TSU-AH is also involved in strengthening inter-sectoral co-ordination and convergence between ministries and other agencies working on adolescent health issues, for better synergies.

Human Resources for Health- Health & Wellness Centres (HRH-HWC) In India, MCSP is providing technical assistance for strengthening delivery of RMNCH+A and Comprehensive Primary Health Care (CPHC) services and creation of sustainable training ecosystems in five high focus states (Assam, Chhattisgarh, Jharkhand, Madhya Pradesh and Odisha) and seven north- eastern states (Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura).

The project includes developing of roadmaps, operational plans and financial proposals for setting up of HWCs in intervention states. Additionally, the project will also build the institutional capacity of the intervention states to train Mid-level Health Providers (MLHPs) in six-month certificate course on community health by establishing the required number of training sites (Program Study Centers) and creation of a pool of trainers.

About this report

This report is a narration of MCSP activity updates for PY5Q1 and covers the progress on the following program components:

 Family Planning  Technical Support Unit- Adolescent Health  Human Resources for Health - Health & Wellness Centers

1.0 FAMILY PLANNING

GOAL: CONTRIBUTE TO UNIVERSAL ACCESS TO QUALITY CONTRACEPTIVE SERVICES IN INDIA; THUS CONTRIBUTING TO THE FP 2020 COMMITMENTS

Objective 1: National level, 5 States: Odisha, Chhattisgarh, Maharashtra, Telangana, and Assam, 5 Districts, 52 facilities

Objective 2: National level, 5 States: Odisha, Chhattisgarh, Maharashtra, Telangana, and Assam, 19 Districts, 186 facilities

1.1 OBJECTIVE 1: TO PROMOTE THE EXPANSION OF THE CURRENT BASKET OF CONTRACEPTIVES AVAILABLE IN INDIA BY ADVOCATING FOR (AND DEMONSTRATING) THE INCLUSION OF MORE PROVEN MODERN CONTRACEPTIVE OPTIONS I.E. PROGESTERONE-ONLY PILL (POP) AND CENTCHROMAN.

MCSP continues to maintain POP supplies at the 52 focus facilities beyond the 18-month demonstration period that ended on October 31, 2018. MCSP has initiated advocacy with the respective state governments of the five focus states for procurement of POP through state resources and its’ addition in the contraceptive basket at present public health facilities. Government of Chhattisgarh has included and budgeted for POP in the Essential Drug List using state funds to maintain POP commodities at current facilities so that the gains made so far in POP service provision are not wasted. The program is working closely with India Mission in this regard and looks forward to further guidance. Image 1: POP has been included and budgeted in the Chhattisgarh state’s Essential Drug List. (Mubeen Siddiqui/ In PY5Q1, MCSP focused on the strengthening the MCSP India) service provision further for the two new methods (POP and Centchroman) at 52 focus facilities (FF) across five states: Assam, Chhattisgarh, Maharashtra, Odisha and Telangana, increasing the number of women choosing a postpartum family planning (PPFP) method to 21%, as compared to 10% at the beginning of the demonstration (baseline).

120%

100% 10% 17% 21% 80%

60% 90% 40% 83% 79%

20%

0% Apr - Dec'16 (Deliveries Apr - Dec'17 (Deliveries Apr - Dec'18 (Deliveries = 69,177) = 74,627) = 74,725)

No Method accepted PPFP Method accepted

Graph 1: PPFP Shift (Immediate postpartum)

The introduction of two newer contraceptives in the public sector contraceptive basket created additional PPFP users, rather than erode the acceptance of other FP methods, as an increase in uptake of methods like PPIUCD and PPS was also witnessed. (Graph 2)

0.… 2.0% 2.3%

Apr'18 to Dec'18 (N=25,752) 26.7% 5.2% 33.2% 6.7%4.2% 16.1% 3.4%

1.5% 3.0% 2.1%

Apr'17 to Dec'17 (N=20,471) 32.4% 27.2% 8.9% 14.2% 10.0% 0.0% 0.6%

1.9%

Apr'16 to Dec'16 (N=16,818) 36.4% 5.8%3.5%6.4% 33.4% 12.5% 0.1%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Sterilization NSV COC ECP Condom PPIUCD IUCD POP Centchroman Inj. DMPA

Graph 2: Comparing the Method Mix across 52 focus facilities

Since the roll out of POP and Centchroman services in April 2017 at 52 focus facilities (FF), 4,369 and 7,479 women have accepted POP and Centchroman, respectively, as of December 2018. In the reporting quarter, 375 women accepted POP while 1,119 women accepted Centchroman. Overall, 4.2% of total postpartum women delivering at focus facilities between October to December 2018, accepted either POP (1.4%) or Centchroman (2.8%).

Table 1- POP and Centchroman Acceptors by State POP Centchroman Other POP Other State Deliveries Post- than Post- Centchroman Post- than Post- partum Post- partum Post-partum partum partum partum Assam 5667 31 2 0.5% 128 83 2.3% Chhattisgarh 4472 131 2 2.9% 414 150 9.3% Maharashtra 3711 49 2 1.3% 58 79 1.6% Odisha 5633 96 0 1.7% 102 25 1.8% Telangana 7323 60 2 0.8% 54 26 0.7% Total 26806 367 8 1.4% 756 363 2.8% Source: Monthly Progress Reports (MPRs) received from October 2018 – December 2018

The program followed up with both POP and Centchroman acceptors at prescribed intervals of one, three and six months, to see how many among them were continuing with the chosen method. For POP acceptors at completion of 6 months: (Graph 4) o 3,511 acceptors were due for follow-up o 2,598 (74%) were followed-up o 2,374 (91%) were continuing the method

All POP acceptors are informed and counselled to switchover to a more effective method at six months and 56% (1,336) of the 2,374 POP acceptors had made a decision to do so. 75% (1,000) of the 1,336 acceptors chose a spacing method, with more than half of them, choosing the Combined Oral Contraceptive (COC) pill (533). Other popular spacing methods included Centchroman (208) and condoms (179). The remaining opted to undergo sterilization (a limiting family planning method). (Graph 3 and Table 2) Most POP discontinuers reported that they discontinued the method due to family reasons (12%). Other reasons for discontinuation included bleeding/menstrual related issues (6%) and the acceptor deciding to become pregnant (6%).

Graph 3: Transition of POP Acceptors after Six months (Combined result for all five states) 6

Table 2-Transition of POP acceptors after six months

State Continuation Mala-N Centchroman Condom Injectable IUCD Sterilization No Method Assam 297 166 76 34 0 21 0 0 Chhattisgarh 761 33 73 4 3 16 11 621 Maharashtra 273 49 22 36 0 9 10 147 Odisha 869 276 20 89 14 15 309 146 Telangana 174 9 17 16 0 2 6 124 Total 2374 533 208 179 17 63 336 1038 Source: Monthly Progress Reports (MPRs) received from April 2017 – December 2018

Similarly, for Centchroman, the third follow-up was due 6 months after acceptance. (Graph 4) o 4,073 acceptors were due for follow-up. o 2,460 (60%) were followed-up. o 1,691 (69%) were continuing the method.

The most common reason for discontinuation cited by Centchroman acceptors was difficulty in complying with the Centchroman regime and family reasons, each at 7%. Bleeding/menstrual related issues was another key reason for discontinuation (6%).

