Dashboard India: Service Delivery 30-Hour Magic +

India Toolkit: Services & Supply

30-Hour Magic +

Purpose: The tool is designed to train people on an innovation to rapidly scale-up quality family planning services at urban primary health centers (UPHC) via a special Fixed Day Static (FDS)/Family Planning Day within 30 hours, divided into three 10-hour intervals. The “plus” factor refers to the increased confidence of facility staff, motivation of local government officials, and prioritization of family planning that is actualized by this innovation, which in turn inspires community confidence in services by UPHCs.

Audience:

City Managers, Program Managers, Coordinators
Chief Medical and Health Officers (CMHO/CMO/CDMO)
District Quality Assurance Committee (DQAC)/District Quality Assurance Unit (DQAU) members, Chief Medical Superintendents (CMS)
Nodal Officers – Urban Health, Family Planning
Facility-in-Charges, Medical Officers in Charge (MOIC)
District Program Managers (DPM)
Urban Health Coordinator/Assistant Program Manager, NUHM
Representatives of relevant NGOs

Background: The Challenge Initiative for Healthy Cities (TCIHC) is built upon evidence-based approaches. These approaches have proven effective in earlier projects, such as the Urban Health Initiative (UHI) and Expanded Access to Quality Family Planning Choices (EAQ). These projects demonstrated the approaches of success within a specific population and limited geographical area. Consequently, TCIHC seeks to scale these approaches to benefit a broader population intentionally on urban poor populations. TCIHC started its effort to increase the uptake of family planning services in cities, which were struggling to activate Urban Primary Health Centres (UPHCs) for family planning services.

As a result, when TCIHC introduced Fixed Day Static (FDS)/Family Planning Day– a high impact approach that ensures trained manpower, equipment and supplies are provided on a pre fixed day and time for family planning counseling and services. – at the UPHCs, the city officials including UPHC staff had a mindset that family planning at the primary level cannot happen beyond what is happening. They in fact felt that it is impossible to carry out FDS at UPHCs. There were challenges related to the lack of trained staff, equipment and supplies as well as competing priorities among staff related to the national immunization and polio drives.

Catering to this situation, TCIHC decided that it would need to demonstrate to cities that UPHCs can provide quality family planning services to the community that they serve. As a result, an experienced team was brought together to develop a robust system for rolling out the FDS strategy at the UPHCs, which resulted in the development of the 30-hour magic + innovation.

Evidence of Effectiveness

With local government support, Varanasi was selected for the first demonstration site. The special FDS team arrived in the city three days in advance of the first scheduled FDS to demonstrate the concept of ’30-hour magic +’ to ensures that the minimum requirements for FDS are in place within a 30-hour period – three 10-hour intervals. This one-day FDS resulted in uptake of 136 IUCD acceptors, 14 condom acceptors, 20 oral contraceptive pills acceptors and referral of two women for female sterilization. Interestingly, this one-day FDS was responsible for nearly all but six of the IUCDs that were inserted that quarter (142 IUCDs) among the selected UPHCS.

The “30-hour magic +” approach was next demonstrated in Firozabad, which again clearly showcased the contribution of this one-day special demonstration FDS to the total month’s IUCD uptake of that UPHC. Once this was demonstrated in Varanasi and Firozabad, it influenced the mindsets of the local government and UPHC facility staff. Demand for special FDS demonstrations came from all cities.

The magic of the 30-hour magic + is its ripple effect. Although only four UPHCs were selected for the special FDS, all 24 UPHCs in Varanasi were conducting FDS by May 2018. This ripple effect is seen across TCIHC cities, as noted in the chart below.

This unique concept has been repeated in other cities with similar promising results each time.

Guidance on Using Data to Manage Urban FP Programs

30-Hour Magic+ or the special FDS drive is implemented in four steps.

Step 1: Initial Planning & Steps

A team is constituted to carry out the special FDS drive & responsibilities are assigned accordingly.
The special FDS drive team arrives in the city three days in advance.

Step 2: Enabling the Environment (First 10 hours)

Ensuring key government stakeholders buy-in:

On Day 1, the special FDS team meets with the Chief Medical Officer (CMO/CMHO/CMDO), Urban Health Officials, District Quality Assurance Committee (DQAC), Medical Officer In-charge (MOIC) and other UPHC staff to brief them about the purpose of the drive and discuss the plan of execution.
The team assesses all UPHCs of that particular city to identify which meet the minimum criteria required for quality family planning services and selects “ready-to-start” UPHCs for demonstrating FDS via the 30-hour magic + innovation.
After consultation with the team as to its findings, the team approaches CMO to issue directives for organizing the special FDS in selected UPHCs. These letters are sent from CMO’s office to the participating UPHCs.

