Convergence of Services at the Community Level:

Meeting Family Planning Needs

Purpose: To facilitate integration of Family Planning (FP) and other Maternal, New Born and Child Health (MNCH) services at the community level,through coordination and integrated actions among all relevant departments.

Audience:

  • Chief Medical and Health Officers (CMHO/CDMO/CMO)
  • Chief Medical and Health Officers (CMHO/CDMO/CMO)
  • Chief Medical Superintendents (CMS)
  • Heads of the different departments (Integrated Child Development Service, District Urban Development Agency, National Urban Livelihoods Mission, Health, Municipal Corporation, Education)
  • Nodal Officer-Urban Health and Family Planning
  • Persons In-charge of Public Health Facilities
  • District Program Managers (DPM)

Background:Convergence ensures that each community level worker is supported by others in his/her activities and responsibilities. It is important to assist these frontline workers to understand that their overlapping responsibilities provide many opportunities for joint work and mutual support. For example –

  • Collaboration between Urban ASHA, DUDA link workerand AWW facilitates the Urban ASHA’s task of mapping households in her jurisdiction. The other workers can also aid the ASHA in subsequent daily tasks towards mobilizing and liaisoning between the community and the public health system.
  • On the Urban Health and Nutrition Day (UHND), all the frontline workers can jointly publicize the UHND, generate a list of potential beneficiaries requiring FP and MNCH services and mobilize their attendance.
  • The AWW can assist the ASHA and the ANM in identifying women who have recently given birth and are in need of post-partum FP, while at the same time the ASHA can motivate such women to take part in activities at the Anganwadi Center.

Convergence at the community service delivery level is dependent on the collaboration at the district level whereby the departments and schemes work together. Although the concept and need for convergence has been mandated by the government and widely discussed at the national, state and district levels, it does not automatically translate into action at the level of the local government or the community. Thereby to ensure implementation of convergence, a deliberate focus and guidance is needed at the level of the district government officials.

Key community workers with tasks related to FP and MNCH:

  • District Urban Development Authority (DUDA)–National Urban Livelihood Mission (NULM) link workers: Mandated to help the urban poor engage with government systems such as getting ration cards, accessing public sector schemes
  • ICDS Anganwadi Workers (AWWs): Offer nutrition, health and education to all children below six years of age, adolescent girls and pregnant and lactating mothers.
  • Auxiliary Nurse Midwives (ANMs): Provide FP and MNCH services through outreach to the community.
  • Accredited Social Health Activists (ASHAs): Community volunteers under National Health Mission (NHM), who create awareness and mobilize communities for FP and MNCH services.

Evidence of Impact

The community based volunteers (ASHAs) engaged by the Urban Health Initiative(UHI) in 11 cities of Uttar Pradesh worked closely together with other community workers such as the AWWs, DUDA link workers and the ANMs. Although empirical evidence is not available, there appeared to be a positive relationship between the collaboration of these workers and the uptake of services and family planning outcomes in these communities.

Activities demonstrating convergence:

  • ASHAs made household visits to promote family planning, antenatal care and institutional delivery services.
  • ASHAs conducted community mobilization for Fixed Day Static services, community health days and routine immunization at the AWW centers.
  • Through collaboration, the frontline workers established a more robust system of tracking pregnant women by comparing lists and triangulating information.
  • Women’s groups such as Mahila Mandal / MahilaArogyaSamiti (MAS) were established to facilitate community level discussions on FP and MNCH issues.
  • ASHAs supported community level health events including pulse polio drives, measles catch-up immunization programs, health days etc.

Guidance For Establishing and Strengthening Convergence

To facilitate convergence at the community level, collaboration is required at various levels as described below:

City-Level Collaboration
  • Collaboration required between the departments of Health, ICDS, Livelihood, Education and the Municipal Corporation / Urban Local Bodies.
  • Collaboration required with FOGSI, private providers, IMA, development partners / NGOs working in the field of urban health and development.
  • CMHO/CDMO/CMO to take a lead in forming and chairing a city coordination committee that includes ICDS, DUDA, FOGSI, Municipal Corporation, health partners, medical colleges, and other urban health stakeholders
  • Authorizing letters to be issued and initial meeting to be organized to facilitate collective work of departments to increase the demand and utilization of health services and products including FP (refer to sample invitation letter). Such meetings to be held on a routine basis (refer to the sample list of stakeholders for city coordination committee; sample agenda – city coordination committee; and sample city coordination committee meeting minutes).
  • CMHO/CDMO/CMO to facilitate the development of an urban health plan (refer to the sample urban health plan) to be approved by the city coordination committee.
Ward-Level Collaboration
  • Collaboration required between the MoIC, ICDS supervisor, Communication officer from DUDA, Elected representative of the municipal ward and Ward level representative for Primary Education (Additional Basic Shiksha Adhikari).
  • MoIC to convene a ward health coordination meeting once a month wherein the committee reviews the progress and plans for the coming month.
  • Key decisions and proceedings of these meetings to be recorded and maintained.
Slum-Level Collaboration
  • Collaboration required between ASHA, AWW, ANM and other community level workers
  • CMHO/CDMO/CMO, MoIC to ensure that all frontline workers understand their respective roles and responsibilities, their areas of overlapping interests and the need for mutual support.
  • It should be considered to undertake a situational analysis by visiting a few slums to see the actual status of convergence and identify the bottle necks.
  • Frontline workers to be supported to create more robust community maps and household lists by sharing data with one another.
  • ANMs to be supported towards establishing a slum-level coordination committee that would serve to build relationships, advocate for community and individual entitlements, and establish and strengthen community groups.
  • Sharing of resources, such as AWC and DUDA premises as spaces for meetings or for community events like UHND and Out-Reach Camps (ORCs) to be encouraged.
  • Information, Education and Communication (IEC) materials to be shared and distributed (Refer to the Government of India IEC materials).