POP Centchroman

98% 98% 3500 96% 100% 5000 100% 91% 90% 88% 3000 78% 77% 4500 90% 3328 80% 3266 74% 4000 4496 69% 80% 2500 4412 69% 2878 2775 70% 3500 70% 2604 63% 60% 3566 2000 2374 3000 60% 60% 50% 2500 3138 50% 1500 40% 2000 2460 40% 1000 30% 1500 30% 1691 20% 1000 20% 500 10% 500 10% 0 0% 0 0% At 1 month At 3 month At 6 month At 1 month At 3 month At 6 month

Followed up Continuation Followed up Continuation % Follow- up % Continuation % Follow- up % Continuation

Graph 4: Client Follow-up and Continuation (Apr 2017 to December 2018)

Table 3- Follow-up of POP acceptors by State 1st Follow up 2nd Follow up 3rd Follow up

6 months 6

Follow up Follow

up at 1 month at 1 up months at 3 up months at 6 up

Follow up Follow

- - -

Follow up Follow

State

st nd rd

Follow up Follow

st nd rd

% POP users followed users % POP followed users % POP followed users % POP

Acceptors Due for 1 Due for Acceptors 1 had Acceptors Continue Acceptors month 1 after users POP continued % of 2 Due for Acceptors 2 had Acceptors Continue Acceptors months 3 after users POP continued % of 3 Due for Acceptors 3 had Acceptors Continue Acceptors at users POP continued % of Assam 413 367 89% 367 100% 383 336 88% 335 100% 344 302 88% 297 98% Chhattisgarh 1425 1161 81% 1145 99% 1302 985 76% 940 95% 1198 888 74% 761 86% Maharashtra 571 412 72% 411 100% 527 323 61% 315 98% 491 296 60% 273 92% Odisha 1247 1125 90% 1087 97% 1151 995 86% 960 96% 1046 890 85% 869 98% Telangana 646 263 41% 260 99% 586 239 41% 225 94% 477 228 48% 174 76% Total 4302 3328 77% 3270 98% 3949 2878 73% 2775 96% 3556 2604 73% 2374 91%

Table 4- Follow-up of Centchroman acceptors by State 1st Follow up 2nd Follow up 3rd Follow up

up at 3 months 3 up at months 6 up at

- -

State

Follow up Follow

st nd rd

Centchroman users after one month one after users Centchroman

Follow up Follow

st nd rd

% Centchroman users followed users Centchroman % followed users % Centchroman

% Centchroman users followed up at one month one at up followed users % Centchroman

% of continued Centchroman users after 3 months after users Centchroman continued % of 6 months after users Centchroman continued % of

% of continued continued % of

Acceptors Due for 1 Due for Acceptors 1 had Acceptors Continue Acceptors 2 Due for Acceptors 2 had Acceptors Continue Acceptors 3 Due for Acceptors 3 had Acceptors Continue Acceptors Assam 780 513 66% 513 100% 637 346 54% 340 98% 385 269 70% 261 97% Chhattisgarh 2777 2136 77% 2101 98% 2449 1785 73% 1592 89% 1945 1263 65% 926 73% Maharashtra 1568 891 57% 879 99% 1459 549 38% 459 84% 1090 312 29% 205 66% Odisha 877 762 87% 737 97% 809 661 82% 543 82% 601 423 70% 177 42% Telangana 887 208 23% 204 98% 808 225 28% 213 95% 583 193 33% 122 63% Total 6889 4510 65% 4434 98% 6162 3566 58% 3147 88% 4604 2460 53% 1691 69%

1.2 OBJECTIVE 2: DELIVERY OF QUALITY FAMILY PLANNING SERVICES THROUGH INNOVATIVE PROCESSES AND TOOLS.

1.2.1 Fixed Day Services (FDS) Strategy ‘Fixed Day Static’ (FDS)1 approach is envisioned as one of the long-term strategies to fulfil the unmet demand for family planning, throughout the year on a regular and routine manner. MCSP strengthened the FDS approach and service assurance at 122 facilities. During PY5Q1, 1,536 FDS days were planned across the 122 facilities, on which 8,256 clients were pre-registered by frontline workers on 1,180 FDS days. Of the 7,615 clients that turned up for services on their designated days, 97% (7,390) received services. (Graph 5) Graph 5: Fixed Day Services- Progress

Graph 6: Fixed Day Services- Progress in provided services: Planned vs Unplanned

1 Fixed Day Static (FDS) approach in sterilization services is defined as “providing sterilization services in a health facility by trained providers posted in the same facility, on fixed days, throughout the year on a regular routine manner. 9

Graph 7: FDS Compliance by Facility- 5 States

MCSP’s efforts to strengthen the FDS approach has improved FDS compliance (FDS days conducted as per the FDS calendar set) to 86% in December 2018 as compared to 49% in PY4 (September 2018). The program has been working to improve the FDS compliance in the state of Odisha, where mass transfer of trained service providers to non-MCSP sites affected the delivery of quality FP services. The FDS compliance in the state has been improved to 72% in December 2018 as compared to 53% in October 2018. The team’s advocacy efforts with the Odisha state government resulted in the issue of a letter from Mission Directorate, NHM Odisha for ensuring quality of FDS services. (Annexure 1: Letter from Mission Directorate, NHM, Odisha)

1.2.2 Service Delivery Assessments

To assess and measure the progress on quality of service provision and further improve it, MCSP conducts service delivery assessments at the focus facilities in all five states using service delivery performance standards. As of December 2018, the fourth assessment has been completed at all 186 focus facilities and the fifth assessment has been completed at 155 focus facilities. An overall improvement of 14% has been observed during the fifth assessment so far over baseline.

Graph 8: Progress in service delivery through standards (Area wise)

1.2.3 Quality Assurance (QA) Structures

State Quality Assurance Committee The MCSP team participated in State Quality Assurance Committee (SQAC) meeting held at Raipur, Chhattisgarh on December 22, 2018. While discussing the status of the DQAC and QC meetings held at the district and facility level respectively, it was decided that one DQAC member will be present during the QC meetings in the respective districts to ensure quality discussion. The NQAS certification status of the identified MCSP focus facilities was discussed. Similarly, status of certification of facilities under LaQshya was also reviewed and discussed. The committee discussed the achievement levels of PPIUCD, PAIUCD and Interval IUCD procedures. It was also decided that the State would issue a letter regarding non-performing surgeons. The MCSP team used this platform to discuss the SOP developed for Prevention and Management of Complications related to Female Sterilization Surgery for the Odisha government and explored the possibility of a similar document being developed for the state of Chhattisgarh.

District Quality Assurance Committee MCSP is working towards strengthening and improving the frequency of District Quality Assurance Committee (DQAC) meetings at the district level. In this quarter seven DQAC meetings were conducted in four states (Chhattisgarh, Odisha, Maharashtra and Assam) leading to: mobilization of resources for strengthening infrastructure (Renovation of operation theatre (OT), procurement of key equipment for OT), regular tracking of empaneled providers and tracking progress of facility improvement plans. FDS compliance was also discussed during these meetings and subsequent action plans were developed including the development of rosters and FDS calendars. MCSP used this

platform to present the client feedback data captured through Parivar Swasthya Vaani (Interactive Voice Response System) in the states of Chhattisgarh and Odisha, to identify gaps in provision of quality FP services and develop subsequent action plans to address them.

