Convergence of Services

Convergence of Services at the City Level:

Meeting Family Planning Needs of the Urban Poor

Purpose: This tool helps to facilitate integration of Family Planning (FP) and other Maternal, New Born and Child Health (MNCH) services at the city level, through coordination and integrated action among all relevant departments.

Audience:

General Manager-FP and Urban Joint Director (JD)/Additional Director (AD)
Chief Medical Officer (CMO)/Additional Chief Medical Officer (ACMO)
Chief Medical Superintendents (CMS)
Divisional Urban Health Consultant (DUHC)/Nodal Officer-Urban Health and Family Planning/District Program Managers (DPM)
Urban Health Coordinator
City Community Process Managers (CCPM) Medical Officer In-Charge (MOIC)/Private facilities In-charge
Heads of various departments-Integrated Child Development Service (ICDS), District Urban Development Agency (DUDA), National Urban Livelihoods Mission (NULM), Rashtriya Kishor Swasthya Karyakram (RKSK), Municipal Corporation (Urban Local Bodies), Education, Tuberculosis
Medical College/Federation of Obstetric and Gynaecological Societies of India (FOGSI)/Indian Medical Association (IMA) representatives
NGO/Health Partners

Background: The National Urban Health Mission (NUHM) recognizes ‘convergence between departments’ as essential element to meet the health needs of ever-growing urban population. Towards this, Government of India released a letter in June 2017 to the states regarding formation of City Coordination Committee (CCC) in NUHM cities. However, CCCs were not formed and activated hence opportunity to utilize this convergence platform remained untapped. The inter and intra department convergence can be ensured by the following:

Convergence at the service delivery level is dependent on 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. Hence, to ensure implementation of convergence, a deliberate focus and guidance is needed at the level of district government officials.

Collaboration between Accredited Social Health Activist (ASHA), DUDA link worker and Anganwadi Worker (AWW) facilitates the ASHA's task of mapping households in her coverage area. The other workers can also support ASHA in daily tasks of liaising 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, prepare a list of potential beneficiaries requiring FP and MNCH services and mobilize their attendance from the FP and MNCH due list.
AWW can assist ASHA and the Auxiliary Nurse Midwife (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 (AWC).

Key community workers with tasks related to FP and MNCH:

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

Evidence of Impact

As an outcome of The Challenge Initiative (TCI) India’s advocacy efforts. The Director General, Family Welfare Uttar Pradesh, issued a letter in July 2018 to CMOs of 75 districts regarding activation of CCCs along with the structure, roles and responsibilities of the committee. Across 25 TCI India supported cities government formed and activated committee, and quarterly CCC meetings became a mandatory convergence activity of NUHM. In CCC meetings the FP achievements, issues and challenges were presented to the committee to sort solutions by seeking support from the relevant departments.

Some of the noteworthy outcomes from CCC forum are listed below:

In many cities self-help groups (SHGs) of NULM and AWW of ICDS were coached by ANM on motivating eligible couple from the slum areas for fixed day static services (FDS)/Antral diwas, outreach camps and urban health nutrition day.
In Mathura through the support of education department school teachers were oriented on family planning who later motivated parents by discussing the advantages of family planning in parent-teacher meetings.
In Varanasi TCI’s Male Engagement Team Leader participated in Municipal Corporation training to orient and motivate sanitation workers on family planning.
In many cities Jal Nigam supported in resolving UPHC water issue, UPHCs were relocated to a better place and UPHCs surrounding was cleaned up taking support of Municipal Corporation.
In Varanasi education department demanded for initiating school health check of urban poor children the way it is organized in rural areas. CMO Varanasi, took District Magistrate’s approval and children in urban area received health check services in their schools.

Guidance For Establishing and Strengthening Convergence

City-level formation and activation of CCC

A directive from CMO should be issued towards formation of the committee as per NUHM 2017 letter.
Following the directive, UHC should ensure that CCC is established. Collaboration required between the departments of Health, ICDS, DUDA, Education, Municipal Corporation/ ULB, FOGSI, private providers, IMA, development partners/ NGOs working in the field of urban health and development.
Prior to quarterly CCC meeting CMO should send an invitation letter to all the urban health stakeholders and NUHM officials to prepare presentation slides for discussion during the CCC meeting. (Refer to: sample invitation letter for City Coordination Committee).
CMO should chair the CCC meeting and NUHM officials should highlight the existing gaps identified through City Consultation Workshop/Know your city exercise which could be plugged with support from stakeholders. The committee can discuss issues around prioritizing FP and Adolescent and Youth Sexual and Reproductive Health (AYSRH), identifying FP and gender champions to build an enabling environment. It is crucial to ensure that the discussions encompass and address a diverse range of FP, AYSRH and gender-related issues by involving various stakeholders. The minutes of meetings should be documented and later to be released by CMO. (Refer to: sample list of stakeholders for city coordination committee; sample agenda - City Coordination Committee; and sample minutes of meetings of City Coordination Committee).
The action points emerged from CCC meetings should be adhered and reviewed in next CCC meeting. CMO/ACMO should facilitate preparation of a city health plan (Refer to: Sample urban health plan) and support in approval of the plan by CCC.
The CMO/ACMO should facilitate preparation of the Urban Health Plan (Refer: Sample Urban Health Plan) and assist in approval of the plan by the CCC.
Similarly, ward level and slum level convergence should be established which can be utilized for sharing of resources, such as AWC and DUDA premises for meetings or for community events like UHND and Out-Reach Camps (ORCs). Cross utilization of Information, Education and Communication (IEC) materials and distribution through community health workers of various departments should be encouraged to generate awareness on health issues including FP. (Refer to: UHI-Government approved IEC materials).

