Fixed Day Static Services/Family Planning Day Approach to Expand Access To Quality Family Planning Services

Evidence of Effectiveness

Figure 1: Increase in annual clients accessing FP services across TCI cities in India.

The government officials of Uttar Pradesh, Madhya Pradesh and Odisha implemented FDS/FPD approach with the coaching and mentoring support of The Challenge Initiative (TCI) India. Across 31 intervention cities of these three states, the FDS/FPD approach helped the government to maximize its use of limited human resources and increase the provision of FP in 503 urban primary health center (UPHCs). The experience revealed that when FDS/ FPD for FP were regularly organized in a facility, they enhanced the quality and utilization of routine FP services in that facility.

TCI India conducted two rounds of population-based surveys, which found that the modern contraceptive prevalence rate among currently married women (ages 15 to 49) in poor areas of cities increased significantly from 49.8% in Round 1 (September 2018) to 53.7% in Round 2 (September 2019). Furthermore, UPHC Health Management Information System (HMIS) (NHM, HMIS, 2019) data show that the TCI India program contributed a 168% increase in annual FP client volume as of March 2020 (compared with baseline), or 175,671 more clients accessing FP care (Figure 1). The UPHC proportion of FP clients is around 67% of the total annual FP client volume at the city level.

Figure 2: Estimated acceptors in family planning method in TCI, India,
Sep 2017-Feb 2020 UPHCs only

HMIS trends also show a rapid increase of short-acting reversible methods, including injectable contraceptives, and an increase in IUCD use. Figure 2 represents the increase in annual FP client volume. To prevent overestimation of short-term methods, HMIS data have been adjusted using standard couple-year protection, which is the total estimated protection provided by contraceptives in a one-year period. To account for seasonal variations, the data represent a 12-month average for short-acting methods and rolling sums for long-term and permanent methods. An increase in the trend therefore means that the latest month outperforms the same month from the last year.

  With the support of TCI India, we rolled out Fixed Day Static (FDS) in a staggered manner across 52 UPHCs and 8 UCHCs. This resulted in electrifying increase in overall FP users, motivating government to expand FDS to all rural and urban PHCs across all 75 districts, in the form of ‘Antral Diwas.”

– Dr. Narendra Agarwal, Former Chief Medical Officer, Lucknow, Uttar Pradesh

Guidance for Implementing FDS/FPD/Antral Diwas

Roles and Responsibilities

General Manager FP and Urban

• Ensure timely procurement of FP commodities from the state to strengthen supply chain management
• Review FP data of urban facilities -UPHCs, higher order facilities and private facilities
• Issue guidance to all the districts/cities to refer this tool as one of the guidance documents for implementation of FDS/FPD for spacing method at UPHCs and for all methods at other public and accredited private sector health

AD/JD

• Review FP data of the cities of the division to take decisions and provide guidance
• Replicate best practices of performing cities with other cities to strengthen FP data of the division

CMO/ACMO

• Send a directive to the persons in-charge of all the facilities and accredited private facilities to obtain facility-wise FDS/ FPD schedule and to approve and allocate resources
• Encourage all accredited private facilities to organize FDS/ FPD
• Proactively plan and organize FDS/ FPD in the district
• Ensure that empaneled providers are available for conducting FDS/ FPD
• Monitor quality and outputs of each facility
• Review FDS data by facilities in district level review meetings

CMOS/MoIC/Facility in-Charge (In case of private facilities)

Coach to ensure the following:

• Devising FDS/ FPD calendar, establishing FDS/ FPD teams and facility readiness
• Informed choice and method-specific counseling is done as per guidelines
• Clients are appropriately screened. In case, they are not eligible for their preferred method, clients should be counseled about other appropriate contraceptive alternatives
• Methods are provided with appropriate quality of care including recommended infection prevention practices
• Monitor the quality of FDS/FPD services and ensure correct reporting.
• Wage loss compensation for sterilization clients
• Minimize waiting time for clients at the facility on the day of FDS/ FPD

Nodal Officer- Urban Health and FP/DUHC/DPM/UHC

• Lead in planning and organizing FDS/ FPD in the district
• Manage the FDS/ FPD operations including team deployment and logistics
• Coordinate and oversee all quality parameters and work as an interface between district leadership and facilities
• Ensure methods are provided with appropriate quality of care including recommended infection prevention practices
• Ensure a smooth supply of commodities and supplies
• Monitor FDS/ FPD for quality and ensure data validation and reliability
• Ensure client verification for accredited private facilities.