Table 5: DQAC Meetings held in PY5Q1 State District Date Assam Nagaon 13-October-2018 Bilaspur 9-October-2018 Chhattisgarh Rajnandgaon 1-December-2018 Maharashtra Nashik 12-December-2018 Mayurbhanj 19-November-2018 Odisha Cuttack 17-December-2018 Khurda 27-December-2018 Image 2: DQAC Meeting held at Mayurbhanj, Odisha in November 2018 Quality Circles The teams in each state regularly follow-up with facilities to organize and conduct Quality Circle (QC) meetings. 104 QC meetings were conducted across four states (Chhattisgarh, Odisha, Maharashtra and Telangana) in this quarter. The aim of these meetings is to strengthen monitoring of quality FP services provided at the facility. In addition, MCSP, through its advocacy efforts, rolled out the FP dashboard2 across 169 facilities to be presented during these facility level meetings to promote the use of data for better decision making.

During these QC meetings, MCSP facilitated discussions on progress on quality of FDS and FDS compliance along with strengthening follow-up of clients accessing FDS services by ensuring timeliness and improving documentation. Proper use of various QI and QA tools like the Client Card, Clinical Safety Checklist (CSC) and the Manager’s Checklist was discussed for strengthening the FDS approach further and facility Image 3: QC meeting at CHC Athagarh, Odisha staff were oriented on the use of these tools during some meetings. While discussing the status of uptake of various FP methods including newer contraceptives like POP and Centchroman, the respective facility in-charges of low performing facilities were requested to regularly follow up with their respective facility staff to take status of uptake of newer contraceptives. Other topics that were focused on during these facility level meetings included FP counselling services and improving record keeping practices. Status of implementation of the IVRS platform was also discussed in the QC meetings in the states of Chhattisgarh and Odisha, along with sharing of the client feedback. These meetings have also led to mobilization of RKS funds for procurement of minilap kits and other essential equipment for the Operation Theatre (OT) complex such as Mayo Trolley, Pulse Oximeter and Trendelenburg operating table.

2 The FP Dashboard captures key FP indicators as well as client feedback to enable the facilities to take appropriate corrective actions to improve the Quality of FP service provision. 12

Table 6: QC Meetings held in PY5Q1 State District Name No. of meetings Name No. of meetings Raipur 4 Durg 7 Janjgir-Champa 5 Chhattisgarh 39 Bilaspur 8 Rajnandgaon 9 Dhamtari 6 Maharashtra 6 Nashik 6 Balasore 10 Mayurbhanj 21 Khurda 3 Odisha 58 Cuttack 9 Bolangir 5 Kalahandi 10 Telangana 1 Sangareddy 1 Total 104

1.2.4 Parivar Swasthya Vaani – Interactive Voice Response System

A mobile technology-based Interactive Voice Response System (IVRS) digital platform, Parivar Swasthya Vaani (PSV), was developed and rolled out in two states (Chhattisgarh and Odisha) in PY4. In Chhattisgarh, IVRS was integrated within the state owned ‘104’- a toll free helpline for clients accessing health services. Clients and communities use this platform to receive vital information on FP and to share feedback on quality of FDS service provision at project focus facilities. The IVRS platform aims to strengthen the FP program’s responsiveness to clients’ feedback on quality of services and promote system’s accountability for quality of FDS service provision at recognized FDS facilities.

In PY5Q1, the platform had received 6,185 calls of which, 856 accessed information on FP and 1,113 provided feedback on the quality of FP service delivery. 89% of the clients who provided feedback were satisfied with the providers’ response to their questions/concerns, while 82% found privacy during counselling and examination to be adequate. 26% reported misbehavior, abuse or denial of services, 14% reported experiencing discrimination by the service providers or facility staff and 20% reported that they incurred out of pocket expenditure for availing services at the facility.

Images 4 and 5: Clients sharing FP feedback through PSV in Odisha

To further streamline processes, the platform also provides the facility of pre-registration of interested and eligible clients to avail services as per the FDS calendar. The pre-registration is facilitated by a frontline worker (auxiliary-nurse midwives (ANMs) supported by ASHAs at the community level following an initial screening of interested clients to ascertain her eligibility for the chosen method, for surgery in case of tubal ligation. This reduces the uncertainty for the clients regarding receiving the desired service at the facility on the chosen and scheduled FDS day. In the reporting quarter, 4,216 such appointments at 69 facilities were made using the platform for pre-registering clients to receive FP services as per the FDS calendar. Ongoing efforts are underway for both the promotion of the platform at the community and facility level and the capacity building of health providers on its basic features and steps to access information.

An update on the additions made on the IVRS dashboard and IVRS promotional activity during PY5QI is as follows:

 In Chhattisgarh, in response to MCSP’s advocacy efforts for strengthening the implementation of the IVRS platform, a letter was issued from the Mission Directorate, National Health Mission to all the CMHOs of the six focus districts in the State-Raipur, Dhamtari, Durg, Rajnandgaon, Bilaspur and Janjgir-Champa, regarding strengthening the use and promotion of the IVRS platform in their respective districts. (Annexure 3).  Two additional phone lines for the IVRS platform in Chhattisgarh were installed with BSNL in October 2018. This was done in response to reports of erratic connectivity with the PSV server and with the 104 phone line on few occasions, contributing significantly to registering low number of calls for both information and feedback. The issue of connectivity with 104 was taken up with Piramal Swasthya on a regular basis along with audio recordings.  Post a review meeting held in November, 2018, the following suggested additional details were incorporated in the IVRS dashboard: o User Activity: A live number added which indicates the number of districts/blocks that have received feedback from the community in the period as selected in the main dashboard filters. The live number was plotted on real-time and this allows the PSV Dashboard analysis for where feedback is being provided. o Monthly Report: A PDF version of the dashboard as on the 10th of every month, which can be reviewed and compared. This will be shared as both, an attachment as well as a hyperlink to navigate to the live dashboard. o Users’ Manual: The “How to Use” manual has been revised based on the recent addition of the comparative reports. The technology partner is currently designing a system wherein the manuals can be uploaded for more than one type of user and is also exploring the possibility of uploading the manual in multiple languages as required in the two states.

 In Odisha, the PSV dashboard indicators were presented at the district level review meetings of Medical Officers-I/C, BPMs, PHEO and CDPOs in the districts of Kalahandi, Mayurbhanj and Khordha. Additionally, district level orientation was facilitated, of block level officials such as BPM, BDM & PHEOs on Parivar Swasthya Vaani (PSV) in Mayurbhanj and Khorda districts.  In Chhattisgarh, to promote PSV104, pamphlets were distributed through newspapers and hoardings were placed at 44 facilities in six districts. Different forums such as ANM & RHO meetings, Mitanin meeting, Mitanin trainer’s meetings and VHSND were used to promote PSV104, along with demonstration of IVRS information call, distribution of IEC materials and sharing of facility codes.

Image 6: Sharing information on PSV during on VHSND Image 7: PSV hoarding at CHC Dharsiwa, Raipur sites

1.2.5 Community Participation

MCSP is working to activate, strengthen and ensure regular meetings of community-based platforms such as Rogi Kalyan Samitis (RKS), at project focus FDS facilities (Community Health Centers (CHCs) and District Hospitals (DHs) in the state of Odisha and Chhattisgarh. This has helped in promoting community engagement along with strengthening accountability and transparency in health systems. RKS consists of members from local Panchayati Raj Institutions (PRIs), NGOs, local elected representatives and government officials and are free to prescribe, generate and use the funds with it as per its best judgement for smooth functioning and maintaining the quality of services. MCSP is working to broaden the scope of these patient welfare societies beyond the management of local funds, to include monitoring quality of services and encouraging community participation in prioritizing local issues.