Facilitating facility preparedness:

All identified UPHCs are equipped to be able to conduct FDS on the third day. Family planning supplies (IUCD, DMPA, OCPs and condoms), equipment, IUCD insertion kit, infection prevention kit, etc. are ensured by either procuring or pooling resources from the nearby UPHCs/hospitals as per the estimated client load.
All existing service providers at the facility are sensitized on the importance of the special FDS and briefed on effective communication and counseling of contraceptive methods.
The team also ensures preparedness of accredited private facilities and district women’s hospitals to offer services to referral clients from special FDS. They inform all the nearby hospitals for accommodating sterilization clients referred by the UPHC during the FDS day.

Ensuring community engagement:

The team obtains the list of ASHAs along with their family planning training status. From this list, they identify high performing ASHAs for supporting the special FDS day.
The team conducts an orientation meeting with identified ASHAs in order to strengthen their capacity and formulate a plan to reach out to eligible couples residing near the selected UPHCs through group meetings and household visits.

Facilitating quality assurance:

Same day liaising is done with DQAC members to visit UPHC on the special FDS day for assessing it on quality parameters.

Step 3: Bolstering Demand (Next 10 hours)

Further ensuring community engagement:

On Day 2, selected ASHAs are coached and mentored on the process of making priority list, identifying potential clients, and counseling them for giving voluntary choice of family planning. The ASHAs are accompanied and given on-site coaching support as they engage potential eligible couples during their household visits.
The details about the FDS day of services are made available via handmade posters and handbills and temporary posters are pasted in the visitor’s area of the UPHC.

Step 4: Strengthening Access & Quality (Last 10 hours)

Continuing to ensure community engagement:

On Day 3, the due lists from all ASHAs are aggregated and shared with the participating UPHCs to estimate demand. Follow-up is done with all the interested clients.

Further facilitating facility preparedness:

To reduce waiting time and for systematic client flow, registration desk and counseling corner are properly labeled and all family planning methods are displayed to facilitate informed choice consent. IEC materials are kept as well. To maintain privacy, an area is assigned for screening and service provision.

Ensuring monitoring & data reporting:

To ensure proper reporting, a standardized format is shared across all UPHCs for maintaining family planning client’s record, and client exit interview checklist is also shared for assessing client satisfaction.

Ensuring visit of DQAC members & health officials

DQAC members are informed to visit facilities during FDS for quality assurance. CMO and other health officials are invited to observe the special FDS day and reinforce the enthusiasm of UPHC staff and ASHAs.

Spotlight on 30-hour magic + for AYSRH

Adolescent and youth sexual and reproductive health (AYSRH) is layered onto TCIHC to cater to the spacing needs of 15- to 24-year-old first-time parents in the five first phase cities of Uttar Pradesh. Focusing on this younger cohort of women with zero to one child is challenging in the socio-cultural context of India where women are often recognized by the health system and society at large once they have proven their fertility and become mothers. As a result, TCIHC knew that it would need to overcome established mindsets blocking 15- to 24-year-old first-time parents from accessing family planning services. Hence, the 30-hour magic + strategy was adapted. The steps of the 30-hour magic + were used with the following minor modifications:

Sensitizing service providers at the facility on social challenges which are faced by first-time parents
Addressing negative attitudes of providers related to “young mothers and contraception”
Coaching ASHAs on how to extract non-user list by ‘age’ and ‘number of children’ from their register, how to approach and communicate with a young woman about AYSRH information, and how to counsel focusing on the benefits of birth spacing
Engaging decision-makers of the family, such as mother-in-law/husband, during demand generation activities

The 30-hour magic + strategy produced remarkable results in accelerating the uptake of family planning services among the 15- to 24-year-old population in the five first phase cities of Uttar Pradesh.