Staff nurse/Facility counselor

• Develop the FDS/ FPD calendar and establishing FDS/ FPD teams
• Supervise facility readiness prior to FDS/FPD
• Provide informed choice and method-specific counseling to clients
• Ensure that clients are appropriately screened
• In case the client is not eligible for their preferred method, they should be counseled about other appropriate contraceptive alternatives
• Ensure that methods are provided with appropriate quality of care including recommended infection prevention practices
• Monitor the quality of FDS/ FPD services and ensure correct reporting
• Ensure wage loss compensation for clients to be sterilized
• Minimize client waiting time at the facility on the day of FDS/ FPD
• Do post-procedure follow-up of clients

ANMs/NGO

Coach community health workers (ASHA, MAS, AWW, NGO outreach workers) on the following:

• Generate awareness and mobilize clients for FP through home visits and group meetings
• Prepare potential client list before each FDS/ FPD
• Use IEC materials to provide information to men, women and community leaders about FP and specific contraceptive methods
• Use handbills to provide information on FDS/ FPD schedules and availability of services
• Accompany clients to the facilities to help them access services
• Share client’s feedback with the facility-in-charge on services
• Support post-procedure follow-up of clients

Monitoring FDS/FPD/Antral Diwas

FDS can be monitored by including FDS/ FPD as a regular agenda item for discussion in the Facility level QI Team, DQAC meeting, District Health Society (DHS) meeting, and monthly meeting of MOIC convened by the CMO. The following indicators should be reviewed:

• Number of FDS/ FPD planned as compared to the number of FDS/ FPD held
• Number of FP clients served through FDS/ FPD, and their method-mix distribution
• Percentage of FP clients served through FDS/ FPD vis-a-vis total FP clients served, by method and by month
• Client-provider ratio for sterilization (to ensure that client safety and quality of care is not compromised)

Further, spot checks by the CMO/ACMO-Nodal/DUHC/UHC and by in-charge of facility should be undertaken to ensure attention to quality parameters and resolution of bottle-necks. Monitoring the reasons for which women are screened out or service provision is postponed, particularly for sterilization, can provide important information on quality of care and provider-driven barriers to services. This information can be obtained by noting the reasons for screening out/ postponement in the client register.

Data Quality Assurance

Although there is a tendency to collect and report service provision data from FDS/ FPD together with the data from routine service days, separate record-keeping for a certain period of time is recommended for monitoring and validation.

Cost Elements

The elements required for FDS/ FPD are mentioned below along with their Program Implementation Plan (PIP) codes for easy reference. They may be covered under existing budget line items, but if not, they should be incorporated through the PIP. Any additional support can also be sought from the flexi-pool. The table below is indicative and illustrates the manner in which cost elements are provided 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.

Source: NHM PIP Guideline 2022-2024

Sustainability

Sustainability of FDS/FPD can be achieved through the following measures:

• Select and set one day in a week when assured high-quality FP will be provided at facility. Equip facility with trained human resources, equipment, and supplies for FDS/FPD days. To strengthen demand, coach ASHAs on prioritizing client, preparing FP due list, publicizing FDS days in community and mobilizing clients on FDS/FPD. Ensuring that financial resources required for FDS/ FPD are included in the annual PIP.
• Establish a routine schedule of implementation through an order by the CMO and institutionalize monitoring in monthly meetings.
• Make a specific staff member accountable for FDS/ FPD (for example, a doctor/ matron/ senior nursing staff of a District Womens Hospital (DWH) or the in-charge of a private accredited facility) at each facility. By making quality FP services more frequently available at a facility, FDS/ FPD serves as a first step towards providing comprehensive FP services on a regular basis. FDS/ FPD at the DWH and other accredited private facilities have become a regular practice where a broad range of FP services are provided. Still, the need is to continuously publicize the event in poverty clusters and other slum areas to create demand.
• Ensure that providers have skills and knowledge to provide all methods (as it decreases the need for contracting-in providers on special days and facilitates availability of all methods on a regular basis). Ensure periodic refresher training of service providers on method techniques.
• For sustaining FDS/ FPD in private accredited facilities, constant follow-up should be done with private providers by the CMO or his designated nodal officer to motivate them, build their capacity, provide them timely reimbursements and support them in generating demand for FP services on the FDS/ FPD days.