These meetings saw discussion on issues such as the performance of and feedback received through the IVRS platform and identify and address the gaps in quality and respectful care in FP.

During this quarter, 12 RKS meetings were organized in the state of Odisha in two districts (Mayurbhanj and Kalahandi), where the Parivar Swasthya Vaani (PSV) dashboard indicators were shared with a special focus on identifying gaps related to respectful care. The review meetings focused on developing action plans to minimize these identified gaps. Specific issues such as privacy in the counselling center, issues related to seating arrangement for the patients coming to facility, toilet and water facility were focused on. In Chhattisgarh, no RKS (referred to as Jeevan Deep Samiti (JDS) in the state) meetings were held in this quarter, due to competing political and systems priorities due to state assembly elections.

MCSP is working to form linkages between RKS and facility level quality assurance bodies- Quality Circles. MCSP has been successful in convening 33 such interface meetings across 21 facilities in seven districts in Odisha (3) and Chhattisgarh (4). These joint meetings were also utilized for presenting the client feedback received via the IVRS platform related to cleanliness and hygiene, adequate sitting arrangement, counselling corner and respectful behavior towards clients. This led to identification of gaps in the provision of quality FP services as well as developing subsequent action plans to address the identified gaps.

1.3 OBJECTIVE 3: To expand and strengthen quality provision of family planning services at current MCSP focus facilities in five states.

As per the approved. workplan addendum, MCSP-FP has proposed an additional objective focusing on improving the quality provision of FP services by strengthening and expanding the basket of FP services at MCSP focus facilities in five states at the project focus facilities. Following is an update on the progress made so far under the newly proposed activities.

1.3.1 Strengthening the provision for expanded basket of FP services MCSP is supporting the focus states and districts in expediting the approved provider trainings on PPIUCD services. The team is regularly monitoring the status of the training and undertakes supportive supervision visits to ensure the same. The training calendar for the approved provider training has been developed in all the five states and trainings are underway to expand the pool of trained providers. The program is also working towards establishing PPS services at facilities with a minimum load of 100 deliveries per month.

Table 7: PPFP service availability % of focus facilities where PPFP services Method initiated Target Achieved Postpartum Sterilization (PPS) 80 92 Postpartum Intrauterine 80 60 Contraceptive Device (PPIUCD) Centchroman 80 31 (non-Objective 1 MCSP focus sites)

Graph 9: Expanded FP Service Bouquet: Number of clients accepting different FP methods at focus facilities

1.3.2 Strengthening Quality Counselling Services: The program has supported the focus districts and facilities in strengthening provision of counselling services by training dedicated counsellors, other facility level providers and setting up dedicated spaces ensuring privacy to provide counselling services. Since April 2017, MCSP has trained 23 RMNCHA+ counsellors and 85 other facility staff (Staff nurse/ANM) on FP counselling. Dedicated counselling corners have been established at 163 facilities, which ensured provision of quality counselling services to 76,084 clients in the reporting quarter (Graph 11). These efforts have resulted in overall improving the quality of counselling services rendered at the focus facilities, as observed during the quarterly assessments. (Graph 10)

Graph 10: Counselling related indicators: Baseline compared to Quarterly assessment 5 To increase the pool of counsellors and strengthen quality of counselling services further, MCSP advocated for the engagement of alternate cadres of counsellors (for example Integrated Counseling and Testing Center (ICTC) counselors and those associated with other programs such as NCD) to increase their engagement in the provision of FP counselling at their respective facilities. MCSP trained 51 ICTC counsellor and successfully engaged them in FP counselling at focus facilities across six districts in Odisha. Observing the results, the Government of Odisha took a key decision to scale this initiative of engaging ICTC counsellors for FP counselling across all 30 districts in the state. (Annexure 2: Letter from Mission Directorate, NHM, Odisha).

27187 24423 24480 22956 21260 21784

Jul' 18 Aug' 18 Sep' 18 Oct' 18 Nov' 18 Dec' 18

Graph 11: Number of clients counselled on Family Planning

1.3.3 Strengthening of contraceptive security: To improve availability of all contraceptive methods provisioned in the public sector basket and reduce stock outs, MCSP is mapping FP-LMIS orientation of facility staff at focus facilities. Additionally, during supportive supervision visits, the program is supporting focus facilities in transitioning to FP-LMIS to share updates on stock position at individual facility and district levels as well as indenting of FP supplies in real time. Currently FP-LMIS orientation of facility staff has been completed at 91% (170) of the focus facilities in the 5 states and 70% (130) of the facilities have already started indenting ground stock using the software. 17

MCSP at present monitors availability and stocks of contraceptives at project focus facilities, periodically through quarterly assessments using service delivery standards, leading to strengthened FP commodity stock management. (Graph12)

Graph12: Stock management Indicators-Baseline compared to Quarterly Assessment 5

1.4 MEETINGS & COORDINATION

1.4.1 State level Meetings and Coordination

 October 1, 2018, Raipur. MCSP team attended a state team visit that was organized at District Hospital, Raipur and saw all concerned Government State Nodal Officers including that for Family Planning, visit the facility to oversee the orientation of the facility staff on the implementation of the National Quality Assurance Standards (NQAS). This was done post the order for the NQAS accreditation of DH Raipur. A similar visit was organized previously on September 28, 2018.

1.4.2 District level Meetings and Coordination

October 2018

Chhattisgarh  Advocacy meetings with district officials of Durg and Rajnandgaon districts respectively, were organized by the MCSP team.  The team participated in a district level FP review meeting at Durg, Chhattisgarh, that also saw the attendance of service providers.

Maharashtra  In Nashik, Maharashtra, a meeting was convened for all Taluka Medical Officers (TMO). The meeting saw discussion on the following topics: training requirement and calendars, including for newer contraceptives, requirement of infrastructural changes at MCSP facilities and OT requirements at PHC Nanashi & PHC Naitale, etc. Medical Officers were instructed to include these expenses in the PIP template. 18

Odisha  A district level program review meeting was convened at Balasore, Odisha. Issues such as low FDS compliance at the facilities in the district were discussed and the FDS calendar for November 2018 was finalized. The use of tools like client card and CSC was discussed and facilities where the use was either low or the tools were not being used, were identified. Further use of Manager’s Checklist, review of FP activity during QC meetings, repair of biomedical equipment, strengthening the monitoring system, remedial measure and documentation, etc. were also discussed.

Telangana  A meeting was held with the District Medical and Health Officer (DMHO) at Sangareddy, Telangana, and the issue of starting FDS services at CHC Gajwel and PHC Vergal was discussed. Further names of surgeons were suggested to undertake standardization trainings.

November 2018

Maharashtra  MCSP participated in a district level meeting at the District Health Office, called by the District Health Officer (DHO) that saw attendance of Taluka Health Officers (THO) of all blocks in Nashik, Maharashtra. Review of IUCD/PPIUCD training plan at the training center was done and the status of GoI annexures filled by the TMO was reviewed and scale-up of Antara injectable was discussed.