Roles and Responsibilities

Role	Responsibility
City Manager / Special team constituted for 30-hour magic +	Brief key city officials including CMO/CMHO/CDMO, DQAC members, UPHC staff, nodal officer urban health / family planning about the concept and the plan to roll it out Identify ready-to-start facilities in coordination with CMO’s office Coordinate with CMO’s office to get relevant orders issued for 30-hour magic + demonstration Coach and mentor ASHAs on how to make a priority list, how to identify potential clients, and how to counsel them for giving voluntary choice of family planning Accompany ASHAs for few household visits to provide on-the-job coaching support Ensure publicity of the 30-hour magic + Ensure facility preparedness before 30-hour magic + Ensure visit of DQAC before the 30-hour magic + Support CMO office in monitoring and data reporting Ensure results are shared with CMO post-demonstration of 30-hour magic +
CMHO/CDMO/CMO/CS	Issuance of letter to UPHCs Address all the issues identified by DQAC members Monitor the progress Ensure regular uploading of UPHC data in HMIS portal Visit both public and private facilities Build the capacity of the program officers and DQAC members
Nodal Officer	Ensure supply chain Coordinate between DQAC members and facilities for implementation of activities
ASHA/ANM	Update EC section of the urban health index registry (UHIR) Data base of non-users list of each area Reach and counsel potential non users Organize group meetings of non-users Prepare due list Accompany referrals to UPHCs and other facilities per their desired method Conduct post-service follow-up
Facility In-Charge	Ensure all supplies at facility Ensure infection prevention practice is followed Ensure screening and family planning product/service availability on FDS day Ensure proper record keeping as per government of India standards
DQAC Member	Quality assessment of facility before FDS and on the day of FDS Complete quality checklist forms and share with CMO for necessary action

Monitoring Benchmarks

100% of identified ready-to-start facilities meet minimum criteria required for quality family planning services.
100% selected facilities are visited by DQAC members.
At least 30% high performing ASHAs are identified to mobilize community for the special FDS.
No patients are turned away on the day of special FDS for lack of family planning services (for reasons other than on medical grounds).

Cost Elements

No specific cost is required to execute 30-hour magic +. However, budget provisioned for FDS/FPD in a PIP can be utilized, if required. In addition, innovative approaches can be made to take up demand generation/IEC activities by ASHA/ANM in order to reach potential non-users with various games and infotainment.

The table below is indicative and illustrates the manner in which cost elements are provisioned in a government PIP, thus giving guidance to the audience on where to look for elements related to a particular task, such as implementing FDS/FPD services.

Cost Elements	FMR Code
Demand generation, strengthening service delivery	1.1.3.2.1; 3.2.1
IEC, mid media, mass media	11.6.1; 11.6.3; 11.6.4; 11.6.5; 11.6.6
Interpersonal communication	U.11.3; 11.6.2
Necessary kits, surgical equipment and supplies	U.6.1.1 & U.6.1.2; 6.1.1.3.a till 6.1.1.3.f
Printing of FP manuals, guidelines	1.2.3.1 till 12.3.5
Training & capacity building, additional manpower	U.8.1.8.1.2: U.9.5.1 till U.9.5.8; 3.1.2.5; 9.5.3.1; 9.5.3.1 till 9.5.3.27
POL for family planning/others (including additional mobility support to surgeon’s team if required)	2.2.1
Drop-back scheme	7.3
Quality assurance	U.16.2.1: U.13.1.1 & U.13.2.1

Source: NHM PIP Guideline; 2018-19

Sustainability

The successful implementation of 30-hour magic + in selected ‘ready-to-start’ UPHCs has prompted more cities to come forward and adapt this strategy to suit their needs. The 30-hour magic + effectively scale up FDS as a routine service. Government functionaries of many cities have shown their interest in the approach and have guided their teams to have at least one special FDS every month in order to increase family planning service uptake in their cities. The tool has proven to be an emerging best practice with ample evidence from the field and could be replicated and scaled-up in other countries for improving family planning services at the urban primary care level.

Based on TCIHC evidence and learning, the following points should be considered in adapting the innovation to ensure its sustainability.

Start small and take it to scale: Demonstrate in only one or two facilities and make buzz/noise about it.
Ensure cooperation among all frontline workers: One of the key learnings of the special FDS drive (30-hour magic +) is that it cannot succeed with only one person’s efforts, especially at the frontline worker level. FDS drive requires all of the frontline workers to meet and interact regularly. A complete team effort of all frontline workers is essential for the success and sustainability of this approach.
Monitor regularly for quality assurance and confidence building: Regular visits of DQAC/Urban health officials to the facility ensure and endorse quality services. Their regular visits also help in recognizing the effort of staff and frontline workers. Staff and frontline workers feel appreciated for their work, which contributes to better service delivery.

Disclaimer: This document is based on the learnings collated from The Challenge Initiative for Healthy Cities. This document is not prescriptive in nature but provides overall guidance for how this particular aspect was dealt with for possible adoption and adaptation.