Given that FP receives little emphasis from other community functionaries, it will be important to:

Orient community health workers on FP: Orient all community level workers through basic training on FP, gender inclusion including AWWs and DUDA workers. Without this understanding, workers are likely to neglect FP and fail to include it as a priority for convergent action (Refer to: UHI_Government approved IEC materials, for orientation on FP). Ensure that the benefits of FP and of gender integration for the health of women and children and their families are well understood by the trained AWWs and other community workers.

Provide a combination of integrated FP and MNCH services: Ensure collaboration among ASHA and AWWs to help in counseling pregnant women on FP when they come to the AWC for check-ups and supplementary nutrition. CHWs should seek an opportune moment during such interactions when they can talk about gender equality. They can also engage the couple through gender sensitization games such as white and black marble game to change the mind-set of son preference, Kranti Bhranti an interactive game of Rashtriya Kishore Swasthya Karyakram (RKSK).

Support in formation of Mahila Arogya Samiti (MAS): Encourage other frontline workers to participate in strengthening existing women's groups to form MAS through their membership and leadership roles. With their experience and presence in the community, DUDA link workers and AWWs can help ASHAs to form MAS where there are no women's groups (Refer to TCI India HIA- Strengthening MAS). ASHA should sensitize MAS members on gender neutrality by using IEC or simulation games. Further, during MAS members home visits, such gender sensitization games can be used to promote shared decision-making among eligible couples.

Utilize group meetings: Encourage frontline workers to conduct joint meetings with MAS and use MAS as a platform to provide women with FP and maternal health information and mobilize eligible couples to demand these services. AWWs during routine UHND sessions give information on FP and other mothers' group meetings on nutrition at the AWC.

Roles and Responsibilities

Role	Responsibility
General Manager FP and Urban/JD/AD	Ensure formation and activation of CCC in all cities Issue guidance to all the cities to refer this tool as one of the guidance documents to facilitate integration of FP and other MNCH services through coordination and integrated action among all relevant departments
CMO/ACMO	Issue directives for the formation and activation of CCC Send quarterly CCC meeting invitation to stakeholders After meeting release CCC meeting minutes and share with all stakeholders timely Chair a CCC and ensure decisions are taken and adhered timely to strengthen urban FP program Ensure availability of funds for convergence activities through the PIP
DUHC/ Nodal FP and Urban/ DPM/UHC	Develop CCC meeting agenda by integrating FP and MNCH Ensure participation of stakeholders from various departments in CCC meeting Support CMO/ACMO in convening CCC meeting and highlight existing gaps to take support from stakeholders Post-meeting follow-up with stakeholders based on actionable decided during CCC meeting Identify gender champions among staff, community, and stakeholders
ICDS/DUDA Program Officers/ CCPM/ANM	Convey message of support to ASHAs working at the community level in routine meetings like supporting ASHAs in their mapping and listing exercises by introducing them and by providing information Share the list of pregnant women and Married Women of Reproductive Age (MWRA) with other departments Provide a platform for FP orientation of ICDS/DUDA employees (Refer to: UHI_Government approved IEC materials) Share resources including the AWC, DUDA premises and IEC materials Monitor the effectiveness of activities conducted by ASHAs like demand generation and gender sensitization activities and accordingly provide feedback and coaching

Monitoring for Convergence

The following are the indicators of level of convergence in promoting health behavior including FP:

Number of quarterly CCC meetings conducted at the city and ward levels
Number of meetings attended by representatives of each department (Health, ICDS, DUDA, Municipal Corporation etc.)
Number of UNHDs and ORCs organized where FP was integrated
Number of MAS meetings facilitated by ASHAs and participated by other frontline workers

Cost Elements

Though no additional funds are required for convergence activities, however in case need arises then current PIP should be checked. And in case, this need is long- term or perpetual, then it can be requested for inclusion in the next PIP.

Sustainability

To sustain convergence concept, utilize CCC as a platform where city specific issues can be jointly discussed and resolved with the support of all urban stakeholders and ensure this collaboration improve overall health services for the urban poor in the city. To sustain ongoing relations between frontline workers in delivering FP, maternal, infant and child health services, it is essential for their higher authorities to continue giving directives. Similarly, it is necessary to continue with reviewing of activities in monthly meetings of health and other sectors. It is also necessary to institutionalize the inclusion of more in-depth training on FP in the basic training programs of AWW’s and DUDA link workers.

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