Odisha  MCSP participated in a PIP Dissemination Meeting at Cuttack, Odisha. Training calendar and budget for oral pills training for urban providers was discussed, as was the training calendar for other trainings like that, for Staff Nurses, IUCD training for ANMs/LHVs, PPIUCD insertion training and Training on Injectable for Medical Officers, etc. were discussed. District and facility wise PIP budgets were discussed. While OT construction and renovation was included in the PIP, other logistic like Minilap kits, OT table etc. are yet to be approved by the state to be included. It was discussed that these might be provided by Odisha State Medical Corporation Limited (OSMCL).  MCSP participated in a District Monthly Meeting at Cuttack, Odisha. Status of uptake of newer pills at the 11 facilities in the district was discussed. An addition of 8% acceptors in the PPFP method mix after inclusion of newer contraceptives was highlighted and facilities with low acceptance rate of Centchroman were identified. Status of FDS compliance was discussed. Training calendar of oral pills and injectable was discussed.  MCSP participated in a District Review Meeting at Balasore, Odisha. While discussing the decreasing compliance to the FDS calendar, the MOICs and PHEOs were requested to take action to improve compliance by ensuring pre-registration for male and female sterilization. Importance of tools like client card and clinical safety checklist was discussed and MOICs and PHEOs were asked to ensure their use. Visit Plan of DQAC members to visit FDS sites was discussed. While discussing FP counselling, use of trained ICTC counselors for FP counseling services where a designated FP counsellor is absent was discussed. Facility in-charges were requested to nominate Medical officers for Minilap Induction Training. While discussing male and female sterilization, the MOIC and Surgeons were requested to ensure proper documentation of the procedures as per GoI guidelines and issue of sterilization certificates.

Telangana  MCSP participated in a meeting with DMHO, Sangareddy, Telangana and discussed about non- performing surgeons in the district and less number of PPS performed for normal delivery clients. The DMHO issued a letter to all the trained providers to improve sterilization services including PPS. The

DMHO agreed to the purchase of Inj. Fortwin when the team highlighted its sack of supply and how it affected uninterrupted female sterilization services.  The MCSP team met with the Director, Health and Family Welfare, Telangana cum Chief Program Officer, NHM Telangana at Hyderabad, Telangana, to discuss the need for PPIUCD trainings and standardization training of providers in the state. The Director instructed the respective DMHOs of Sangareddy, Medak and Siddipet districts ensure the timely conduction of the said trainings with the support of the MCSP team. Further, the supply of Inj. Fortwin was discussed.

December 2018

Chhattisgarh  MCSP participated in a District Review Meeting at Bilaspur, Chhattisgarh that was attended by the Chief Medical Officer, District Health Officer and District Program Manager among others. Strengthening of the FDS approach at CHC Gaurella, CHC Masturi and CHC Kota was discussed and the issue of mobilization of service providers for the same was discussed. The issue related to the data operator at the District Hospital was also discussed.

Odisha  The MCSP team met with the ADMO (Family Welfare) at Mayurbhanj, Odisha to discuss the progress of IVRS implementation at facilities conducting FDS days. Status of capacity building of surgeons was discussed including the Minilap and Oral Pill training plans. The status of FP-LMIS orientation of FLWs and facility staff was also discussed.

1.4.3 Capacity building initiatives

 December 12-14, 2018, Sangareddy, Telangana. A three-day PPIUCD training was organized by MCSP at MCH Sangareddy. Eleven participants: three doctors, seven Staff Nurses and one ANM, from ten facilities in Sangareddy and Siddipet participated in this training.  During the month of December 2018, MCSP supported the Odisha government in organizing sixteen batches of training on newer contraceptive at Cuttack, Kalahandi and Balasore districts.

1.5 COMMUNITY PARTICIPATION IN DELIVERY OF FAMILY PLANNING SERVICES AND CAPACITY BUILDING OF SERVICE PROVIDERS ON RESPECTFUL CARE With MCSP support, subaward partner Centre for Catalyzing Change (C3) carried out the following key activities in the states of Chhattisgarh and Odisha in PY5Q1:

1.5.1 Meetings, Coordination and Follow-up

Odisha  The team met with the newly joined Joint Director-FW to brief about MCSP activities in the state including training on Gender, Social Inclusion and Respectful Care (GIRC) in family planning services and PSV implementation. Key state level health officials were identified and given access to the online PSV dashboard and given the responsibility of regularly reviewing the feedback received via the IVRS platform and sharing with the Directorate of Family Welfare in the state.  The PSV dashboard indicators were presented during the district level review meetings in Kalahandi, Mayurbhanj and Khorda districts. The Chief Medical Officers of the districts issued letters to the respective Medical Officers in-charges (MOIcs) to promote usage of PSV by clients for providing feedback. 20

 The C3 team visited 44 facilities in the state in the reporting quarter to review and support in the implementation of PSV platform, facilitate in the organization of RKS and QC meetings and support respectful care.  The team attended 21 sector meetings of ASHA and ANMs in PY5Q1, and discussed respectful care and couple counselling and involvement of the male partner in FP counselling along with reinforcing the key messages of Gender Social Inclusion and Respectful care (GIRC). The platform was also used to promote the use and implementation of Parivar Swasthya Vaani.

Chhattisgarh

 The team met with the State FP Nodal officer to discuss the poor implementation of PSV 104 and discussed the possibility of mobilization of government IEC funds for the promotion of PSV 104.  A meeting was held with the Mission Director, National Health Mission, Odisha to discuss the low number of client feedback calls received via PSV 104. A directive was issued to the CMHOs in the implementing districts in this regard by the Mission Director.  During the reporting quarter, the C3 team met with various stakeholders, including the CMHO, DPM, RMNCH+A Consultant etc. in the districts of Durg, Dhamtari, Raipur, Rajnandgaon, Bilaspur and Janjgir-Champa, to promote IVRS. The team demonstrated the use of IVRS as well as shared a status of the feedback calls as captured using the IVRS dashboard.  In PY5Q1 the C3 team attended nine sector level ANM meetings in the districts of Dhamtari, Raipur, Rajnandgaon and Janjgir-Champa. This platform was utilized to orient the ANM on the use of the IVRS platform for client feedback. Similarly, the team attended 33 Mitanin Trainers’ (MT) meetings and 10 Mitanin meetings across the state, orienting 500 MTs and 200 Mitanins respectively on the IVRS platform.