Given that family planning receives little emphasis from other community functionaries it will be important to:

  • Ensure that the benefits of family planning for the health of women and children and their families are well understood by AWWs and other community workers. Without this understanding, workers are likely to neglect family planning and fail to include FP as a priority for convergent actions
  • Collaborate with AWWs to help in counseling pregnant women for FP when they come to AWC for check-ups and supplementary Conversely, ASHAs should advise pregnant women to take supplementary nutrition from the AWC
  • Orient all community level workers with basic training on family planning, including AWWs and DUDA workers (See approved IEC materials for orientation on FP)
  • Provide a combination of integrated FP and MNCH services as these are likely to be more attractive to the recipients. For example, give information on FP at the AWC and other mothers’ group meetings on nutrition that are routinely conducted by AWWs on UHND
  • Ensure that the DUDA link workers are aware that they can receive incentives, provided through the government FP schemes
  • Encourage frontline workers to conduct joint meetings with MAS and use MAS as platforms to provide women with FP and maternal health information and to mobilize women to demand FP and maternal health services
  • Encourage other frontline workers to be involved in strengthening existing women ‘s groups to become MAS through their membership and leadership With their experience and presence in the community, DUDA link workers and AWWs can help U-ASHA to form a MAS where there are no existing women’s groups
  • Ensure that convergence receives support from all levels of government and from all relevant departments and is emphasized in the supervision of the ASHAs, as well as other community workers.

Roles and Responsibilities

Role
Responsibility
CMHO/CDMO/CMO
  • Promote an ethos of collaboration and convergence
  • Ensure all partners come to District Health Society (DHS) meetings
  • Form and chair and city coordination committee
  • Ensure the availability of funds for convergence activities through the PIP
ICDS and DUDA Program Officer
ICDS and ASHA Supervisors
  • In the monthly meetings, share information and materials on FP and establish linkages between AWWs and community volunteers like U-ASHAs
  • Conduct community level meetings and joint visits
  • Provide support to each other by offering additional manpower for special events or sharing resources
ASHA/AWW/DUDA LINK Worker
  • Support ASHAs in their mapping and listing exercises by offering information and conducting introductions
  • Share the list of pregnant women and Married Woman of Reproductive Age (MWRA)
  • Share resources including the AWC, DUDA premises and IEC materials
  • Conduct joint home visits
  • Collaborate in community mobilization for health and FP related activities
  • Support formation of MAS and their activities

Monitoring for Convergence

The following are indicators of the degree of convergence in promoting healthy behaviors including FP:

  • Number of regular meetings conducted at the city and ward levels
  • Number of meetings attended by representatives of each department (Health, ICDS, DUDA, Municipal Corporation)
  • Number of UNHDs and ORCs conducted
  • Number of UHNDs organized by AWWs and ANMs and participated in by other frontline workers
  • Number of ORCs organized by ANMs and participated in by other frontline workers
  • Number of MAS meetings facilitated by ASHAs and participated in by other frontline workers

If the above indicators show a high level of joint activity, that would indicate an effective district and sector level convergence.

Cost Elements

The costs elements specified below can be utilized in NUHM-PIP. If not budgeted, then these cost line items should be budgeted in the PIP/supplementary PIP.

Cost Element
FMR Code
Source
Cost for City Coordination Committee for convergence P.2.2.3 ROP 2017-18, NHM-UP
Costs of production and distribution of IEC materials and job aids for community workers P.9.1 ROP 2017-18, NHM-UP

Costs associated with orienting DUDA link workers and AWWs in FP is not covered in the current PIP, however need-based additions can be requested in the upcoming PIP.

The table is indicative and illustrates the manner in which cost elements are provisioned in a govt. PIP, thus giving guidance to the audience on where to look for elements related to a particular task, such as Convergence.

Sustainability

Essential to the sustainability of ongoing relationships between frontline workers in delivering FP, maternal, infant and child health services are directives from higher authorities, as well as ongoing review of activities at the health and other sectoral monthly meetings. It is also necessary to institutionalize the inclusion of more in-depth training on FP in the AWWs’ and the DUDA link workers’ basic training programs.

Disclaimer: This document is based on the learnings collated from Urban Health Initiative (supported by BMGF), Health of the Urban Poor (supported by USAID) and Expanded Access and Quality (EAQ) to broaden method choice in Uttar Pradesh (supported by BMGF). This document is not prescriptive in nature but provides overall guidance of how this particular aspect was dealt with in these projects for possible adoption and adaptation.