1.5.2 Strategic plans for MCSP post December 2019 through documenting change in Model FDSs

Twelve model facilities have been identified in the states of Chhattisgarh and Odisha. These facilities have been identified to be receptive of intensive interventions such as regularizing RKS meetings, QC and RKS interface meeting and planning actions for improving RC indicators. The list of facilities selected to model this change – called Model Health Facilities is:

Name of the Model State District Health Facility Sirsa CHC Mayurbhanj Kapatipada CHC Khunta CHC Odisha Koksara CHC Kalahandi Pastikudi CHC Keshinga CHC Akaltara CHC Janjgir Pamgarh CHC Kurud CHC Chhattisgarh Dhamtari Magarlod CHC Mohla CHC Rajnandgaon Dongargaon CHC

1.6 MAJOR CHALLENGES 1. Frequent transfer of MCSP trained providers to non-MCSP facilities, hampered operations in the states of Assam, Odisha and Maharashtra. 2. Observing FDS days as per the calendar planned was affected in Odisha to due various unavoidable reasons such as Durga Puja holidays in October and strike of trade union and the High Court bench in Balangir. Similarly, compliance to FDS calendar was affected in certain blocks in Maharashtra affected by Swine Flu and in the district of Bilaspur in Chhattisgarh due to administrative reasons. The phone lines for the IVRS platform in Chhattisgarh and Odisha experienced connectivity issues reading to call drop and poor compliance and finally poor implementation. 3. In Chhattisgarh, no Jeevan Deep Samiti (JDS) meetings were held in this quarter, due to competing political and systems priorities due to state elections. 4. The ongoing Measles-Rubella campaign affected FDS compliance in the state of Maharashtra and promotion of the IVRS platform in Chhattisgarh. 5. Kayakalp-an assessment of facility hygiene and cleanliness, was being conducted at most of the focus facilities in Odisha and Chhattisgarh as a priority task in which block level health officials were heavily invested. This adversely affected timely conduction of RKS meetings and their postponement.

1.7 WAY FORWARD In the coming quarter, MCSP will disseminate the results and the lessons learnt from the POP demonstration with the government at the national and state levels to advocate for the inclusion of POP in the public health basket of contraceptives and scale-up across the country. The program will focus on strengthening and expanding the basket of FP services at MCSP focus facilities to initiate provision of all FP services as per the current approved public sector contraceptives basket including PPS and PPIUCD. The program will provide support to the respective state governments for the capacity building of providers for the expanded basket of FP services. MCSP will also provide post training mentoring to the providers to ensure initiation and provision of services at the facilities.

To further strengthen the FDS strategy at the focus facilities, MCSP will work to ensure that all focus facilities conduct at least one FDS day as planned per month. Advocacy efforts will be made with the state government of Chhattisgarh in the context of scale-up of the IVRS platform across the state. The state of Odisha has already budgeted monies in the annual NHM Program Implementation Plan (PIP) for scale-up of the IVRS application across the state (all 30 districts) which has been approved by the national government. The Government of India has approved a budget of INR 15 lacs ($21,127) for the implementation of the platform across the state of Odisha. In Odisha, MCSP will provide technical and implementation support to NHM in the roll out of the IVRS platform across the current six MCSP focus districts. The program will orient government health officials and facility staff. Further, four additional non- MCSP districts will be identified in consultation with the Odisha government, for the roll out of the IVRS platform, including development of roadmaps and SOPs for training of government personnel.

Focus will be given on respectful care as the facilities performing poorly on the respectful care indicators (as per the service delivery standards and client feedback received via the IVRS platform) will be identified and re-orientation of facility staff will be conducted.

MCSP will take its work forward at the twelve model facilities identified in Chhattisgarh and Odisha. Efforts will be strengthened at these facilities to form linkages between the RKS and QC bodies, as well as provide support to regularize the RKS/QC meetings for improved quality assurance structures. The program will facilitate review of the FP dashboard during DQAC, QC and RKS meetings to promote use of data for better decision making.

MCSP developed the Quality Index (QI) with the intention of shifting the focus away from individuals and onto the facility as a driver for quality change. The Quality Index ranks facilities based on their program performance, quality of FDS services provision, and client feedback on the quality of service providers (utilizing the IVRS platform) as opposed to the current facility ranking criteria used by the Government that are entirely quantitative. Currently, the QI has buy-in from the state government of Odisha regarding a reward mechanism for the higher-ranking facilities in each district, and to budget through the existing state’s ‘Sampurna’3 project. Moving forward, the program will advocate with the state government of Chhattisgarh, which also implemented the IVRS component for their buy-in for the Quality Index.

3 Government of Odisha launched the SAMPURNA — (Sishu Abond Matru Mrityuhara Purna Nirakaran Abhijan) programme under the state budget to increase institutional deliveries in order to reduce infant mortality rate (IMR) as well as mother mortality rate (MMR). 23

Selected Performance Indicators for PY5Q1 MCSP Global or Country PMP Indicators Target Achievement Objective 1: To promote expansion of proven modern contraceptive options Percentage of demonstration sites from which at least five providers trained in service 80% 79% provision of the two newer contraceptive methods (POP and Centchroman) Percentage of demonstration sites where the first supportive supervision visit completed 90% 92% within a month of completion of provider trainings Percentage of demonstration sites with a 70% 85% dedicated FP counseling area Percentage of demonstration sites having at least one provider trained in FP counseling, 80% 92% including counseling skill on the two newer methods (POP and Centchroman) Percentage of delivery clients who have accepted POP before discharged from the As per trends 2.4% facility. Percentage of delivery clients who have accepted Centchroman before discharged from As per trends 2.8% the facility. Percentage of POP acceptors 1st Follow up As per trends 77% continuing to use POP, over 2nd Follow up As per trends 74% the specified follow-up intervals. 3rd Follow up As per trends 74% Percentage of Centchroman 1st Follow up As per trends 65% acceptors continuing to use 2nd Follow up As per trends 58% Centchroman, over the specified follow-up intervals. 3rd Follow up As per trends 48% Objective 2: To demonstrate at a reasonable scale strengthening of quality FP services delivered through the public health system through improved clinical governance and other innovative processes and systems, and advocate for subsequent scale-up Percentage of facilities having Fixed Day Static services for sterilization where Quality Circle 60% 81% started monitoring sterilization services Dashboard Indicators Percentage of PPFP (postpartum services/postpartum intrauterine As per trends 69% device/POP/Centchroman) acceptors counseled during the antenatal period Cross-Cutting Indicators Number of people trained through US Exact numbers 26,848 government- supported programs Number of facility-based providers and Exact numbers 24,769 community-based workers trained on gender CYP in MCSP-supported areas Exact numbers 4,70,060

2.0 TECHNICAL SUPPORT UNIT- ADOLESCENT HEALTH

GOAL: TO PROVIDE TECHNICAL SUPPORT TO MINISTRY OF HEALTH & FAMILY WELFARE (MOHFW) GOI FOR ADOLESCENT HEALTH (AH)

2.1 OBJECTIVE 1: TO PROVIDE STRATEGIC TECHNICAL SUPPORT TO THE MOHFW IN PLANNING, IMPLEMENTATION AND MONITORING OF NEW INITIATIVES AND STRENGTHENING OF THE SIX STRATEGIC PRIORITY (PROGRAM) COMPONENTS UNDER THE RKSK.

Strengthening Adolescent Health Days: Under National Adolescent Health Programme (NAHP), special emphasis is given to organize Adolescent Health Days once every quarter to address the health needs of adolescents. AHDs are envisaged to increase awareness on six thematic areas of NAHP among adolescents and parents, improve community linkages and foster improved communication between parents and their adolescents. During the field visits to States and interaction with frontline workers and peer educators, TSU reported that AHDs are not being held as planned in the guidelines due to issues like lack of role clarity to organize AHDs, not taking up issues such as Mental Health, substance etc. TSU discussed the need to rework on AHD guidelines with AH Division of MoHFW. Thus, as per the directions from MoHFW, TSU prepared and designed a document summarizing the operationalization of Adolescent Health Day (AHD) both at the community and school level. We adopted a unique strategy by making it thematic Adolescent Health Day covering all themes. The document is submitted to Image 8: Adolescent Health Day-Document MoHFW and it is under review.

Curriculum of Health & Wellness Ambassadors under School Health Programme: TSU is working closely with Ministry of Human Resource and Development (MHRD), National Council of Education Research and Training (NCERT) and other stakeholders to develop training material for Health and Wellness Ambassadors under School Health Programme. TSU, on behalf of MoHFW, is providing relevant technical inputs on six thematic areas of NAHP included in the training material. The first draft of the training material is submitted and the same is under review by MHRD.

School Health Programme Advocacy Film: TSU- AH developed a film showcasing basic contours of the School Health Program. The film is envisaged as an advocacy tool for the program which can be used by all relevant stakeholders to provide brief description of the program. The film was showcased and launched in India Day side event of PMNCH Partners’ Forum 2018. Image 9: Snapshot of advocacy film 25

Position Paper on Adolescent Health: MoHFW set up the working group on Adolescent Health including Government, Development Partners, Civil Society, Academia and Research Organizations and Independent consultants to recognize the achievements in the National Adolescent Health Programme and to think through plausible mechanisms to further strengthen it. In this context, AH paper was prepared to present an overview of key heath and development indicators of adolescents in India, multi-sectoral policy and programme provisions to advance their agenda and specifically discuss the provisions, progress and challenges of the National Adolescent Health Programme. TSU played a key role in developing the position paper and pen down several sections. The position paper is submitted to MoHFW

2.2 OBJECTIVE 2: PROVIDE SUPPORT TO THE AH DIVISION TO INSTITUTIONALIZE ROBUST SYSTEMS AND MECHANISMS FOR COORDINATION/CONVERGENCE WITHIN THE MOHFW, WITH OTHER GOVERNMENT DEPARTMENTS AND MINISTRIES AND WITH OTHER PARTNERS IN THE ADOLESCENT SPACE.

Marketplace-PMNCH Partner's Forum: • For the PMNCH Partner’s forum held on 12th and 13th December 2018, a market place was established to showcase India to global audience in terms of innovations and advances made. TSU act as a focal point for facilitating and coordinating various activities for Market Place. Overall, 95 exhibits were evaluated, out of which 40 was shortlisted and shared with MoHFW for final decision. Thereafter, TSU facilitated establishment of Health System Strengthening Pavilion.

Image 10: Design snapshots of Pavilions established during PMNCH Partners’ Forum 2018

2.3 OBJECTIVE 3: PROVIDE SUPPORT TO DEVELOP INNOVATIVE APPROACHES IN THE SBCC STRATEGY 26

National Youth Campaign: YouthBol is a national campaign implemented by Centre for Catalyzing Change (C3) under the USAID flagship Maternal Child Survival Program (MCSP). The campaign has following outcomes:

 Articulation of top priority for adolescents and young people in India on quality healthcare information and services – from accessing services, service provider attitudes and the quality of services received  Data to inform the youth policies and programs to enable tailoring of interventions more in-line with the needs of the youth  Clear understanding of barriers faced by adolescents and young people in accessing healthcare services. Till December 2018, name and tagline for the campaign has been Image 11: Logo of National Youth Campaign developed. It is named as ‘Bol’ meaning ‘Speak’. Pre-test of the questionnaire has been completed. A film and website under development. Currently, C3 is identifying grassroots level partners for implementation of the campaign.

2.4 OBJECTIVE 4: ADVOCATE WITH THE STATE GOVERNMENTS FOR ADOPTING AND BUDGETING EVIDENCE-BASED INTERVENTIONS AS PER THE NATIONAL AH POLICY FRAMEWORK

Regional Review Meetings: MoHFW is organizing five regional review meetings across the country to review the progress achieved in implementation of National Adolescent Health Program and to discuss the way forward. Till December 2018, two regional reviews meetings had completed in Tamilnadu and Odisha wherein 7 States/UTs (A&N islands, Andhra Pradesh, Goa, Karnataka, Kerala, Puducherry and Tamil Nadu) and 4 States (Jharkhand, West Bengal, Uttar Pradesh and Odisha) participated respectively. TSU developed template to review the status of implementation and the same was shared with all States/UTs. Also, provided inputs to MoHFW on key critical implementation gaps and analyzed programmatic data. TSU also oriented State Nodal Image 12: Regional Review meeting under the chairpersonship of officers on School Health Programme guidelines. Secretary (H&FW), Tamil Nadu The key summary of findings from the meetings are as follows:

1. The districts with well trained counsellors in place have better average monthly client load at AFHCs. Therefore, there is need to recruit and train adequate counsellors for all AFHCs. 2. The block/villages with active peer education programme has also led to good demand generation form the community and hence better footfalls at the AFHCs. 3. States need to optimally utilize the platforms of AHDs and AFC meetings to generate demand in community and sensitize various gatekeepers like parents, neighbours, local leaders, teachers etc.

4. The States having dedicated help lines or adolescent health trained staff in help lines receive more calls related to adolescent’s health issues. 5. States have adhoc IEC material available for RKSK. All the States need to have 360 degree holistic IEC/BCC material to reach maximum beneficiaries and community. 6. There is huge variation among States/UTs in their WIFS coverage. States need to strengthen their supply chain management for WIFS to prevent any stock out and delays in procurements. WIFS also needs to have strong inter departmental convergence within Health, ICDS and Education departments for smooth inventory management and regular reporting. 7. States brought out the issue that the accountability of AFHCs needs to be fixed with sub line department in medical colleges for better performance review. Therefore, it was suggested that AFHCs above the CHC level can come under pediatric department for administrative purposes. And the AFHCs at CHC level and bellow will be led by medical officer incharge of that facility.

2.5 ACTIVITIES PLANNED FOR NEXT QUARTER:

o The availability of quality data remains a major challenge with adolescent health. The analyses of primary program data is not done. Realizing the importance and power of data, TSU is developing a mobile based application for real time reporting of Adolescent Friendly Health Clinics (AFHCs). Based on the reports, dashboards will be auto generated from National, State, District and block levels for analysis and review and these will be later linked to the NHM website. o As per the suggestions from MoHFW, Menstrual Hygiene technical brief is updated to include an additional chapter on operationalization of incinerators and vending machine. o Three regional review meetings planned in January in the states of Punjab, Chhattisgarh and Meghalaya and TSU would be facilitating these meetings. o Finalization of regional review meeting reports highlighting key action points and discussion points of each States/UTs. o Developing States/UTs wise fact sheets having secondary data and action points from regional review meeting reports. o Finalization of teachers training material for primary, upper primary, secondary and upper secondary with NCERT. o Development of operational plan to roll out school health program across the country o Based on the findings of the Regional Review meeting, MoHFW is proposing a meeting of National Technical Advisory Group to facilitate convergence for the RKSK program.

3.0 HUMAN RESOURCES FOR HEALTH-HEALTH & WELLNESS CENTRES

GOAL: CREATION OF A NETWORK OF ‘HEALTH AND WELLNESS CENTRES’ ACROSS INTERVENTION STATES FOR PROVISION OF COMPREHENSIVE PRIMARY HEALTH CARE, THEREBY LEADING TO UNIVERSAL HEALTH COVERAGE

The description of activities during the reporting period is given below:

 USAID’s Delegate Visit to Manipur: A team from USAID India Mission including Mr. Xerses Sidhwa, Director Health Office, USAID India and Dr. Gautam Chakraborty, Development Assistance Specialist, USAID India, visited Imphal in Manipur on December 1-2, 2018 to understand the work done by MCSP under the Ayushman Bharat initiative of Health and Wellness Centers (HWCs). The delegation visited HWC Awang Wabagai in Imphal and interacted with health workers of the HWC, government officials as well as the beneficiaries residing in catchment area of the HWC. Following the visit, the team interacted with the state leadership- Smt. N. Bandana Devi Mission Director, NHM and Shri V. Vumlunmang, Principal Image 13: The TEAM: USAID, Government of Manipur Secretary, Health and Family Welfare, Government of and MCSP Manipur, who acknowledged the catalytic role played by USAID-MCSP in supporting Manipur to establish the Health and Wellness Centers.

 Fifth National Summit on Good, Replicable Practices and Innovations in Public Health Care Systems in India: MCSP supported the state of Chhattisgarh in developing and presenting the internal branding strategy as a best practice intervention in the national summit on good, replicable practices and innovations in public health care systems in India.

 Creation of institutional mechanisms at state and district levels: MCSP has been instrumental in advocating and constituting institutional mechanisms such as steering committees and task forces at state and district levels for ensuring quick decision making on operationalizing the HWCs. These committees play a key role in reviewing program implementation, regular monitoring of activities and ensuring timely corrective actions. Formation of such mechanisms go a long way in ensuring long term sustainability of the program. Till date state level steering committees for HWC have been constituted in the states of Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Meghalaya, Mizoram, Sikkim and Nagaland. Further, 70 district level task forces have also been constituted in the states of Chhattisgarh, Madhya Pradesh, Jharkhand, Odisha and Meghalaya.

 Adoption of Internal Branding Package for Health and Wellness Centers by different states: MCSP developed a comprehensive internal branding package for HWCs (includes facility branding as well as IEC materials to be displayed in the facility) for the state government of Chhattisgarh. During the quarter, this package was adopted by the states of Jharkhand, Tripura, Meghalaya and Mizoram. Till date the package has been replicated and adopted by nine states.

 Support for operationalization of HWCs: Supported the intervention states in identification and finalization of 4856 health facilities for upgradation to HWCs in FY 2018 – 19. During this quarter, MCSP included one more intervention state – Arunachal Pradesh on request from the state government to support strengthening delivery of comprehensive primary healthcare services. Support was provided to intervention states in ensuring completion of gap analysis of facilities, branding of facilities, population enumeration, streamlining the services, procurement and regular supply of equipment, medicines and other logistics, development of Programme Implementation Plans (PIP), initiating wellness activities and other services as per the Government of India guidelines. A total of 137 facilities in MCSP demonstration districts have been fully operational while 1263 facilities have initiated upgradation to HWCs.

 Domestic resource mobilization for infrastructure development and operationalization of HWCs: Recognizing the potential of HWCs in bringing a remarkable improvement in provision of care in Chhattisgarh, many districts in the state collaborated closely with MCSP to mobilize domestic resources such as Panchayati Raj funds and District Mineral Funds (DMF) for infrastructure development and operationalization of HWCs. The table below illustrates the amount of funds leveraged through different domestic resources apart from the traditional National Health Mission funds. Around 45,000 USD have already been leveraged within a short span of three months.

Sl. District HWC Name Activity Source of Amount No. Funding leveraged (USD) 1 Durg Amleshwar Approach road PRI 700 2 Durg Thanod Boundary wall PRI 7,005 3 Bemetera Hasda Approach road PRI 700 4 Bilaspur 4 model HWCs Portable Labs DMF 23,117 5 Jashpur 2 model HWCs Portable Labs DMF 12,217 6 Jashpur 2 model HWCs Stadiometers DMF 700

 Institutionalization of fixed day Non- Communicable Diseases (NCD) screening in Jharkhand: MCSP facilitated microplanning, scheduling and execution of fixed day village wise NCD screening for the targeted beneficiaries at community level in the state of Jharkhand.

 Streamlining monitoring and reporting processes for HWCs: MCSP developed a standard district level reporting format to monitor the progress of work on HWCs which was rolled out across the states to streamline and standardize reporting structures. Further, supportive supervision visits were also initiated in the last quarter as part of regular monitoring of the operationalization of HWCs, given below are the total visits undertaken in the last quarter:

State No. of HWCs Visited Assam 9 Chhattisgarh 144 Jharkhand 44 Madhya Pradesh 69 Manipur 22 Meghalaya 25 Mizoram 11 Nagaland 5 Odisha 207 Sikkim 15 Tripura 6 Grand Total 557

 Support for operationalization of Program Study Centers (PSCs): Technical support was provided to all the intervention states in submission of proposals for notification of PSCs to Indira Gandhi National Open University (IGNOU), facilitating disbursement of funds for PSCs, timely completion of classes, facilitating term end examination and recruitment of the next batch. Till date MCSP has supported establishment of 37 Program Study Centers (PSCs) which have trained more than 1100 MLHPs.

 Development of Branding Package for Program Study Centers (PSCs): A branding package was developed for PSCs which included posters for the academic counsellors and students and facility branding. This package was adopted by states of Madhya Pradesh, Mizoram and Meghalaya.

 Mentoring and Quality Assurance (MQA) visits: MQA visits were initiated across the operational PSCs in all the intervention states. In the last quarter, a total of 64 MQA visits have been conducted.

State No. of MQA visits conducted Chhattisgarh 8 Jharkhand 12 Madhya Pradesh 15 Manipur 6 Meghalaya 6 Nagaland 6 Odisha 6 Sikkim 3 Tripura 2 Grand Total 64

 Development of Communication materials and Knowledge Products: The following knowledge products were developed during the quarter:

 Success stories:  Wellness: the true aspect of a healthy community  Family Planning: The armour of a strong economy  Leveraging Existing Platforms to Reach the Unreached  Leveraging Funds for a Healthy and Resilient Chhattisgarh  In Learning One Teaches, and in Teaching One Learns  Other communication material:  Developed a photo story on “A vow to save Medha”  Developed one lessons learned on “Nursing Institutions as Program Study Centers”  Developed one case study on “Effective planning of Mid-Level Health Provider training ensures timely initiation of Health and Wellness Centers – Experiences from Odisha

ACTIVITIES PLANNED FOR NEXT QUARTER

 Technical support for streamlining provision of services in HWCs.  Development of community mobilization plan and materials for HWCs  Development of audiovisuals and other communication materials on Health and Wellness Centers for social media platforms of Ministry of Health and Family Welfare, Government of India  Mapping and identification of innovative models of service delivery, health promotion, demand generation and capacity building to be piloted at selected HWCs  Training of counsellors of new Program Study Centers on IGNOU norms, course planning, and learning resource package across all operational PSCs in intervention states  Mentoring and Quality Assurance support to PSCs  Facilitate the identification, gap assessment and documentation for establishment of new PSCs for January 2019 batch. 32

Annexure 1: Letter from Mission Directorate, NHM, Odisha regarding ensuring quality of FDS services

Annexure 2: Letter from Mission Directorate, NHM, Odisha regarding Family Planning Counselling at Sub-district level through ICTC counselors

Annexure 3: Letter from Mission Directorate, NHM, Chhattisgarh regarding strengthening the implementation of the IVRS platform in the focus districts.